Understanding the Multilevel Factors Influencing the Implementation of Mindfulness-based Mobile Applications in Adolescents and Young Adult (AYA) Cancer Survivorship Care

doi:10.21203/rs.3.rs-3571508/v1

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Research Article

Understanding the Multilevel Factors Influencing the Implementation of Mindfulness-based Mobile Applications in Adolescents and Young Adult (AYA) Cancer Survivorship Care

https://doi.org/10.21203/rs.3.rs-3571508/v1

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Background

A growing body of evidence supports the efficacy of a range of mind-body therapies in alleviating psychosocial stress and other symptoms in cancer patients and survivors. Healthcare providers can leverage the convenience and appeal of technology to deliver psychosocial interventions for AYA cancer survivors. The goal of this study was to identify key patient-, provider-, and organization-level barriers and facilitators to implementing evidence-based mindfulness mobile applications for AYAs with cancer.

Methods

Twenty semi-structured interviews were conducted with stakeholders including AYA survivors (n = 10) and clinical providers and administrators (n = 10). Interviews were transcribed and deductively mapped using the CFIR and TDF complementary frameworks.

Results

Results indicated that factors like cost and patients’ needs and resources were prevalent among both survivors and providers. There were key differences between providers and AYA survivors. Providers’ adoption and promotion of mindfulness mobile applications were influenced most strongly by contextual factors. That is, providers described available resources (Inner Setting), culture (Outer Setting), and networks and communications (Outer Setting) as important factors in their adoption. On the other hand, survivors emphasized individual and intervention-related factors; they reported that social influence and knowledge influenced their adoption of meditation apps.

Conclusions

These results identified barriers and facilitators to the adoption of mindfulness mobile interventions from multiple stakeholders. Results can be used to guide the development of implementation strategies to improve the uptake of evidence-based mindfulness interventions in care, ultimately improving the psychosocial well-being of AYA cancer survivors.

Psycho-Oncology

Adolescents and Young Adults

Cancer Survivorship

Digital Health/mHealth

Adolescent and young adult (AYA) survivors of childhood cancer are recognized as a vulnerable group with unique emotional, social, and practical needs due to the intersection of cancer survivorship and normal developmental processes (1). While the developmental transition can become overwhelming and stressful in and of itself, managing cancer survivorship care during this time can be extremely difficult (2). Studies suggest that AYA survivors of childhood cancer are at increased risk of poor mental health compared to non-cancer peers (3). While 20–25% of AYA survivors of childhood cancer report experiencing impaired mental health (4, 5), many more experience subclinical levels of distress potentially impacting their daily functioning. However, most AYA cancer survivors do not receive formal psychological treatment (6, 7), suggesting that alternative interventions are needed to reach and support more survivors.

Complementary and Alternative Medicine (CAM) such as meditation and other mindfulness modalities have become increasingly popular (8) and have shown efficacy in improving psychological distress among cancer patients (9). Although participating in meditation for anxiety and stress reduction is recommended by the Society of Integrative Oncology Clinical Practice Guidelines (10), many cancer patients have reported barriers to the uptake of these practices. For example, adult patients found traveling to attend face-to-face sessions burdensome when enrolled in a class or intervention study (11). Even when delivered virtually or remotely (e.g., via Zoom), there are other barriers to attending mindfulness practice sessions: 1) virtual weekly attendance may not fit participants’ schedule; 2) meditation programs can be very time intensive (e.g., 90-min sessions, 8–12 weeks long); and 3) they could be costly if not covered by insurance (12). Thus, alternative methods to deliver mindfulness interventions are needed.

Most AYA cancer survivors own a mobile phone, regularly use mobile apps, and are interested in accessing supportive care information via mobile apps (13, 14). Unlike traditional mindfulness interventions, mobile app interventions can be short (e.g., 10 minutes a day), with daily practice, and goals adjusted to fit one’s schedule (15). Mobile apps have been demonstrated to be an effective delivery medium for mindfulness training (15), and these apps have demonstrated efficacy in improving mental health outcomes across the general and cancer populations (15–18).

Evidenced-based mindfulness mobile apps have been demonstrated to be a good alternative to address AYA cancer survivors’ unmet psychosocial needs (19). Providers can provide support by leveraging the convenience (e.g., making simple recommendations/referrals) and appeal of technology (e.g., AYA as “digital natives” (20)). However, it is difficult to translate and implement research-based interventions into actual clinical practice (21). There is a gap in identifying acceptable implementation strategies, and the goal of this study is to identify potential barriers and facilitators to implementing evidence-based mindfulness mobile app interventions in AYA survivorship care. Results will guide the development of implementation strategies to improve the uptake of evidence-based mindfulness interventions in practice, ultimately improving the psychosocial well-being of AYA cancer survivors (22).

Theoretical approach

A multiple complementary framework approach was employed in this study. The Consolidated Framework for Implementation Research (CFIR) and Theoretical Domains Framework (TDF) are both well-operationalized, multi-level, theory-driven implementation determinant frameworks (23). Birken and colleagues have extensively described the similarities between the CFIR and the TDF in terms of purpose, level, degree of theoretical heritage, and operationalizability (23). For this study, the rationale behind using two complementary frameworks is, while CFIR (24) includes five main domains: intervention characteristics (e.g., adaptability), outer setting (e.g., patient needs and resources), inner setting (e.g., culture), process (e.g., planning), and characteristics of individuals (e.g., self-efficacy; focuses on individual-level constructs), TDF (25, 26) provides an additional focus on individual-level behavior change factors (i.e., Capability – Knowledge, Motivation – Reinforcement, Opportunity – Social Influences). Stakeholders, especially AYA cancer survivors, are expected to focus more on individual-level factors as they are more relevant to them. Lastly, both CFIR and TDF have been applied as determinant frameworks to a variety of studies exploring barriers and facilitators of intervention adoption including identifying determinants of successful implementation of evidence-based practices in public health agencies (27) and engaging pregnant women in smoking cessation (28). Together, these frameworks provided a multilevel perspective to understand these important factors for implementation.

Sampling and setting

A combination of convenience and snowball sampling strategy was used to select participants. Ten (n = 10) AYA cancer survivors were referred from a previous meditation mobile app study within a local cancer survivorship clinic. We decided to recruit participants from another meditation mobile app study because we were interested in learning from survivors who have experience with meditation mobile apps. Inclusion/exclusion criteria include: 1) Current age 18–29 years; 2) No documented or self-reported cognitive impairment that would prevent completion of the interview; 3) English speaking; and 4) Owns a mobile phone. For clinical providers and administrators, the research team generated a preliminary list of potential stakeholders through the team’s professional network. Participants would also give referrals/suggestions. A total of 10 potential participants were recruited for the study. Inclusion/exclusion criteria include: 1) Fulltime healthcare worker and 2) Currently working or have worked with AYA cancer survivors in a professional capacity.

All potential participants were sent an introductory email, outlining the purpose of the study and inviting their participation. Participants who expressed interest were scheduled for an interview, which was conducted via Zoom.

Data collection and analysis

Perspectives of key informants were sought via semi-structured interviews. The semi-structured interview guide was adapted from previous research by Hwang and colleagues designed to understand multilevel determinants of clinicians’ decision-making on adopting imaging for prostate cancer (29). The interview questions were open-ended to elicit implementation strategies by identifying relevant factors within the CFIR + TDF frameworks (see Theoretical approach). In addition, Wienert and Zeeb’s (30) CFIR’s construct definitions were adapted to better reflect digital health app-focused implementation factors.

Interviews were audio recorded and transcribed verbatim. A total of three team members conducted and analyzed data. First, the transcripts were independently read and coded using content analysis (31, 32); content analysis is frequently used by health researchers to interpret interview data (33). The coding process itself involved interpreting and assigning interview responses into the coding schema and they would be deductively mapped onto the CFIR + TDF frameworks. The coders would then meet to discuss and reconcile any discrepancies in the mapped codes. Additional inductive coding was done to identify other relevant factors outside of the current frameworks, which could potentially inform future implementation strategy development.

Ethics and Governance

This study received ethical approval from the Rutgers Biomedical and Health Sciences Institutional Review Board (IRB# Pro2021001403). Informed consent to participation was obtained from all participants. Anonymity was protected using generic descriptors throughout and redacted identifiable information when necessary.

Fifty percent of the AYA survivors and 90% of the providers/administrators are females. A variety of clinical and administration positions were recruited including n = 3 oncologists, n = 2 registered nurses, n = 3 psychosocial providers, and n = 2 others (i.e., administrator in patient experience and child life specialist). The overarching question posed to providers addressed facilitators and barriers they might encounter related to promoting meditation apps in the clinical setting (i.e., survivorship care). Survivors were asked questions regarding what factors may influence their adoption and use of mindfulness-based mobile apps. Table 1 presents the frequency of factors/themes that emerged for providers and patients. Patient Needs and Resources (Outer Setting), Cost (Intervention Characteristics), Evidence Strength and Quality (Intervention Characteristics), and Reinforcement (Motivation) emerged as the factors most frequently endorsed by the two groups. Several notable differences emerged. While providers reported greater importance of Available Resources (Inner Setting), Culture (Inner Setting), and Networks and Communications (Inner Setting), survivors emphasized the importance of Social Influences (Opportunities).

Table 1

Frequency of Factors Mentioned by Providers and Patients (N = 20)
Factor	Provider (n = 10)	n	Factor	Patient (n = 10)	n
Outer	Patient Needs & Resources	10	Outer	Patient Needs & Resources	10
Intervention	Cost	10	Intervention	Cost	10
Intervention	Evidence Strength & Quality	9	Opportunity	Social Influences	10
Inner	Available Resources	9	Intervention	Evidence Strength & Quality	8
Motivation	Reinforcement	8	Intervention	Adaptability	7
Outer	Culture	8	Motivation	Reinforcement	7
Inner	Networks & Communications	7	Capability	Knowledge	6

[Insert Table 1]

Providers

As part of the Outer Setting domain of the CFIR framework, all 10 providers discussed at length patient stressors and needs as well as the lack of easily accessible mental health resources for cancer patients and survivors (Patient Needs and Resources). For example, Provider 1 said “We’ve seen an increase in depression and anxiety related to things going on in the world complicated by the survivorship issues, particularly if there are long-term late effects that people are also coping with”, adding, “We are in a mental health provider crisis, particularly for young adults, and particularly for young adults who do not have a lot of money to pay out of pocket… Once people are in survivorship, it becomes much more difficult to access those services” (see Table 2).

Table 2

Selected Themes Mapped on the CFIR + TDF Frameworks (N = 20)
Framework	Domain	Construct	Definition	Illustrative Quotes - Providers	Illustrative Quotes - Patients
CFIR	Outer Setting	Patient Needs and Resources	Consideration of the needs and resources of the app's target group (e.g., perceived vulnerability, literacy, language, … availability of hardware, network connection)	“[There is] Anxiety around treatment, anxiety around … what the life looks like now. ... missing out on school because you’re in treatment all the time. Not being able to see your friends; those are really big factors that impact mental health.” (Provider 1) "Finances certainly are big. Not having money and insurance. Some of our young adults don't have family or are not documented. So they have no insurance. They're working menial labor jobs." (Provider 8)	“I think … [my] PTSD is coming from the diagnosis, or an event similar to the cancer experience. … and certain thoughts and fears are…, oh my God, what if this lump is coming back … There’s always this thought like relapse and it’s a very common thought. It’s a very common fear.” (Patient 1)
CFIR	Inner Setting	Networks and Communication	High social capital within a team, i.e. dimensions of shared vision and information sharing, can contribute to effective implementation through a sense of "team spirit" or "community".	"You're in a team environment in our clinic; you have the patient care associates and the PCs and the regular nurses and nurse practitioners, and we all act together to get the patient through their visit." (Provider 4)	n/a
CFIR	Inner Setting	Culture	Norms and values, or a mindset and culture of an app provider.	"We ultimately all have the same goal for these kids is to help them as much as we can during their treatment." (Provider 9)	n/a
TDF	Opportunity	Social Influences	Those interpersonal processes that can cause an individual to change their thoughts, feelings, or behaviors	n/a	“If my provider, my medical professional thinks that it’s best the interest for me to do it, I definitely would give it a try.” (Patient 9) “Coming from the hospital is like a plus. I think for me that would be enough.” (Patient 6)
CFIR	Characteristics of Individuals	Knowledge and Beliefs about the Intervention*	Perception of a credible external presentation of the app, as well as knowledge of the users how to handle it.	n/a	"I think definitely mindfulness and meditation is helpful. It helps to track harmful thoughts and anxiety" (Patient 1) "If I was being diagnosed today, I think having a meditation app is probably good. … I think meditation should be a part of it [the treatment plan]." (Patient 4) "Mindfulness is a lot about kind of like reconnecting with your body and managing how you feel by being aware of like seeing in the moment and controlling how certain things affect you. 'Cause usually a lot of stuff is out of your control. So it's helping out with like realizing when you can and when you can't really control something. And then working to release whatever physical reactions you're getting." (Patient 5)
TDF	Motivation	Reinforcement	Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus	n/a	"Just having an article that lists Okay, you should do this, you should read for like five seconds, you should do this next, that's very boring. It's very monotonous, ... but if there is a video or even a live person speaking...." (Patient 1)
CFIR	Intervention Characteristics	Cost	Costs of the app and costs related to the implementation of this app, including investment, supply and opportunity costs. Costs should be in relation to the expected benefits, both for the user and the developer.	"Money is often an issue and I don't want to burden the kids or the families." (Provider 6)	"I think cost is the biggest one [factor]." (Patient 7) "Just thinking about my medical bills before, even in the future, or if this were to happen again. Am I gonna be able to afford that?" (Patient 9)
CFIR	Intervention Characteristics	Evidence Strength and Quality	Description of the current status of previous, scientific findings on the quality and validity of the app.	“There's the problem with the mobile apps as there's a million of them right. You have to have one that's been vetted.” (Provider 4). "Just be very concrete: This is what the scientific research is and the data that supports it, and that it truly can help, what parts do we not know for sure if it's helping or not, and just being very kind of scientific about it." (Provider 5)	If it really helps you, helps your mental state, then I’d be willing to pay however much because it's actually helpful.” (Patient 10) “I would say that I’d be more encouraged to use it if I could see some evidence behind it.” (Patient 2)
CFIR	Intervention Characteristics	Adaptability	Description of the extent to which core components of an app can be adapted, tailored, refined or newly developed to individual or local needs.	n/a	"I do like whenever they explain the logic behind like why it works in a way we kind of understand, why are you doing what you're doing." (Patient 5) "The only thing I wish that some of the meditation sessions would be shorter towards the end. ... I'm fidgety, my mind just wanders all the time. ... I guess shorter bites of meditation will be better." (Patient 7)
CFIR	Process	Planning Engaging	Apps should be implemented according to plan. & Attracting and involving appropriate people in the implementation and use of the app through a combined strategy of social marketing, education, role modelling, training and other similar activities.	"I think there needs to be an introduction, or like a class or tutorials about what meditation is, what mindfulness is, what it's not. ... We have regular meetings before we start our clinic, a huddle, where they go through what everyone is doing. So maybe if everyone else is talking about it [app], and you're the only one not doing it, you know, maybe you'll try it too." (Provider 4)	n/a
Combined with Knowledge* in TDF

Cost, part of CFIR’s Intervention domain, seems to overlap some of these concerns. For example, the cost associated with mental health care was another prominent topic mentioned by all ten providers. There was a shared understanding that for a mental health app to be useful to patients, it needs to be freely available to them (e.g., Providers 6 and 8). Another intervention-related factor discussed was Evidence Strength and Quality; providers discussed the need for evidence-based research on the validity of mental health apps. Some providers expressed skepticism regarding the evidence of mindfulness apps: “Most people don't understand it, and physicians are going to be the exact same way. They're [physicians] going to have their preconceived biases and think it's about being like some hippie in the woods” (Provider 6). Furthermore, they note the importance of making evidence-based literature available to them: “There're articles in the medical journals that are about it… send in that kind of stuff to them [physicians] from time to time reminding them that we have the [mindfulness app] study that's available. Because often patients will take what the physician says as more relevant than what other people might say” (Provider 6 about physicians). Several providers stressed the importance of utilizing a “vetted” mindfulness app: “Meditation has a lot of solid research attached to it. Now it's more acceptable. They’re really gonna have to show it's evidence-based because they do not want to be associated with [lack of evidence], which is how most of what my mind body stuff is today” (Provider 1). In general, providers are receptive to learning about new evidence; Provider 10 discussed, “I would be happy to hear about the evidence behind a meditation app if there was ‘showcasing the evidence behind mindfulness is vital in its promotion…’ to really show that [it works is to say], look, this is the data, these are the trials, this is what people have studied, this is the outcomes. Because that at the end of the day is where we make most of our decisions. It's utilizing evidence-based medicine” (Provider 5).

As part of the Inner Setting domain (CFIR), providers strongly voiced the need for a supportive leadership and company culture (Structural Characteristics and Culture), open communication among the care team (Networks and Communications), and education about the implementation of such an app (Readiness for Implementation). For example, Provider 9 praised the formal and informal communication within the department (Networks & Communication): “We meet weekly to talk about our patients to see if anybody has any concerns and it’s a good way to sort of just make sure that we’re all on the same page.” Provider 8 also highlighted the importance of communication among care team members: “Because this is such a team approach that we do that even if it's a family that I resolve everything [with]… it's still something that I'm going to share with the rest of the team so that the next time they come in that they can be involved and be a support.”

Available Resources (Inner Setting) are another key element in the care and support of survivors: “We give that passport for care, with all their instruction sheets of all the potential late effects that can happen. There are things on mental health and post-traumatic stress there. I call it their ‘encyclopedia for health…’ And just leaving the door open, knowing that they can always call the social workers or the psychologist, and if they need assistance or things aren't working or going in the way they think and they need to come talk to somebody, the doors are open here” (Provider 3). Provider 4 shared “We have a lot of resources in this cancer institute. We have a licensed social worker for counseling onsite. We have a licensed psychologist. We have access to a young adult psychiatrist where we can prescribe medications” which further highlighted the strength of resources dedicated to the implementation and ongoing care of survivors.

Further, providers noted that the promotion of the app needs to be reinforced (Reinforcement in TDF) among the care team to help staff stay aware and informed of any changes and updates. Provider 1 pointed to the advantage of mental health apps as they are easily accessible, “even if they’re [patients] not with us,” however, cautioned that these services must be provided by “people who understand the impact of cancer on survivorship” which again spoke the direct relationship with the Evidence Strength and Quality of the app (Intervention Characteristic).

One cannot assume that mindfulness is a known entity even among healthcare providers. The authors noted that education is a crucial element in successfully implementing the broad application of mindfulness apps within the hospital system. The entire care team including physicians, nurses, and staff should be part of educational efforts to seamlessly introduce the app and to speak with ‘one voice’ when promoting the app to cancer patients (Provider 4). Provider 6 shared: “It is important for providers that not all of them [patients] necessarily are going to use it. They’re [patients] also going to have some misconceptions about meditation and mindfulness. Giving them some of the neuroscience behind it and the brain research that is done about it and giving them more of the hard facts as opposed to oh it's really helpful.” In sum, promoting and implementing an app hospital-wide would surely require education integrated with the Process domain as outlined in the CFIR framework. This highlights providers’ goal of “…teach[ing] our patients they have to advocate for their own health with their own healthcare providers. That's what we try and do… we're trying to do is to make them independent and taking care of their own health needs” (Provider 4).

[Insert Table 2]

Patients

Like providers, all (n = 10) AYA survivors expressed the relevance of stressors and needs, sometimes years and decades after treatment (Patient Needs and Resources). Patient 8: “My biggest hurdle was… learning different coping mechanisms to deal with PTSD, experiencing flashbacks, dealing with hospital settings and things of that nature. I think all of that really affects you going forward and trying to get back to whatever your life will shape out to be when you’re done.” This is underscored by Patient 1 who shared that they are still “dealing with complications from late effects… even like 15 years after completed treatment because of my leukemia and side effects as a result.”

Cost is a consensus concern and survivors were cautious about their choices. Patient 7: “I think costs are the biggest one, time and for me personally depending on whether it's an app or [in]person location… I have little vision and I’m unable to drive, getting to some places is very either hard or expensive.” Free trials could be enticing and allow survivors to use the app without commitment; Patient 10 mentioned: “I feel like the best situation would be you kind of get a test trial. See what the app is like, and then go from there.” Aligned with Patient 9, survivors want to know if it does work before making any further commitment, which reflects the importance of Evidence Strength and Quality; Patient 1 suggested: “For me, it will be nice to see empirical evidence. Let's say this app out in the market is tailored just for survivors. If there is some research that let's say improves the mood of these patients or these survivors by, I don't know, about 12% or 20% versus prior to using the app, that might pique my interest a little bit more.” Patient 3 raised the rating aspect of apps: “I try to read all the comments to see how they will do. And then I would consider.”

Individual factors such as motivation to use mindfulness apps are apparent. Patients emphasized the importance of Reinforcement (Motivation in TDF) in terms of app features and content. Patient 1: “It's about the app being interactive and engaging,” explaining further “having that interactive component I think is essential.” Another patient discussed the advantage of a “live” element: “I like a live chat… [where] we can really speak to another person and then meditate with them.” Another survivor: “I think it'll be really cool to have somebody else I can communicate with and meditate with” (Patient 3). Patient 4: “I think it would be helpful if there was a survivorship section not necessarily totally related to cancer. There's a lot of chronic diseases and illnesses that can go through with various degrees of daily impact on their daily lives. It doesn't necessarily have to be tailored to young adult cancer survivors. In my opinion, maybe people who have chronic medical issues or diagnoses who are young adults… It would be good to have people who have that history. As a survivor, or as a person who has a complex medical background, I think separating it by different stages of life as well would be helpful.”

Additionally, the trust survivors have in their clinicians makes them more amiable in giving mindfulness a chance (Social Influence in TDF). For example, Patient 4 noted, “I would say if my doctor and oncologist’s office suggested it and recommended it, that’s good enough for me.” Patient 8 shared: “[If the] Doctor tells me, ‘Hey, I think this would be helpful,’ I'm gonna try it.” Their trust in their clinical providers (Social Influence) offset concerns over other important factors (i.e., Evidence Strength and Quality shared by both providers and patients).

In discussing Intervention Characteristics (CFIR domain), Patient 10 expressed the advantages of a mindfulness app (versus going to an in-person appointment; Relative Advantage): “There’s a lot of things that you need to remember [as a cancer survivor]. It’s almost like this constant additional stressor, in addition to all of the other things that you have to do in terms of being alive. That sometimes I do feel like it’s like the straw that broke the camel’s back. So having that [an app] as an alternative avenue to kind of make sure that you’re taken care of and accounted for up to that point would probably be helpful.” AYA survivors also highlighted the need for the app to be adaptable (Adaptability), such as having reminder features (Patient 8), adjustable timeframes (Patient 7), progress tracking, and explanations that provide the logic behind mindfulness (Patient 5). Others expressed that the app should allow for opportunities to connect with others (i.e., forum options; Patient 6). Patient 3 voiced “I think it’d be really cool to have somebody else I can communicate with and meditate with them… [where] I just feel like I’m in a community with everyone who is in the same situation.” These responses elucidate the unique experiences (Patient 5) of cancer survivors. In the context of Social Influence, the ability to connect with others could improve the use of meditation apps. Patient 4 raised the opportunity for a mindfulness app to also serve as a support for the broader family system: “It's a stressful time and not just for the patient themselves, but for any family member that's directly involved or a spouse. It's more than just the individual going to treatment. I think the people who are in that immediate bubble, like immediate family and members, would also benefit from that as well.”

The goal of this study was to identify key patient-, provider- and organization-level barriers and facilitators to implementing evidence-based mindfulness-based mobile applications for AYAs with cancer. The findings suggest that some factors related to adoption and promotion were both shared by providers and survivors, while others were participant-specific. Both providers and patients described Patient Needs and Resources (Outer Setting), Cost (Intervention Characteristics), and Evidence Strength and Quality (Intervention Characteristics) as priorities when it comes to factors influencing their adoption and use of meditation mobile apps. These factors were also found in prior studies; for example, a recent scoping review found that 10 articles suggested Cost is a barrier to the adoption of digital health interventions (34). In addition to the overall cost of the app (35), other expenses such as having a device (36) and paying for internet data (37, 38) could be potential barriers for patients when deciding to use digital health interventions. Although not explicitly mentioned, clinical providers have concerns over the time and effort it takes to integrate digital health interventions into practice as well as workflow (39) because these investments are often not reimbursed (40–43) which speaks to the larger External Policy and Incentives (Outer Setting). Similarly, medical personnel (i.e., physicians and nurses) will not be reimbursed when providing psychosocial services. Thus, it is important to collaborate with the mental health team (i.e., social workers and psychologists) to support patients’ psychosocial needs. This reflected the importance of the interdisciplinary approach in the context of the Inner Setting (CFIR): Networks and Communications, Structural Characteristics, and Culture.

Skepticism toward mindfulness is well documented (44) and could be a barrier to influencing mindfulness-based mobile app use and adoption (Evidence Strength and Quality). Our results showed that providers believed education is a crucial element in successfully implementing meditation mobile apps. The interdisciplinary team including physicians, nurses, psychologists, social workers, and staff should be a part of the educational efforts to seamlessly introduce mindfulness. Prior research has suggested implementing mindfulness training sessions for new employees or as a continuing education option offered to staff (45). Education can demystify any uncertainty about mindfulness interventions and provide evidence and support, thus enhancing buy-in. Buy-in from providers can also instill patient confidence in the intervention. This coincides with Social Influence (TDF), where our AYA survivors expressed their trust in their providers when recommending any interventions. This aligns with prior studies about the importance of the patient-physician relationship (34). In addition, the trust patients have in their providers can perhaps overcome doubts or skepticism that patients may have about mindfulness interventions (Evidence Strength and Quality). Thus, educating providers and ensuring their buy-in may have additional benefits. Similarly, educating patients about the evidence in support of mindfulness can answer any misconceptions about the practice (Knowledge). Knowledge is an important factor as suggested by previous studies; for example, wrong perception (36–38, 46) and a lack of knowledge (36, 47–50) were seen as problematic to mobile health usage. However, time and effort could present as barriers due to the lack of reimbursement structure for extended patient education about mindfulness mobile applications (Cost and External Policy and Incentives; (40–43)).

Although there were common factors shared by clinical providers and survivors, there are noticeable differences among them. In general, providers discussed structural/contextual (i.e., Inner and Outer Settings) and intervention-related (Intervention Characteristics) factors impacting adoption and workflow which in turn influences patient care. For example, providers highlighted the need to use an interdisciplinary team approach to handling patients’ mental health care reflecting the importance of Culture and Networks and Communications (Inner and Outer Settings). Survivors, on the other hand, focused on intervention- and individual-related factors. In addition to aspects of the intervention adaptability and evidence of effectiveness, survivors also spoke about how Reinforcement and Knowledge may assist their adoption and sustained usage of meditation mobile apps. It is no surprise that the groups differ in their perspective on the importance of factors related to the adoption of meditation mobile apps supporting our rationale to include multiple key stakeholders in this work. Specifically, survivors were likely to focus on the individual as well as intervention factors because those are the most relevant concerns directed at their own behaviors. On the other hand, the providers’ frame of reference is based on their views on how well meditation mobile apps can be integrated into their workflow and meet the needs of their patients. Workflow integration demands contextual and structural compatibility which is manifested in Inner and Outer Settings.

Study Limitations

Strengths of this work include using a multiple stakeholder perspective to understand factors relevant to implementing mindfulness mobile apps in AYA survivorship care and the use of a theory-driven framework (23) in design and analysis. There are also several limitations to our study. Our sample was a convenience sample with a relatively small sample size. We also had predominantly female psychosocial providers in the sample. Lastly, although we employed a multiple-stakeholder approach, we did not include possible external influences such as health insurance companies and policymakers who have a better understanding of the Outer Setting. Future work should explore the policy-level factors with the intention of developing implementation strategies targeting factors such as Cost.

Clinical Implications

The results from this study can inform the development of implementation strategies to improve the adoption of mindfulness mobile apps in AYA survivorship care. For instance, implementation strategies may focus on education to target Knowledge and Evidence Strength and Quality. For example, we can utilize interactive group training (51), performance-related feedback (51), and opinion leaders (51) to improve knowledge, skills, and attitudes in training sessions among staff. Post-training, we can provide champions/clinical supervision (51) and make guidelines and resources pertaining to mental health available to providers (i.e., dissemination of training materials (51)). Similarly, providers can serve as champions (51) to recommend and promote patients’ usage. In a structural approach, evidence-based apps can be incorporated into Electronic Medical Record (EMR) workflows; for example, EMR could include built-in process reminders to encourage mindfulness app usage (51) when providers conduct mental health screenings with their patients. App adaptability (51) can be enhanced by working with app companies to tailor apps specifically to AYAs (e.g., cancer-tailored content, free trials available, etc.).

In summary, this qualitative study explored the potential barriers and facilitators of implementing meditation mobile apps in AYA survivorship care. Potential facilitators and barriers to mHealth adoption were identified that could help guide the development of implementation strategies to promote and sustain the adoption of these digital interventions. Overall, the findings suggest that while AYA survivors reported that both individual and intervention characteristics influenced their adoption or use, clinical providers were more concerned about intervention and contextual factors related to the implementation of meditation mobile apps in survivorship care. Future research should continue to explore policy-level factors such as insurance payors and policymakers while aiming to develop implementation strategies related to individual and contextual factors.

AYA Adolescent and Young Adult

CFIR The Consolidated Framework for Implementation Research

TDF Theoretical Domains Framework

Ethics approval and consent to participate: This article does not contain any studies with animals performed by any of the authors. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study is approved by Rutgers Biomedical and Health Sciences Institutional Review Board (IRB# Pro2021001403). Informed consent was obtained from all individual participants included in the study.

Consent for publication: Not applicable.

Availability of data and materials: The data that support the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy or ethical restrictions.

Competing interests: The authors declare that they have no competing interests.

Funding: The study was supported by a grant from the New Jersey Commission on Cancer Research.

Authors' contributions: IM and GK were responsible for the data collection. GK and AS analyzed and interpreted the data, and were the major contributors in writing the manuscript. KD and AS provided feedback on subsequent drafts of the manuscripts. All authors read and approved the final manuscript.

Acknowledgments: The authors want to thank Mitali Shroff, Research Assistant, for supporting the data collection.

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No competing interests reported.

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Understanding the Multilevel Factors Influencing the Implementation of Mindfulness-based Mobile Applications in Adolescents and Young Adult (AYA) Cancer Survivorship Care

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