JMIR Publications

ABSTRACT

Background:

People living with and beyond breast cancer can face internal barriers to physical activity (e.g., fatigue, pain). Digital interventions that promote psychological acceptance and motivation may help this population navigate these barriers. The degree to which individuals 1) adhere to intervention protocols and 2) reflect on and internalize intervention content may predict intervention efficacy.

Objective:

The objective of this study was to characterize the nature of reflective processes brought about by an 8-week acceptance- and mindfulness-based physical activity intervention for insufficiently active breast cancer survivors (N=75). Further, we explored the potential utility of a metric of reflective processes for predicting study outcomes (i.e., physical activity behaviors, motivation for physical activity, physical activity acceptance, health-related quality of life).

Methods:

The intervention’s weekly modules included an item that asked participants to reflect on what they found to be most useful. Two coders conducted directed content analysis on participants’ written responses. They assessed each comment’s depth of reflection using an existing framework (ranging from 0-4, with 0 representing simple description and 4 involving fundamental change with consideration of social and ethical issues). The coders identified themes within the various levels of reflection. We fit multiple linear regression models to evaluate whether participants’ 1) intervention adherence (i.e., number of modules completed) and 2) mean level of depth of reflection predicted study outcomes.

Results:

Participants were 57.2 (±11.2) years old, mostly non-Hispanic white (n=58; 77%), and mostly overweight or obese (n=54; 72%). Of the 407 responses to the item prompting personal reflection, 17.2% (n=70) were rated as reflection level 0 (i.e., “description”), 60.7% (n= 247) were level 1 (i.e., “reflective description”), 18.2% (n=74) were level 2 (i.e., “dialogic reflection”), 3.4% (n=14) were level 3 (“transformative reflection”), and 0.005% (n=2) were level 4 (“critical reflection”). Lower levels of reflection were often characterized by the acquisition of knowledge or expressing intentions. Higher levels were often characterized by personal insight, discussion of behavior change processes, and change of perspective. Intervention adherence was associated with increases in self-reported weekly bouts of muscle strengthening exercise (B= 0.26, SE=0.12, 95% CI [0.02, 0.50]) and decreases in sleep disturbance (B=-1.04, SE=0.50, 95% CI [-0.06, -2.02]). Mean level of reflection was associated with increases in psychological acceptance (B= 3.42, SE=1.70, 95% CI [0.09, 6.75]) and motivation for physical activity (i.e., integrated regulation: B=0.55, SE=0.25, 95% CI [0.06, 1.04]).

Conclusions:

We identified a useful method for understanding the reflective processes that can occur during digital behavior change interventions serving people living with and beyond breast cancer. Intervention adherence and depth of reflection each predicted changes in different study outcomes. Deeper reflection on intervention content was associated with beneficial changes in determinants of sustained behavior change. More research is needed to investigate the interplay between digital behavior change intervention usage, psychological processes, and intervention efficacy.