Title: Adapting a smartphone-based rehabilitation programme for older adults living with and beyond cancer: a development study using Intervention Mapping
Funder: Department of Health and Social Care

Abstract: Background & Aim Older adults living with and beyond cancer (LWBC) have greater risk of other cancers, other chronic diseases, and functional decline compared to those without cancer. Around two-thirds of new cancer cases each year in the UK are among those aged 65 or older; a proportion expected to grow ~40% by 2040. This represents a large and growing burden on patients, informal carers, and the healthcare system. Physical activity and wellbeing programmes improve cancer-related patient-reported outcomes, and cancer-specific and all-cause mortality. However, many older adults LWBC are not meeting minimum physical activity guidelines. Digital health programmes (using information and communications technologies to support health) show promise in delivering and supporting healthy lifestyle behaviours. Robust evidence is needed to test the efficacy of digital health programmes for implementation into standard care pathways. The purpose of this mixed-methods intervention development study is to adapt an existing, feasible, smartphone-based cardiac rehabilitation programme (REMOTE-CR) for older adults LWBC. We aim to 1) explore the needs and preferences of older adults living LWBC and exercise/healthcare professionals for a smartphone-based, tailored rehabilitation programme, 2) build a cancer-specific version of the programme based on step 1, and 3) test the usability and acceptability of the programme among this population. Methods This study addresses the development, modelling, and formative testing phases of the MRC Framework for Complex Intervention Development. We will use Intervention Mapping and the Digital Inclusion Evaluation Toolkit to guide the process. Qualitative interviews and focus groups: 30 older adults LWBC (10 each age group; 65-74, 75-84, 85+) and 20 healthcare professionals (HCPs) will be recruited to explore desired goals and outcomes, and necessary adaptations to the existing REMOTE-CR programme. All interviews will be conducted via video or telephone. Interviews and focus groups will be recorded and transcribed verbatim. Data will be analysed using a thematic framework, using a deductive and inductive approach. Themes will guide the mapping of intervention components to desired outcomes. Usability Testing: The existing REMOTE-CR software platform will be adapted for older adults LWBC to produce a functional cancer-specific prototype (REMOTE-C) ready for usability testing. Ten older adults LWBC will be recruited to participate in three rounds of formative user testing. Participants will complete a series of tasks with the aim of identifying usability challenges and design problems, and solutions maximising overall user experience. Primary outcomes will be perceived ease of use and perceived usefulness of the intervention components measured by the Technology Acceptance Model. Route to Definitive Trial This study will deliver a co-adapted smartphone-based wellbeing programme with older adults LWBC ready for feasibility testing. The next step will be a two-site, feasibility randomised controlled trial (RCT) to determine whether a definitive trial is feasible, perform summative usability testing, and explore the potential magnitude for a signal of benefit in patient reported outcomes (to be submitted to NIHR RfPB). If the feasibility RCT meets pre-determined progression criteria, we will continue to a multi-site, definitive evaluation phase trial (to be submitted to NIHR HTA) commencing within the next five years.

Lay abstract: The number of people living with and beyond cancer is growing; many are over 65 years old who often have different and more complicated healthcare needs than younger people. Being active is one of the best things people with, or who have had, cancer can do to help avoid future cancer. Research shows we could have fewer cancer cases, cancer-related deaths, and healthcare costs if people were more physically active. Regular physical activity, together with healthy eating, helps people maintain their daily activities and improves their energy levels and quality of life. However, many older adults living with or beyond cancer are inactive with an unhealthy diet. Supervised activity programmes improve health short-term, but less so longer-term, and the pandemic has restricted available support. Recent studies have used technologies like smartphones and wearable devices to deliver unsupervised programmes, but these show smaller benefits. More research into how lifestyle behaviours can help cancer recovery is urgently needed (a Top 10 Patient Priority (James Lind Alliance)) and remote delivery is being encouraged by the NHS. Our own research and patient and public involvement (PPI) work shows most older adults with cancer would like a personalised wellbeing programme. However, there are obstacles to overcome in such a programme, such as patients not knowing what is safe or having enough feedback from healthcare professionals. We plan to work with 30 older adults living with and beyond cancer to learn about what is important to them, their daily activities, and their needs and preferences for a personalised smartphone-based wellbeing programme. We want to find out what support and education would encourage them to use such a programme. We will also talk to practitioners to learn their perspective. Insights and suggestions from study participant perspectives will be incorporated into a cancer-specific version of a smartphone-based programme shown to be effective in heart disease rehabilitation. We will then complete user testing with 10 older adults living with and beyond cancer. We have met with our PPI group members to discuss the importance of our proposed work. They have contributed to the study design, been involved in writing and reviewing the lay summary, and will take part in co-producing the project. Members of the PPI group Involve Hull are working with us on a number of projects and are keen to continue our established working relationship. At the end of this study, we will have developed a personalised smartphone-based programme for older adults living with and beyond cancer, and completed user testing to understand if it could help this population manage and improve their everyday wellbeing. The programme will then be ready to use in an early clinical trial to look for signs of patient benefit.

Research activity codes: 6.7 PHYSICAL;5.7 PHYSICAL
Health categories: CANCER AND NEOPLASMS