Head and neck cancer (HNC) is the sixth most frequent cancer type worldwide (1). In China, approximately 115,000 new HNC cases were diagnosed in 2014, including 84,000 men and 31,000 women. The crude incidence rate was 8.32/100,000 (2). With recent advances in cancer treatment and HNC management, the 5-year survival rate of HNC is estimated as 40–50% (3, 4). Financial toxicity is a significant issue for some HNC patients, which is associated with a reduced health-related quality of life (5). Additionally, patients with HNC are at significant risk of cardiovascular events; hence, cardiovascular risk mitigation is essential to survivorship care (6).

Physical activity (PA) is considered an effective non-pharmacological treatment to improve the health status of HNC patients. Higher levels of PA were associated with a 7% reduction in the overall cancer risk (hazard ratio [HR] = 0.93, confidence interval [CI]: 0.90–0.95), with a moderate negative association (10–20% risk reduction) observed for HNC (HR = 0.85, CI: 0.78–0.93) (7). PA can be an effective intervention that complements the treatment and prevents treatment-related cardiovascular disease (8). Moreover, PA during or after treatment in HNC patients significantly improves the functional capacity, prevents the worsening of fatigue, and improves the quality of life (9). PA interventions in cancer survivors are cost-effective, with cost-effectiveness better than US$ 101,195 per quality-adjusted life years gained (10).

Despite the well-documented benefits of PA, adherence of HNC patients to the recommended PA guidelines is poor (11). Objective barriers experienced by HNC patients in performing PA include time pressure, distance to program, and lack of facilities or space. Low self-efficacy and lack of knowledge also prevent patients from participating in PA (12). Additionally, the cultural context is an important factor affecting patients’ PA preferences; for example, patients’ perceptions of PA in traditional Chinese culture may act as an implicit barrier to exercise (13). Moreover, with the coronavirus disease 2019 pandemic and regulations enacted to reduce its spread (e.g., home isolation, gym and recreation center closures, and social distancing) (14, 15), the preexisting pandemic of physical inactivity has become more serious. Therefore, using expanded telehealth to provide non-traditional care delivery models has been encouraged (16).

The use of mobile health (mHealth) as a core public health tool has increased dramatically in healthcare, because it changes the environment for patient care and the delivery of healthcare, addressing the geographic and logistical barriers of traditional programs and improving the efficiency of rehabilitation services (17, 18). The mHealth-based PA interventions may be safe and feasible to help HNC patients improve their PA levels and compatible with concurrent chemotherapy or radiotherapy treatment (19, 20), however, compliance of HNC patients with mHealth programs for PA has been reported as 50–70% (21). The willingness of patients to use mHealth programs will be stronger if they believe that it is useful and easy to use (22, 23), and they are often subject to the social influence around them when making mHealth decisions (24). However, there is limited knowledge about the needs and perceptions of HNC patients regarding these interventions. Therefore, it is needed to explore the patients’ needs and perceptions with respect to four core factors influencing user acceptance (performance expectations, effort expectations, social influence, and convenience) based on the Unified Theory of Technology Acceptance and Use (UTAUT) (25). The UTAUT explains more than 70% of the variance in behavioral intentions and outperforms eight existing models.

In this study, we aim to explore the needs and perceptions of HNC patients regarding mHealth-based PA programs before developing such interventions, which was conducted to inform a pilot feasibility study to provide support for PA to HNC patients. The findings of this study could provide the limited evidence needed to promote digital adherence techniques and public health education.

This study included 17 participants, and their characteristics are presented in Table 2. The age range of the participants was 40–80 years, and most of them were men (14/17). Oral or nasopharyngeal cancer was diagnosed in 12/17 patients, and 13/17 patients had Stage III–IV cancer. Most of the patients (13/17) had received radiotherapy or chemotherapy.

The following four themes were analyzed from the interview transcripts: (1) functionality needs; (2) system usage requirements; (3) social support; and (4) perceived barriers and facilitators. Figure 1 shows the themes and subthemes, and these are discussed in detail with illustrative quotations of participants below.

This study examined the needs and perceptions of HNC patients for developing mHealth-based PA intervention programs. Data analysis identified functionality needs, system usage requirements, social support, and perceived barriers and facilitators for the widespread use of mHealth-based PA programs, providing the first step in designing mHealth-based PA interventions for inactive HNC patients to achieve recommended PA levels. Overall, HNC patients expect highly customized and specialized mHealth interventions that consider individual factors, address their concerns about security, network, and cost, and prefer improved comfort. Moreover, they expect to receive support from their HCPs, families, and peers.

As for the functionality needs, patients particularly emphasized the importance of health education. Targeted educational and informational content for specific groups in mHealth interventions may increase disease awareness, bridge knowledge gaps, and encourage healthy behaviors (32), which is consistent with the findings of our study. Furthermore, our research found that especially in older or poorly literate patients, video-based education has gained popularity because the vividness of the videos provides clear learning content and motivates patients to obtain information on their own, as reported in other areas of global healthcare (33). The mHealth strategies comprising educational videos and video consultations could reduce the use of unplanned medical services and aid in rapid patient-reported recovery (34).

Our findings suggest that patients undergoing treatment or have completed treatment may want HCP engagement and access to tailored programs to ensure the safety and effectiveness of PA. Moreover, patients undergoing treatment expressed the need for additional programs in case of acute treatment-related side effects, such as fatigue and nausea. However, there is currently a serious imbalance between the number of patients and doctors and nurses in China (35), restricting effective communication between HCPs and patients. Patients felt that HCPs sometimes ignored their needs and delayed providing services to them because they were too busy at work. Many mHealth technologies fail to be adopted because HCPs are poorly equipped with digital technology and deliberately avoid the system because they perceive it to be time-consuming and want to maintain the status quo (36). Therefore, increasing the awareness of the clinicians and nurses regarding the tools available and engaging in digital training to develop the necessary skills for applying these tools is central to the success of new technologies. Fundamentally, promoting digital training in medical education may help equip HCPs with the necessary skills to implement and manage new technologies.

Although endorsement by clinicians is a key facilitator of patient acceptance of these tools, the role of the care team is also critical, especially after discharge. This is because they are best positioned to support problem-solving, considering their expertise in managing illness and excellent communication skills in establishing a therapeutic relationship with the patients (37). Furthermore, if the care team encourages patients to use mHealth-based systems but fails to monitor the data entered into the mHealth program actively, it would eventually lead to mHealth abandonment even if the user initially agrees to adopt the tool (38). This highlights the importance of integrating mHealth into the clinical workflow in the future so that the data generated by these tools can be used seamlessly in standard clinical practice.

Patients are often subject to the social influence such as the support from family members (29) and peers interaction (37), which is consistent with our findings. Interestingly, the availability of strong social support and regular caregiver may sometimes discourage adoption of the mHealth system, as they receive sufficient help from their caregivers and believe that mHealth is unnecessary (39). Additionally, because the family is a highly significant concept in Chinese culture, it is the duty of other family members to care for the ailing family members, support them, and encourage them to limit their activities. Moreover, despite acknowledging the advantages of exercise, they reject vigorous activity and classify all forms of exercise—except walking—as strenuous (13). Since the role of the family is important, educating family members, transforming their traditional attitudes and thoroughly understanding the importance of PA could help patients gain effective support. As for peer support, it is recommended that a face-to-face peer network be established in the hospital, which can be expanded as an online network after discharge and facilitated by a professional (40).

It is obvious that mHealth would reduce the reliance on HCPs and make interventions more accessible and cost-effective and was perceived by patients as a good complement to traditional face-to-face healthcare services (41, 42). However, the costs associated with using mHealth, such as the cost of internet access, remain a concern for patients. Despite the rapid increase in the use of smartphones in China, access to smartphones and the internet remains limited in some remote rural areas. Poor network services and wireless signal coverage are barriers to the mHealth program. The same problems exist in other countries; for example, in the UK, the cost of technology and poor access to free internet services prevent many people from participating in the mHealth program (43). Considering these problems, although China is strongly advocating internet-based healthcare, the government still needs to improve the infrastructure of network facilities. The manufacturers of the mHealth-based systems should also provide ongoing assistance services and usage guidelines to support patients in using mHealth applications. Moreover, encouraging reimbursement of costs generated by the mHealth system may help overcome the cost-related barriers.

To our knowledge, this is the first study to provide insights regarding the needs and preferences of HNC patients for developing mHealth-based PA interventions, thus filling the current knowledge gap. Rigorous and reliable qualitative methods were used to analyze the data, providing insights beyond those acquired quantitatively. However, this study has several limitations. First, the sample primarily comprised HNC patients from a hospital in northern China. The deep-rooted social and cultural issues highlighted in this population may not be prevalent in other contexts; therefore, case-to-case transferability may be limited in other contexts. Second, the results need to be strengthened further, as the patients were asked to provide their own needs and perceptions about future PA management applications rather than the developed application. Furthermore, since data collection was completed at one point in time, the needs and perceptions of HNC patients for future PA applications may change over time.

This study provides pragmatic ready-to-use recommendations to develop mHealth-based PA interventions for HNC patients. Future mHealth interventions should be tailored according to the needs of the patient, utilizing perceived facilitators and removing perceived barriers that enable HNC patients to engage in PA actively and improve their quality of life.

Further research is warranted to explore optimizing and tailoring interventions to address these considerations. Given the necessity of HCPs in intervention programs as perceived by patients, future studies should incorporate perspectives of the HCPs to customize mHealth PA interventions. Additionally, healthcare systems need to boost training and resource allocation to make the HCPs more proficient in technology and encourage more patients to participate in PA. Furthermore, strengthening the progression of information technology to reduce barriers perceived by patients and promote public health education is warranted.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding authors.

YN: Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing, Project administration, Supervision. ZD: Project administration, Resources, Writing – original draft, Formal analysis. ZJ: Formal analysis, Investigation, Writing – original draft. WZ: Formal analysis, Methodology, Writing – review & editing. YD: Methodology, Supervision, Writing – review & editing. QW: Formal analysis, Investigation, Methodology, Supervision, Writing – review & editing. RZ: Formal analysis, Methodology, Project administration, Supervision, Writing – review & editing. SH: Formal analysis, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing.