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Original Paper

A Stress Management App Intervention for Cancer Survivors:
Design, Development, and Usability Testing
Elin Børøsund1, PhD, RN; Jelena Mirkovic1, PhD; Matthew M Clark2, PhD, ABPP, LP; Shawna L Ehlers2, PhD,
ABPP, LP; Michael A Andrykowski3, PhD; Anne Bergland1, MS, RN; Marianne Westeng1, MS, RN; Lise Solberg
Nes1,2,4, PhD, LP
1

Center for Shared Decision Making and Collaborative Care Research, Division of Medicine, Oslo University Hospital, Oslo, Norway

2

Department of Psychiatry and Psychology, College of Medicine and Science, Mayo Clinic, Rochester, MN, United States

3

Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, KY, United States

4

Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway

Corresponding Author:
Elin Børøsund, PhD, RN
Center for Shared Decision Making and Collaborative Care Research
Division of Medicine
Oslo University Hospital
PO Box 4950 Nydalen
Oslo, 0424
NorwayPhone: 47 92667262
Fax: 47 23075450
Email: elin.borosund@rr-research.no

Abstract
Background: Distress is prevalent in cancer survivors. Stress management interventions can reduce distress and improve qualityof life for cancer patients, but many people with cancer are unfortunately not offered or able to attend such in-person stressmanagement interventions.
Objective: The objective of this study was to develop an evidence-based stress management intervention for patients livingwith cancer that can be delivered electronically with wide reach and dissemination. This paper describes the design and development
process of a technology-based stress management intervention for cancer survivors, including the exploration phase, intervention
content development, iterative software development (including design, development, and formative evaluation of low- andhigh-level prototypes), and security and privacy considerations.
Methods: Design and development processes were iterative and performed in close collaboration with key stakeholders (N=48).
In the exploration phase, identifying needs and requirements for the intervention, 28 participants gave input, including male andfemale cancer survivors (n=11) representing a wide age range (31-81 years) and cancer diagnoses, healthcare providers (n=8)
including psychosocial oncology experts, and eHealth experts (n=9) including information technology design and developers.
To ensure user involvement in each phase various user-centered design and service design methods were included, such as
interviews, usability testing, and think aloud processes. Overall, participants were involved usability testing in the softwaredevelopment and formative evaluation phase, including cancer survivors (n=6), healthy volunteers (n=7), health care providers(n=2), and eHealth experts (n=5). Intervention content was developed by stress management experts based on well-known
cognitive behavioral stress management strategies and adjusted to electronic format through multiple iterations with stakeholders.
Privacy and security issues were considered throughout.
Results: The design and development process identified a variety of stakeholder requirements. Cancer survivors preferred stressmanagement through a mobile app rather than through a personal computer (PC) and identified usefulness, easy access, user
friendliness, use of easily understandable language, and many brief sections rather than longer ones as important components of
the intervention. These requirements were also supported by recommendations from health care providers and eHealth experts.
The final intervention was named StressProffen and the hospital Privacy and Security Protection Committee was part of the final
intervention approval to also ensure anchoring in the hospital organization.

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Conclusions: Interventions, even evidence-based, have little impact if not actively used. This study illustrates how user-centered
design and service design can be applied to identify and incorporate essential stakeholder aspects in the entire design anddevelopment process. In combination with evidence-based concepts, this process facilitated development of a stress management
intervention truly designed for the end users, in this case, cancer survivors.
Trial Registration: ClinicalTrials.gov NCT02939612; https://clinicaltrials.gov/ct2/show/NCT02939612 (Archived at WebCite
at http://www.webcitation.org/71l9HcfcB)(JMIR Formativ Res 2018;2(2):e19) doi: 10.2196/formative.9954
KEYWORDS
stress management; mindfulness; cancer; eHealth; mHealth; mobile apps; development; usability; user-centered design; mobile
phonesIntroduction
Cancer diagnoses and subsequent treatments can be disruptive
and traumatic, often accompanied by a multitude of stressors
for the cancer patients and their support network [1-3].
Uncertainty of outcome and medical procedures with adverse
side effects are not uncommon, and although people differ
widely in how they experience and cope with such challenges,
cancer-related distress, including worry, anxiety, depression,and reduced quality of life (QoL), are prevalent [2,4,5].
Fortunately, cancer survival rates are improving, but
survivorship is accompanied by long-term health challenges,
and many survivors struggle to cope and maintain a positive
QoL [6,7].
Psychosocial cognitive behavioral stress management
interventions are usually delivered face-to-face, either as
individual or group interventions. They are widely recognized
as effective, well documented, structured, and multidisciplinary,focusing on specific strategies to improve physical, social,emotional, functional, and overall well-being [4,8-13]. Theinterventions are based on the cognitive behavioral therapeuticmodels and address factors related to cognitive, emotional, andbehavioral aspects that might enhance coping, including but notlimited to educational information, problem-solving skills,
self-care strategies, thought awareness and mood management,
health behavior change, communication strategies, social
support, and relaxation and mindfulness training. Such
psychosocial cognitive behavioral stress management
interventions have been shown to facilitate psychological
adaptation to cancer, including reducing distress, anxiety,negative affects, and depression, as well as improving QoL incancer patients and survivors [4,8-10,12,13]. These positive
findings are also supported by reviews and meta-analyses[14-20]. Some of the psychosocial cognitive behavioral stressmanagement interventions for cancer patients and survivors
have even been shown to have beneficial effects on immune
markers [8,21,22], and there are indications that cancer
recurrence and survival rates may also be positively affected[20,23].
Unfortunately, face-to-face psychosocial interventions are notalways offered or easily available to the cancer survivor. In
addition, patients with cancer face many demands and stressors,often feel overwhelmed, and may be reluctant to take on the
additional commitment of attending and engaging in
psychosocial intervention programs [13]. If psychosocial
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interventions are unavailable or attending in-person services
appears too challenging despite unmet needs, innovative
thinking is needed about how psychosocial challenges can beaddressed and coping skills supported in a format that is
appealing and available to cancer survivors.
With the rapid advance of technology, the evolving concept ofeHealth encompasses a range of systems or services in a novel
cross-section between medicine, health care, and information
technology. eHealth solutions have the potential to provide
support anytime and anywhere, which again can facilitate ways
to reach, service, and intervene when most needed or convenient
for the cancer trajectory [24]. Development and testing of
psychosocial eHealth interventions programs for cancer
survivors are still at an early stage, and evidence of the effectsof eHealth interventions so far are mixed. A meta-review
identified eHealth interventions to have positive links toperceived support, knowledge, and information competence
among cancer patients but found inconsistent or lacking results
for areas such as psychological well-being and QoL [25].
Another systematic review examining the use of Web-based
resources for adult cancer survivors also found efficacy to varywith some positive effects on QoL and related psychosocial
factors but overall mixed efficacy and limited duration of benefit[26]. Examples of promising findings include improved
self-efficacy for coping with cancer through the use of a
Web-based stress management workbook for breast cancer
patients [27], improved QoL and physical activity for breast
cancer survivors through use of a Web-based portal [28], andimproved QoL and reduced distress for newly diagnosed patientswith cancer through use of a Web-based structured Web-based
stress management program guided by psychologists [29]. There
are indications that the therapist-guided eHealth interventions
may be more effective than self-guided interventions [30]. Withpromising yet mixed results, some investigators and clinicians
have called for more use of evidence-based interventions andrigorous monitoring of program impact for future eHealthintervention research in cancer [26]. Even though several studies
report on results from psychosocial interventions delivered via
the internet, Web, or Web-based sources, few, if any, have
explored building and testing app-based psychosocial
interventions for cancer survivors. A recent review of available
breast cancer apps concluded that most such apps appear to belacking evidence and an evidence base and that health careproviders, not just start-up companies and entrepreneurs, should
be included in such developments [31].
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JMIR FORMATIVE RESEARCHThis study reports on the design and development of atechnology- and app-based stress management intervention forcancer survivors. The study combined well-established cognitive
behavioral stress management concepts shown to be effective
for patients with cancer in face-to-face interventions[4,8-10,12,13,32,33] with a user-centered design approach toensure that the intervention was designed in line with users’
needs and context of use. The main philosophy behind theuser-centered design approach is to include users in the designand development process and allow system end users to
influence how the product takes shape [34,35]. To support thisprocess, the user-centered design provides a variety of methods
enabling user involvement in different phases of developmentwith different levels of user engagement. Service design isanother approach to system design, focusing on service
development. This approach focuses on the entire ecosystemand experiences around it (eg, how it is used, by whom, when,
and where) rather than the end product alone [36]. This study
combined the user-centered and service design approaches toenable stakeholder involvement throughout the entire designand development process. This was done to ensure interventionalignment with the needs and requirements of cancer survivors
and health care professionals alike. The ultimate goal was tohave an end product that is both user friendly and useful andalso engaging and motivating and that fits into the bigger context
of the everyday life and challenges of people living with cancer.
Cancer survivors, health care providers, including psychosocial
oncology specialists, and eHealth experts were actively involvedin the entire process.

Methods
Overview
The design and development process encompassed amultidisciplinary approach and continuous systematic evaluation
throughout, as recommended in the Center for eHealth Researchand Disease Management comprehensive roadmap approach to
improve the uptake and impact of eHealth technologies [37].
The intervention development work was led by the study
principal investigator, who is a clinical psychologist with healthpsychology specialization and longstanding experience in
psychosocial oncology, stress management, and cognitive
behavioral treatment approaches for medical patients. The
multidisciplinary project team had weekly meetings during thedesign and development phase and consisted of experts in stress

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management, psychosocial oncology, eHealth research, andinformation technology (IT) developers as well as a designerand content specialists. User-centered and service design
methodologies were applied to ensure user involvement
throughout the entire design and development process. Patient
representatives, health care providers, including psychologists
and cancer nurses, and security experts were consulted
throughout.
The stress management intervention program was developedin iterative processes, as shown in Figure 1, through a
combination of exploration phase: input from user
representatives (ie, cancer survivors), health care providers, andeHealth experts including designers and developers; intervention
content development: identified and adjusted from theevidence-based cognitive behavioral stress management concept;
iterative software development and formative evaluation; and(4) privacy, security, and organization anchoring considerations.

Exploration
Input from User Representatives (Cancer Survivors)
To identify user needs and requirements of the technology-based
stress management intervention, people with any type of cancer
diagnosis were invited to participate in individual interviews.
They were recruited through the Oslo University Hospital, Oslo,
Norway, and collaborating networks, social media such as
Facebook, and through the Norwegian Cancer Society. Inclusion
criteria for participation in interviews were as follows: diagnosed
with cancer or cancer survivors, 18 years or older, and fluent
in the Norwegian language. Potential participants were given
oral and written information about the study and if interested
in participation, they were provided written informed consent
prior to study enrollment.
Participants in this phase could choose if they wanted to beinterviewed face-to-face or by telephone. They were asked about
challenges in their health situation, their use of technology (eg,smart phones; tablets; or personal computers [PCs]) and healthtechnology (eg, websites and apps), their requirements for theuse of eHealth interventions, and any suggestions they might
have for the design and development of an electronic stressmanagement intervention. Interviews were conducted by 2
representatives from the research team and audiotaped, thentranscribed focusing on essential parts, and analyzed using
content analysis [38].

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Figure 1. Development timeline.

Input from Health Care Providers and eHealth Experts
Supplementing patient user input, health care providers (ie,registered nurses and clinical psychologists) with longstanding
experience working with cancer patients were invited to act asconsultants and give input on intervention development,
including design, intervention content, and ideas on how andwhen a stress management intervention could be offered tocancer survivors. eHealth experts collaborating with the project
team with extensive experience in development ofself-management apps for chronically ill people were also
invited to give input on how the intervention could best be
designed and delivered to optimize presentation, engagement,
adherence, and potential effect.
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Intervention Content Development
Evidence-Based Content Development
A major goal of this study was to identify evidence-based factors
and areas from well-known cognitive behavioral stressmanagement strategies and then synthesize and adapt these into
a new technology-based stress management intervention forcancer survivors. When identifying concepts and factors todevelop content for this intervention, potential underlying
mechanisms, including likely mediators such as psychosocial
resources, were considered to best integrate theory, research,and practice in support of cancer survivors [8,10,15,39-41].
Such integrations have the potential to address a wide array of
issues and challenges faced by many patients with cancer.
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Adjustment to Electronic Format
Intervention content was adjusted to an electronic format tofacilitate intuitive use for the cancer survivors. Adjustments
were made in 6 iterations to ensure easy language, short
sentences, and focus on clear content for small screens.

Software Development and Formative Evaluation
Iterative Development and Low-Fidelity Prototypes
Based on needed content adjustments and stakeholder input
identified in the exploration phase, the first low-fidelity
prototype version of the software was developed. This initial
paper prototype consisted of the start page, the menu page, andscreens presenting the first intervention module design andcontent. Next, the prototype was evaluated via 4 consecutive
iterations and refined and adjusted based on user feedback, asseen in Figure 2.

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In the first iteration, eHealth experts tested and gave feedbackon the prototype to ensure that the intervention program was
logically built and would meet the stakeholder requirements.
After minor adjustments, the paper prototype was implemented
into an electronic tool for testing of paper prototypes bysimulating the app idea (Prototyping on Paper app by Marvel)[42]. Hospital-employed healthy volunteers then tested theprototype in the second iteration and provided feedback. A third
iteration, including hospital-employed healthy volunteers,
resulted in minor adjustments, and the prototype was deemed
ready for usability testing with cancer survivors. In the final
iteration, 2 female cancer survivors and one health care provider(psychologist) tested the final version of the low-fidelity
prototype. Healthy volunteers and cancer survivors were given
oral and written information about the study and provided
written informed consent prior to user testing.

Figure 2. Intervention development process and participants.

During testing, the participants were asked by a facilitator tonavigate through the prototype and describe their actions. All
movements from elbow to fingertips were filmed; using thethink aloud method, a research assistant asked follow-up
questions as the module testing progressed [43]. An observer
made notes and summarized the input from notes and the video
into a report that subsequently provided recommendations for
prototype adjustments. Following the development of a final
low-fidelity prototype, the high-fidelity prototype development
started.

Iterative Development and High-Fidelity Prototypes
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conditions of use [44]. During the high-fidelity prototype
development, the actual software start page, menu page, andfirst intervention module were built. To ensure the usability anduser need fit of the high-fidelity prototype, a new round of
iterative testing and evaluation was performed. To incorporate
the gender and age perspective, testing encompassed male andfemale participants aged 18-70 years old. Six participants wereinvolved in this iteration, as elaborated in Figure 2.
Following adjustments, the new high-fidelity prototype version
was then tested by 3 cancer survivors and a health care provider(a psychologist). During this high-fidelity prototype testing,participants were asked to go through the entire first intervention
module and comment on their movements. Testing was again
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performed through the filming of movements (elbow tofingertip), follow-up questions (eg, Can you tell me why you
are doing this? Can you find the exercise overview/mypage/settings?), note taking, and a summarizing report. Resulting
stakeholder feedback data were again used to evaluate, refine,
iteratively adjust, and upgrade the prototype. All functionalities,
content descriptions, and modules were tested, and user feedback
was obtained. Because this is a self-help program with extensive
and, at times, repetitive cognitive behavioral content, allfunctionalities, but not all content paragraphs, were user tested.

Input from User Representatives (Cancer Survivors)

Privacy, Security, and Organization Anchoring

All participants had access to a smartphone and a PC and rated
their user experience as medium to high. The majority (7/11,
64%) had access to a tablet. They all used apps, installed either
by themselves or by their children, and they used the internet
at least once a day. Mostly, they reported using the smartphone
for practical issues, communication, or distraction. Those who
used health apps preferred relaxation programs. Others had
installed health apps but had limited engagement, stating thatthey forgot to use them or lost interest after a while.

One major stakeholder in this project is the hospital (ie,organization) where the intervention is developed. To plan for
postproject implementation, the initial project idea and plan
were registered at the hospital innovation unit. This unit provides
advice for potential commercialization and anchoring in theorganization and welcomes all innovative ideas. It is arequirement to register all innovations at the hospital innovation
unit. To ensure that all privacy and security requirements wereconsidered and attended to for the project, the hospital Privacy
and Security Protection Committee was consulted at a very
early stage. Topics discussed were options to store personal andhealth-related data in the solution, local versus server data
storage, user authentication requirements, and other related
issues. All procedures, including the informed consent process,were conducted in accordance with existing ethical standards[45]. The study was approved by the hospital Privacy andSecurity Protection Committee. It describes development of theintervention that will be tested in a Randomized Controlled
Trial as registered at ClinicalTrials.gov (NCT02939612).

Results
Exploration
Participants
Cancer survivors (n=11) with a variety of cancer diagnoses
participated in individual interviews giving input on daily
challenges and support during cancer treatment, their use oftechnology and health information, and needs and requirements
for a stress management intervention program. Participants were
women (6/11, 55%) and men (5/11, 45%) aged 31-81 years old(median 54 years). Time since cancer diagnosis was 0-14 years(median 4.7 years). Most participants (8/11, 73) chose telephoneinterviews. The participants represented a variety ofdemographic factors, including gender, age, and diagnosis. Few
new topics emerged after the first 2/3 of interviews, andrecruitment was therefore completed at n=11 (saturation).
Health care providers (n=8), 3 cancer nurses and 5 psychologists
working within psychosocial oncology, eHealth experts (n=9),3 research scientists, 2 content experts, a designer, and 3
developers also gave input on when a stress management
intervention could or should be offered to cancer survivors andhow the intervention content could best be presented anddelivered.

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Participants reported a broad spectrum of everyday challenges
during cancer treatment including stress, loss of memory,
confusion about the situation, sleep disturbance, depression,
worries, new self-image, fatigue, pain, stiffness, and being
isolated from work and society or social settings. Their main
sources of social support during treatment were reported to be
family and friends, but they also reported support from healthcare providers, including nurses, psychologists, and generalpractitioners, as well as peer support through the internet.

User-reported needs and requirements for the use of an eHealthintervention can be summarized in 3 key areas. The app had tofulfill their needs as cancer survivors, be easily accessible, andbe intuitive and easy to use. When asked about the potential use
of a PC for stress management, a majority of participants
reported associating use of PC with work. When relaxing, they
preferred to use either their tablet or their smartphone. Some ofthe oldest participants (n=4; age range 51-81 years) anticipatedthat they would not use a stress management program on asmartphone owing to difficulties with a small screen. Twoparticipants preferred to use their smartphone, however, because
it was “always around” 4 participants preferred to use an app
compared with a static website because they expected an app
to be more easily accessible. Preferred presentation of theintervention content was a combination of sound files, text, anda video. Some participants expected that they would like to havea possibility to read more about the topics.

Input from Health Care Providers and eHealth Experts
It was advised that patients should wait to utilize the intervention
until minimum 1 month after receiving a cancer diagnosis andat least a few weeks after the initial cancer treatment had started.
This is often a very challenging time with patients mainly
focusing on processing the new situation and getting started
with cancer treatment as soon as possible. The intervention
could be offered at out-patient clinics, radiation treatment
clinics, and the learning and mastery units or psycho-oncology
units. Male patients were described as those who seldom attend
group interventions for stress management, and the design team
was advised to focus on a design that could appeal to male aswell as female users.
Because cancer diagnosis and subsequent treatment are often
accompanied by lack of energy, problems with concentration,
stress, and distress, it was suggested that the content is madeeasy to access and understand as possible, written in a common
nonacademic language, and made available in smaller sections
to avoid overwhelming patients. To increase engagement andadherence, it was considered essential to ensure that all
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participants could easily download the intervention. Having an
actual person, a “human contact,” connected to the technology
was also described as a potentially important factor for success.
Table 1 summarizes participant comments in the exploration
phase of the research.

Personas and Journey Map
Insights from the interviews were used to create Personas. The
use of Personas is a method from user-centered and service
design utilized to create and visualize fictional representationsof the target group [46]. Use of Personas is an effective method
for all project team members, particularly for the IT designers
and developers, to get an enhanced understanding of the target
group that the app is built for. Personas in this study contained
information about the cancer survivors’ background andchallenges, their use of technology, and their needs andrequirements for an electronic stress management intervention,
as seen in Figure 2. The Personas were used in the design anddevelopment process as a tool to ensure that user voices weretaken into account during the design and development phase;
See Figure 3 for illustrated examples of study personas.
In addition, a Journey Map (a roadmap visualizing the userinteraction with the service) [36] was created based on theinterviews and input from the multidisciplinary team with healthcare providers, eHealth experts, the designer, and IT developers(see Multimedia Appendix 1). The Journey Map was createdto visualize a common project understanding, displaying touchpoints between the user and the intervention (from the user or
patient perspective), including all potential contact points withthe project team and health care providers during the information
stage, inclusion process, app use, and follow-up.

Needs and Requirements: Decisions and Deliverables
Based on input from cancer survivors, health care providers,and eHealth experts, the research team decided that the stressmanagement intervention program would be developed as anapp made available for tablets and smartphones. This would
also facilitate offering a combination of text, sound files,
pictures, and a video. Suggestions were solicited to identify anappropriate intervention app name; with many inputs containing
the words “stress,” “management,” and “boss” or “professional,”
the final name of StressProffen was chosen. Given the describedcancer survivor difficulties, such as concentration problems andfatigue, it was also decided that the content should be presented
in smaller parts, be intuitive, and easy to navigate.

Table 1. Exploration phase: user needs and requirements.
Topics of importance to users

Cancer survivors (n=11)

Health care providers (n=8) and eHealth experts (n=9)

Content•••••

Fulfill their needs
Accessible
Easy to use
Intuitive and user friendly
Combination of sound files, text, and a video•••

Small content sections
Easy to access and understandUse of common or lay language

Design•Smartphones or tablets preferred•

Gender neutral or appeal to male and female cancer
survivors alike

Timing and place for intervention •delivery

N/Aa

•
•
•
•
•

A while after diagnosis
Out-patient clinics
Radiation treatment clinics
Learning and mastery units
Psycho-oncology service units

•

N/A

•
•
•

Easy to download
Offer log-on support
Human contact point

Engagement and adherenceaN/A: not applicable.

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Figure 3. Illustrated examples of personas. PC: personal computer.

To facilitate individual contact and increase the potential for
engagement and adherence, it was also decided that the stressmanagement intervention would include one face-to-face
introductory session where participants would also receive help
installing the app. It was also decided that participants would
receive a follow-up call during the course of the intervention.

Intervention Content Development
At the base of the StressProffen intervention are concepts fromwell-known cognitive behavioral stress management
interventions for cancer patients [8-12], including the Mayo
Clinic QoL and Stress Less Interventions [4,13,33], all guided
by theoretical models where cognitive, behavioral, social,

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personal, and environmental factors interact in guiding
motivation and behavior.
The actual initial intervention content for this study was firstdeveloped by the primary investigator, then adapted and tailoredto Norwegian conditions by the entire research team throughiterative processes (average 6 iterations per module) to fit a
10-module-based intervention in electronic format through text,
sound, video (explaining the fight-or-flight concept), andpictures. Each version was user tested to meet user requirements
described above, make the content easily accessible, confirm
adaptation to an app format, and ensure that the scientificfoundation for the intervention was intact. The iterative content
development processes were parallel to app programming, andadjustments were made based on usability testing. The final
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intervention contained a face-to-face introductory session where
StressProffen could be downloaded and installed on study
participant smartphones or tablets. Figure 4 lists and briefly
describes the 10 modules and the topics covered in each module.

Software Development and Formative Evaluation
Usability testing of the paper prototype app resulted inadjustments to ensure easier navigation, new icons, andimplementation of engaging design to stimulate adherence,

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adding optional quotes and a more visible option of listening
versus reading. In addition, to allow for individual user
preferences, it was decided that the app-based program would
allow users to mark favorite exercises, which would show up
as “My favorites-Exercises.” Individual progress would beavailable as a part of “My Page,” where participants could findtheir tracking and progress information, as seen in seen in Figure
5.

Figure 4. The StressProffen overview of modules and their content. QoL: quality of life.

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Figure 5. Paper Prototypes from development.

Following app programming and complete content
implementation, a new set of usability testing and iterations was
conducted, as described in the Methods section. Based on user
feedback in this phase, the following design recommendation
adjustments were made and used to adjust the prototype:
information should be stepwise, brief, and short (eg, presented
as maximum 3 screens of text); provide information about how
much time would be required; all modules should requireapproximately the same amount of time to complete; type ofcontent (eg, informative, a recommended practice exercise)should be easy to determine by the user; favorite exercises
should be easy to locate and access; it should be easy to choose
whether one would like to read or listen; the content should beeasy to understand and presented in common language with noacademic or medical terminology; use of animations andillustrations to create visual aids and substantiate the informationin clear and engaging manners; and recorded stress levels shouldbe easy to track in a “My page” option.
The final version showed the duration of information or
exercises (ranging from 1 to 14 minutes), and users could easily
see how long each module and section would last, as seen in
the screenshot examples in Figure 6.
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Privacy, Security, and Organization Anchoring
Security and Privacy Considerations
The StressProffen intervention program focuses on stressmanagement for cancer survivors. It was developed at and would
be distributed from a major hospital with cancer centers.
Therefore, sensitive health-type information had to be carefully
considered and protected. When asked about data protection
and security, most participants had no concerns. One participant
expressed “My life is not that exciting,” and another said “Ihave nothing to hide.” Protecting patients and patient
information is, nevertheless, the responsibility of the hospitaland health care professionals, and some of the participants did
acknowledge safety concerns and reported being careful about
what they posted about their personal information on social
media.
To address all security and privacy issues, a risk assessment of
the StressProffen intervention was evaluated and approved by
the hospital Privacy and Security Protection Committee. For
example, one security concern was that if the intervention
mentioned diagnoses (eg, cancer), this could compromise user
privacy. To ensure that patient diagnoses is not revealed if
anyone was watching or the phone or tablet lost, one alternative
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was to ask users for a pin code or password each time they wereaccessing the app. Even though this measure would protect
privacy for the users, such protection could potentially reduceease of use, which was one of the most important user
requirements, and thereby also reduce engagement, adherence,and the potential effect of the intervention. Another option was
to completely avoid the word cancer and any cancer-specificinformation in the app. Based on user input and security
recommendations, it was decided to choose the second option
and not include diagnosis-specific information.

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Anchoring the Intervention Within the Organization
To anchor the intervention within the organization, receiving
approval from the hospital Privacy and Security Protection
Committee was essential. The project was then registered withthe hospital innovation unit (ie, Idépoliklinikken). The following
topics were addressed in the registration: the potential usefulnessof the innovation for patients and providers, potential economic
impact, a prospective plan for upgrading, and responsibility forrunning the intervention program after study completion to test
intervention effects. After registration, the StressProffen app
was approved as an official Oslo University Hospital app.

Figure 6. StressProffen app screenshots.

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Discussion
Principal Findings
This study process identified a variety of stakeholder needs,
requirements, and challenges in designing and developing auser-centered evidence- and technology-based stressmanagement intervention program for cancer survivors. Cancer
is a major threat to life, health, and well-being [2,4-7], andinterviews with cancer survivors in this study underlined this,describing a multitude of stressful daily challenges including
fatigue, pain, social isolation, worries, and depression. Targetingthese issues through interventions has great potential, but theprocess of involving stakeholders in intervention design anddevelopment is fundamental [37].
Interviews with cancer survivors and feedback from health careproviders and eHealth experts in the study gave vital direction
for intervention design and development. Cancer survivors
preferred stress management through an easy-access user
friendly mobile app and identified usefulness, easily
understandable language, and brief and to the point sections asother important intervention components. These requirements
were also supported by recommendations from health careproviders and eHealth experts. Intervention content was rooted
in evidence-based cognitive behavioral stress management
strategies, synthesized, and adapted to the new StressProffen
intervention. As an easy-to-access app with evidence-based
content in 10 main modules, the intervention was divided into
briefer subsections in a variety of readable, auditory, or visualpresentations.

User Requirements
All users stressed the importance of easy access and intuitive
programming for them to use a stress management intervention
program on an ongoing basis. They also described theimportance of using an easily understandable language rather
than an academic language or difficult-to-understand medical
terminology and stressed the importance of not receiving too
much information at once but rather dividing the intervention
into smaller, more manageable parts.
A majority of participants preferred using either a tablet or
smartphone for stress management because they associated theuse of PCs with work. Age appeared to play a role in thepreferred choice of device because younger cancer survivor
users anticipated preferring smartphones due to easy access,whereas some of the older patient users (>50 years) anticipatedpreferring to use tablets due to the smaller smartphone screens.
Older age has been reported to be a barrier to the uptake of a
Web-based intervention for cancer-related distress [47].
However, once enrolled, older individuals have demonstrated
better intervention adherence. Adjusting the intervention to fit
preferences among different age groups might, therefore,
increase uptake and adherence [47].
Several cancer survivors in the study described not having any
interest in health apps, with the exception of relaxation apps
already used by some of them. Some cancer survivors describedsearching the internet for health information at times, whereas
others stated that they did not want to be scared by all the
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Børøsund et alavailable information without knowing whether the information“out there” could be trusted. This again pointed to the need forevidence-based information.

Intervention Content
Rooted in the concept of cognitive behavioral stressmanagement, the final StressProffen intervention app contains
educational material related to topics such as stress, QoL,
planning, thoughts and feelings, coping, social support, anger
management, assertiveness and communication, healthbehaviors, and setting goals. The intervention also contains avariety of exercises, including thought challenges, positive
self-talk, diaphragmatic breathing, progressive muscle
relaxation, guided imagery, mindfulness, and meditation.
Finally, the app also contains a video visualizing and explaining
the fight-or-flight concept.
Cancer-specific education material was not included because
this would have required a higher privacy and security level(eg, pin code or password log-on), subsequently impacting theuser-required aspect of easy access. Such cancer-specificmaterial would also need continuous field-related updates, which
would have been labor intensive and potentially complicate
implementation. Writing exercises were encouraged, separatelyfrom the intervention program, because typing information into
the actual app would again require higher privacy and security
levels.

Importance of User Involvement and EvidenceStressProffen as a stress management intervention program isrooted in evidence-based methods, a necessity for bringing
about change and stress reduction in cancer survivors.
Nevertheless, intervention success also depends on whether theintended users consider the app helpful and easy to use [35].
An intervention that is poorly designed, focuses on providing
too much or too little information, or complicated to use will
not have the intended effect due to low engagement, no matter
how evidence-based the stress management content is. The
opposite is also true. Although a perfectly designed andpleasurable app may be used a lot, if it is not rooted in evidence,the chance of bringing about positive change is unlikely.
Evidence-based strategies, user input, and user-friendly
technology need to work in harmony for an app to be widelyused and effective.
In this study, using service design and user-centered design
methods, involving stakeholders, including cancer survivors,
health care providers, and essential organizational units suchas the hospital Privacy and Security Protection Committee andthe Innovation unit, facilitated the identification of a range ofnecessary needs and requirements for a potentially effective
stress management app for cancer survivors. This process is inline with the Center for eHealth Research and Disease
Management comprehensive roadmap approach to improve theuptake and impact of eHealth technologies [37]. The approach
recommends multidisciplinary project management in
combination with contextual user and environmental inquiry
along with iterative design processes with end-user prototype
testing to enhance chances of future implementation success.

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Privacy and Security Aspects

barriers to continuous use over time. This will need to be further
addressed in ongoing user research. Accordingly, to refine theStressProffen intervention, a feasibility pilot is planned wherea larger number of participants will test the entire 10-moduleintervention in their own environment, complete outcome
measures to gauge preliminary effects, and participate inqualitative interviews to elaborate on user experiences. Userlog data will also be extracted to observe actual use.

An important factor contributing to use is the fact that an app
is easy to use and access [35]. The StressProffen intervention
is developed by and anchored in a large hospital withhealth-related privacy and security regulations at the forefront.
Any information considered sensitive requires a secure user
log-in procedure for user access. Therefore, StressProffen
contains no cancer-specific information and does not allow users
to write or store their own notes in the app. As such, the user
requirement of easy access was given priority over providing
cancer-specific information or advice. It remains to be
determined if this decision will be viewed as a weakness orstrength by future users. The lack of cancer-specific content
might limit the user’s sense of having an individually tailoredapp, which again might reduce engagement, adherence, andeffect.
In contrast, neutralizing content to allow for easy app accessthrough reduced demands for privacy and security can beparticularly beneficial for cancer survivors who face challenges
such as fatigue and difficulties with memory and concentration.
Additionally, in the long run, a more generic stress management
program might have a potential benefit for other groups ofpatients, caregivers, or family members [48].

Strengths, Limitations, and Future Directions
The study has some limitations that need to be considered.
Cancer survivors participating in the user interviews responded
to hospital or social media-related invitations and represented
a sample of convenience, which can introduce selection bias.
However, the cancer survivors were both male and female andrepresented a wide range of age and cancer diagnoses. As such,the survivors participating in the study were representative of
future potential app users. The usability testing methods in thisstudy may also present with limitations. First, usability testing
involved all functionalities but not all content sentences. Second,the usability testing included a limited number of participants,
which is, however, not uncommon for iterative design processes[49]. Based on the above, it is possible that the usability testingof StressProffen so far captured only some of the potential

This design and development study also has a number ofstrengths. First, the study employed key stakeholder involvementfrom the very beginning, including cancer survivors, health careproviders working with survivors in various hospital units,
eHealth experts including a designer and IT developers, thehospital Privacy and Security Protection Committee, and theInnovation unit. Having user involvement from the start andcombining input obtained from the patient user with thatobtained from health care providers along with evidence-based
concepts and content likely increases the potential for theintervention to be effective. Also, early stakeholder involvement,
including ensuring privacy and security requirements andanchoring the intervention in the organization, may increase
the potential for poststudy implementation.

Conclusions
Intervention programs, even evidence-based, have at best limited
impact if not actively used over time. The ultimate goal of theStressProffen intervention is to have an end product that is bothuser friendly and useful, engaging and motivating, and fits into
the bigger context of the everyday life and challenges of people
living with cancer. Even though the user-centered design process
can be labor intensive, time consuming, and as such also costly,
it is likely a waste of resources not to invest enough time andeffort in the essential design and development phase. This study
illustrates how user-centered design and service design
approaches can identify and incorporate vital user andstakeholder aspects in the early design phase and then in
combination with evidence-based concepts facilitate thedevelopment of a stress management intervention truly designed
for the end users, in this case, people living with cancer.

Acknowledgments
This study was supported by the Norwegian Cancer Society (Kreftforeningen) grant # 4602492-2013 (Principal Investigator:
LSN) and additional funds from the Center for Shared Decision Making and Collaborative Care Research, Division of Medicine,at the Oslo University Hospital. The authors would like to thank the cancer survivors who volunteered their time for this study
and to advance research. The authors also thank the psychosocial oncology team at Oslo University Hospital, particularly
psychologist Gerd Gulbrandsen, for helpful input and feedback throughout the study, and the design and development team atCenter for Shared Decision Making and Collaborative Care Research, particularly designer Yizhak Itzchaki and IT developers
Fredrik Svensen and Stein Jakob Nordbø for their exceptional work throughout the project process.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Journey map.
[PNG File, 2MB-Multimedia Appendix 1]

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Abbreviations
IT: information technology
PC: personal computer
QoL: quality of life

Edited by G Eysenbach; submitted 29.01.18; peer-reviewed by W van Harten, D Hasson; comments to author 21.03.18; revised version
received 14.05.18; accepted 29.06.18; published 06.09.18
Please cite as:
Børøsund E, Mirkovic J, Clark MM, Ehlers SL, Andrykowski MA, Bergland A, Westeng M, Solberg Nes L
A Stress Management App Intervention for Cancer Survivors: Design, Development, and Usability Testing
JMIR Formativ Res 2018;2(2):e19
URL: http://formative.jmir.org/2018/2/e19/
doi: 10.2196/formative.9954
PMID: 30684438©Elin Børøsund, Jelena Mirkovic, Matthew M Clark, Shawna L Ehlers, Michael A Andrykowski, Anne Bergland, Marianne
Westeng, Lise Solberg Nes. Originally published in JMIR Formative Research (http://formative.jmir.org), 06.09.2018. This is
an open-access article distributed under the terms of the Creative Commons Attribution License(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information,a link to the original publication on http://formative.jmir.org, as well as this copyright and license information must be included.

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