Overview
A total of 19 elibble women aged 40 and over without breast cancer agreed to take part in the study. Table 3 shows a summary of the demographic characteristics of all 19 women.
Table 3: Characteristics of interview women (N=19).
Characteristics
|
N
|
%
|
Age, in years
|
|
|
|
40-45
|
10
|
52.63
|
|
46-50
|
5
|
26.32
|
|
≥ 50
|
4
|
21.05
|
Marital status
|
|
|
|
Married
|
14
|
73.68
|
|
Single
|
3
|
15.79
|
|
Divorced
|
2
|
10.53
|
Educational level
|
|
|
|
Primary
|
6
|
31.58
|
|
Secondary
|
2
|
10.53
|
|
Higher
|
11
|
57.89
|
Employment status
|
|
|
|
Employed
|
11
|
57.89
|
|
Unemployed or housewife
|
8
|
42.11
|
After a six-phase deductive analysis, and according to five main themes related to the app content, interactive performance, template, extended action and output, and motivational nature. These five themes offered the meaning of level proposing contextual visions into the progress of m-BCPBP. Summaries of the key themes, subthemes, and examples of meaning units are offered in Table 4.
Table 4: Key themes, subthemes, and examples of meaning units
Themes
|
Subthemes
|
Examples of meaning units
|
Content
|
Tailored to women
|
Whatever breast cancer prevention-related information I can seek from various sources including social networks or internet is generally recognized from anywhere in this world […] therefore breast health status, ways to control stress, cancer prevention . . . my stress level is very high. Moreover, my viewpoint on life has become very pessimistic. So I believe I should cater my health toward breast cancer and another type of diseases that threaten our health as mothers.
|
Multi-element
|
I am not aware of what range of physical activity I can have. Is the proper exercise several times? [...] How much physical activity per day or week should I perform that is suitable for my body?
|
Trustworthiness
|
In my opinion, if information regarding breast cancer prevention come from physicians, midwives, health care workers, or clinics, reliability is the first thing I would think, and the trustworthiness is now there
|
Goal Setting
|
I have heard that regular exercise and weight loss are effective in preventing breast cancer, but I am always lazy [...] I am not adept at self-care and regular physical activity; therefore, perhaps this goal setting in this new app can encourage me
|
Interactive performance
|
Mutual and flexible interaction with experts
|
I want some doctors and health care workers to offer expert recommendations on suitable healthy lifestyle, self-care like regular breast check-ups, and stress management. Therefore, smartphone-based consultation should be right useful and supportive of women
|
The decisive role and worth of peer support
|
is worthy of having our online conversations with friends and peers, and we can negotiate and argue our opinions or perhaps even acquire some data and assistance via online conversation meetings
|
Interactive software
|
I desire more pictures, cartoons, and charts. I think an online test is an amazing section. At first, I acquire the data; next, I just check whether I have realized it appropriately via tests
|
Relationship-creating
|
“Well, yes, that is right. As a woman, having this app on my cell phone allows me to communicate well [...] with my friends about their interest and efficiency in maintaining their health and self-care [...] Of course, that is not all [...] However, if the app is like that, it’s able to connect with all people who use this app. An opportunity to interact more with others in the virtual world.".
|
Template
|
Appealing and beautiful features
|
My first choice is a colorful format and shape, such as light color. I read on social media that the color pink is related to breast cancer, and the sign is a pink ribbon
|
Apparent and graphic aspects
|
I prefer more images and photographs for knowing my breast health condition.
|
Easy-to-use smartphone apps
|
In my view, I tried out some self-care and lifestyle apps such as Healthcare and Healthy Lifestyle Training Programs, Cancer Prevention Application, My Pillbox Software, Health Measurement Software. I found the smartphone is precisely useful, and downloading mobile apps is easy and comfortable.
|
App charge
|
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 a day. Consequently, it assists in reminding me when I require to use the diabetes drugs. My first experience with the mobile app was satisfactory until just because it's been practically 20 days; it declared my free trial version is finished. Thus, if you are designing for those who are economically weak, I believed that we should provide it for free. If we can run that [it would be worthy] due to 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 this
|
User-friendly
|
Personally, the essential issue for using mobile apps is user-friendly… due to the direct and straightforward way to find subjects. It is vital for me that the number of contents provided in the software be short that I can quickly go from the top of the page to the bottom of the page or the page before and after the software.
|
Privacy and security
|
Privacy subjects. Suppose we placed our information into the cloud, 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? […]
|
Notifications
|
Similar to something that appears on your mobile […] you are required to save and perform your behaviors. I believed that might be respectable. Or perhaps […] it has some variety of messages, rather than just words; it could arise like maybe [a] picture or perhaps […] similar to an audiovisual like somebody saying what they require the user to perform
|
Extended action and output
|
Self-care for personal aims setting
|
Having a mobile application helps me register my health condition data for the physician to see through the chart or the diagram to check how well I control the things to do past to the follow-up appointment so that the physician can appraise
|
Checking the Improvement
|
Hoping to have a fit weight, regular physical activity, healthy food, and breast check-ups, software or appliances [help] to control my progression and a proper automatic message reminds me
|
Systematic update
|
I would like to read the present study and see the newest breast check-up advice or recommended self-care and stress management regarding breast cancer prevention and behaviors.
|
Motivational nature
|
Ability to compete with other methods and apps
|
Seeing relatives’ use, I identify I have to run it. Therefore, it keeps you motivated to perform it
|
Features of app components to increase individual motivation
|
Virtual awards: I have a calorie counting and weight loss program on my mobile phone. With each calorie reduction, I am given a star. Although these awards and stars are not real, they give me a good and positive feeling [...] Earning stars was notable when I was doing it […] Be sure to consider virtual and attractive prizes to design your mobile app.
|
Concrete awards: I prefer the awards (i.e., symbols) 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 to below 1000, you acquire a free pool card or another thing, or cash is one of the most important motivators […] things like that, it will be exciting. Awards are significant, but only if you can sense and see them [...]
|
Inward commitment: Possibly, they require to be supplied that app, but finally, it is an inner thing. People are excited from the inner out.
|
Adding fun element
|
I would like a mobile app that has gaming factor... it is exhilarating for a specific link ... adding games in the educational app makes learning more comfortable and more appealing. I think it revives the inner child…
|
Theme 1: Content
Subtheme 1.1: Tailored to women
Almost all women believed that they would be extremely tempted to participate in the app-based interventional program if it offered them detailed breast cancer-preventive strategies. Some women stated their views as follows:
Some women desired breast cancer prevention in a specific healthy lifestyle. Some reported:
"I would like all delivered evidence to be preventive behavior-based; any recommended actions should be women's health-friendly […]" (Participant 9; age: 41; single; upper diploma; employed)
"We are women, so it is very different from the men […] thus; in my opinion, preventive information about breast cancer will be supportive only toward women." (Participant 7; age: 43; married; upper diploma; employed)
Subtheme 1.2: Multi-element Content
Furthermore, the women advised that multi-element content possesses a vital role in developing the content of intervention based on various educational requests and necessities. Intervention elements should significantly highlight suitable and regular exercises, healthy diet recommendations, regular breast check-ups, self-care, and stress management. Women’s favorite is explained in the following declarations:
“It is beneficial to regularly identify the methods for controlling daily stress, how many stresses, or what kinds of methods I can apply for controlling my stress.” (Participant 2; age: 40; single; upper diploma; employed)
“I do not distinguish what kind of method I can apply. What is the appropriate stress management method for various times?” (Participant 4; age: 44; married; upper diploma; employed)
“I am not aware of what range of physical activity I can have. Is the proper exercise several times? [...] How much physical activity per day or week should I perform that is suitable for my body?“ (Participant 11; age: 45; married; upper diploma; employed)
Subtheme 1.3: Trustworthiness
Women proposed the topic regarding the intervention’s trustworthiness. They sensed peace with attaining facts from trustworthy sources, such as their gynecologists, physicians, midwives, health care workers, or clinics, instead of from unreliable and unfamiliar sources about the source or organization of origin. Three women explained their experiences:
“Some cyberspace and social networks such as Telegram, WhatsApp, Instagram, Facebook, [...] do not afford correct information about breast cancer and its preventive behaviors, and I don’t believe them [...] I like information from trustworthy and reliable sources such as gynecologists, physicians, midwives, health care workers, or clinics that I can believe.” (Participant 11; age: 45; married; upper diploma; employed)
“In my opinion, if information regarding breast cancer prevention come from physicians, midwives, health care workers, or clinics, reliability is the first thing I would think, and the trustworthiness is now there.” (Participant 3; age: 51; married; under diploma; housewife)
“To have a healthy life, we need the right information about a healthy and cancer-free lifestyle from scientific sources like doctors [...] Despite the growth of new technologies, many websites and social networks have incorrect and unscientific information about breast cancer and its incurability [...] It's my responsibility as a woman to be able to get the right and correct information from scientific and accurate source.” (Participant 12; age: 47; married; upper diploma; employed)
Subtheme 1.4: Goal Setting
Besides tailoring and multi-element features for the app, many women wanted the goal-setting characteristic in the content of this app. They believed that goal setting, particularly small daily and weekly aims, could aid them in persuasion themselves and gradually modify their behaviors. Some women showed that goal setting would work well with immediate feedback and advance reports as well. Two women said:
"I have heard that regular exercise and weight loss are effective in preventing breast cancer, but I am always lazy [...] I am not adept at self-care and regular physical activity; therefore, perhaps this goal setting in this new app can encourage me [...]." (Participant 18; age: 45; married; upper diploma; employed)
"For me, the problem is to maintain the behaviors. I always have a good start for many behaviors, but I'm not a good follower [...] Perhaps at the start of the week, like you, I can ‘perform it' in the middle of the week, or even at the end of the week … I cannot keep it. For example, when I decide to skip sweets from my daily meals […] I'm very successful for a few days, but I can't go after that, especially if I'm going to a party with my friends." (Participant 16; age: 48; divorced; upper diploma; employed)
Theme 2: Interactive performance
Subtheme 2.1: Mutual and flexible interaction with experts
Women accepted that smartphone-based consultation is essential to deliver supportive information and recommendations regarding BCPBs. Additionally, women favor communicating with health care workers and doctors mutually and flexibly by various methods. Two women explained that:
“I want some doctors and health care workers to offer expert recommendations on suitable healthy lifestyle, self-care like regular breast check-ups, and stress management. Therefore, smartphone-based consultation should be right useful and supportive of women.” (Participant 8; age: 44; married; under diploma; housewife)
“I might be incapable of making a meeting with somebody due to traffic problems, and most of all because of my job problems and the responsibility of living and having a small child […] It’s easier for me to ask health care workers or doctors via telephone or social networks (for example WhatsApp, Emo, and Skype) if there are any errors and misinterpretations I can request explanations.” (Participant 12; age: 47; married; upper diploma; employed)
Subtheme 2.2: The crucial role and worth of friends' and peers' support
Women felt that intervention could offer expert support and highlighted the crucial role and worth of friends' and peers' support from online conversation meetings. Some women reported:
“It is worthy of having our online conversations with friends and peers, and we can negotiate and argue our opinions or perhaps even acquire some data and assistance via online conversation meetings." (Participant 6; age: 52; married; diploma; housewife)
“I would like online conversation and talking with other women and friends, and it can suggest recommendations for a healthy lifestyle and self-care toward breast cancer […] Objectively, I want comfort about my health status, and it means a lot to me with somebody’s support.” (Participant 4; age: 44; married; upper diploma; employed)
Subtheme 2.3: Relationship-creating
Some women sensed that by sending in-app announcements or a private text to the users to tell them again to perform their preventive behaviors and self-care, this could support nurturing an encouraging connection between the users and the educators or designers, with the users taking it as a symbol that the educator or expert pays particular attention to their health results.
"Well, yes, that is right. As a woman, having this app on my cell phone allows me to communicate well [...] with my friends about their interest and efficiency in maintaining their health and self-care [...] Of course, that is not all [...] However, if the app is like that, it’s able to connect with all people who use this app. An opportunity to interact more with others in the virtual world." (Participant 19; age: 56; married; under diploma; housewife)
Subtheme 2.4: Interactive software
The overall favorite of the women is the application of interactive software, including diagrams, pictures, online tests, short clips, and animation to make the mobile app extremely attractive. Some women mentioned that they seek the choice of utilizing various multimedia to take part in the intervention, as repeated in the following quotes:
“A short clip to advise the process of performing breast self-examination, health instructions, and the suggested self-care would be exciting and suitable.” (Participant 11; age: 45; married; upper diploma; employed)
“I desire more pictures, cartoons, and charts. I think an online test is an amazing section. At first, I acquire the data; next, I just check whether I have realized it appropriately via tests.” (Participant 7; age: 43; married; upper diploma; employed)
Theme 3: Template
Subtheme 3.1: Appealing and Beautiful feature
Almost all women said that the appealing and beautiful feature of the intervention is a critical factor in their application of the smartphone app. Therefore, design and templates in an exciting and beautiful style are necessary. In this case, two women explained:
“Beautiful style and colorful, as it can interest women to look at it […] consequently, it is easy to get noticed and simplify learning." (Participant 15; age: 50; married; under diploma; housewife)
“My first choice is a colorful format and shape, such as light color. 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-efficacy to understand their improvement and know their preventive behavior performance. One woman mentioned:
“I prefer more images and photographs for knowing my breast health condition.” (Participant 1; age: 41; married; upper diploma; employed)
" It's useful and valuable to display to me what the standard time of a breast check-up looks like since I need to know it." (Participant 4; age: 44; married; upper diploma; employed)
Subtheme 3.3: User-friendly and easy-to-use smartphone apps
Almost all women said that the use of a smartphone application is an excellent tool platform. The key benefits of applying smartphone applications are that they are convenient and useful to navigate and can be used any time and place. Women mentioned the following quotations:
“In my view, I tried out some self-care and lifestyle apps such as Healthcare and Healthy Lifestyle Training Programs, Cancer Prevention Application, My Pillbox Software, Health Measurement Software. I found that the smartphone is exactly useful, and downloading mobile apps is easy and comfortable […].” (Participant 2; age: 40; single; upper diploma; employed)
"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, all of which are aimed at improving our lifestyle.” (Participant 9; age: 41; single; upper diploma; employed)
Another woman said:
“Mobile applications are similar to a one-stop place for everybody, and I can access any place at any time. Mobile applications can deliver communication links that I could click on if I desired. For example, even if I'm traveling, I follow my healthy eating plan because I've installed diet and calorie-consuming software on my phone [...].” (Participant 7; age: 43; married; upper diploma; employed)
The women stated that the mobile app design should be appropriate, easy, and user-friendly. One woman mentioned that:
“The most important for an appropriate use of mobile-based training software is that it is user-friendly and that people enjoys working with it. User-friendly is important so that we can quickly enter, and catch desired information.” (Participant 10; age: 46; divorced; upper diploma; employed)
The other woman believed that:
“Personally, the most important issue for using mobile apps is to be user-friendly … due to the simple and direct way of finding subjects. The contents provided in the app must remain minimal. 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 3.4: App charges
Implementing the mobile application at a charge would be a due to many people's economic problems and their worse socioeconomic context. Thus, there was consensus that the mobile app should be free of charge. Women also thought that they would not buy the mobile app and run it for free if it intended more advertisements for the health care centers or clinics. Furthermore, it was advised that to conflict the matter of price, the app could be involved as one of the benefits of a link to health care centers or clinics. Women expressed 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 confirm 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 a day. Consequently, it assists in reminding me when I require to use the diabetes drugs. My first experience with the mobile app was satisfactory until just because it's been practically 20 days; it declared my free trial version is finished. Thus, if you are designing for those who are economically weak, I believed that we should provide it for free. If we can run that [it would be worthy] due to 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 this. (Participant 18; age: 45; married; upper diploma; employed)
Subtheme 3.5: Privacy and security
There were worries that the user's privacy may be hazarded, since users’ data kept in the cloud may be unprotected from hacking. Furthermore, there were worries about privacy locations and if 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 an ID, and users were given IDs specific to the clinic or health care center they visited. This would then prevent other clinics or health care centers from accessing information such as buying history from clinics or health care centers the users visited. One woman expressed her opinions as follows:
“Privacy subjects. Suppose we placed our information into the cloud; 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 3.6: Notifications
However, women desired to apply in-app notifications to deliver messages to users for the gathering of medical data; there were worries of women omitting the in-app notifications, assuming it was a small problem. Women used WhatsApp or Telegram, for example, and people got a lot of inappropriate notifications during the day. Instead, it was advised to transmit the message in either image or audiovisual form. Additionally, one woman advised a function that routinely dispatches reminders 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 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. Or perhaps […] it has some variety of messages, rather than just words; it could arise like maybe [a] picture or perhaps […] similar to an audiovisual like somebody saying what they require the user to perform […].” (Participant 16; age: 48; divorced; upper diploma; employed)
Theme 4: Extended action and output
Subtheme 4.1: Self-care for personal aims setting
The women reported that the nature of being a woman has challenges and various problems. Most of the women mentioned that they need educational programs regarding healthy lifestyles and self-care tailored to their needs and outlooks. A consensus showed that the program should keep operations that will allow self-care and checking. Two women expressed their opinions as follows:
“I am interested in making some charts for checking my health statuses, such as my daily physical activities, daily calorie consumption, regularly breast self-examination, meditation, and weight, which is helpful. I feel handy and comfortable if there is a comprehensive mobile-based software program for this evaluation.” (Participant 4; age: 44; married; upper diploma; employed)
“Having a mobile application helps me register my health condition data for the physician to see through the chart or the diagram to check how well I control the things to do past to the follow-up 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 self-examination, meditation, and weight. This finding matched other speeches from other women, as demonstrated by the quotations below:
"Having a mobile phone program is vital 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 through regular exercise, healthy eating, regular breast check-ups, etc. It is worthy if mobile software can contribute to my follow up.” (Participant 11; age: 45; married; upper diploma; employed)
“Hoping to have a fit weight, regular physical activity, healthy food, and breast check-ups, software or appliances [help] to control my progression and a proper automatic message reminds me.” (Participant 6; age: 52; married; diploma; housewife)
Subtheme 4.3: Systematic Update
Given the quick modification in information, systematic updating of the content of smartphone software is essential. Women demanded a regular update on the smartphone application as a part of the performance of the program. Two women mentioned:
“I would like to read the present study and see the newest breast check-up advice or recommended self-care and stress management regarding breast cancer prevention and behaviors.” (Participant 14; age: 48; married; upper diploma; employed)
“It will be worthy of tabloid update for 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 utilizing 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 in nature: it could be practical and encouraging for some people in specific settings, but it may be discouraging and rush in other conditions, particularly when people worry that they are behind their colleagues or relatives. Two women mentioned:
"Seeing relatives’ use, I identify I have to run it. Therefore, it keeps you motivated to perform it." (Participant 9; age: 41; single; upper diploma; employed)
“In my idea, it would be a mixture related to your plan. If you see someone use a mobile app for losing weight, they may motivate you or demotivate you. I believe that it just depends on where your plan and targets in your life are [...] I guess it is great on one side, but on the flip side, it could demotivate individuals who decided to get started on that.” (Participant 17; age: 42; married; under diploma; housewife)
Subtheme 5.2: Features of app components to increase individual motivation
Each app must have unique features and specifications to increase the individual motivation of consumers to use it more. This theme refers to three topics in its subcategory, including virtual awards, concrete awards, and inward commitment.
Different mobile apps give users virtual awards and symbols in which they could get or unlock ranks. By integrating rewards and incentives into the system, user interaction with the app will be sustained. These unspecified awards are aimed at motivating individuals by activating their competitive characteristics.
"I have a calorie counting and weight loss program on my mobile phone. With each calorie reduction, I am given a star. Although these awards and stars are not real, they give me a good and positive feeling [...] Earning stars was important when I was doing it [...] be sure to consider virtual and attractive prizes to design your mobile app." (Participant 13; age: 53; married; under diploma; housewife)
Although markers and stars, stages, and encouraging statements and notes from a mobile app offer concrete awards, some people want a visible one. A woman expressed her opinions as follows:
"I prefer the awards (i.e., symbols) 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 to below 1000, you acquire a free pool card or another thing, or cash is one of the most important motivators […] things like that, it will be exciting. Awards are significant, but only if you can sense and see them [...]" (Participant 7; age: 43; married; upper diploma; employed)
Inward 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 define whether they would proceed to do it for health behavior increase or behavior modification. One of the participants said:
“[…] Possibly, they require to be supplied that app, but finally, it is an inner thing. People are excited from the inner out.” (Participant 13; age: 53; married; under diploma; housewife)
Subtheme 5.3: Adding a fun element
Attaching a gaming factor or fun to a mobile app was exciting for a specific link of people. However, most of the women did not realize the game factor as 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 some women did not understand the entertainment features of a mobile app and identify it as something they are being trained in. One of the participants believed that:
"I would like a mobile app that has gaming factor or fun [...] it is exhilarating for a specific link [...] adding games in the educational apmakes learning more comfortable and more appealing. I think it revives the inner child […]" (Participant 11; age: 45; married; upper diploma; employed)
Integrating the three-step process (model, document, and user desires into intervention):
According to the outcomes from the literature review and qualitative study results with the target group, this section was organized into the three main categories, including content, components, and format/template of the m-BCPBP app that reflect findings from the three data sources. A detailed description of the app is reported in the following section. The user story box and mock-up screenshots of the m-BCPBP app are demonstrated in Figure 2. The drawings and logo depicted in Figure 2 are our own, and its explanation is accessible in Textbox 2.
1IThe m-BCPBP app content consists of multidimensional, culture-specific, self-care-related, and credible content with four sub-dimensions: educational, expert, and family/friends support and self-controlling/self-monitoring domains. The m-BCPBP app content focuses on understanding the risk factors of breast cancer, knowing the symptoms of breast cancer, positive attitudes toward preventive behaviors, receiving support, receiving motivational advice, seeking correct information, and improving self-efficacy and self-care. It is a user-friendly and interactive app that helps users monitor and track their lifestyle behaviors. Desired behaviors in the m-BCPBP app include regular breast check-ups, suitable physical activity, weight control, healthy diet recommendations, and stress management that is offered in eight weeks, as presented in Textbox 2.
1. Educational support: Educational support aims to motivate women and users by determining and knowing the importance of changing their lifestyle (e.g., healthy diet, regular physical activity, having a fit weight) and improving their self-care (e.g., regular breast check-ups) to keep their breasts healthy (Figure 2, Textbox 2).
2. Family and friends support: Family and friends support aims to mediate the interaction of women with one another using a pseudonym via online peer-to-peer interactions, which are used to mobilize and increase combined knowledge and attitudes (49). (Figure 2, Textbox 2).
3. Expert support: Expert support aims to reach adherence and improve self-care and healthy lifestyle knowledge of breast cancer prevention through simultaneous and non-synchronous feedback (130). (Figure 2, Textbox 2).
4. Self-monitoring/Self-care: Self-monitoring and self-controlling aim to encourage women to self-regulate and self-care their lifestyle behavior and stress management according to their intentions and strengthen any modifications. If the outcome is below or above the range, the system gives notifications and announcements through the m-BCPBP app (Figure 2, Textbox 2).
II. The m-BCPBP components:
a. Framework/format of m-BCPBP:
A multidisciplinary study group composed of a computer software professional, an expert mobile app designer, two health education and promotion experts, a dietician, content design experts, and a gynecologist was established to design the m-BCPBP app framework. The m-BCPBP app framework aims to improve BCPBs in obese or overweight women 40 years and older. To develop an automated smartphone app with a user-friendly connection line, m-BCPBP’s user connection line, framework, and components were developed by a computer technician and a trained mobile app designer. 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 (sister and mother’s history with breast cancer, as well as a history of developing cancer [breast, ovarian, and prostate] in first-degree relatives). A visual graphing function was also designed to let the user configure their behaviors, such as physical activity, diet, daily stress, and breast self-examination during the use of the m-BCPBP app. Real-time feedback and automatic notifications were also established in the m-BCPBP app. In terms of format, the m-BCPBP app is an interactive multimedia mobile application, including pictures, animations, short videos about the signs and symptoms of breast cancer, prevention and screening methods, the correct way to perform breast self-examination, external links to reliable sources, and customizable features for the user to change the interface color. In terms of security, the m-BCPBP app also has password protection to ensure online security and a user portal via a privacy-compliant shared record platform. After launching the m-BCPBP app, the user was directed to a screen where they entered their username and password. After authentication, the user was presented with the functional components of the application in a tab-accessible format.
b. The m-BCPBP app evaluation:
1. Evaluating the usability of the designed application:
Field testing and validation of the app were conducted during the initial phase of development by collecting informal user reviews from 20 women who were referred to health care centers affiliated with Kurdistan University of Medical Sciences. After the final launch of the m-BCPBP app, 30 women over 40 years old who were referred to Sanandaj health centers were invited via a convenience sampling method to use the app. First, the m-BCPBP app was installed on the mobile phones of the selected samples. After two weeks of continuous use of the m-BCPBP app, the participants' opinions about the usability of the m-BCPBP app were evaluated using the standard questionnaire of usability and user satisfaction assessment (QUIS) (131). QUIS is a 30-item questionnaire translated from the original English version into Farsi, which was then validated to assess the usability of a mobile app (132). The QUIS questionnaire has 30 questions and is designed in six parts: the first part is related to identity information of the person completing the questionnaire (three questions), the second part is related to the general application of the program (six questions), the third part is related to display capabilities (four questions), the fourth part is related to the terms and information of the program (six questions), the fifth part is related to the learning capabilities of the program (six questions), and the sixth part is related to the general capabilities of the program (five questions). This questionnaire is designed based on a ten-point Likert scale in which each question has an answer with a zero score. The zero score is classified as three weak levels, 1.3 to 6 at the intermediate level, and 1.6 to 9 at the good level. The internal consistency (alpha=.94) and interrater reliability (.76) for QUIS are acceptable (133, 134).
2. Outcome evaluation of the m-BCPBP app:
Considering that one of the theoretical frameworks in designing the content of the m-BCPBP app was the ASSISTS model (109). Therefore, to evaluate the outcome of the m-BCPBP app, the section about online exams is designed based on the ASSISTS scale. The ASSISTS scale consists of a 33-item self-report scale. Items in the ASSISTS scale map seven constructs: attitude (8 items), efficacy (3 items), stimulation (3 items), supportive systems (5 items), information seeking (4 items), self-care (7 items), and stress management (3 items). The ASSISTS scale has proved to be reliable and valid in the past, with ethnically diverse Iranian women. All items on the ASSISTS scale are rated on a five-point scale, ranging from 1 = never to 5 = always. Possible scores ranged from 33 to 165. Higher item scores are indicative of more encouraging preventive behaviors toward breast cancer. In the present sample (n=140), the Cronbach's alpha coefficient for the ASSISTS scale was found to be acceptable (alpha = 0.79), and the Intraclass Correlation Coefficient (ICC) was satisfactory (0.86) (135).
III. Template/platform of the m-BCPBP app:
The m-BCPBP app can be preinstalled on phones and delivered as a web app that can be performed on PCs, tablets, or phone devices via public web browsers and operating systems.
a. User interface:
Due to the nature of the m-BCPBP app, which had a complex user interface, our main goal was to attract users who used their favorite operating system. Whether iOS or Android, we used the Cross-Platform Mobile Applications with React Native framework to build the m-BCPBP app. The m-BCPBP app is a user-friendly app that can be delivered as a web app to provide colorful online features, such as social networking and tracking within a web browser. The software program was used in multiple mobile platforms, such as Android and iOS (iPad and iPhone). In other words, the m-BCPBP app is a responsive web app that can be used on personal computers, tablets, or smartphone devices through common web browsers and operating systems.
b. Interactivity/Social Communication:
The m-BCPBP app allows users to connect to web-based social media platforms and has a built-in chat feature so that the users can share their experiences and advice, which positively impacts users’ preventive behavior (136). Users can utilize the built-in social network feature for interaction with other users, share their experiences, and offer valuable information and support. Furthermore, this allows users to become familiar with each other and then outlook each other’s improvement, conversation and post photos, and share them on numerous social media platforms, for example, WhatsApp and Telegram. This real-time communication allows users to get answers to several queries immediately, and users can respond to questions by chatting with each other. The decision to comprise this feature was based on usability examination and users’ suggestions to design the chat interface to be like other extensively used messenger apps, such as WhatsApp. Users can communicate through email, Short Message Service (SMS), and/or telephone for individual consultation from experts if required. Additionally, messages tailored to the user's favorites are displayed in the m-BCPBP app and sent via SMS.
Textbox 2: The m-BCPBP app explanation:
- Technology platform: The m-BCPBP app can be preinstalled on phones and delivered as a Web app that can be performed on PCs, tablets, or phone devices via public Web browsers and operating systems.
- User interface: online colorful features and user-friendly
- Content: multidimensional with four sub-dimension.
The first dimension: Educational support
- Content
- Content is developed from the Iranian Ministry of Health and Medical Education medical guidelines, documents, experts, behavior change models, and cognitive theories.
- Related information and content are continually updated to keep the user's attention and enthusiasm.
- Smartphone app is combined with in-person contact via phone session, short message services (SMS), and social media (WhatsApp, Telegram).
- Breast cancer prevention behaviors
- Regular physical activity such as walking, swimming, and yoga
- Eating a healthy diet includes a combination of fruits, vegetables, protein and an emphasis on reducing fat intake.
- Appling relaxation and stress reduction techniques such as meditation, light music, deep breathing, light yoga, imagination, self-massage, and religious techniques such as worship and prayer.
- Performing breast self-examination and knowledge of other screening methods such as clinical breast examination and mammography.
- Healthy lifestyle behaviors considering both the Islamic-Iranian social and cultural norms
- Appropriated weight gain.
- Healthy diet plan based on Islamic-Iranian styles.
- Introducing varieties of healthy local food tailored to the Iranian culture, their ingredients needed, their providing in an easy way.
- Responsibility for health, interpersonal relationships, and interaction with other peers.
- Physical exercise advised by the m-BCPBP app matches the social and cultural norms of Iranian and Kurdish users’ physical status.
- Format and security
- Interactive multimedia mobile application, including pictures, animations, and short video about the signs and symptoms of breast cancer, prevention and screening methods, and the correct way to perform breast self-examination, online exams based on ASSISTS scale.
- Outward links to reliable, accurate, and reputable sources.
- Adjustable items for the user to control settings and personalize the m-BCPBP app through setup depending on what satisfied them Such as changing colors and themes.
- Users’ consent after creating an account and before actually using the m-BCPBP app to access users’ information.
- A comprehensive privacy policy with describing the purposes of study, permissions in simple Farsi language.
- Creating a user profile to input basic information such as their name and email address and to select a password.
- Password-protected to guarantee online security
- User portal through a shared recording template proportionate with privacy.
The second dimension: Family and friends support
- Content
- Provide a panel for the women to discuss with family members, friends, or one another.
- Interactivity/Social Communication:
- Online peer-focused panel for participating and support.
- Users can apply the built-in social network feature to interact with other women, giving their experiences, and contribute helpful advice and support.
- User can observe how other women answered the survey topics about preventive behaviors toward breast cancer and self-monitoring.
- User can read posts by other women; furthermore, they can take part to reply in the online panel.
- Using an alias via online peer-to-peer communications, which are utilized to motivate and rise shared awareness and attitudes toward breast cancer preventive behaviors.
- User can share their activities with others in the built-in chat platform which will positively influence users’ preventive behavior.
- The m-BCPBP app gives an online platform particularly for the app’s users, which enables them to share knowledge, support, and motivate one another.
The third dimension: Expert support
- Content
- Feedback from health care experts (health education and promotion experts, gynecologist, dietician, and nurse) will promote the agreement and awareness about self-care and healthy lifestyle knowledge.
- Interactivity/Social Communication:
- Online consultation panel for group discussion with users.
- Users can communicate through email, SMS, and/or telephone for individual consultation from experts if required.
- Content-related issues are handled and resolved quickly, and users' questions will be responded appropriately.
The fourth dimension: Self-monitoring/Self-controlling/Self-care
- Individualized goal setting
- Regular exercise: All kinds of favorite sports for the user, provided that they involve in 30 min of moderate to intensive physical activity at least 5 days per week.
- Healthy diet: promoting or preserving the quality of foods through the use of all five groups of food pyramid according to body kcal/day necessities by focusing on low consumption of sweets and fats, and more consumption of vegetables and fruits.
- Weight: Due to the negative role of obesity in increasing the risk of breast cancer, especially in women over 40 years old - Following the Medical Institute- Recommended to lose weight and control it regularly.
- Reduce Stress and Achieve Emotional Balance: Exercise regularly, keep a positive attitude, let go of negatives, find ways to relax, develop new interests, get enough rest and sleep, eat healthily. These recommended ways reduce stress, improves mood, and boosts overall health and sleep better.
- Regular breast check-up: Following Iran's Health Ministry-recommended regular breast check-up. Breast cancer screening services are now running. Regular breast screening is beneficial in identifying breast cancer early. The earlier the condition is found, the better the chances of surviving it.
2- Functionality:
- Users regulate tailored behavioral goals, success in the goal causes positive congratulatory feedback to be displayed on the screen. Make a list of personalized goals in the form of a weekly action plan, and then document the target content;
- Offer visual tools, such as graphic progress chart and breast self-examination colorful image–assisted breast health counseling or evaluation. Present colorful diagram physical activity, or nutritional advice with appropriate color images.;
- The announcement, follow up, and notification regarding all target behaviors;
- Messages tailored to the user's favorites are displayed in the m-BCPBP and sent via SMS;
- Continually updating the m-BCPBP with new content.