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. 2024 May 31:10:e52386.
doi: 10.2196/52386.

Engagement With a Relaxation and Mindfulness Mobile App Among People With Cancer: Exploratory Analysis of Use Data and Self-Reports From a Randomized Controlled Trial

Sonja Schläpfer  1 , Fabian Schneider  2 , Prabhakaran Santhanam  2 , Manuela Eicher  3   4 , Tobias Kowatsch  2   5   6 , Claudia M Witt  1 , Jürgen Barth  1
Affiliations

Engagement With a Relaxation and Mindfulness Mobile App Among People With Cancer: Exploratory Analysis of Use Data and Self-Reports From a Randomized Controlled Trial

Sonja Schläpfer et al. JMIR Cancer. .

Abstract

Background: Mobile health (mHealth) apps offer unique opportunities to support self-care and behavior change, but poor user engagement limits their effectiveness. This is particularly true for fully automated mHealth apps without any human support. Human support in mHealth apps is associated with better engagement but at the cost of reduced scalability.

Objective: This work aimed to (1) describe the theory-informed development of a fully automated relaxation and mindfulness app to reduce distress in people with cancer (CanRelax app 2.0), (2) describe engagement with the app on multiple levels within a fully automated randomized controlled trial over 10 weeks, and (3) examine whether engagement was related to user characteristics.

Methods: The CanRelax app 2.0 was developed in iterative processes involving input from people with cancer and relevant experts. The app includes evidence-based relaxation exercises, personalized weekly coaching sessions with a rule-based conversational agent, 39 self-enactable behavior change techniques, a self-monitoring dashboard with gamification elements, highly tailored reminder notifications, an educational video clip, and personalized in-app letters. For the larger study, German-speaking adults diagnosed with cancer within the last 5 years were recruited via the web in Switzerland, Austria, and Germany. Engagement was analyzed in a sample of 100 study participants with multiple measures on a micro level (completed coaching sessions, relaxation exercises practiced with the app, and feedback on the app) and a macro level (relaxation exercises practiced without the app and self-efficacy toward self-set weekly relaxation goals).

Results: In week 10, a total of 62% (62/100) of the participants were actively using the CanRelax app 2.0. No associations were identified between engagement and level of distress at baseline, sex assigned at birth, educational attainment, or age. At the micro level, 71.88% (3520/4897) of all relaxation exercises and 714 coaching sessions were completed in the app, and all participants who provided feedback (52/100, 52%) expressed positive app experiences. At the macro level, 28.12% (1377/4897) of relaxation exercises were completed without the app, and participants' self-efficacy remained stable at a high level. At the same time, participants raised their weekly relaxation goals, which indicates a potential relative increase in self-efficacy.

Conclusions: The CanRelax app 2.0 achieved promising engagement even though it provided no human support. Fully automated social components might have compensated for the lack of human involvement and should be investigated further. More than one-quarter (1377/4897, 28.12%) of all relaxation exercises were practiced without the app, highlighting the importance of assessing engagement on multiple levels.

Keywords: adherence; app development; behavior change; cancer; chatbot; conversational agent; digital health; eHealth; fully automated; implementation; mHealth; mobile health; mobile phone; self-care; self-guided; smartphone; tailoring; unguided.

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Conflict of interest statement

Conflicts of Interest: ME received institutional research grants from Kaiku Health, reports grants from Bristol Myers Squibb and Roche, and institutional fees as a Scientific Advisory. ME is also a Board Member and Consultant from Roche, outside the submitted work. CMW has active research grants to the university for digital health projects from the DIZH, the Swiss Cancer Research foundation, the German health care Innovation Fund, and Newsenselab GmbH. CMW also received honoraria from Swiss hospitals for scientific presentations on digitalization and AI in medicine and integrative oncology. TK, FS, and PS are developers and promoters of the open-source software platform MobileCoach. TK, FS, and PS are affiliated with the Centre for Digital Health Interventions, a joint initiative of the Institute for Implementation Science in Health Care, University of Zurich; the Department of Management, Technology, and Economics at ETH Zurich; and the Institute of Technology Management and the School of Medicine at the University of St. Gallen. The Centre for Digital Health Interventions is funded in part by CSS, a Swiss health insurer, Mavie Next, an Austrian health insurer, and MTIP, a Swiss digital health investor. TK was also a cofounder of Pathmate Technologies, a university spin-off company that creates and delivers digital clinical pathways. However, neither CSS, Mavie Next, MTIP, nor Pathmate Technologies was involved in this study. JB received honoraria for workshops on digital health. The remaining authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Screenshot of the CanRelax app 2.0—resource library with relaxation exercises. (1) Filter for exercise characteristics (male or female voice with or without background music), (2) search results (can be scrolled for further exercises), (3) audio files, and (4) breathing training.
Figure 2
Figure 2
Screenshot of the CanRelax app 2.0—interaction with the conversational agent Lumy (reviewing and adjusting goals). (1) Lumy: “Well done, Robin. Now let’s talk about the goal you want to set for yourself in the coming weeks.” (2) Answer options: “Okay” or “I prefer to skip this part.”.
Figure 3
Figure 3
Screenshot of the CanRelax app 2.0—dashboard. (1) Intervention start date, current week, and next chat appointment with Lumy; (2) collected points in the current and previous week and in total; and (3) personal relaxation goals (number of relaxation exercises) in the current and previous week and outcome goal of the participant.
Figure 4
Figure 4
Theoretical framework and operationalization of the CanRelax app 2.0.
Figure 5
Figure 5
Comparison of completed relaxation exercises and completed coaching sessions in the high-distress group versus the low-distress group (N=100).
Figure 6
Figure 6
Comparison of completed relaxation exercises and completed coaching sessions in the high-distress group versus the low-distress group for 3 subgroups (N=100).
See this image and copyright information in PMC

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