O iginal Pape
De elopmen and E alua ion o he Use ulness, Usabili y, and
Feasibili y o iNNOV B eas Cance : Mixed Me hods S udy
C is ina Mendes-San os1,2,3,4, PhD; F ancisco Nunes5, PhD; Elisabe e Weide pass6, MSc, MD, PhD; Rui San ana3,4,
PhD; Ge ha d Ande sson7,8,9, PhD
1Depa men o Cul u e and Socie y, Linköping Uni e si y, Linköping, Sweden
2Expe imen al Pa hology and The apeu ics G oup, Po uguese Ins i u e o Oncology, Po o, Po ugal
3Public Heal h Resea ch Cen e, NOVA Na ional School o Public Heal h, Uni e sidade No a de Lisboa, Lisbon, Po ugal
4Comp ehensi e Heal h Resea ch Cen e , Po ugal
5F aunho e Po ugal AICOS, Po o, Po ugal
6In e na ional Agency o Resea ch on Cance , Lyon, F ance
7Depa men o Beha iou al Sciences and Lea ning, Linköping Uni e si y, Linköping, Sweden
8Depa men o Biomedical and Clinical Sciences, Linköping Uni e si y, Linköping, Sweden
9Depa men o Clinical Neu oscience, Psychia y Sec ion, Ka olinska Ins i u e , S ockholm, Sweden
Co esponding Au ho :
C is ina Mendes-San os, PhD
Depa men o Cul u e and Socie y
Linköping Uni e si y
Linköping, 581 83
Sweden
Phone: 46 917890798
Email: [email p o ec ed]
Abs ac
Backg ound: Despi e he e icacy o psychosocial in e en ions in minimizing psychosocial mo bidi y in b eas cance su i o s
(BCSs), in e en ion deli e y ac oss su i o ship is limi ed by physical, o ganiza ional, and a i udinal ba ie s, which con ibu e
o a men al heal h ca e ea men gap in cance se ings.
Objec i e: The aim o his s udy is o de elop iNNOV B eas Cance (iNNOVBC), a guided, in e ne -deli e ed, indi idually
ailo ed, accep ance and commi men he apy–in luenced cogni i e beha io al in e en ion p og am aiming o ea mild o
mode a e anxie y and dep ession in BCSs as well as o imp o e a igue, insomnia, sexual dys unc ion, and heal h- ela ed quali y
o li e in his g oup. This s udy also aims o e alua e he use ulness, usabili y, and p elimina y easibili y o iNNOVBC.
Me hods: iNNOVBC was de eloped using a use -cen e ed design app oach in ol ing i s p ima y and seconda y end use s, ha
is, BCSs (11/24, 46%) and men al heal h p o essionals (13/24, 54%). We used mixed me hods, namely in-dep h semis uc u ed
in e iews, labo a o y-based usabili y es s, sho - e m ield ials, and su eys, o assess iNNOVBC’s use ulness, usabili y, and
p elimina y easibili y among hese a ge use s. Desc ip i e s a is ics we e used o cha ac e ize he s udy sample, e alua e
pe o mance da a, and assess su ey esponses. Quali a i e da a we e eco ded, ansc ibed e ba im, and hema ically analyzed.
Resul s: O e all, pa icipan s conside ed iNNOVBC highly use ul, wi h mos pa icipan s epo ing on he pe inence o i s
scope, he digi al o ma , he ele an con en , and he app op ia e ea u es. Howe e , a ious usabili y issues we e iden i ied,
and pa icipan s sugges ed ha he p og am should be e ined by simpli ying na iga ion pa hs, using a mo e dynamic colo
scheme, including mo e icons and images, displaying in o ma ion in di e en o ma s and e sions, and de eloping sma phone
and able e sions. In addi ion, pa icipan s sugges ed ha ables should be con e ed in o plain ex boxes and da a isualiza ion
dashboa ds should be included o acili a e he acking o p og ess. The possibili y o using iNNOVBC in a lexible manne ,
ailo ing i acco ding o BCSs’changing needs and along he cance ca e con inuum, was ano he sugges ion ha was iden i ied.
Conclusions: The s udy esul s sugges ha iNNOVBC is conside ed use ul by bo h BCSs and men al heal h p o essionals,
con igu ing a p omising poin -o -need solu ion o b idge he psychological suppo i e ca e gap expe ienced by BCSs ac oss he
su i o ship ajec o y. We belie e ha ou esul s may be applicable o o he simila p og ams. Howe e , o ul ill hei ull
suppo i e ole, such p og ams should be comp ehensi e, highly usable, and ailo able and mus adop a lexible ye in eg a ed
s uc u e capable o e ol ing in acco dance wi h su i o s’changing needs and he cance con inuum.
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 1h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X
(JMIR Cance 2022;8(1):e33550) doi: 10.2196/33550
KEYWORDS
accep ance and commi men he apy; anxie y; b eas cance su i o s; cogni i e beha io al he apy; dep ession; digi al men al
heal h; e-men al heal h; use -cen e ed design; in e ne in e en ions; usabili y; mobile phone
In oduc ion
Backg ound
Since 2020, b eas cance has been he mos diagnosed cance
wo ldwide and he leading cause o cance mo ali y in women.
In Po ugal, as many as 7041 women a e diagnosed pe yea
wi h b eas cance , and in 2020, a o al o 1864 women died
owing o he condi ion [1,2]. Ne e heless, owing o
imp o emen s in ea ly diagnosis, umo molecula
cha ac e iza ion, and inno a i e sys emic ea men s, b eas
cance p ognosis has signi ican ly imp o ed ac oss he globe,
wi h 5-yea su i al a es eaching app oxima ely 90% in
high-income coun ies [3]. In Po ugal, he 5-yea p e alence
o b eas cance was es ima ed a 27,051 in 2020, making b eas
cance su i o s (BCSs) he la ges g oup o cance su i o s
in he coun y [1,2].
In spi e o a posi i e p ognosis, he su i o ship ajec o y is
equen ly cha ac e ized by di icul ies associa ed wi h sequelae
o cance and i s ea men and la e physical and psychosocial
e ec s ha hinde BCSs’heal h- ela ed quali y o li e (HRQoL)
[4]. Anxie y, dep ession [5,6], ea o ecu ence [7], a igue
[8], sleeping p oblems [9], and sexual dys unc ion [10,11] a e
among he mos common p oblems BCSs expe ience ac oss
su i o ship and can mani es up o se e al yea s a e p ima y
ea men comple ion [12].
In he pas decades, se e al in e en ions ha e been de eloped
o minimize psychosocial mo bidi y in BCSs. Recen
me a-analyses demons a ed he e icacy o such in e en ions
in imp o ing a ange o psychosocial ou comes [13,14].
Cogni i e beha io al he apy (CBT) has been iden i ied as he
mos e ec i e in e en ion o ea anxie y and dep ession in
BCSs, o en showing signi ican small- o-mode a e ea men
e ec s in pa ien s wi h hese condi ions [13,14]. O he
psychosocial in e en ions such as psychoeduca ional ea men s
[14], mind ulness-based in e en ions [15], and accep ance and
commi men he apy (ACT) ha e been es ed among BCSs wi h
success as well [16]. ACT, owing o i s model o heal hy
adap a ion o di icul ci cums ances and ansdiagnos ic
app oach, has been appoin ed as pa icula ly use ul in add essing
he high le els o psychological and medical como bidi ies ha
mani es in cance popula ions [17,18]. Reg e ably, he deli e y
o such in e en ions ac oss he su i o ship ajec o y is limi ed
owing o dis ance om heal h ca e se ices, heal h ca e sys em
limi a ions, men al heal h illi e acy, and a i udinal ba ie s, all
o which con ibu e o a men al heal h ca e ea men gap in
cance se ings [19].
In e ne in e en ions—sel -help echnology-enabled
in e en ions ha p o ide synch onous o asynch onous
heal h- ela ed and men al heal h– ela ed assis ance based on
es ablished psycho he apy models [20]—p o ide an oppo uni y
o ul ill he men al heal h ca e gap wi hin oncology and o e
BCSs wi h pa ien -cen e ed suppo a a dis ance. Ne e heless,
despi e in e ne in e en ions’a es ed e icacy [21] in ea ing
a ious men al heal h condi ions and i s po en ial
cos -e ec i eness [22,23], in e ne in e en ions a ge ing cance
su i o s a e scan [24]. Al hough p omising e ec s o such
in e en ions ha e been documen ed conce ning anxie y,
dep ession [25,26], dis ess [27], a igue [28], physical ac i i y
[29], symp om managemen [30], insomnia [31,32], sexual
dys unc ion [33], and quali y o li e [34,35], he o e all bene i
o such in e en ions o BCSs is s ill unclea . Mos s udies in
his domain epo on dissimila in e en ions o p esen high
me hodological he e ogenei y, which makes hei compa ison
di icul and inconsis en [30,36]. Mo eo e , in e en ions’
design p ocesses a e a ely epo ed, and he absence o
e idence-based easoning behind i s de elopmen [36]
con ibu es o a esea ch-p ac ice gap in he in e ne
in e en ions domain, whe ein e idenced-based ea men s
s uggle o be adop ed in ou ine ca e [37]. Ano he cause o
he low up ake o in e ne in e en ions in clinical se ings is
he pe iphe al posi ion end use s a e o en e e ed o du ing
de elopmen [38]. In e en ion p og ams a e equen ly planned
by neglec ing end use s’ pe spec i e (eg, indi idual’s goals,
needs, skills, and con ex s) and esea che s o en ail o in ol e
end use s in he de elopmen p ocess [37,38]. This lack o
human-cen e edness in he de elopmen pa ly explains he high
a i ion a es and poo engagemen o en epo ed in clinical
ials and con igu es a limi a ion ha needs o be add essed o
e ec i ely impac su i o ship suppo i e ca e p o ision
[39,40].
The aim o his s udy is o epo on he de elopmen , use ulness,
usabili y, and p elimina y easibili y o iNNOV B eas Cance
(iNNOVBC), a guided, in e ne -deli e ed, indi idually ailo ed,
ACT-in luenced CBT p og am de eloped o ea mild o
mode a e anxie y and dep ession in BCSs, as well as o imp o e
a igue, insomnia, sexual dys unc ion, and HRQoL in his g oup.
Besides in o ming iNNOVBC’s u he de elopmen and
e inemen , he con ibu ion o his pape esides in he
desc ip ion o men al heal h p o essionals’(MHPs’) and BCSs’
pe spec i es on he use o digi al echnology o suppo cance
su i o s and he design implica ions ha a ise om conside ing
hese.
iNNOVBC O e iew
iNNOVBC (Figu es 1 and 2) is a guided, in e ne -deli e ed,
indi idually ailo ed, ACT-in luenced CBT p og am and was
de eloped wi h a use -cen e ed design app oach [37]. The
p og am was c ea ed o add ess he psychosocial needs o BCSs
ha we e p e iously iden i ied ia li e a u e e iew, namely,
anxie y, dep ession, a igue, insomnia, sexual dys unc ion, and
HRQoL. The in e en ion s uc u e and con en build up on
p io CBT- and ACT-inspi ed in e en ions de eloped by he
Depa men o Beha iou al Sciences and Lea ning a Linköping
Uni e si y, a ge ing o he popula ions [41-45]. The applicable
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 2h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X
p e iously a ailable con en was ansla ed om Swedish and
English o Po uguese and e iewed by ex e nal expe s (ie, an
oncologis , a nu se, a psychologis , and a BCS). Addi ional
con en was de eloped based on pee - e iewed sou ces [46-50],
as well as mixed me hods esea ch conduc ed by he esea ch
eam and in ol ing iNNOVBC’s p ima y and seconda y end
use s [51,52].
iNNOVBC is composed o 10 ea men modules (Mul imedia
Appendix 1), namely, i e manda o y modules (li ing wi h
b eas cance and beyond, dep ession, anxie y, elaxa ion, and
key poin s summa y, and planning o he u u e) and i e
op ional modules (beha io al ac i a ion pa s I and II, sleep
a igue, and in e pe sonal ela ionships, sex, and in imacy), o
be comple ed in 10 weeks. An in oduc o y module p o ides
gene al in o ma ion abou he p og am. Each module is designed
o be comple ed in app oxima ely 60 minu es and includes
w i en ex , images, ideos, audio iles, quizzes, ACT- and
CBT-based exe cises, homewo k assignmen s, and espec i e
wo kshee s. The p og am adop s a ansdiagnos ic s uc u e,
ea u ing psychoeduca ion, accep ance, cogni i e de usion,
connec ing wi h alues, commi ed ac ion, exposu e, beha io al
ac i a ion, and elaxa ion as cen al componen s. Sleep
managemen , ene gy conse a ion, p oblem sol ing, and sensa e
ocusing echniques a e complemen a y componen s o he
p og am. To gua an ee op imal use o he p og am, he s udy
in e en ion was de eloped acco ding o he ollowing
pe suasi e sys em p inciples ca ego ized by Oinas-Kukkonen
and Ha jumaa [53]: esponsi eness, unneling, ailo ing,
pe sonaliza ion, eminde s, and p o essional suppo .
A he onse o he in e en ion, BCSs using he p og am should
ailo hei ea men wi h he suppo o hei assigned he apis
and acco ding o hei baseline assessmen and p e e ences.
Once hey each an ag eemen , he selec ed modules should be
p esc ibed and made a ailable weekly o he BCSs. Then, BCSs
a e p omp ed o comple e he modules in app oxima ely 1 week.
Wi hin 24 hou s o module comple ion, he he apis s assess
he BCSs’ p og ess based on he epo ed ou comes and
de e mine whe he hey should p oceed o he nex module.
When a new module is made a ailable, BCSs ecei e an email
no i ying hem. I no , he apis s should ins uc hem on wha
needs o be comple ed o be able o ad ance o he nex module.
In eg a ed 2-way communica ion ea u es such as email, cha ,
SMS ex messaging, and ideocon e ence suppo he
in e en ion. The p og am is deli e ed ia iTe api, a web-based
ea men pla o m de eloped a Linköping Uni e si y [54].
Figu e 1. The landing page o he iNNOV B eas Cance p og am.
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 3h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X
Figu e 2. The in oduc o y and 10 ea men modules o he iNNOV B eas Cance p og am.
Me hods
S udy Design
Mixed me hods (Figu e 3), namely in-dep h semis uc u ed
in e iews, usabili y es s, sho - e m ield ials, and su eys,
we e combined o ul ill he ollowing speci ic goals: (1)
e alua e iNNOVBC’s use ulness, (2) assess iNNOVBC’s
usabili y, and (3) explo e iNNOVBC’s pe cei ed easibili y and
accep abili y among i s a ge use s. The s udy was app o ed
by he e hical commi ees o Ins i u o Po uguês de Oncologia
do Po o, F ancisco Gen il, EPE; Cen o Hospi ala Uni e si á io
do Po o; Cen o Hospi ala São João; Unidade Local de
saúde–Ma osinhos; Hospi al CUF Po o; O dem dos Psicólogos
Po ugueses; and he Po uguese Da a P o ec ion Commi ee
(app o al numbe : 10727/2017). W i en in o med consen was
ob ained om all pa icipan s.
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 4h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X
Figu e 3. S udy design. BCS: b eas cance su i o ; iNNOVBC: iNNOV B eas Cance ; MHP: men al heal h p o essional.
Sampling and Rec ui men
The s udy a ge ed BCSs and MHPs, who a e iNNOVBC’s
p ima y and seconda y end use s. Eligibili y c i e ia o BCSs
consis ed o women, aged >18 yea s, wi h a his o y o
his ologically con i med b eas cance , who had comple ed
p ima y adju an ea men (excep ho monal he apy), and we e
capable o eading and w i ing in Po uguese. MHPs we e
egis e ed psychologis s o psychia is s, capable o eading and
w i ing in Po uguese. A nonp obabilis ic sample o BCSs and
MHPs was ec ui ed ollowing e e als om he esea che s
and p o essionals wo king a ea men cen e s in Po o
(Po ugal) and ia snowball sampling. Pa icipan s we e
pu posi ely sampled o di e si y in age, academic deg ee, and
digi al echnology p o iciency. A o al o 28 MHPs and 16 BCSs
we e in i ed o pa icipa e in he s udy in pe son, ia email, o
by elephone. O he in i ed indi iduals, 54% (15/28) o he
MHPs and 88% (14/16) o he BCSs ag eed o pa icipa e.
Meaning sa u a ion was used as a s opping c i e ion, which
mean ha new pa icipan s would no be en olled once no el
ieldwo k insigh s s opped changing analysis signi ican ly [55].
Da a collec ion ended a e 87% (13/15) o he MHPs and 69%
(11/16) o he BCSs comple ed he esea ch p o ocol, as meaning
sa u a ion was eached du ing he las in e iews and usabili y
es s.
Da a Collec ion P ocedu es
Da a we e collec ed be ween No embe 2019 and Feb ua y
2020 (ie, be o e he COVID-19 pandemic). Up o 2 o 3
in e iewe s o mode a o s (CMS, Ana Al es, and Elsa Oli ei a)
pa icipa ed in da a collec ion. The esea ch p o ocol included
an explo a o y semis uc u ed in e iew (N=24; ie, 11/24, 46%
BCSs and 13/24, 54% MHPs; Mul imedia Appendix 2), a
labo a o y-based usabili y es (Mul imedia Appendix 3),
ollowed by he comple ion o a sel - epo ed usabili y su ey
[56] (N=24; ie, 11/24, 46% BCSs, and 13/24, 54% MHPs), and
a deb ie ing pos usabili y es in e iew (N=24; ie, 11/24, 46%
BCSs, and 13/24, 54% MHPs; Mul imedia Appendix 4). The
explo a o y in e iew aimed o in es iga e he use ulness o
iNNOVBC and ga he equi emen s o u he e inemen o
he p og am. The usabili y es assessed he pa icipan s’
pe o mance while execu ing a se ies o ep esen a i e
p ede ined asks on dis inc pa s o he pla o m. The
hink-aloud p o ocol was implemen ed o enable pa icipan s
o oice hei hough s and issues [57]. The deb ie ing in e iew
ocused on pa icipan s’ expe ience wi h using he pla o m,
issues hinde ing hei expe ience, and changes o be pe o med
o achie e be e e ec i eness, e iciency, and sa is ac ion wi h
he p og am. These ac i i ies occu ed in pe son a F aunho e
Po ugal–Cen e o Assis i e In o ma ion and Communica ion
Solu ions mee ing ooms. Pa icipan BCSs willing o u he
assess iNNOVBC we e in i ed o pa icipa e in an addi ional
2-week ield ial (8/11, 73% BCSs; Mul imedia Appendix 5)
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 5h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X

mimicking he expe ience o using he p og am, and o ill ou
a su ey h ough he pla o m on he pe cei ed use ulness and
easibili y o he p og am (Mul imedia Appendix 6).
In e iews and usabili y es s we e audio and ideo eco ded,
espec i ely. App oxima ely 36 hou s o audio eco dings and
9 hou s o ideo eco dings we e c ea ed. The a e age du a ion
o p e es in e iews was 49 minu es ( ange 26-81 minu es) o
MHPs and 74 minu es o BCSs ( ange 39-106 minu es).
Usabili y es s we e comple ed on a e age in 20 minu es and
ollowed by 28 minu es ( ange 10-46 minu es) o deb ie ing
in e iews. In e iew eco dings we e ansc ibed e ba im
(CMS and Ana Al es) in pa allel o da a collec ion, using
oT ansc ibe (c ea ed by Ellio Ben ley; a p ojec o he
MuckRock Founda ion) [58]. Usabili y es s we e assessed using
p ede eloped obse a ion g ids and by egis e ing pa icipan s’
oiced ema ks. Da a we e s o ed in a pseudoanonymized o ma
in a secu e passwo d-p o ec ed loca ion.
Measu es
Clinical, Sociodemog aphic, and In e ne -Rela ed
Cha ac e is ics
Backg ound ques ionnai es ailo ed o each a ge g oup
collec ed clinical, sociodemog aphic, and in e ne - ela ed
cha ac e is ics. BCSs we e inqui ed abou age, gende , educa ion
le el, ma i al s a us, occupa ion, p o essional s a us, dis ance
be ween esidence and ea men cen e , ime since diagnosis,
ype o ea men pe o med, su i o ship s a us, p o iciency
using digi al echnology, and expe ience in using digi al men al
heal h (DMH) p og ams. MHPs we e inqui ed abou age, gende ,
educa ion le el, ma i al s a us, occupa ion, p o essional s a us,
wo k con ex , p o essional expe ience (in yea s), heo e ical
o ien a ion, p o iciency in using digi al echnology, and
expe ience in using DMH p og ams.
Use ulness
Semis uc u ed in e iew guides (Mul imedia Appendix 2) we e
de eloped based on a li e a u e e iew o assess pa icipan s’
pe cei ed use ulness o he p og am. The in e iew guides
co e ed he ollowing domains: (1) su i o ship main
challenges, unme ca e needs, and sel -ca e s a egies de eloped
o add ess hose challenges and needs; (2) he p o ision o
psychosocial su i o ship ca e o BCSs and he main ba ie s
impac ing i ; (3) knowledge and use o DMH; and (4) a i udes
owa d DMH p og ams aimed a p o iding su i o ship suppo .
In addi ion, a ques ionnai e de eloped o assess he quali y o
iNNOVBC’s ea men modules was used o his pu pose
(Mul imedia Appendix 6).
Usabili y
We conduc ed usabili y es s and analyzed he pe o mance and
accep ance o he sys em. To assess pe o mance, ask analysis
was conduc ed and he numbe o comple ed asks, e o s, and
assis ances we e eco ded in obse a ion g ids (Mul imedia
Appendix 3). Accep ance was measu ed using he Po uguese
e sion o he Sys em Usabili y Scale [56], whe e a sco e <68
is conside ed below a e age. The deb ie ing in e iews also
in o med abou accep ance and con ibu ed o iden i ying con en
and design changes o be pe o med o imp o e use expe ience
and sa is ac ion (Mul imedia Appendix 4).
Feasibili y
The p elimina y easibili y o he p og am was assessed ia
deb ie ing semis uc u ed in e iews and assessmen
ques ionnai e in iNNOVBC’s ea men modules (Mul imedia
Appendix 6). The pa icipan BCSs who used he sys em a
home also p o ided w i en commen s.
Analysis
A combina ion o quan i a i e and quali a i e me hods was
applied o assess iNNOVBC’s use ulness, usabili y, and
pe cei ed easibili y. Desc ip i e s a is ics, namely, coun s,
pe cen ages, medians, and IQRs, we e used o cha ac e ize he
s udy sample, e alua e pe o mance da a, and assess p e e ence
da a collec ed ia he Sys em Usabili y Scale and he ea men
modules’assessmen ques ionnai e. No e iciency me ics we e
compu ed because he hink-aloud me hod was applied.
Mic oso Excel was used o compu e quan i a i e a iables.
Quali a i e da a esul ing om he in e iews and BCSs’w i en
commen s we e ansc ibed e ba im and analyzed using he
hema ic analysis me hod o B aun and Cla ke [59]. Fi s , a
deduc i e app oach was adop ed based on h ee p ede e mined
high-le el hemes: use ulness, usabili y, and easibili y.
Subsequen ly, induc i e analysis was pe o med on he da a
collec ed wi hin hose hemes, and salien sub hemes we e
coded. Ini ial coding was pe o med by he i s au ho (CM).
Regula discussions we e p omo ed be ween esea che s (CMS
and FN) o discuss esul s and coding ees. Da a pa e ns we e
hen iden i ied and i e a i ely o ganized (CMS and FN) un il
consensus be ween esea che s was achie ed and no addi ional
insigh s we e esul ing om he analysis o he da a. Sc i ene
so wa e [60] was used o suppo he coding p ocess.
Resul s
Pa icipan s’Cha ac e is ics
The sample comp ised 24 pa icipan s (Table 1), including 11
(46%) BCSs and 13 (54%) MHPs. The median age o BCSs
was 48 yea s (IQR 14; minimum 32, maximum 68). Mos
su i o s we e ma ied (7/11, 64%) and college-educa ed (7/11,
64%). App oxima ely 55% (6/11) o he su i o s we e
p o essionally ac i e. Mos BCSs had been ea ed wi h su ge y
(11/11, 100%), chemo he apy (9/11, 82%), adio he apy (8/11,
73%), and ho monal he apy (9/11, 82%). Conside ing he
su i o ship s a us [61], he sample was he e ogeneous,
including pa icipan s a acu e (2/11, 18%), ex ended (3/11,
27%), and pe manen (6/11, 55%) su i o ship s ages. No
pa icipan had p e ious expe ience in using DMH p og ams,
bu he majo i y epo ed medium (4/11, 36%) o s ong (5/11,
45%) skills in using digi al echnology.
The subsample o MHPs was composed o 15% (2/13)
psychia is s and 85% (11/13) clinical psychologis s. Mos
p o essionals we e emale (11/13, 85%), and hei median age
was 35 yea s (IQR 11; minimum 25, maximum 56). The median
o MHPs’ p o essional expe ience was 11 yea s (IQR 11).
Mo eo e , 92% (12/13) o p o essionals we e ac i e, and 30%
(4/13) wo ked in psycho-oncology se ices. App oxima ely
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 6h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X
hal o ou sample (7/13, 54%) held a CBT o ien a ion.
Conside ing pa icipan s’p o iciency in using digi al echnology,
mos p o essionals (11/13, 85%) classi ied hei skills as
medium. App oxima ely hal o p o essionals (7/13, 54%)
epo ed p e ious expe ience in using DMH p og ams.
Table 1. Pa icipan s’cha ac e is ics (N=24).
BCSb(n=11)MHPa(n=13)Va iables
Sex, n (%)
11 (100)11 (85)Female
0 (0)2 (15)Male
Age (yea s), n (%)
0 (0)3 (23)23-30
4 (36)7 (54)31-40
4 (36)2 (15)41-50
2 (18)1 (8)51-60
1 (9)0 (0)61-70
Highes academic deg ee, n (%)
2 (18)0 (0)Basic deg ee (≤9 school yea s)
2 (18)0 (0)Seconda y deg ee (12 school yea s)
7 (64)13 (100)Uni e si y deg ee
Sel - epo ed p o iciency in using digi al echnology, n (%)
2 (18)1 (8)Poo
4 (36)11 (85)Medium
5 (45)1 (8)S ong
Sel - epo ed use o digi al men al heal h, n (%)
11 (100)6 (46)None
0 (0)4 (31)Occasional
0 (0)3 (23)Regula
aMHP: men al heal h p o essional.
bBCS: b eas cance su i o .
Use ulness
iNNOVBC’s pe cei ed use ulness was assessed du ing he
in e iews conduc ed be o e and a e he usabili y es s and by
su eying ield ial pa icipan s on he use ulness and adequacy
o he p og am’s modules. Du ing he ield ials, he con en
o he modules li ing wi h b eas cance and beyond (4/11,
36%), anxie y (1/11, 9%), elaxa ion (1/11, 9%), sleep (1/11,
9%), and a igue (1/11, 9%) we e app aised, wi h all being a ed
wi h 5 (ou o 5) s a s by BCSs e alua ing i . O e all,
pa icipan s ound he p og am’s app oach, con en , and ea u es
as highly ele an and use ul. BCSs classi ied he con en o
he modules as e y use ul (3/8, 36%) o ex emely use ul (5/8,
63%) and e y adequa e (3/8, 36%) o ex emely adequa e (4/8,
50%) in add essing hei di icul ies and needs. Only 13% (1/8)
o he pa icipan s epo ed ha he elaxa ion module was
nei he adequa e no inadequa e o he needs. All su i o s (8/8,
100%) epo ed ha hey would ecommend he modules o a
iend o amily membe going h ough he same condi ion.
Conside ing he ole iNNOVBC could play in BCSs suppo i e
ca e, bo h su i o s and p o essionals conside ed iNNOVBC
could ha e a signi ican impac in suppo ing BCSs h oughou
he cance con inuum:
The e we e a lo o doub s, e e s, discom o s,
disquie udes... he e s ill a e...and i I had his ype o
esou ce, I could ha e used i ins ead o googling o
looking in o pa ien g oups, o some kind o
answe ...Because you do eel he need o go o o ums
and ask, does anyone eel like his? Wha ha e you
done? And i he e we e a pla o m like his, he ype
o suppo p o ided would be di e en , mo e c edible
and app op ia e. [BCS11]
Simila o BCS11, mos pa icipan s alued he possibili y o
accessing “ us wo hy” (BCS6) sel -ca e in o ma ion p o ided
“any ime, anywhe e” (BCS7) ia iNNOVBC. The in e iewed
BCSs had sea ched on he web o in o ma ion on ea men s’
ad e se e en s, p ac ical s a egies, and emo ional challenges
hey we e aced wi h, bu hei sea ches we e leng hy and
equi ed hem o assess he quali y o in o ma ion hey we e
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 7h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X
p esen ed wi h. Bo h BCSs and MHPs conside ed ha ha ing
“easy access o e idence-based eady o use psycho-educa ional
con en ” (MHP10) could help su i o s be e manage hei
condi ion and p oblems.
Acco ding o he pa icipan s, he su i o ship ajec o y is
cha ac e ized by many biopsychosocial challenges ha deeply
impac su i o s’ well-being. Se e al pa icipan s desc ibed
he pe asi e and long-las ing impac ha ea men ’s ad e se
e en s o sequelae had on hei physical and men al heal h,
unde lining he impo ance o ecei ing accu a e and
comp ehensi e in o ma ion abou i . E ec s such as alopecia,
onycholysis, pain, menopausal symp oms, a igue,
ca dio oxici y, lymphedema, os eopo osis, in e ili y, and
memo y loss we e o en discussed by in e iewees as key
in o ma ion poin s o add ess in a nuanced and dynamic manne .
Du ing he cou se o ea men , a ious su i o s ecei ed lye s
and bookle s abou ea men s’ ad e se e ec s, bu mos
complained abou hei unappealing design and low in elligibili y
and ocus on he ac i e ea men s age, he e o e ailing o
p o ide a con inuous pe spec i e on i s managemen a e
ea men comple ion. The ac ha iNNOVBC app oached
many o hose hemes “in a ch onological way” (BCS1) was
app ecia ed by a ious BCSs because i enabled hem o p epa e
and cope wi h i in he long e m.
The impac o cance and i s ea men s on su i o s’emo ional
heal h was ano he ma e o conce n. Bo h MHPs and BCSs
unde lined he impo ance o p o iding psychological suppo
o BCSs h oughou he cance con inuum, pa icula ly du ing
he ansi ion om ac i e ea men o ollow-up ca e:
Ge ing psychological suppo is e y impo an a
all s ages...a he diagnosis, du ing ea men and
a e ea men ...People a e no awa e o his, hey
end o say “Ah, ha ’s o e now!” and expec us o
e u n o whom we used o be...Bu ha ’s no
possible...you s ill need suppo . This eels almos
like...a pos - auma ic si ua ion...and by saying ha
i ’s almos like hey’ e aking away you legi imacy
o eel he pain, so i can eel e y isola ing o c oss
ha pa h. [BCS2]
I ’s an ab up shi om being ex emely ca ed o ,
om ha ing ha uncondi ional suppo du ing chemo
o s opped being ca ed o ...As soon as you hai
s a s o g ow, e e yone assumes ha e e y hing is
ine. Bu i ’s no . I will ne e be able o say again ha
I’m ine. I’m no healed, I’m ull o ea s, anxie y, and
so ow. So...i was ex emely ha d o me o deal wi h
ha because I el abandoned...people had pulled he
ug ou om unde me. [BCS7]
Simila o BCS2 and BCS7, a ious pa icipan s discussed he
expe ience o eeling in dis ess and unsuppo ed a e inishing
he p ima y ea men . P oblems such as “dealing wi h low
mood” (BCS11), “ eeling anxious all he ime” (BCS2), “ ea ing
ha cance had e u ned” (BCS8), o ea o “dying” (BCS9)
we e common, o en impac ing BCSs’ sleep and in e pe sonal
ela ionships. Di icul ies in adap ing o a “sca ed body image”
(BCS5) we e also p e alen in in e iewees’ na a i es and
a ious pa icipan s epo ed on he p o ound impac i had on
hei sel -es eem, sexuali y, and in ima e ela ionships:
Losing my b eas shook my sel -es eem, i shook
e e y hing...i ’s ha d o li e wi hou i , I’m a woman.
I...I’m incapable o being naked in on o my
husband. I eel emba assed...I’m no able o hug him
anymo e. I’m a aid he eels ha i ’s no my b eas ,
ha i isn’ eal. I sleep...wi hou he p os hesis, bu
I always y o sleep wi h my back o him and when I
ealize I’m acing him, I u n o e igh away...I’m
a aid ha i he sees me, he migh lose his in e es in
me, ha he s ops desi ing me. ...We s ill ha e sex bu
i ’s no he same. I’m always a aid ha he ouches
whe e he’s no supposed o...I do no lean agains
him...I a oid his ouch. I ’s di icul and...I know ha
he e a e women ha deal wi h his well, bu I...I do
no . [BCS9]
Simila o BCS9, a ious pa icipan s alked abou no being
able o adap o hei changed sel , eeling like a ake e sion
o hemsel es, incapable o es o ing los in imacies, and isola ed
by he “ abu cance had become” (BCS2) in hei inne ci cles.
Coping wi h such p oblems was highly demanding, and many
s uggled o discuss such opics wi h iends, amily, and
p o essionals owing o hei sensi i e na u e. Thus, many
in e iewees app ecia ed he “asse i eness o he hemes”
(BCS6) explo ed a iNNOVBC and he possibili y o ecei ing
p o essional suppo a a dis ance o wi hou ace- o- ace
con ac :
I ’s impo an o ha e suppo bu i ’s uncom o able
o alk abou hese issues ace- o- ace...Maybe h ough
his pla o m, i could be easie ...I belie e I could eel
mo e com o able o ask some ques ions i I knew his
was anonymous, i I didn’ ha e o iden i y me...I
belie e i would be much easie o app oach in ima e
opics ia cha o e-mail han in-pe son. [BCS3]
Pa icipan s such as BCS3 app ecia ed he ac ha iNNOVBC
allowed di ec communica ion be ween MHPs and BCSs. Bo h
p o essionals and su i o s conside ed ha ing cha , email, and
ideocon e ence communica ion al e na i es o be help ul. By
o e ing synch onous and asynch onous communica ion
channels associa ed wi h di e en deg ees o exposu e,
pa icipan s conside ed ha iNNOVBC “could p omo e
su i o s’ sel -disclosu e” (MHP6) and acili a e he “ imely
discussion” (MHP4) o sensi i e opics, ul ima ely, “bene i ing
he he apeu ic p ocess” (MHP12). They also saw ad an ages
in he possibili y o au oma ically sending psychoeduca ional
con en and scheduling and no i ying BCSs abou asks and
ques ionnai es o be comple ed along he implemen a ion o he
p og am:
The unc ionali ies a e well hough and he ac ha
e e y hing is in eg a ed is awesome... his combines
a modula ea men app oach wi h ideocon e ence
and cha ...i allows you o ake no es...and he
ins umen s a e embedded...Tha ’s awesome and
exac ly wha I need in my p ac ice! [MHP5]
The ac ha iNNOVBC combines e idence-based con en wi h
communica ion, moni o ing, and documen a ion ea u es was
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 8h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X
p aised by a ious p o essionals. The in e iewed MHPs
conside ed ha i could educe he ime and e o hey need o
in es in inding, p epa ing, and assessing ma e ials, enabling
hem o wo k mo e e icien ly. iNNOVBC was also conside ed
use ul o p omo e “con inui y o he ela ionship es ablished
be ween he he apis and he clien ” (MHP7) beyond
appoin men s. Mos impo an ly, by doing so, iNNOVBC could
con igu e a poin -o -need se ice ha could suppo BCSs along
he su i o ship ajec o y. Ne e heless, i is impo an o say
ha iNNOVBC’s use ulness could be comp omised by i s “lack
o in ui i eness” (MHP9).
Usabili y
Bo h he quan i a i e and quali a i e da a collec ed du ing he
usabili y es s and in e iews iden i ied design and unc ionali y
issues ha could be imp o ed o enable mo e e ec i e and
e icien use o iNNOVBC and inc ease use s’sa is ac ion wi h
he p og am. In gene al, pa icipan s’e ec i eness, as measu ed
by comple ion a es, was high in bo h g oups ( ange 69.2-100;
Tables 2 and 3), bu he Sys em Usabili y Scale median sco e
was 65 (IQR 35) o BCSs and 47.5 (IQR 25) o MHPs, which
may be conside ed below a e age in e ms o usabili y. These
esul s a e aligned wi h he usabili y issues iden i ied du ing
he usabili y es s.
Table 2. MHPalabo a o y-based usabili y es esul s.
Assis ances,
mean (SD)
E o , mean
(SD)Task pe o mance, %Task g oups and asks
A: Log-in
0.1 (0.3)0.2 (0.4)100
1. Log in o he iNNOVBCb
B: No i ica ions
0.4 (0.6)0.8 (1.2)84.62. Check no i ica ions
0.7 (0.8)2.3 (2.6)1003. Comply wi h he no i ica ions’ins uc ions by accessing he pa ien ’s ile
C: T ea men p esc ip ion
0.7 (1.1)3.2 (5.1)1004. Click on he pa ien ’s link o sea ch o he pa ien
0.2 (0.4)1.1 (1.2)1005. Check he modules p esc ibed o he pa ien
0.1 (0.3)0.6 (1.1)1006. Assign he sleep module o he pa ien
0.3 (0.8)0.4 (0.7)69.27. Send a no i ica ion o he pa ien
0.2 (0.4)0.1 (0.3)1008. Sa e he p e ious p ocedu e
1 (1.3)3.2 (6.6)1009. Check he a ailable clinical ials
0.4 (1.1)0.6 (1.3)10010. P esc ibe iNNOVBC o he pa ien and schedule he onse o he ea men
0.1 (0.3)0 (0)10011. Sa e he p e ious p ocedu e
D: T ea men p og ess assessmen
1.1 (1.2)3.8 (5.1)10012. Send eedback o he pa ien abou he homewo k assignmen
0.4 (0.7)0.7 (1.4)10013. Access he pa ien ’s ile
1.4 (1.4)3.8 (3.0)10014. Click on ques ionnai es
0.4 (0.8)1.6 (3.4)10015. Check he ques ionnai es a ailable o p esc ibe
0.6 (0.8)1.5 (2.4)10016. Assign he weekly ques ionnai e o he pa ien
0 (0)0 (0)10017. Sa e he p e ious p ocedu e
E: Con e sa ions
0.5 (0.6)1.6 (2.1)10018. W i e an email o he pa ien
0 (0)0 (0)10019. Send he email
0 (0)1.5 (2.8)10020. S a a cha con e sa ion wi h he pa ien
0.1 (0.4)0.1 (0.3)10021. S a a ideocon e ence appoin men wi h he pa ien
0.8 (1.2)4.4 (5.2)10022. Upda e he pa ien 's clinical dia y
0.1 (0.3)0.6 (0.8)10023. Schedule he nex appoin men and se an ala m
aMHP: men al heal h p o essional.
biNNOVBC: iNNOV B eas Cance .
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 9h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X
[DOCX File , 24 KB-Mul imedia Appendix 2]
Mul imedia Appendix 3
B eas cance su i o s’and men al heal h p o essionals’iNNOV B eas Cance usabili y es p o ocol and obse a ion ables.
[DOCX File , 35 KB-Mul imedia Appendix 3]
Mul imedia Appendix 4
B eas cance su i o s’and men al heal h p o essionals’deb ie ing in e iew sc ip s.
[DOCX File , 18 KB-Mul imedia Appendix 4]
Mul imedia Appendix 5
Field ial p o ocol.
[DOCX File , 14 KB-Mul imedia Appendix 5]
Mul imedia Appendix 6
Use ulness and easibili y ques ionnai e.
[DOCX File , 19 KB-Mul imedia Appendix 6]
Mul imedia Appendix 7
Iden i ied usabili y issues.
[DOCX File , 32 KB-Mul imedia Appendix 7]
Re e ences
1. Sung H, Fe lay J, Siegel RL, La e sanne M, Soe joma a am I, Jemal A, e al. Global Cance S a is ics 2020: GLOBOCAN
es ima es o incidence and mo ali y wo ldwide o 36 cance s in 185 coun ies. CA A Cance J Clin 2021;71(3):209-249.
[doi: 10.3322/caac.21660] [Medline: 33538338]
2. Global cance obse a o y: cance oday. In e na ional agency o esea ch on cance . 2020. URL: h ps://gco.ia c. / oday/
da a/ ac shee s/popula ions/620-po ugal- ac -shee s.pd , [accessed 2021-09-10]
3. Na din S, Mo a E, Va ughese FM, D'A anzo F, Vachana am AR, Rossi V, e al. B eas cance su i o ship, quali y o li e,
and la e oxici ies. F on Oncol 2020;10:864. [doi: 10.3389/ onc.2020.00864] [Medline: 32612947]
4. Beckjo d E, Ahe n DK, Hesse B. Beha io al medicine and in o ma ics in he cance communi y. In: Edmunds M, Hass C,
Hol e E, edi o s. Consume in o ma ics and digi al heal h: solu ions o heal h and heal h ca e. Cham: Sp inge ; 2019:245-274.
5. Pile a zadeh M, Ami shahi M, A sa gha ehbagh R, Ra iemanesh H, Hashemi SM, Balouchi A. Global p e alence o
dep ession among b eas cance pa ien s: a sys ema ic e iew and me a-analysis. B eas Cance Res T ea
2019;176(3):519-533. [doi: 10.1007/s10549-019-05271-3] [Medline: 31087199]
6. Maass SW, Roo da C, Be endsen AJ, Ve haak PF, de Bock GH. The p e alence o long- e m symp oms o dep ession and
anxie y a e b eas cance ea men : a sys ema ic e iew. Ma u i as 2015;82(1):100-108. [doi:
10.1016/j.ma u i as.2015.04.010] [Medline: 25998574]
7. Ellegaa d MB, G au C, Zacha iae R, Bonde Jensen A. Fea o cance ecu ence and unme needs among b eas cance
su i o s in he i s i e yea s. A c oss-sec ional s udy. Ac a Oncol 2017;56(2):314-320. [doi:
10.1080/0284186X.2016.1268714] [Medline: 28093034]
8. Reine sen KV, Engeb aa en O, Loge JH, C anca o a M, Naume B, Wis E, e al. Fa igue du ing and a e b eas cance
he apy-a p ospec i e s udy. J Pain Symp om Manage 2017;53(3):551-560. [doi: 10.1016/j.jpainsymman.2016.09.011]
[Medline: 28042070]
9. Lowe y-Allison AE, Passik SD, C ibbe MR, Reinsel RA, O'Sulli an B, No on L, e al. Sleep p oblems in b eas cance
su i o s 1–10 yea s pos ea men . Pallia Suppo Ca e 2018;16(3):325-334. [doi: 10.1017/s1478951517000311] [Medline:
28508735]
10. Solde a SV, Ennis M, Lohmann AE, Goodwin PJ. Sexual heal h in long- e m b eas cance su i o s. B eas Cance Res
T ea 2018;172(1):159-166. [doi: 10.1007/s10549-018-4894-8] [Medline: 30027300]
11. Raggio GA, Bu yn ML, A igo D, Miko ski R, Palme SC. P e alence and co ela es o sexual mo bidi y in long- e m
b eas cance su i o s. Psychol Heal h 2014;29(6):632-650. [doi: 10.1080/08870446.2013.879136] [Medline: 24404999]
12. Ca ei a H, Williams R, Funs on G, S anway S, Bhaska an K. Associa ions be ween b eas cance su i o ship and ad e se
men al heal h ou comes: a ma ched popula ion-based coho s udy in he Uni ed Kingdom. PLoS Med 2021;18(1):e1003504
[FREE Full ex ] [doi: 10.1371/jou nal.pmed.1003504] [Medline: 33411711]
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 16h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X

13. Ma hews H, G un eld EA, Tu ne A. The e icacy o in e en ions o imp o e psychosocial ou comes ollowing su gical
ea men o b eas cance : a sys ema ic e iew and me a-analysis. Psychooncology 2017;26(5):593-607. [doi:
10.1002/pon.4199] [Medline: 27333194]
14. Gua ino A, Polini C, Fo e G, Fa ie i F, Boncompagni I, Casag ande M. The e ec i eness o psychological ea men s in
women wi h b eas cance : a sys ema ic e iew and me a-analysis. J Clin Med 2020;9(1):209. [doi: 10.3390/jcm9010209]
[Medline: 31940942]
15. Xunlin NG, Lau Y, Klainin-Yobas P. The e ec i eness o mind ulness-based in e en ions among cance pa ien s and
su i o s: a sys ema ic e iew and me a-analysis. Suppo Ca e Cance 2020;28(4):1563-1578. [doi:
10.1007/s00520-019-05219-9] [Medline: 31834518]
16. González-Fe nández S, Fe nández-Rod íguez C. Accep ance and commi men he apy in cance : e iew o applica ions
and indings. Beha Med 2019;45(3):255-269 [FREE Full ex ] [doi: 10.1080/08964289.2018.1452713] [Medline: 29558259]
17. Fashle SR, Wein ib AZ, Azam MA, Ka z J. The use o accep ance and commi men he apy in oncology se ings: a na a i e
e iew. Psychol Rep 2018;121(2):229-252. [doi: 10.1177/0033294117726061] [Medline: 28836916]
18. Gudenkau LM, Ehle s SL. Psychosocial in e en ions in b eas cance su i o ship ca e. B eas 2018;38:1-6. [doi:
10.1016/j.b eas .2017.11.005] [Medline: 29169071]
19. Nakash O, Le a I, Aguila -Gaxiola S, Alonso J, And ade LH, Ange meye MC, e al. Como bidi y o common men al
diso de s wi h cance and hei ea men gap: indings om he Wo ld Men al Heal h Su eys. Psychooncology
2014;23(1):40-51 [FREE Full ex ] [doi: 10.1002/pon.3372] [Medline: 23983079]
20. Ande sson G, Ti o N. Ad an ages and limi a ions o In e ne -based in e en ions o common men al diso de s. Wo ld
Psychia y 2014;13(1):4-11. [doi: 10.1002/wps.20083] [Medline: 24497236]
21. Ande sson G, Ca lb ing P, Ti o N, Linde o s N. In e ne in e en ions o adul s wi h anxie y and mood diso de s: a
na a i e umb ella e iew o ecen me a-analyses. Can J Psychia y 2019;64(7):465-470 [FREE Full ex ] [doi:
10.1177/0706743719839381] [Medline: 31096757]
22. Massoudi B, Hol as F, Bock ing CL, Bu ge H, Blanke MH. The e ec i eness and cos -e ec i eness o e-heal h
in e en ions o dep ession and anxie y in p ima y ca e: a sys ema ic e iew and me a-analysis. J A ec Diso d
2019;245:728-743. [doi: 10.1016/j.jad.2018.11.050] [Medline: 30447572]
23. Donke T, Blanke s M, Hedman E, Ljó sson B, Pe ie K, Ch is ensen H. Economic e alua ions o In e ne in e en ions
o men al heal h: a sys ema ic e iew. Psychol Med 2015;45(16):3357-3376. [doi: 10.1017/s0033291715001427] [Medline:
26235445]
24. Pos KE, Flanagan J. Web based su i o ship in e en ions o women wi h b eas cance : an in eg a i e e iew. Eu J
Oncol Nu s 2016;25:90-99. [doi: 10.1016/j.ejon.2016.10.004] [Medline: 27865259]
25. Kim AR, Pa k HA. Web-based sel -managemen suppo in e en ions o cance su i o s: a sys ema ic e iew and
me a-analyses. S ud Heal h Technol In o m 2015;216:142-147. [Medline: 26262027]
26. Agboola SO, Ju W, El iky A, K eda JC, Je hwani K. The e ec o echnology-based in e en ions on pain, dep ession,
and quali y o li e in pa ien s wi h cance : a sys ema ic e iew o andomized con olled ials. J Med In e ne Res
2015;17(3):e65. [doi: 10.2196/jmi .4009] [Medline: 25793945]
27. Ugalde A, Haynes K, Bol ong A, Whi e V, K ishnasamy M, Scho ield P, e al. Sel -guided in e en ions o managing
psychological dis ess in people wi h cance - a sys ema ic e iew. Pa ien Educ Couns 2017;100(5):846-857 [FREE Full
ex ] [doi: 10.1016/j.pec.2016.12.009] [Medline: 28081937]
28. Seile A, Klaas V, T ös e G, Fagundes CP. eHeal h and mHeal h in e en ions in he ea men o a igued cance su i o s:
a sys ema ic e iew and me a-analysis. Psychooncology 2017;26(9):1239-1253. [doi: 10.1002/pon.4489] [Medline: 28665554]
29. Habe lin C, O'Dwye T, Mockle D, Mo an J, O'Donnell DM, B ode ick J. The use o eHeal h o p omo e physical ac i i y
in cance su i o s: a sys ema ic e iew. Suppo Ca e Cance 2018;26(10):3323-3336. [doi: 10.1007/s00520-018-4305-z]
[Medline: 29909476]
30. F id iksdo i N, Gunna sdo i S, Zoëga S, Ingado i B, Ha s einsdo i EJ. E ec s o Web-based in e en ions on cance
pa ien s' symp oms: e iew o andomized ials. Suppo Ca e Cance 2018;26(2):337-351. [doi: 10.1007/s00520-017-3882-6]
[Medline: 28921391]
31. Dozeman E, Ve donck-de Leeuw IM, Sa a d J, an S a en A. Guided web-based in e en ion o insomnia a ge ing b eas
cance pa ien s: easibili y and e ec . In e ne In e 2017;9:1-6 [FREE Full ex ] [doi: 10.1016/j.in en .2017.03.005]
[Medline: 30135831]
32. Zacha iae R, Amidi A, Damhold MF, Clausen CD, Dahlgaa d J, Lo d H, e al. In e ne -deli e ed cogni i e-beha io al
he apy o insomnia in b eas cance su i o s: a andomized con olled ial. J Na l Cance Ins 2018;110(8):880-887
[FREE Full ex ] [doi: 10.1093/jnci/djx293] [Medline: 29471478]
33. Kang HS, Kim HK, Pa k SM, Kim JH. Online-based in e en ions o sexual heal h among indi iduals wi h cance : a
sys ema ic e iew. BMC Heal h Se Res 2018;18(1):167 [FREE Full ex ] [doi: 10.1186/s12913-018-2972-6] [Medline:
29514669]
34. La son JL, Rosen AB, Wilson FA. The e ec o eleheal h in e en ions on quali y o li e o cance pa ien s: a sys ema ic
e iew and me a-analysis. Telemed J E Heal h 2018;24(6):397-405. [doi: 10.1089/ mj.2017.0112] [Medline: 29112484]
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 17h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X
35. T ibe i S, Sa ioni L, Seb i V, P a e oni G. eHeal h o imp o ing quali y o li e in b eas cance pa ien s: a sys ema ic
e iew. Cance T ea Re 2019;74:1-14. [doi: 10.1016/j.c .2019.01.003] [Medline: 30658289]
36. McAlpine H, Joube L, Ma in-Sanchez F, Me olli M, D ummond K. A sys ema ic e iew o ypes and e icacy o online
in e en ions o cance pa ien s. Pa ien Educ Couns 2015;98(3):283-295. [doi: 10.1016/j.pec.2014.11.002] [Medline:
25535016]
37. Lyon AR, Koe ne K. Use -cen e ed design o psychosocial in e en ion de elopmen and implemen a ion. Clin Psychol
(New Yo k) 2016;23(2):180-200 [FREE Full ex ] [doi: 10.1111/cpsp.12154] [Medline: 29456295]
38. an Geme -Pijnen JE, Nijland N, an Limbu g M, Ossebaa d HC, Kelde s SM, Eysenbach G, e al. A holis ic amewo k
o imp o e he up ake and impac o eHeal h echnologies. J Med In e ne Res 2011;13(4):e111 [FREE Full ex ] [doi:
10.2196/jmi .1672] [Medline: 22155738]
39. Sho CE, Reba AL, Plo niko RC, Vandelano e C. Designing engaging online beha iou change in e en ions: a p oposed
model o use engagemen . Eu Heal h Psychol 2015;17(1):32-38 [FREE Full ex ]
40. Ni sch M, Dimopoulos CN, Flaschbe ge E, Sa an K, K uge JF, Ga lock L, e al. A guided online and mobile sel -help
p og am o indi iduals wi h ea ing diso de s: an i e a i e engagemen and usabili y s udy. J Med In e ne Res 2016;18(1):e7
[FREE Full ex ] [doi: 10.2196/jmi .4972] [Medline: 26753539]
41. Ca lb ing P, Mau in L, Tö ng en C, Linna E, E iksson T, Spa han E, e al. Indi idually- ailo ed, In e ne -based ea men
o anxie y diso de s: a andomized con olled ial. Beha Res The 2011;49(1):18-24. [doi: 10.1016/j.b a .2010.10.002]
[Medline: 21047620]
42. Jaspe K, Weise C, Con ad I, Ande sson G, Hille W, Kleins äube M. In e ne -based guided sel -help e sus g oup cogni i e
beha io al he apy o ch onic inni us: a andomized con olled ial. Psycho he Psychosom 2014;83(4):234-246. [doi:
10.1159/000360705] [Medline: 24970708]
43. Ande sson G, Hesse H, Veilo d A, S edling L, Ande sson F, Sleman O, e al. Randomised con olled non-in e io i y ial
wi h 3-yea ollow-up o in e ne -deli e ed e sus ace- o- ace g oup cogni i e beha iou al he apy o dep ession. J A ec
Diso d 2013;151(3):986-994. [doi: 10.1016/j.jad.2013.08.022] [Medline: 24035673]
44. Buh man M, Skoglund A, Husell J, Be gs öm K, Go dh T, Hu s i T, e al. Guided in e ne -deli e ed accep ance and
commi men he apy o ch onic pain pa ien s: a andomized con olled ial. Beha Res The 2013;51(6):307-315. [doi:
10.1016/j.b a .2013.02.010] [Medline: 23548250]
45. Lundg en JG, Dahls öm Ö, Ande sson G, Jaa sma T, Kä ne Köhle A, Johansson P. The e ec o guided Web-based
cogni i e beha io al he apy on pa ien s wi h dep essi e symp oms and hea ailu e: a pilo andomized con olled ial. J
Med In e ne Res 2016;18(8):e194 [FREE Full ex ] [doi: 10.2196/jmi .5556] [Medline: 27489077]
46. Denlinge CS, San T, Bake KS, B ode ick G, Dema k-Wahne ied W, F iedman DL, e al. Su i o ship, e sion 2.2018,
NCCN clinical p ac ice guidelines in oncology. J Na l Comp Canc Ne w 2018;16(10):1216-1247 [FREE Full ex ] [doi:
10.6004/jnccn.2018.0078] [Medline: 30323092]
47. NCCN guidelines o pa ien s®: in asi e b eas cance . Na ional Comp ehensi e Cance Ne wo k. 2020. URL: h ps:/
/www.nccn.o g/pa ien s/guidelines/con en /PDF/b eas -in asi e-pa ien .pd [accessed 2022-01-30]
48. Hayes SC, Pis o ello J, Le in ME. Accep ance and commi men he apy as a uni ied model o beha io change. Couns
Psychol 2012;40(7):976-1002 [FREE Full ex ] [doi: 10.1177/0011000012460836]
49. Eu opean Socie y o Medical Oncology. Canc o da mama: um guia pa a o doen e - In o mações baseadas nas Di e izes
de P á ica Clínica da ESMO - .2013.1. Eu opean Socie y o Medical Oncology. 2013. URL: h ps://www.esmo.o g/
con en /download/20414/340350/ ile/canc o-da-mama-un-guia-pa a-o-doen e-esmo.pd [accessed 2021-07-29]
50. Runowicz CD, Leach CR, Hen y NL, Hen y KS, Mackey HT, Cowens-Al a ado RL, e al. Ame ican cance socie y/Ame ican
socie y o clinical oncology b eas cance su i o ship ca e guideline. J Clin Oncol 2016;34(6):611-635. [doi:
10.1200/JCO.2015.64.3809] [Medline: 26644543]
51. Mendes-San os C, Weide pass E, San ana R, Ande sson G. Po uguese psychologis s' a i udes owa d In e ne in e en ions:
explo a o y c oss-sec ional s udy. JMIR Men Heal h 2020;7(4):e16817 [FREE Full ex ] [doi: 10.2196/16817] [Medline:
32250273]
52. Mendes-San os C, Nunes F, Weide pass E, San ana R, Ande sson G. Mapping men al heal h p o essionals' pe spec i es
and p ac ices ega ding he implemen a ion o Digi al Men al Heal h: a quali a i e s udy. JMIR Fo m Res. P ep in pos ed
online on Augus 2, 2021. [doi: 10.2196/p ep in s.32558]
53. Oinas-Kukkonen H, Ha jumaa M. Pe suasi e sys ems design: key issues, p ocess model, and sys em ea u es. Commun
Assoc In Sys 2009;24(1):28 [FREE Full ex ] [doi: 10.17705/1cais.02428]
54. Vlaescu G, Alasjö A, Milo A, Ca lb ing P, Ande sson G. Fea u es and unc ionali y o he I e api pla o m o in e ne -based
psychological ea men . In e ne In e 2016;6:107-114. [doi: 10.1016/j.in en .2016.09.006] [Medline: 30135819]
55. Hennink MM, Kaise BN, Ma coni VC. Code sa u a ion e sus meaning sa u a ion: how many in e iews a e enough?
Qual Heal h Res 2017;27(4):591-608. [doi: 10.1177/1049732316665344] [Medline: 27670770]
56. Ma ins AI, Rosa AF, Quei ós A, Sil a A, Rocha NP. Eu opean Po uguese alida ion o he sys em usabili y scale (SUS).
P ocedia Compu Sci 2015;67:293-300 [FREE Full ex ] [doi: 10.1016/j.p ocs.2015.09.273]
57. Jaspe s MW, S een T, an den Bos C, Geenen M. The hink aloud me hod: a guide o use in e ace design. In J Med
In o m 2004;73(11-12):781-795. [doi: 10.1016/j.ijmedin .2004.08.003] [Medline: 15491929]
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 18h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X
58. oT ansc ibe: a ee web app o ake he pain ou o ansc ibing eco ded in e iews. oT ansc ibe. URL: h p://o ansc ibe.
com/be a/ [accessed 2022-01-31]
59. B aun V, Cla ke V. Using hema ic analysis in psychology. Qual Res Psychol 2006;3(2):77-101 [FREE Full ex ] [doi:
10.1191/1478088706qp063oa]
60. Sc i ene . Li e a u e and La e. URL: h ps://www.li e a u eandla e.com/sc i ene /o e iew [accessed 2022-01-30]
61. Mullan F. Seasons o su i al: e lec ions o a physician wi h cance . N Engl J Med 1985;313(4):270-273. [doi:
10.1056/NEJM198507253130421] [Medline: 4010738]
62. Zahabi M, Kabe DB, Swangne M. Usabili y and sa e y in elec onic medical eco ds in e ace design: a e iew o ecen
li e a u e and guideline o mula ion. Hum Fac o s 2015;57(5):805-834. [doi: 10.1177/0018720815576827] [Medline:
25850118]
63. Fi ch M, Zome S, Lockwood G, Louzado C, Shaw Moxam R, Rahal R, e al. Expe iences o adul cance su i o s in
ansi ions. Suppo Ca e Cance 2019;27(8):2977-2986 [FREE Full ex ] [doi: 10.1007/s00520-018-4605-3] [Medline:
30588549]
64. Kapoo A, Nambisan P. Usabili y and accep ance e alua ion o ACESO: a Web-based b eas cance su i o ship ool. J
Cance Su i 2018;12(3):316-325. [doi: 10.1007/s11764-017-0670-8] [Medline: 29372486]
65. Smi h AB, Bamgboje-Ayodele A, Bu ow P, Klein B, Tu ne J, Sha pe L, iConque Fea Communi y Ad iso y G oup, e
al. De elopmen and usabili y e alua ion o an online sel -managemen in e en ion o ea o cance ecu ence
(iConque Fea ). Psychooncology 2020;29(1):98-106. [doi: 10.1002/pon.5218] [Medline: 31483911]
66. O'Malley DM, Da is SN, De ine KA, Sulli an B, Ba o A, Clemow L, e al. De elopmen and usabili y es ing o he
e-EXCELS ool o guide cance su i o ship ollow-up ca e. Psychooncology 2020;29(1):123-131 [FREE Full ex ] [doi:
10.1002/pon.5222] [Medline: 31626397]
67. Lange L, Fink J, Bleich C, G ae en M, Schulz H. E ec i eness, accep ance and sa is ac ion o guided cha g oups in
psychosocial a e ca e o ou pa ien s wi h p os a e cance a e p os a ec omy. In e ne In e 2017;9:57-64 [FREE Full
ex ] [doi: 10.1016/j.in en .2017.06.001] [Medline: 30135838]
68. Mo adian S, K zyzanowska MK, Magui e R, Mo i a PP, Kuk e i V, A e y J, e al. Usabili y e alua ion o a mobile
phone-based sys em o emo e moni o ing and managemen o chemo he apy- ela ed side e ec s in cance pa ien s:
mixed-me hods s udy. JMIR Cance 2018;4(2):e10932 [FREE Full ex ] [doi: 10.2196/10932] [Medline: 30578238]
69. Bad H, Lipnick D, Die enbach MA, Posne M, Ko z T, Miles B, e al. De elopmen and usabili y es ing o a web-based
sel -managemen in e en ion o o al cance su i o s and hei amily ca egi e s. Eu J Cance Ca e (Engl)
2016;25(5):806-821 [FREE Full ex ] [doi: 10.1111/ecc.12396] [Medline: 26507369]
70. Leach CR, Die enbach MA, Flesza S, Al ano CM, S ephens RL, Riehman K, e al. A use cen e ed design app oach o
de elopmen o an online sel -managemen p og am o cance su i o s: Sp ingboa d Beyond Cance . Psychooncology
2019;28(10):2060-2067. [doi: 10.1002/pon.5193] [Medline: 31379069]
71. Igels öm H, Hau man A, Al onsson S, Sjös öm J, Cajande Å, Johansson B. Use expe iences o an In e ne -based
s epped-ca e in e en ion o indi iduals wi h cance and concu en symp oms o anxie y o dep ession ( he U-CARE
Adul Can T ial): quali a i e s udy. J Med In e ne Res 2020;22(5):e16604 [FREE Full ex ] [doi: 10.2196/16604] [Medline:
32427108]
72. Wagne LI, Du ecy J, Begale M, Vic o son D, Golden SL, Smi h ML, e al. De elopmen and e inemen o FoR i ude:
an eHeal h in e en ion o educe ea o ecu ence among b eas cance su i o s. Psychooncology 2020;29(1):227-231.
[doi: 10.1002/pon.5297] [Medline: 31760667]
73. Bø øsund E, Mi ko ic J, Cla k MM, Ehle s SL, And ykowski MA, Be gland A, e al. A s ess managemen app in e en ion
o cance su i o s: design, de elopmen , and usabili y es ing. JMIR Fo ma i Res 2018;2(2):e19. [doi:
10.2196/ o ma i e.9954] [Medline: 30684438]
74. Kuijpe s W, G oen WG, Oldenbu g HS, Wou e s MW, Aa onson NK, an Ha en WH. De elopmen o MijnAVL, an
in e ac i e po al o empowe b eas and lung cance su i o s: an i e a i e, mul i-s akeholde app oach. JMIR Res P o oc
2015;4(1):e14 [FREE Full ex ] [doi: 10.2196/ esp o .3796] [Medline: 25614924]
75. Rink J. Rhapsody. In: Sadie S, Ty ell J, edi o s. The new g o e dic iona y o music and musicians. 2nd Edi ion. London:
Macmillan Publishe s; 2001.
76. Woo en AC, Abbo JA, Chisholm K, Aus in DW, Klein B, McCabe M, e al. De elopmen , easibili y and usabili y o an
online psychological in e en ion o men wi h p os a e cance : my oad ahead. In e ne In e 2014;1(4):188-195 [FREE
Full ex ] [doi: 10.1016/j.in en .2014.10.001]
77. Bea y L, Koczwa a B, Bu ow P, Tu ne J, Gi gis A, Scho ield P, e al. De elopmen and usabili y es ing o a web-based
psychosocial in e en ion o women li ing wi h me as a ic b eas cance : inding my way-ad anced. J Cance Su i
2021;15(3):403-409. [doi: 10.1007/s11764-021-01019-5] [Medline: 33723741]
78. Mendes-San os C, Weide pass E, San ana R, Ande sson G. A guided in e ne -deli e ed indi idually- ailo ed ACT-in luenced
cogni i e beha iou al in e en ion o imp o e psychosocial ou comes in b eas cance su i o s (iNNOVBC): s udy p o ocol.
In e ne In e 2019;17:100236 [FREE Full ex ] [doi: 10.1016/j.in en .2019.01.004] [Medline: 30949435]
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 19h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X
79. Mi anda A, Maye -da-Sil a A, Gló ia L, B i o C. Regis o Oncológico Nacional: de Todos os Tumo es na População
Residen e em Po ugal, em 2018. Regis o Oncológico Nacional. 2018. URL: h ps:// on.min-saude.p /media/2196/
2021-0518_publica%C3%A7%C3%A3o- on_2018.pd [accessed 2022-01-30]
80. Nielsen J, Landaue TK. A ma hema ical model o he inding o usabili y p oblems. In: P oceedings o he INTERACT
'93 and CHI '93 Con e ence on Human Fac o s in Compu ing Sys ems. New Yo k: Associa ion o Compu ing Machine y;
1993 P esen ed a : CHI '93; Ap il 24-29, 1993; New Yo k p. 206-213 URL: h ps://doi.o g/10.1145/169059.169166 [doi:
10.1145/169059.169166]
Abb e ia ions
ACT: accep ance and commi men he apy
BCS: b eas cance su i o
CBT: cogni i e beha io al he apy
DMH: digi al men al heal h
HRQoL: heal h- ela ed quali y o li e
iNNOVBC: iNNOV B eas Cance
MHP: men al heal h p o essional
Edi ed by A Ma agani; submi ed 12.09.21; pee - e iewed by M P i cha d, T Cai; commen s o au ho 05.01.22; e ised e sion
ecei ed 07.01.22; accep ed 12.01.22; published 15.02.22
Please ci e as:
Mendes-San os C, Nunes F, Weide pass E, San ana R, Ande sson G
De elopmen and E alua ion o he Use ulness, Usabili y, and Feasibili y o iNNOV B eas Cance : Mixed Me hods S udy
JMIR Cance 2022;8(1):e33550
URL: h ps://cance .jmi .o g/2022/1/e33550
doi: 10.2196/33550
PMID:
©C is ina Mendes-San os, F ancisco Nunes, Elisabe e Weide pass, Rui San ana, Ge ha d Ande sson. O iginally published in
JMIR Cance (h ps://cance .jmi .o g), 15.02.2022. This is an open-access a icle dis ibu ed unde he e ms o he C ea i e
Commons A ibu ion License (h ps://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and
ep oduc ion in any medium, p o ided he o iginal wo k, i s published in JMIR Cance , is p ope ly ci ed. The comple e
bibliog aphic in o ma ion, a link o he o iginal publica ion on h ps://cance .jmi .o g/, as well as his copy igh and license
in o ma ion mus be included.
JMIR Cance 2022 | ol. 8 | iss. 1 | e33550 | p. 20h ps://cance .jmi .o g/2022/1/e33550 (page numbe no o ci a ion pu poses)
Mendes-San os e alJMIR CANCER
XSL
•
FO
Rende X