Introduction

Cancer is a leading cause of disease burden worldwide [1]. Effective physical activity (PA) interventions to curb the growth in inactivity and prevent chronic illness in cancer survivors are essential [2–3]. PA prevents cardiovascular disease (CVD) [4–5] and can reduce the risk of cancer recurrence [6–9] and improve overall survival, yet few survivors meet current PA guidelines of at least 150-minutes per week of moderate-intensity exercise [10]. Furthermore, there are significant geographic inequalities in cancer survival, which need to be addressed [11]. Effective, distance-based PA interventions are essential in order to reduce such geographic inequalities in survival.

Evidence from trials support the efficacy of PA interventions in producing short-term, but not long-term change in cancer survivors [12,13]. Most interventions tend be supervised and/or facility-based, and subsequently resource-intensive. Home-based and distance-based interventions (such as those using wearable activity technology) may mitigate access and transport issues, and are less expensive than supervised, facility-based programs requiring participants to attend classes or maintain a health club membership [14]. There is a current gap in the literature on less intensive home-based interventions that could be cost-effective, and more scalable.

Interventions that offer opportunities for self-monitoring have successfully increased PA in cancer survivors [13], and survivors report that self-monitoring is a helpful tool for improving PA [15,16]. Wearable activity trackers (WATs) hold great potential as a low-cost self-monitoring tool to increase PA. Lyons et al [17] reviewed 13 different WATs and their associated apps, and concluded that they use many behavior change techniques employed in typical PA interventions (i.e. self-monitoring, feedback, goal-setting). WATs are perceived as useful and acceptable to individuals with chronic conditions [18]. Thus, WATs may represent a relatively low-cost, feasible and scalable approach for widespread PA promotion in cancer survivors.

To date, only a few studies have examined the acceptability and usefulness of WATs to promote physical activity amongst older adults or those with chronic diseases, [18–21] and only one study has explored acceptability in breast cancer survivors [22]. This found participants mostly increased their awareness of the amount of time spent active or number of steps achieved. However, the study recruited only metropolitan breast cancer survivors, and half were already active.

Little is known about the feasibility of using WATs in interventions with survivors, and in particular, to promote PA to regional and remote survivors. In order to design and develop effective interventions, it is essential to first understand the utility of, and preference for WATs, and WAT features amongst such survivors. The aim of this study is to explore the acceptability and utility of, and preference for WATs in cancer survivors living in regional and remote areas of Western Australia, in order to develop more effective interventions.

Methods

Procedure

The procedure was based on a previous study by co-authors [22] and involved using five commercially available WATs to assess acceptability and feasibility of wearable technology to increase PA. The selected devices were chosen on the basis that they: (i) included a step-count function; (ii) included a non-movement notification; (iii) had an associated app; and, (iv) were affordable (less than $300AUD). Based on these criteria, five devices were selected for testing: Fitbit Alta, Garmin Vivofit2, Garmin Vivosmart, Polar Loop2 and Polar A300. The selected devices had a range of different features. For example, the Garmin Vivofit 2 used a long life battery rather than needing to be charged; the Garmin Vivosmart measured stairs climbed and the Fitbit had a fixed goal of 10,000 steps.

Participants were assigned two of the five WATs to wear for a minimum of four weeks, two weeks per device. A one-week non-wear ‘wash out’ period took place between trackers. Some participants wore a third device, if time permitted and they were interested in trialling a third device. The expectation was that two wearable trackers would be trialled. A RA mailed written instructions, alongside the tracker concerning how to initialise their tracker and install the app on their smartphone. Participants were also given brief information on how to operate the tracker, its basic features and its app. Tracker features are found in Table 1.

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Table 1. Specific features of wearable activity trackers selected for testing in the study.

https://doi.org/10.1371/journal.pone.0210039.t001

Data collection.

Semi-structured interviews lasting up to 60-minutes were conducted. Interviews took place either at the participant’s home, cafe, or via telephone. S1 Fig provides an overview of the interview guide used with questions concerning experiences, acceptability and preferences of WATs. Questions also explored the utility of devices to increase PA and/or reduce sedentary behaviour (SB) and comfort with technology. Interviews were digitally recorded and transcribed verbatim. Data collection ceased at the point when no new information was gained and data saturation was reached [25]. The study adhered to the consolidated criteria for the reporting of qualitative research (COREQ) [26].

Results

Seventy-seven cancer survivors were invited to participate. Of these seven (9%) expressed interest but were ineligible. Twenty survivors participated in the trial (26%). Sixteen (14 female and 2 male) completed the study with a mean age of 63 (SD 13) years. There were no significant differences in age (t (73) = 1.29, p = 0.20) and months since diagnosis (t (73) = -0.43, p = 0.67) of participants that completed the study compared to those who declined participation or dropped out. Participant demographics and study tracker allocation are summarized in Table 2 and Table 3 respectively.

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Table 2. Participant characteristics.

https://doi.org/10.1371/journal.pone.0210039.t002

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Table 3. Overview of participants and wearable activity trackers trialed.

https://doi.org/10.1371/journal.pone.0210039.t003

Analysis of the data identified four main themes: Increasing Self-Awareness of PA and SB; Prompts and Feedback; Accuracy and registry of activities; WAT preferences and features. Several participants purchased (n = 5) their own WAT following participation in the study and several others (n = 8) were considering purchasing one. Pseudonyms are used throughout the manuscript. A summary of the themes and illustrative quotes can be found in Table 4.

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Table 4. Overview of themes and illustrative quotes.

https://doi.org/10.1371/journal.pone.0210039.t004

Discussion

This is the first study to explore the experiences, acceptability and usability of WATs amongst rural cancer survivors. Despite the evidence of the importance of PA for healthy survivorship [4–9], few survivors meet the PA guidelines [10]. As a powerful self-monitoring tool, WATs present a potential opportunity for PA promotion and in particular, to reach survivors living in rural communities. WATs may also play a role in objectively monitoring patient PA remotely and used to predict important clinical outcomes such as readmission. A recent study found that a higher mean daily step count, derived from the Fitbit, predicted lower risk of readmission following metastatic peritoneal cancer [29]. In addition to the use of WATs to promote PA to survivors following active treatment to prevent CVD, WATs could also play an important role in identifying opportunities for real-time adaptive interventions during cancer treatment to improve clinical outcome [29, 30].

We found that WATs increased self-awareness of their PA and SB consistent with previous research [18,20]. The provision of prompts and feedback were the most motivational aspects of the WATs. The trackers provided continuous self-monitoring and real time feedback in relation to step goals and appeared to reinforce progress or nudge behaviour towards goals. Recognition of achievements (either from the device or through the App) were also enjoyed by participants. The motivational nature from immediate feedback on step count and progress towards step goals has been reported previously [20]. The features of WATs that most motivated participants (i.e., monitoring behavior, prompts, setting goals, receiving feedback) are also behavior change techniques known to be effective for promoting PA [31,32]. For example, ‘provide instruction’ and ‘reinforcing efforts towards behavior’ are techniques associated with a significant increase in PA [32]. Interventions that employ self-monitoring and at least one other self-regulatory technique (i.e., goal setting, receiving feedback on performance, review of goals) are significantly more effective in promoting PA [31].

The majority of participants found the WATs to be highly acceptable and useful consistent with previous research in older populations, [19,21] chronic disease [18,20] and breast cancer survivors [22]. This is the first study to indicate that the provision of written instructions and/or telephone technical support in conjunction with WATs may be sufficient in rural survivors and that such interventions do not require face-to-face contact. Only one participant reported finding the devices intrusive and one other who was unable to use the technology.

Some were sceptical of the authenticity of the Fitbit-recorded data, noting that it tended to over-count steps. Others failed to notice the devices misclassifying steps during SB or light activity leading to a false sense of achievement. However, research supports the accuracy of WATs, including the Fitbit for counting steps [33,34]. The reliability and validity of two Fitbit models (Flex and ChargeHR) has shown to be good in older adults (aged over 65), with high intra class correlations of the WATs with direct observation of steps [35]. Good strength of agreement was also found for total distance and moderate-to-vigorous physical activity in the free-living environment compared to an accelerometer [35]. A further study in older adults also found excellent agreement between the Fitbit (One and Zip) and direct observation for step count, and also between the Fitbit and Actigraph for average step count/per day over 7days [36]. It would appear that Fitbit trackers are sufficiently accurate to be used in community-dwelling older adults to increase physical activity. The over-count of steps found in the present study appears to occur only during light household activities. Therefore, future trials should ensure the device is worn on the non-dominant wrist or taken off when performing stationery activities involving much arm movement. Some participants were disappointed that activities such as swimming and cycling were not recorded by the device. Such frustration that WATs fail to register activities has been noted elsewhere [20]. This is a limitation with some models which are not waterproof and/or do not have more sophisticated features.

In relation to preferences, the aesthetics of the WATs were deemed crucial in determining preference and likelihood of use, consistent with previous research [18, 21,22]. The smaller trackers were mostly preferred with the Fitbit Alta being considered the most stylish. The Garmin models were also favourable due to their slim in appearance and because the screen was bigger and the display stayed on. The most common complaint regarding useability concerned the Fitbit Alta and difficulties tapping to view the statistics. The acceptability of WATs is highly influenced by device characteristics such as display, comfort and most of all aesthetics.

The most preferred feature across WATs was step counting and this is consistent with the previous study in breast cancer survivors [22]. The prompts were deemed helpful although the tone of the prompt was considered important. The Fitbit appeared to be the preferred App; participants found it more intuitive and some were interested in self-monitoring food intake, which were not available on other Apps.

Conclusion

WATs appear to be acceptable to cancer survivors living in rural locations and may represent a low-cost, feasible and scalable approach for PA promotion. WATs increased self-awareness of physical activity, provided real time feedback in relation to goals, and reinforced progress and efforts toward goals. The aesthetics of the WATs were deemed crucial in determining likelihood of use. Future interventions may do well to have two different WATs available for participants to select from, according to activity preferences, aesthetic preferences and display size. Future research should explore whether WAT use and increased PA is sustained over time.

Supporting information

Acknowledgments

The research team would like to thank the participants who generously shared their time and experiences for the purposes of this project. We also thank Tracie Barbour for her kind assistance in recruiting gynaecologic survivors.