## 4 Discussion  
### Principal Findings  
This study partially supports the initial hypothesis [25], suggesting that mHealth applications can positively influence self-efficacy, patient activation, and satisfaction with care among colorectal and breast cancer survivors, although statistical significance was not consistently achieved. While the CASE-Cancer questionnaire results (Table 3) did not show significant changes over time, the baseline scores for Factor 1 indicated a high level of patient understanding and engagement in their care at recruitment, consistent with previous findings [33]. The stability of the PAM scores (Table 4) suggests that patients maintained good self-management skills throughout the study, indicating the potential of the PERSIST app to support these skills [9], even without demonstrable improvement. The increasing SUS scores (Table 5) reflect improvements in perceived usability, likely due to iterative app development based on user feedback. The final positive usability ratings, while not universally excellent, emphasize the importance of continuous user-centered design in mHealth development [42]. Positive patient feedback regarding study participation, clarity of instructions, and explanations (Tables 6 and 7) indicates successful patient engagement. High patient ratings for the emotion wheel/detection feature, instructions, and questionnaires within the app (Tables 8 and 9) suggest user acceptance of these specific functionalities. Furthermore, positive experiences with smart bracelets and mobile phones (Tables 10 and 11), with no decline in user satisfaction over time, further support the feasibility of this technology within this population. However, clinician evaluations of the mClinician web version (version 1.0) revealed significant challenges. Low SUS scores (Table 12) and predominantly negative or neutral responses regarding their integration into clinical practice highlight the need for substantial revisions to improve usability and align with clinical workflows. While the mClinician app (version 1.0) fared better, with most clinicians willing to use it, addressing identified usability issues could enhance its adoption and effectiveness. Critically, the disparity in clinician acceptance between the PERSIST system and the mClinician web version (version 1.0) suggests that system design and integration with existing clinical practices are crucial determinants of successful mHealth implementation. Positive clinician feedback on PERSIST, particularly regarding patient feedback integration, vital parameter tracking, and risk factor identification, points to specific areas of value in mHealth solutions for cancer survivors. Physical activity was identified as the most important potentially modifiable lifestyle factor for cancer survivors that the PERSIST system detects [43; 44]. Future research should focus on identifying the factors contributing to successful mHealth implementation and tailoring interventions to meet the specific needs of both patients and clinicians. The PERSIST system's support for self-efficacy and patient activation can be attributed to several key features. The emotion wheel/detection feature, along with the app's clear instructions and questionnaires, provided patients with tools to actively monitor their health and engage in their care. By empowering patients to track their emotional states and understand their health data, these features likely enhanced their sense of control and self-efficacy. Furthermore, the integration of smart bracelets and mobile phones facilitated consistent data collection and monitoring, reinforcing patient activation by enabling them to actively participate in their health management. The CDSS component, particularly the features related to patient feedback integration, vital parameter tracking, and risk factor identification, supported clinicians in providing personalized care, which in turn likely contributed to patient confidence and self-efficacy.