Design and Development of a Mobile App Framework to Facilitate Breast Cancer-Preventive Behaviors (m-BCPB) in the At-Risk Women: Qualitative Study

Background Smartphone apps are becoming a gradually universal template for an offering of preventive behavior interventions among women who are at risk of getting breast cancer. Although, only limited methodological procedures on mixing model, document, and qualitative study for their developments are presented. Thus, this study was aimed to design and develop a model-based, document-driven, and user-centered mobile app framework to facilitate breast cancer preventive behaviors targeting at-risk women. Methods The present study explains how intervention progress may be enriched with a theoretic foundation, literature review, and qualitative research. A semi-structural individual interview and focus group dissection (FGD) were accomplished to combine the user’s participation in the development. Participants were employed using a purposing sampling method. All interviews were audio-recorded, transcribed verbatim, and coded by applying the software MAXQDA. The thematic analysis method was employed for developing themes and sub-themes. Results The ASSISTS model, self-regulation model, and the self-control model were chosen to design the app framework. Data from the literature review presented the most inuential document for the designing of the programs. Nineteen women were invited to participate in a semi-structured interview and FGDs. The following ve main themes revealed: content, interactive performance, template, extended action and output, and motivational nature. Mobile apps are a useful tool for learning self-care tips, suitable and healthy lifestyles, and stress management, due to their user-friendly and easy feature. The mobile app framework that developed in the present study includes culture-appropriate, user-centered, and reliable content. The mobile app design should include beautiful, visualized features, and interactive multimedia. Conclusions By applying three phases way combining a model basis, the document from the literature review, and qualitative study from the target group can be held as a pattern for the prospective app design.


Background
Cancer is a leading cause of death globally; in this case, breast cancer has been widely considered (1).
The incidence rate has slowly risen in advanced countries in current decades; this rate has quickly risen in developing countries (2). The risk factors that increase the chance of developing breast cancer can be categorized in unchangeable factors, like sex, age, delay in menarche or menopause, and family history of breast cancer (3,4), and changeable factors, like obesity (5), high intake of fat foods (6), low level of regular exercise (7), alcohol drinking (6,8), smoking (9), and facing a high level of stress (7). These changeable lifestyle factors are important risk factors for developing breast cancer (5). As such, changing one's lifestyle may prevent breast cancer and reduce the risk of getting breast cancer to a large extent (8)(9)(10)(11)(12)(13). For instance, it has been detected that routine exercises prevent too much weight gain and therefore decrease the risk of developing breast cancer (14). backgrounds, and they fail theoretic content. A literature review on quality evaluation for mobile apps is different (37,39). Therefore, the design of quality and document-based mobile app to enhance breast cancer preventive behaviors in women is necessary.
Model-based intervention supports planners in recognizing theoretic structures to consider in an intervention to extract behavioral modi cation (40,41). Furthermore, the theoretic basis offers an approach to smartphone preventive behavior intervention improvement (42). The Template for Intervention Description and Replication (TIDieR) guideline suggested the applying of theoretic frameworks in planning preventive interventions (43). Above all, model-informed design eases the process of an intervention (44,45). Evidence from literature review and meta-analysis is applied as a base to generate suggestions for smartphone app design. The literature review is the source standard in integrating data in health care systems (46). Furthermore, a meta-analytic method is recognized as the most in uential document due to its methodological precision (47).
On the other hand, considering the views and experiences of users in designing and developing mobilebased educational software helps to increase the effectiveness and practicality of the educational app.
So that, by exploring users' experience about the mobile app, investigators and app designers can well develop future m-health interventions to be both practical and admitted by nale-users. The user-focused plan is a well-accepted strategy to improve a smartphone app. This plan is purposefully valuable due to its penetrations on users and their context of performance (48). The bene ts of the user-centered plan involve the increase of freedom, capability, helpful, sensitive experience, and a feeling of connection for users (49). The user-centered plan emphasizes on target audience via an iterative plan method that employs users in building a concept, design, and improvement of a mobile app (50,51). User contribution enhances demand and user-friendliness (52). The target group can choose personalized data about their favored method, which is vital to expand the adequacy and e ciency of interventions (49). User-based design procedures can support identifying the priority of possible users for content, template, and structure on a smartphone app, thus causing in a singularly useful plan. In conclusion, with probable advantages of little cost, high accessibility, and proper adherence, the current study aimed to develop an m-BCPBP app framework to facilitate breast cancer preventive behaviors among at-risk women applying for a model, literature review, and user-based method by the qualitative study.

Methods
Concerning the m-BCPBP app framework design, three phases procedure was used by combining possible sources, the document from a literature review, and results from by qualitative study from the target group (at-risk women).
Step 1: Model-Informed Design Intervention development by performing a theoretical source can considerably advance health behavior (41). Therefore, the m-BCPBP app framework design was according to the combined of three-model, including ASSISTS model (53), self-regulation model (54), and self-control model (55). The ASSISTS model focuses on the key mechanism through the seven principal sub-functions, including attitude, motivation, perceived social support, information seeking, self-e cacy, stress management, and self-care.
Based on the ASSISTS model, self-care behavior and stress management are affected directly by attitude, self-e cacy, motivation, information seeking, and social support. Furthermore, women try to nd more information when they are motivated, have more self-e cacy, have a more positive attitude toward breast cancer prevention, and experience more social support. Self-e cacy is the belief we have in our abilities, especially our skill to run into the contests ahead of us and complete a task effectively (53). The selfregulation model emphasizes on a ve phases self-regulation, counting determination of targets, creation of responsibilities to modi cation, physical and environmental management to comfort achieving one's goals, and performance of self-regulation elements to attain the target (54). The self-control model contains the following elements: wanted behavior criteria, motivation to ful ll criteria, monitoring of conditions that attain the criteria, and internal power to control desires. Self-control plays a signi cant role in a person. This role is an essential key to prosper in life because it changes the person's reactions. In speci c, self-control supports a person with control and standards and aligns the chase of a lasting purpose (55). The theoretical framework (as displayed in Fig. 1) demonstrates the associations between m-BCPBP and health results. In this theoretical model, self-regulation includes perceived support regarding preventive behaviors.
Perceived support can positively have linked to self-e cacy, motivation, and positive attitude, which in turn is positively related to information seeking, self-care, and stress management. Motivation can increase a woman's self-awareness about the current breast health condition, raise positive attitudes, and increases the desire for information seeking breast cancer preventive behaviors. Awareness, positive attitudes, and seeking health information can cause a self-assessment reaction, which includes the explanation of the situation of a woman to some criteria, aim, or a standard. Furthermore, a series of reactions and replies can be identi ed after self-assessment due to self-adjustment and self-e cacy (54) to improve self-care and stress management like having a healthy diet, rise regular exercise program, regular check-up, and obtain healthy breasts. As a result, women who took part in using them-BCPBP app will most likely nd better outcomes about their breasts' health.
Step 2: Document of Literature Review To achieve the most critical available evidence to develop the m-BCPBP app framework, the current study group accomplished a literature review to assess the e cacy of mobile-based (m-based) interventions for breast cancer prevention and screening in women. Seven-database, containing the Medline, Cochrane Library, PsycINFO, ProQuest Dissertations and Theses, Cumulative Index to Nursing and Allied Health Literature, Scopus, Excerpta Medica Database, and PubMed, was explored from their inception to Feb 11, 2017. The study group chose 11 randomized controlled trials in 15 articles among the 1079 accessible papers. This search found that m-based intervention is an appropriate method to perform breast cancer prevention and screening and reduce the risk of getting developed breast cancer.
Several mobile-based delivery templates were detected in 11 chosen articles; these templates include mobile app-based (34,35,37), web-based (56)(57)(58)(59), the internet, email (60,61), short text message (62), and computers (63). Self-care, a healthy lifestyle, and stress management are essential elements in developing healthy lifestyle interventional programs (57). Hopeful approaches have fundamental effects in improving self-care and healthy lifestyle toward breast cancer prevention. Mentioned approaches include de ning behavioral aims, undergoing lifestyle advising or skills teaching, ordered self-controlling, and getting support from the response from health care experts. Intervention initiates at a young age and before the age of 30 years old to cover the positive result of the intervention. E-based templates combining in-woman and phone calls for specialized consultation are effective in decreasing the risk of getting developed breast cancer because parallel interpersonal interactions may help progress the e ciency of the intervention (39,57). Social media amongst peer support is fundamental in improving healthy behavior (64). Table 1 summarizes the proposed advice from our literature review. These suggestions can guide our study in discovering the following stage in developing a mobile app framework for improving breast cancer preventive behaviors in at-risk women. Step 3: Carrying out Qualitative Study to Inform User-Focused Design A qualitative study with end-users, women age 40 and more, in the design process was applied. A qualitative study is important (65) because it offers valuable visions for the rst selection to develop the m-BCPBP framework. A user-focused method helps discover the desires and favorites of platform, content, and design of the m-BCPBP app framework among at-risk women (48). The results of this qualitative study may help in tailoring the intervention, so rising its e ciency and acceptance.

Participant and Background
By purposeful sampling method with maximum variation, 19 women age 40 and more employed from two health care centers a liated by Kurdistan University of Medical Sciences. These health care centers provide comprehensive health care for different demographic and socio-economic groups in Sanandaj (the capital of Kurdistan, Iran).

Data Collection
Data collection was completed from May-August 2017 after getting approval from the Ethics committee of Kurdistan University of Medical Sciences (Grant No: IR.MUK.REC.1396/14). The principal researcher came close to the target women during health care center visits, and eligibility screening was accomplished in a private space. Women were noti ed about the aim of the study, and the datasheet was set. This rst communication was followed up by a phone conversation to create their attention and agreement to take part in the study. Written informed consent was acquired, and women's pro les were nalized. A skilled study assistant, who was quali ed to perform all interviews, performed all interviews to con rm a high level of stability. The data were gathered using two qualitative methods, including a semistructured in-depth interview and focus group discussions with women. An interview guide (Textbox 1) with open-ended queries was used to discover the desires and favorites of women in terms of the content, template, and format for breast cancer prevention behaviors intervention.
i. Semi-structured in-depth interview At the beginning of the qualitative study, 11 semi-structured interviews were performed with women. The semi-structured in-depth interview method lets participants explain their responses easily in their phrases. Based on a structure for a qualitative semi-structured interview guide, the interview questions were designed (51). All interviews were conducted in a private place at the convenience of the women. The interview took long for approximately 40 to 60 min. Each interview was audio-recorded, and eld memos were received. Women were free to participate in the interviews, and the pool card was given as a gift in appreciation of their participation in the interview.
ii. Focus group discussions (FGDs) After a semi-structured in-depth interview, to gain deeper information, two focus group discussions, each involving seven women, were performed. To do this, the volunteered women who contributed to semistructured interviews were requested to take part in FGDs. Six of them decided to be joined in FGDs. In the next part, the eight other new volunteered women approved to take part in FGDs. Generally, FGDs among 14 women were accomplished to discover the subject. Before the beginning of the FGD sessions, the explanatory declaration form was allocated to all women. The purposes of the FGD were clari ed to the women, and women were informed that: the FDS session might yield 90-120 minutes, their answers would be unknown and audio-recorded, and their participants were voluntary.
On the other hand, to get the main topics, eld notes were reserved as well. Women were then set time to request any questions, and those who agreed were now questioned to sign consent forms. Women were mentioned that the main researcher would say some subjects and was requested to explain with accuracy on their answers. Furthermore, they have explained some simple ground principles on how the FGD would carry on, that is: 1) women were stimulated to offer their views as e ciently and as reliably as they could; 2) women were asked to give each other a chance to participate in the discussion, and 3) to respect the lecturer by attending and no disturb discussion between topics. All women were free to participate in the interviews, and the pool card was given as a gift in appreciation of their participation in the interview. Sessions were performed in places that were convenient and easy to get to participants.

Data Analysis
The participants were requested about descriptive characteristics at the launch of each interview. All interviews were audio-recorded. At the end of each interview, the interviews were heard several times and then transcribed verbatim. Thematic analysis was accomplished on the transcripts by two investigators (MK and TP), directed by Braun and Clarke's six-stage method to coding.
(1) acquaintance with information by reading several time the transcripts, (2) primary code generation by regularly detecting and specifying units of meaning with codes, (3) theme searching between the primary codes based on data shapes, (4) rereading and reviewing of themes by establishing the data that may be greatest tting together as subthemes, (5) naming and de ning ending key themes, (6) creating the report (66). This approach was chosen due to its exibility, release from a particular theoretical structure, facility to discover a rich series of data and determination, and analysis of sequential themes. The themes recognized on a semantic level were narrowly related to the data performing an inductive method. The sequential proportional analysis was applied to repeat the difference among theme incidences through opposing women (67). Thematic saturation was reached at the 11th interview as speci ed by two study group members (MK and TP) throughout the simultaneous analysis. Explanatory verbatim quotes were carefully chosen to keep the data validity. Quotations by women were corrected on a partial basis to eliminate content that did not express meaning (frequent words, falters, and stammer) and to correct for syntax. A circle mark was applied to consider the deletion of such unimportant statements. Rectangle brackets were applied in quotes to provide words deleted by the talker or to exchange sensitive data where names were stated.

Validation
For validation, interview transcripts and the resulting codes from each of the semi-structural interviews and FGDs were presented to the participants and their views about the meaning of the codes were asked; if they indicated opposing views, their helpful declaration was included. Moreover, the text of the interviews was presented to some specialists who were not contributed to the current study as external observers to check the coding process accuracy.

Overview
A total of 19 eligible women aged 40 and over without breast cancer approved to take part in the study. Table 2 shows a summary of the demographics characteristics of all 19-woman. After a six-phase thematic analysis, and according to ve main themes related to the app content, interactive performance, template, extended action and output, and motivational nature. These ve themes offered the meaning of level proposing contextual visions into the progress of m-BCPBP.
Summaries of the Key themes, sub-themes, and examples of meaning units are offered in Table 3.  How do you feel about using mobile technology to perform breast cancer prevention behaviors intervention?
What are your experiences in achieving data from the mobile-based template?
Tell me about how you select a desirable technology template to get breast cancer prevention behavior information, and why?
What do you imagine about the preferred method to obtain data about breast cancer prevention behaviors?
What do you imagine about the preferred template for communicating with peers?
What template do you desire in interactivity with health care experts?
What is your favored presentation template by applying multimedia?
What are the necessary features of development that will engage you in the mobile-based intervention?
What do you think about the inhibitors of mobile-based intervention?
What do you think about the facilitators of mobile-based intervention?
How are your smartphone usage habits?
Do you have any further supposed that you have not stated in the offered queries?
To end, is it OK to contact you for some follow-up queries if needed? Almost all women said that the appealing and beautiful feature of the intervention is a critical factor in their applying of the smartphone app. Therefore, design and template an exciting and beautiful style is necessary. In this case, two women explained that: "Beautiful style and colorful as it can interest women to look at it […] consequently, it is easy to get notice and simplify learning." (Participant 15; age:50; married; under diploma; housewife) "My rst choice is a colorful format and shape, such as light color. Indeed, I read on social media that the color pink is related to breast cancer, and the sign is a pink ribbon." (Participant 11; age:45; married; upper diploma; employed).

Subtheme 3.2: Apparent and graphic aspects
Graphical and apparent messages regarding the quantity and kind of behaviors to prevent breast cancer must also be considered. Apparent and graphic aspects progress the women's self-e cacy to understand their improvement and know their preventive behaviors performance. One woman mentioned: "At present, everyone has a smartphone, and many things can be learned or accessed from mobile phones […] There are many mobile applications that we can easily and freely download from mobile phones, such as sports training software programs, diet software, health assessment software, WeightCompanion_1.2 weight loss software, and many other programs, of which all of them are aimed at improving our lifestyle." (Participant 9; age:41; single; upper diploma; employed).

Another woman said:
"Mobil applications is similar to a one-stop place for everybody, and I can access anyplace at any time.

Subtheme 3.4: App charges
Implementing the mobile application at a charge would be a barrier concerning the desire of the user to buy the mobile app, since many people's economic problems and their worse socio-economic context.
Thus, there was a group agreement that the mobile app should be free of charge. Women, although, also thought that they would not buy the mobile app and run it for free to the users except it intended more advertisements for the health care centers or clinics. Furthermore, it was advised that to con ict the matter of price, the app could be involved as one of the bene ts of a link to the health care centers or clinics. Women told concerns that not all people would be ready to provide smartphones. Additionally, they believed that due to the points suggested, cheaper smartphones would not be ready to run the interface suitably. As such, the design of the mobile app should be a balance between simplicity and usability, to con rm even user experience, and that it does not falter. One woman said: "I have experience with a mobile app, in which I have applied for my diabetes drugs… because I have to use it 3-5 times during the day. Consequently, it assists in reminding me as and when I require to use the diabetes drugs. My rst experience with the mobile app was satisfactory until just because it's been practically 20 days; it declares my free trial version is nished. Thus, if you are designing for those who are so economically week, I believed that we should provide it for free charge. If we can run that [it would be worthy] due to being much in-app buying, you see, in light of that, they are uneducated and not so good to perform, if we desire to support them, maybe we can consider about this." (Participant 18; age:45; married; upper diploma; employed).

Subtheme 3.5: Appropriate and User-Friendly
The women stated that the mobile app design should be appropriate, easy, and user-friendly. One woman mentioned that: "In my mind, the most remarkable point in the appropriate use of mobile-based training software is its easy and simple application. It is important that the user is comfortable and friendly with the software and enjoys working with it. User-friendly is important that we can quickly to work, enter, and catch desired information." (Participant 10; age:46; divorced; upper diploma; employed) "Personally, the most important issue for using mobile apps is user-friendly… due to the simple and direct way to nd subjects. The number of contents provided in the app must stay short. As a result, I can easily go from the top to the bottom of the page or the page before and after the app." (Participant 17; age:42; married; under diploma; housewife).

Subtheme 3.6: Privacy and security
There were worries that the user's privacy may be hazarded, since users' data kept in the Cloud may be unprotected to hacking. Furthermore, there were worries about privacy locations -if other people would be able to view their user information. To deal with this issue, women advised that users be given the choice of whether they desired to reveal private data to a particular clinic or health care center while keeping it hidden from another one. Another offer was that each clinic or health care center had its ID, and users were given IDs speci c to the clinic or health care center they visited. This would then prevent other clinic or health care center from having access to information such as buying history, from other clinic or health care center the users visited. One woman expressed her opinions as follows: "Privacy subjects. Suppose we placed our information into the cloud space, others might hack it. Therefore, if I were the client, I may be concerned if my private data may be revealed. For example, suppose I enter my medical history or my breast health status, what guarantee is there that this data will not be disclosed? […] Or are we keeping all private data on the mobile? if you save it in the phone and something occurs to the mobile, then […] all data will be lost." (Participant 14; age:48; married; upper diploma; employed). Subtheme 3.7: Noti cations However, women desired to apply in-app noti cations to deliver messages to users for the gathering of medical data; there were worries of women omitting the in-app noti cations, assuming it was of a small problem. Women used WhatsApp or Telegram as an example where people got a lot of inappropriate noti cations during day, causing in most persons close your eyes and take no notice to them without even seeing at them rst. It was advised instead to current the message either in image or audiovisual shape. Additionally, one woman advised a function that routinely dispatches remembrances to alert users to repeat their behaviors. This would decrease the problem on the operator of having to manually send reminders to the user continually, which would be principally challenging when facing to the great mass of users.
"Similar to something that appears on your mobile […] you are required to save and perform your behaviors. I believed that might be respectable. The women reported that the nature of being a woman has its challenges and various problems. Most of the women mentioned that they need to have educational programs regarding healthy lifestyle and selfcare tailored to their needs and outlooks. An over-all agreement by the women showed that the program should keep operations that will let self-care and checking. Two women expressed their opinions as follows: "I am interested in taking some charts for checking my health statuses, such as my daily physical activities, my daily calorie consumption, regularly breast self-examination, meditation, and weight that is helpful. I feel handy and comfortable if there is a comprehensive software program based on mobile for this evaluation" (Participant 4; age:44; married; upper diploma; employed).
"Having a mobile application helps me to register my health condition data for the physician to perceive through the chart or the diagram to check how well do I control, the things to do past to the following appointment so that the physician can appraise." (Participant 9; age:41; single; upper diploma; employed) Subtheme 4.2: Checking the Improvement Women believed that the smartphone application content should encourage and repeat the users of their improvement. The women stated a demand to check their physical activities, calorie intake, breast selfexamination, meditation, and weight. This nding matched to other speeches from other women, as demonstrated by the quotations below: "Having a mobile phone program is very important for a woman like me who has many responsibilities in life such as housekeeping, babysitting, working outside the home, and caring for a sick mother-in-law. This program reminds us to take care of our health, such as regular exercise, healthy eating, regular breast check-ups, etc. It is worthy if mobile software can contribute to my announcement to follow up." (Participant 11; age:45; married; upper diploma; employed).
"Hoping to have t weight, regular physical activity, healthy food, and breast check-up, software or appliance to control my progression and a proper automatic message aid retell me." (Participant 6; age:52; married; diploma; housewife).

Subtheme 4.3: Systematic Update
Given the quick modi cation in information, systematic updating of the content of smartphone software is signi cantly essential. Women demanded a regular update on the smartphone application as a part of the performance of the program. Two women mentioned as follows: "I would like to read the present study and see the newest breast check-up advice or recommended selfcare and stress management regarding breast cancer prevention and behaviors." (Participant 14; age:48; married; upper diploma; employed) "It will be worthy of tabloid update from the breast cancer prevention program to acquire more updated information." (Participant 17; age:42; married; under diploma; housewife) Theme 5: Motivational nature Motivators are internal and external elements that encourage health mobile app users to either begin or keep to utilize them. Subtheme 5.1: Ability competition with other methods and apps: One of the clear motivators was recognizing other persons applying the mobile app and sharing behavioral data that could be compared to others on social and virtual networking. Women recognized this feature as ambiguous nature: it could be practical and encouraging for some people in speci c settings, but it may be discouraging and rush in other conditions, particularly when people worry that they are also far behind compared to their colleagues or relatives. Two women mentioned as follows: "Seeing relatives use, and I identify I have to run it. Therefore, it holds you motivated to perform it." "I prefer the awards (i.e., symbols) on them inside the mobile app, but it's nothing I can touch and feel like a tangible award. Therefore, for me, if this mobile app was telling once you reduce your calorie intake lower than 1000, you acquire a free pool card or another thing or cash is one of the most important motivators […] things similar that, it will be exciting. Awards are signi cant, but only if you can sense and see them [...]"(Participant 7; age:43; married; upper diploma; employed) Subtheme 5.4: Adding a fun element Attaching a gaming factor or fun to a mobile app was exciting for a speci c link of people. Although, most of the women did not realize the game factor important for women applying user-centered mobile health apps. On the other hand, they believed that a health app with game components might be a positive thing for kids given that they did not understand by the entertainment features of a mobile app, and identify it was something being trained to them. One of the participants believed that: " I would like a mobile app that has gaming factor or fun [...] it is exhilarating for a speci c link [...] adding games in the educational app makes learning more comfortable and more appealing. I think it revives the inner child […]" (Participant 11; age:45; married; upper diploma; employed) Subtheme 5.5: Inner commitment Inherent and inner components are not stimuli produced by a mobile app, but elements inside helping a person to utilize the mobile app. Some women showed that a mobile app could only perform so much.
Finally, it is a person's inner commitment and impulse that will de ne whether they would proceed to do it for health behavior increase or behavior modi cation. One of the participants said: "[…] Possibly, they require to be supplied that app, but nally, it is an inner thing. People are excited from the inner out." (Participant 13; age:53; married; under diploma; housewife).
Interpreting Model, Document, and User Desires into Intervention According to the outcomes from the possible sources and reports of literature review and qualitative study results with the target group, the content, template, and design of the m-BCPBP framework were set. A multidisciplinary study group included a computer software professional, an expert mobile app designer, two health education and promotion experts, content design experts, and a gynecologist was established to design m-BCPBP app framework. M-BCPBP app framework aims to improve breast cancer preventive behaviors in at-risk women. To develop a smartphone application with a user-friendly link, m-BCPBP's user link and aspects were developed by a computer software professional and an expert mobile app designer. The mobile application can be pre-installed on various smartphone types, for example, Android and iPhone. A visual graphing function was designed to let the user arrange their initial factors, such as age, weight, height, and family history of breast cancer (history of developing breast cancer, sister and mother, as well as a history of developing cancer [breast, ovarian and prostate] in rst-degree relatives). Additionally, users were asked about their behaviors, such as physical activity, eating fatty foods, and drinking alcohol, as well as their awareness about risk factors for getting breast cancer and symptoms of breast cancer risk.
The m-BCPBP app framework content consists of risk factors of breast cancer, the symptoms of developing breast cancer, positive attitudes toward preventive behaviors, support, motivational advice, seeking of correct information about breast cancer prevention, self-e cacy advice, self-care advice such as regular breast check-up, suitable physical activity, recommendations about healthy diet, and stress management assistance. The m-BCPBP app framework covers educational, expert, family, and friends support, as well as self-controlling areas (e.g., self-e cacy, self-care, stress management). Educational support offers to encourage users by knowing the effect of improving their lifestyle to keep healthy breasts. Family and friends support aims to conciliate the intercommunication of women, which are used to mobilize and promote common knowledge and attitudes (30). Expert support purposes of attaining and improve healthy lifestyle knowledge, attitudes, and behaviors in order to breast cancer prevention (68). Self-controlling intents to encourage women to self-care of their lifestyle behavior and stress management according to their aims and strengthen any reform made. If the outcome is less or more the range, at that time, the system delivers announcements via the m-BCPBP app framework. The user story box of m-BCPB app is offered in Figs. 2. The drawings and logo depicted in Fig. 2 is our own.

Overview
To the best of our knowledge, this research is the rst to apply a theory-informed, evidence-driven method, and user contribution in designing a smartphone app for an increase in breast cancer preventive behaviors in at-risk women. We applied the explanation of a 3-phase procedure by integrating theoretical sources, the document from our literature review, and study results from at-risk women. Additionally, a multidisciplinary study group was designed to offer expert recommendations and pay applied and scienti c considerations in developing m-BCPBP.

Main Results
A model-based intervention resulting in the TIDieR intervention instruction and guide was designed in order to develop the m-BCPBP app framework (43). Combined concepts from three-model, including the ASSISTS model (53), self-regulation model (54), and self-control model (55), were applied to develop a theoretical framework on the mobile app's design. Our literature review created the most signi cant document applying 11 RCTs (69) to offer valued advice on the aspect, element, period, template, approaches, outcome events, communication, and function of the intervention. Additionally, our qualitative research among at-risk women creates on our earlier literature review (69) to explore the desires and favorites to develop a tailored intervention. The performance of a qualitative method to produce the user's viewpoints throughout intervention design is distinguished as a sound practice (65).
This user-centered strategy is tailor-prepared to the nal-user viewpoints because it can con rm that the mobile app is wanted and appropriate for nal-users (49) by choosing desirable content, technology template, user interface, communication, and function.
Themes and sub-themes that developed from qualitative research recommended that culturally tailored, woman-particular, multidimensional, and trustworthy contents are principally signi cant. Due to the existence of different cultures in Iran, it is essential to note making the content of the m-BCPBP app framework culturally sensitive by adjusting lifestyle and preventive information to the visible features of target users. This work consists and uses healthy habits and behaviors items acquainted and favored by Iranian women in a different language, accent, culture, customs, and habits. Users are likely to involve actively in the m-BCPBP app if they distinguish that the designed interventional program is related to improve their level of health about breast cancer prevention. Multidimensional contents offer the initial presentation to educational messages in the virtual learning setting to provide educational necessities.
Educational support will possibly encourage dynamic learning; furthermore, the general notion is that the users take control of their learning (70). The design structure should contain visual appeal, pictured styles, and collaborative multimedia. Multimedia structures can provide various learning methods (71,72). Information visualizing enhances the user's power to understand their improvement and control their preventive behaviors and lifestyle (73). Mobile app content should offer correct purposes and applied procedures to start modi cation in the target activities and behaviors (41).
Among a variety of technology templates, the m-BCPBP app framework provides the demand for general technology emerging from the current qualitative study due to its helpful and user-friendly style. The extensive use of smartphone technology, accompanied by the accessibility of useful mobile broadband links, suggests a different occasion to design a novel learning technique (74). Users can acquire information about a healthy lifestyle, self-care, stress management, tting physical activity, and controlling weight by applying short lms, cartoons, games, or tests (74,75). The smartphone app has increased acceptance among women due to its favorable characteristics, simple use, and multi-practical points. Moreover, smartphone apps suggest self-monitoring details, which may improve particular knowledge of preventive behaviors in consumers (34,35).
Regarding interaction, consumers favored resilient relationships to doctors and other health care experts via the providing of Web-based conversation and availability to the tailored expert recommendation.
Cloud calculating suggests resilient distribution ways among health environments to health care workers (59). Peer support is an essential component of the behavioral change programs, which lets consumers share their awareness, beliefs, attitudes, experiences, emotional, social, or applied for support with each other (30). Additionally, we require to update the device and the content of the smartphone app regularly to con rm that it is informed and reliable. Enhancing and keeping consumer employment stay a signi cant challenge. Therefore, performing approaches are essential to smartphone application plans. These approaches contain the comfort of usage, appealing design, feedback performance, ability to modify designs to suit a person's favorite, personalized data, and different smartphone structures (76).

Implications
We performed that a three phases method can be applied to design the m-BCPBP app framework for atrisk women about breast cancer. Findings are valuable to design and develop a culture-particular, multidimensional, and user-friendly smartphone application. The ubiquity of the smartphone app simpli es the distribution and sharing of data, cares a wide range of people, and lets the tailoring of data and support based on consumers' features and practices (77). The popularity of scienti c progress can identify a change concerning women empowerment within the self-care and preventive behaviors (36).
Women can get the m-BCPBP app at any time and anywhere. Therefore, the m-BCPBP app can advise assistance for women between consultation visits about breast cancer preventive behaviors, thus decreasing the number of outpatient hospital or clinic appointments (78).

Limitations
This is the rst study of its kind, where explored the viewpoints of at-risk women toward the design of a smartphone app intended to improve their self-care and preventive behaviors about breast cancer in women, who would nally be one of the end-users. However, recent research, like other research, has some limitations. First, the small, purposive, and local sample in one city of Kurdistan (Sanandaj) may limit the generalizability of our results. Second, though all women were living in urban regions, therefore this might not present a realistic depiction of the possible concerns associated with the mobile app that might be met by those living in rural regions. Third, the time to design a three-phase procedure is longlasting, and time delays may too happen due to the variable user-pro les and fast-paced technical progress. Fourth, smartphone app intervention design, counting time, expert workers, capability, tools, and training, is signi cantly resource-serious. Therefore, policymakers should note and study preparing information, nancial, emotional, expert workers, preserved time, legal, and logical support for app design.

Future Work
This project provides the performance of a 3-phase method as evidence of the e cacy of this method. We accommodated the viewpoint of the potential consumer with hypothetical source and document for m-BCPBP app framework design. Further research is required to achieve a beta test in the possibility of a study before RCT. In beta testing, we will assess the simplicity of screen navigation, technological di culties, perverse communication links, and typographical mistakes in numerous internet browsers.
Furthermore, we will perform a qualitative study to extract the consumers' experiences after RCT.
Further use and modi cation will support create a document about the acceptance, reliability, usability, availability, stability, and affordable of the m-BCPBP app. After m-BCPBP improvement, we will assess its e ciency is excellent and well-planned RCTs in varied backgrounds. Therefore, the m-BCPBP app framework is personalized as culturally related to mobile app for women to improve breast cancer preventive behaviors.

Conclusions
With the increase of smartphone devices, a range of mobile apps has been produced to provide training, learning, and support about health di culties. The current study attempts to expand the limited research by applying three methods, including literature review, applying the model and related theories as well as exploring the user perspectives about design the mobile app to enhance breast cancer preventive behavior by conducting qualitative research with a diverse pool of women. Theory, evidence, and user demands are essential in intervention design. The repetitive method lets the adding of nale-consumer feedback, models, and literature reviews to develop the content, template, and construction of the m-BCPBP app framework, which is personalized and tailored to the user's favorites. The present 3-phase developmental way is a valuable and bene cial pattern for investigators or app designers for future app design. Throughout the design of the m-BCPBP app, it is expected that women would be served appropriately with enhanced communication, which will conceivably change to more bene cial health outcomes and increased user satisfaction. From the women's viewpoint, the app will help a better perception and support in performing self-care and preventive behaviors about breast cancer to these populations.

Declarations
Ethics approval and participation consent Figure 1 Conceptual framework of m-BCPBP app.