## 4 Discussion
### Comparison to Prior Work  
This study builds upon a substantial body of research emphasizing the importance of self-efficacy and patient activation in cancer survivorship [4; 5; 6]. Consistent with previous findings [6; 7; 8; 9], our study reinforces the notion that these constructs are critical for positive health outcomes, including improved quality of life, symptom management, and adherence to healthy behaviors. Prior research has also demonstrated the potential of DHIs to enhance these outcomes [11; 12; 13; 14], with studies showing positive effects on treatment adherence, physical activity, and symptom burden [15; 16]. Our findings align with this trend, suggesting that a mHealth application can contribute to self-efficacy, patient activation, and satisfaction with care among colorectal and breast cancer survivors. Specifically, the observed high baseline levels of understanding and participation in care (Factor 1 of CASE-Cancer) and maintained levels of patient activation throughout the study period, despite no statistically significant changes, suggest that the mHealth app effectively supported existing self-management skills. This aligns with findings from [PERSON] et al. [16], who demonstrated that DHIs can be particularly beneficial for individuals with already moderate to high baseline self-efficacy and health literacy by reinforcing and maintaining positive behaviors.  
However, this study distinguishes itself from prior work in several key aspects. While previous studies have often focused on either self-efficacy or patient activation in isolation [12; 16; 21; 22; 23], our research adopted a more holistic approach by examining the impact of a personalized mHealth intervention on multiple dimensions of patient well-being, including self-efficacy (measured using CASE-Cancer), patient activation (measured using PAM), satisfaction with care, and physical activity levels. Furthermore, this study addressed a critical gap in the literature by focusing on the real-world feasibility and acceptability of implementing a DHI in clinical settings. The high ratings received for the app's instructions, explanations, and overall user experience, along with the positive feedback on the smart bracelets and the mHealth app's features, suggest that the PERSIST system was well-received by patients and demonstrates promise for real-world implementation. This emphasis on implementation and user experience aligns with the growing recognition of the importance of user-centered design in DHI development [42]. Although the attrition rate posed a significant limitation, particularly for the SUS analysis, the positive feedback from the remaining participants, including their expressed enthusiasm for future participation, underscores the potential of this approach and highlights areas for improvement in future iterations.  
Moreover, while previous studies have demonstrated the potential of DHIs to improve health outcomes, this study offers valuable insights into the specific challenges and facilitators of implementing such interventions in clinical practice. The identified usability issues with the mClinician app (version 1.0) highlight the importance of considering the needs of both patients and clinicians in DHI design and implementation. The clinicians' feedback regarding the most useful aspects of the PERSIST system (patient feedback, alerts, vital parameter data, and risk factors) provides crucial information for future development and refinement of similar systems. By addressing the practical challenges of implementation, this study offers valuable guidance for translating the potential benefits of DHIs into real-world clinical practice.