Design and Usability Evaluation of a Smartphone Application for Postoperative Self‐Management in Breast Cancer Patients

ABSTRACT

Introduction

Postoperative care is essential for breast cancer patients due to the challenges of managing physical and psychological symptoms. With the rise of digital health technologies, smartphone applications have emerged as valuable tools for facilitating self‐management in this patient population.

Objective

This study aimed to design, develop, and evaluate the usability of a smartphone application for postoperative self‐management in breast cancer patients.

Methods

This applied‐developmental study was conducted in three phases: determining and confirming the functional requirements and educational needs of the application, designing and developing the initial application prototype, and evaluating its usability through heuristic evaluation and user testing with 30 breast cancer patients.

Results

The developed application, PostSurgCare, included features such as educational resources, medication and medical appointment reminders, notetaking functions, and alert notifications. Heuristic evaluation identified primarily minor issues, with an average severity score of 1.56 (out of 4). The usability assessment using the mHealth App Usability Questionnaire (MAUQ) resulted in an average score of 5.91 (out of 7), indicating high user acceptance.

Conclusion

The PostSurgCare application offers a tool to support postoperative self‐management in breast cancer patients by providing educational and management resources.

1. Introduction

Breast cancer remains one of the most diagnosed cancers among women worldwide [1, 2]. With the 5‐year survival rate in Iran reaching around 80%, advances in early detection and treatment have significantly increased survival rates, resulting in an increasing number of women living with breast cancer as a chronic condition [3, 4]. As most patients undergo surgical treatment, long‐term recovery and self‐management have become central components of care for breast cancer patients [5].

Many patients experience a variety of psychological and physical symptoms that linger after surgery and necessitate continuous self‐management outside of the hospital environment. These symptoms include pain, functional restrictions, and emotional distress [5, 6, 7, 8]. These postoperative difficulties might have a major impact on daily activities and quality of life, highlighting the necessity of successful, patient‐centered approaches to promote long‐term recovery and self‐management [9].

Given these challenges, there is a growing emphasis on empowering patients to manage their own recovery. Self‐management involves patients actively participating in the control of their illness's medical, behavioral, and emotional impacts [10, 11]. By prioritizing patient education, skill development, and shared responsibility in care, this method allows people to take an active role in their postoperative recuperation [12]. According to evidence, effective self‐management treatments for breast cancer patients can enhance self‐efficacy, encourage healthy behaviors, improve symptom control, and ultimately improve quality of life [13].

The rising number of surgeries necessitates the provision of high‐quality, patient‐centered care beyond the hospital setting [14]. Nowadays, the broad integration of smartphone technologies has been paving the way for innovative methods to enhance healthcare and its delivery [15]. As the number of breast cancer patients in need of varied supportive care increases, smartphone applications offer a practical and accessible solution that can provide continuous care to large numbers of patients simultaneously at an affordable cost [16]. Smartphone apps can greatly enhance the healthcare system by improving data availability for clinical decisions, lowering healthcare resource use, decreasing patient visits and hospitalizations, and alleviating the workload of healthcare professionals [17]. These applications offer a convenient and available platform for self‐management, particularly for breast cancer patients [14, 18, 19, 20, 21].

Several digital interventions have been developed in high‐income countries to support breast cancer treatment, with an emphasis on areas like symptom monitoring [14], rehabilitation support [22], patient education [23], and psychosocial well‐being [22, 24]. While numerous digital interventions exist in high‐income countries, their applicability in the Iranian context is limited due to differences in healthcare system structure, follow‐up care procedures, technological infrastructure, and cultural attitudes toward postoperative support [25, 26, 27].

In middle‐income countries (MICs), including Iran, the potential of smartphone‐based interventions is increasingly recognized due to the rapid growth in smartphone adoption [25, 28]. In Iran, smartphone ownership reached approximately 69% of the population by early 2021 and is projected to continue rising [29]. Existing applications developed in Iran have primarily focused on specific aspects such as chemotherapy support [30], resilience [31], lymphedema management [32], quality of life [33], or breast self‐examination [34], rather than comprehensive postoperative self‐management following surgery. In Iran, postoperative follow‐up is often constrained by limited access to rehabilitation services and specialized nursing support [35, 36, 37]. This highlights an important gap in culturally adapted, evidence‐based smartphone applications designed to support postoperative care in this context.

Numerous studies highlight the importance of smartphone applications in delivering healthcare services to breast cancer patients [16, 38, 39, 40, 41, 42, 43]. Research highlights the significant positive impact of smartphone applications on various aspects of postoperative care in breast cancer patients, including improved treatment adherence [44], support for rehabilitation [21], symptom management [45], reduced anxiety and depression [14], encouragement of healthy behaviors [20, 46], and relief from chronic pain [47]. Additionally, these applications offer essential resources for delivering comprehensive educational support [48]. Smartphone apps are well‐suited to provide this information in a direct and accessible manner [42]. Various applications for postoperative care have been developed, primarily focusing on education, with some also offering tracking or reminder features [49].

Despite the great potential of smartphone health technologies to support in patient self‐management, their usability and real‐world applicability remain limited [50, 51]. Persistent challenges in this field include insufficient application of user‐centered design principles [52], limited involvement of key stakeholders (patients and clinicians) throughout development [53], problems maintaining engagement [54], and lack of evidence of long‐term clinical usefulness [55].

Considering this gap and the growing need for self‐management support solutions, this study aimed to develop and evaluate the usability of a smartphone application tailored to postoperative self‐management in breast cancer patients.

2. Methods

This applied‐developmental study was conducted between November 2023 and September 2024 at the Cancer Research Center of Shahid Beheshti University of Medical Science in Tehran. Here, “applied‐developmental” refers to research focused on developing and evaluating an application in a real‐world setting. The study consisted of three phases (Figure 1):

1. Determining and confirming the functional requirements and educational information needs of patients to design the application.

2. Designing and developing the application.

3. Evaluating the application.

FIGURE 1.

Workflow of the three‐phase development and evaluation process of the PostSurgCare application.

2.1. Phase 1: Application Requirements

2.1.1. Questionnaire Development and Content

In the initial phase of our study, the educational needs of patients and the required functionalities of the application were determined through a scoping review [49]. This review covered studies published from the earliest records up to January 25, 2024, using databases such as Web of Science, PubMed, IEEE, Scopus, and Cochrane. The search combined terms like “breast cancer,” “postoperative care,” and “mHealth.” To ensure comprehensiveness, insights from surgeons and oncologists were also incorporated into the identified requirements.

Based on the findings from the review, a researcher‐designed questionnaire was developed using the Delphi methodology to gather expert consensus through iterative rounds and evaluate the significance of each feature (see Appendix A). The questionnaire consisted of 100 items organized into the following main sections: demographic information, post‐surgical instructions, post‐surgical chemotherapy, post‐surgical radiotherapy, post‐surgical hormone therapy, follow‐up care, lifestyle‐related recommendations, and application functions. Each item was designed to assess the perceived importance of specific educational topics or application features. Items were rated using a five‐point Likert scale ranging from 1 (completely unnecessary) to 5 (completely necessary). Responses were “completely unnecessary,” “unnecessary,” “neutral,” “necessary,” and “completely necessary.” Items that received an average score below 2.5 out of 5 were eliminated. Those with scores between 3.75 and 5 were retained as core requirements. Previous studies on application design [32, 56] demonstrated that using a mean score of 3.75 (75%) as a threshold helps prioritize the most important educational needs and functionalities, resulting in a more user‐friendly and efficient application. Items with scores of 2.5 to 3.75 were reconsidered in the subsequent Delphi round for further assessment.

2.1.2. Questionnaire Validation

The validity of the questionnaire was assessed by a separate panel of ten experts, distinct from those who participated in the subsequent requirements prioritization phase. This panel consisted of eight surgical oncologists and two health informatics specialists affiliated with Shahid Beheshti University of Medical Sciences. These experts were selected based on their clinical or academic expertise in breast cancer care or digital health and were responsible solely for content validation and reliability assessment of the questionnaire. To determine the essential items, content validity was assessed using the Content Validity Ratio (CVR). CVR is a quantitative index used to measure expert agreement on the essentiality of each item. According to Lawshe's table, for a panel of ten experts, a minimum CVR value of 0.62 is required for an item to be considered acceptable. Items with CVR values below this threshold were excluded [57, 58]. Additionally, reliability was established with a Cronbach's alpha value of 0.78.

2.1.3. Sampling and Recruitment for Application Requirements

Following questionnaire validation, a separate group of 20 surgeons and cancer specialists from Shohadaye Tajrish Hospital participated in the next phase of the study. These experts were recruited through convenience sampling due to practical limitations, including restricted access to a sufficient number of eligible specialists during the early stage of application development. Their role was to rate the selected questionnaire items in order to identify and prioritize essential educational content and functional requirements for application design. Eligibility criteria included clinical experience in breast cancer management and direct involvement in postoperative patient care. Although most participants were affiliated with Shahid Beheshti University of Medical Sciences, efforts were made to include experts with diverse clinical roles and professional backgrounds to mitigate potential institutional consensus bias.

After completing the questionnaire and identifying key smartphone app features, the educational content was developed and finalized. The content was initially extracted from reputable national and international clinical guidelines on postoperative breast cancer care, including those published by the World Health Organization and the American Cancer Society [59, 60, 61]. The extracted content was then reviewed, adapted, and rewritten by the research team in collaboration with clinical experts to ensure clinical accuracy and relevance. To enhance usability for postoperative self‐management, the educational content was simplified and adapted into plain language suitable for patients.

2.2. Phase 2: Application Design and Development

2.2.1. Application Design

The application was developed through conceptual modeling encompassing three stages: behavioral, functional, and structural, using Microsoft Visio 2023. During this phase, the operational requirements were identified, and scenarios and use‐case diagrams were developed. To design the application's user interface, the pages and their interconnections were modeled using Figma.

2.2.2. Application Development

The prototype was developed utilizing the Java programming language within the Basic4Android (B4A) environment. SQLite was employed for database design. The application allows patients to enter, store, and manage their personal and postoperative information locally on their smartphones. All data were stored exclusively on the user's device, and no data were transmitted to external servers or third parties, minimizing privacy risks and enhancing data security. Considering the widespread use of the Android operating system in Iran [62], the prototype was specifically tailored for Android OS version 4.4 KitKat and later versions. The application interface was developed entirely in Persian (Farsi), which is the native language of the target users (Appendix B).

2.3. Phase 3: Application Evaluation

2.3.1. Heuristic Evaluation

This study employed a heuristic evaluation method to identify usability problems within the user interface of the “PostSurgCare” application prototype. The evaluation was conducted based on Nielsen's ten usability heuristics, a widely used framework for expert‐based usability inspection [63, 64, 65].

A structured evaluation process was followed. First, each evaluator independently reviewed the application interface and identified usability issues according to the ten heuristic principles, documenting each problem in a standardized data collection form. After completing individual evaluations, the identified issues were aggregated, and duplicate items were removed to generate a consolidated list of usability problems.

The severity of each identified problem was then rated based on three criteria: frequency of occurrence, impact on user experience, and persistence of the problem. Severity scores ranged from 0 (no usability problem) to 4 (complex), in line with Nielsen's severity rating scale [65]. For each issue, the final severity score was calculated as the mean of the scores assigned by the evaluators who reported that problem. The classification of severity levels is presented in Table 1.

TABLE 1.

Level severity of issues based on their severity.

Severity level	Name	Description
0	No Problem	Not considered a usability problem
1	Cosmetic	Does not need to be fixed unless extra time is available
2	Minor	Should be fixed, but given low priority
3	Major	Important to fix and should be given high priority
4	Complex	Must be fixed before the product can be released

Note: “No problem” severity has an average score of “0.” “Cosmetic” problems have an average severity between “0 and 1.” “Minor” problems fall within the range of “1 to 2,” while “Major” problems have an average severity between “2 and 3.” “Complex” includes problems with an average severity between “3 and 4.”

Heuristic evaluation was performed by a separate group of four experts, independent of the requirements assessment phase. The evaluators had backgrounds in health informatics, and were solely responsible for identifying interface‐related usability issues. The group included two Ph.D. students and two experts with master's degrees in relevant fields. No additional demographic data were collected.

2.3.2. Usability Evaluation

At this stage, the application's usability was evaluated with patient participation using the mHealth App Usability Questionnaire (MAUQ) for standalone health apps. This 18‐item questionnaire, developed by Zhou et al. [66], evaluates app functionality, perceived medical benefits, and ease of use from the user's perspective. The evaluation is divided into three sections: ease of use (5 criteria), user interface and satisfaction (7 criteria), and usefulness (5 criteria). Items are scored on a 7‐point Likert scale, ranging from 1 (“completely disagree”) to 7 (“completely agree”). To facilitate reporting, the total mean value of 7 was divided into four categories: 0–1.75 (poor), 1.76–3.50 (moderate), 3.51–5.25 (good), and 5.26–7 (very good).

The MAUQ was translated into Persian by bilingual experts in medical informatics. The translated version was reviewed by five experts to ensure linguistic clarity, conceptual consistency, and cultural appropriateness. Face validity was confirmed prior to use. Experts were required to have at least 5 years of experience in their field and hold faculty positions at medical universities. The questionnaire demonstrated high internal consistency (Cronbach's alpha = 0.94).

2.3.3. Sampling and Recruitment for Usability Evaluation

The study initially enrolled 37 patients who had undergone breast cancer surgery and were willing to take part in the usability evaluation. However, only 30 patients completed the evaluation. Patients were selected based on availability and willingness to participate, with inclusion criteria requiring them to be at least 18 years old and own an Android smartphone. This sample size was determined based on the availability of eligible and interested patients during the three‐month usability evaluation period. Patients were asked to install the final version of the application on their smartphones. After using the app for 1 month, they completed the MAUQ. Patients received detailed information about the study's purpose and app usage, with assurances of data confidentiality.

2.3.4. Statistical Analysis

The data collected from the questionnaire were analyzed using SPSS 23.0. Descriptive statistics, including frequency, mean, and standard deviation (SD), were applied.

3. Results

3.1. Phase 1: Application Requirements

Our scoping review analyzed 28 articles on mobile health applications for breast cancer postoperative care, identifying nine core features with educational content and reminder systems being most prevalent [49]. Following expert consultation, we developed a 100‐item questionnaire. The finalized questionnaire was subsequently used to collect data from 20 surgeons and cancer specialists. The questionnaire assessed key aspects related to mobile health applications categorized into eight domains: demographic details (15 questions), postoperative education (9 questions), chemotherapy after surgery (21 questions), radiotherapy after surgery (9 questions), hormone therapy after surgery (13 questions), follow‐up care (9 questions), health behaviors (16 questions), and mobile app functionalities (8 questions), with an optional open‐ended question at the end for additional participant feedback. The results of this Delphi process are presented in Appendix A. The demographic data of questionnaire respondents are presented in Table 2.

TABLE 2.

Demographic data of questionnaire respondents.

Characteristics		N (%)
Gender	Male	9 (45%)
	Female	11 (55%)
Age	30–40	8 (40%)
	40–50	8 (40%)
	Above 50	4 (20%)
Educational qualification	Subspecialist	4 (20%)
	Specialist	16 (80%)
Work experience	Less than 10 years	8 (40%)
	10–20 years	8 (40%)
	Over 20 years	4 (20%)

From the initial 100 questionnaire items, 8 were excluded based on the Lawshe table threshold for content validity with 10 experts (≥ 0.62). Reliability of the remaining items was confirmed with a Cronbach's alpha of 0.78. In Table 3, an overview of the survey content is presented.

TABLE 3.

Final survey content.

Sections	Educational content	Final number of items
Demographic information	Patient's first name, patient's last name, age, marital status, weight, height, age at diagnosis, date of surgery, number of children, duration of breastfeeding (in years), age at first pregnancy	11
Postoperative education	Hand exercise, wound care, serum management, pain management, emergency conditions	5
Postoperative chemotherapy	Definition of chemotherapy, intervals and duration of administration, concurrent use of other medications, side effects	4
Postoperative radiotherapy	Definition of radiotherapy, intervals and duration of administration, care during and after radiotherapy, side effects	4
Postoperative hormone therapy	Definition of hormone therapy, drugs and duration of administration, side effects	3
Follow‐up	Visiting the surgeon and oncologist, breast imaging (mammography), pelvic examinations, bone scan, ultrasound	5
Health behaviors	Nutrition, vitamin D intake, physical activity, weight management, comorbidities, depression and anxiety, pregnancy and breastfeeding, early menopause, appearance changes, prevention of recurrence, lymphedema, breast reconstruction	12
Functions	Medications reminder, medical appointments reminder, exercise reminder, paraclinical services reminder, alert for BMI increase, notes on medical recommendations, list of healthcare centers, FAQ	8

3.2. Phase 2: Application Design and Development

The user interface of the application's main and login pages is presented in Figure B1. The application begins with a “start” page, offering a general introduction, followed by “login” and “sign‐up” features for user access, and a “user profile” section for editing personal information. The “education” section provides educational resources on postoperative care, chemotherapy, radiotherapy, hormone therapy, and follow‐up procedures. Within the postoperative care module, the application includes exercise‐related educational content aimed at improving posture, enhancing shoulder mobility, increasing arm strength, and maintaining physical activity during breast cancer recovery. Multimedia materials, such as exercise images and videos for postoperative drain care, are incorporated (Figure B2). In addition, wound care and seroma management are addressed through step‐by‐step educational guidance presented in text‐based formats. Users can manage “reminders” for medications, doctor visits, exercise, and paraclinical services, while the “alerts” section calculates BMI based on entered weight and height, notifying users of deviations from the normal range (Figure B3). In the “notes” section, patients can record health‐related information such as pain level, symptoms, medication, dietary changes, physical activity, treatment follow‐up, mental health status, and personal experience. A “list of healthcare centers” in Iran is provided to patients for counseling services. Additional features include an “FAQ” for common questions and an “about us” to introduce the development team.

3.3. Phase 3: Application Evaluation

3.3.1. Heuristic Evaluation

The evaluation revealed a total of 130 usability problems across Nielsen's ten usability principles, with an average severity score of 1.56. The highest average severity was associated with “user control and freedom” (2.1), followed by “error prevention” (1.93), which also accounted for the highest number of problems (n = 29) (Table 4). The problems identified included the absence of confirmation steps for irreversible actions (e.g., account deletion or data reset), the inability to navigate between sections without data loss, and the lack of mechanisms to prevent incorrect data entry. Additionally, the app failed to follow common smartphone user interface standards, such as the use of a hamburger menu or swipe‐to‐delete functionality. Evaluators also reported difficulties in accessing recently viewed or frequently used sections, as well as the inability to customize content display or receive personalized learning suggestions. Suggestions for improvement included implementing confirmation prompts for required actions, enhancing navigation features, and providing clearer error recovery options. While some aspects of the app, such as its layout and content, were appreciated, the lack of intuitive navigation and error prevention mechanisms were drawbacks.

TABLE 4.

Identified usability problems categorized by violated heuristics and severity.

Principles of heuristic evaluation	Average severity	Severity				Number of problems	Example
		Cosmetic	Minor	Major	Complex
1. Visibility of system status	1.67	4	4	1	0	9	The loading indicator is not displayed when processing data.
2. Match between system and the real world	1.67	2	4	0	0	6	The app does not use colloquial language instead of complex scientific terms
3. User control and freedom	2.1	3	3	4	0	10	There is no confirmation step before performing irreversible actions (e.g., account deletion, data reset). The user cannot move from one part of the app to another without losing data
4. Consistency and standards	1.25	3	1	0	0	4	The app does not follow common smartphone UI standards, such as hamburger menu or swipe to delete
5. Error prevention	1.93	7	14	7	0	29	The app does not prevent incorrect data entry. Confirmation message is not displayed for deleting important data
6. Recognition rather than recall	1.5	6	6	0	0	12	Recently viewed or frequently used sections are not accessible
7. Flexibility and efficiency of use	1.37	17	10	0	0	27	Users cannot rearrange the order of content display based on their needs. The app does not provide learning suggestions based on user behavior
8. Esthetic and minimalist design	1	2	0	0	0	2	The app's color scheme is not suitable for users with vision problems
9. Help users recognize, diagnose, and recover from errors	1.71	6	10	1	0	17	The app does not provide a simple, step‐by‐step solution when an error occurs. There is no option to restore data or rollback changes
10. Help and documentation	1.36	9	5	0	0	14	The guide is not updated regularly and cannot be accessed without disrupting current work
Total	1.56	59	57	13	0	130

Figure 2 displays all the evaluation principles along with the frequency of issues associated with each.

FIGURE 2.

Frequency of usability Heuristic violations.

Based on the findings of the heuristic evaluation, the prototype was improved by implementing a confirmation step prior to executing usability testing (Figure B4A). Additionally, the approach to mitigate incorrect data entry was redesigned (Figure B4B).

3.3.2. MAUQ Evaluation

3.3.2.1. Participant Characteristics

A total of 30 patients prospectively evaluated the usability of the PostSurgCare app for the entire 1 month and therefore completed the MAUQ questionnaire. The participants had a mean age of 42.7 years (SD = 12.4), with the majority (53.3%) aged between 30 and 49 years. Most patients were in stage 1 (43.3%) or stage 2 (40%) of their condition. Employment status showed 46.7% were employed, and 66.7% were married (Table 5).

TABLE 5.

Participant characteristics in usability evaluation.

Characteristics		N (%)
Age	18–29	4 (13.3%)
	30–49	16 (53.3%)
	50–65	10 (33.3%)
	Mean (SD)	42.7 (12.4)
Surgery	Conservation therapy	22 (73.3%)
	Mastectomy	8 (26.7%)
Stage	1	13 (43.3%)
	2	12 (40%)
	3	5 (16.7%)
Chemotherapy	Yes	21 (70%)
	No	9 (30%)
Radiotherapy	Yes	23 (76.7%)
	No	7 (23.3%)
Hormone therapy	Yes	18 (60%)
	No	12 (40%)
Graduation	Below high school diploma	3 (10%)
	High school diploma	8 (26.7%)
	Associate degree	7 (23.3%)
	Bachelor's degree	6 (20%)
	Master's degree	5 (16.7%)
	Doctoral degree	1 (3.3%)
Employment	Unemployed	9 (30%)
	Employed	14 (46.7%)
	Retired	7 (23.3%)
Marital status	Unmarried	6 (20%)
	Married	20 (66.7%)
	Divorced	3 (10%)
	Widowed	1 (3.3%)

3.3.2.2. Usability of the PostSurgCare App

The results of the usability evaluation are presented in Table 6. The average score for the app's applicability was 5.91 (±0.79). Among the criteria of usability, the highest average score was for satisfaction and user interface, with a score of 5.98 (±0.71). The ease of use of the app received an average score of 5.85 (±0.84), followed by the usefulness of the app, which scored 5.88 (±0.79).

TABLE 6.

mHealth app usability questionnaire (MAUQ) scores.

Dimensions of usability	Questions	Mean score (SD)	Range a
Ease of use	1. The app was easy to use	5.90 (±1.02)	6
	2. It was easy for me to learn to use the app	5.70 (±0.80)	6
	3. The navigation was consistent when moving between screens	5.95 (±0.76)	6
	4. The interface of the app allowed me to use all the functions (such as entering information, responding to reminders, viewing information) offered by the app	5.85 (±0.88)	6
	5. Whenever I made a mistake using the app, I could recover easily and quickly	5.85 (±0.75)	6
Interface and satisfaction	6. I like the interface of the app	6.00 (±0.79)	6
	7. The information in the app was well organized, so I could easily find the information I needed	5.55 (±0.83)	6
	8. The app adequately acknowledged and provided information to let me know the progress of my action	5.35 (±0.81)	5
	9. I feel comfortable using this app in social settings	5.70 (±0.73)	6
	10. The amount of time involved in using this app has been fitting for me	6.20 (±0.52)	6
	11. I would use this app again	6.30 (±0.86)	6
	12. Overall, I am satisfied with this app	6.75 (±0.44)	7
Usefulness	13. The app would be useful for my health and well‐being	6.00 (±0.92)	6
	14. The app improved my access to healthcare services	6.20 (±0.62)	6
	15. The app helped me manage my health effectively	6.05 (±0.69)	6
	16. This app has all the functions and capabilities I expected it to have	5.45 (±0.76)	5
	17. I could use the app even when the Internet connection was poor or not available	5.75 (±1.02)	6
	18. This mHealth app provides an acceptable way to receive healthcare services, such as accessing educational materials, tracking my own activities, and performing self‐assessment	5.85 (±0.75)	6
	Total score	5.91 (±0.79)	107

^a Range of participant scores. Possible range for each item is 1 to 7; possible range for total score is 18 to 126 (higher scores indicate better usability).

4. Discussion

This study developed and evaluated the PostSurgCare mobile application to support postoperative self‐management among breast cancer patients. The application integrates evidence‐based educational content, treatment‐specific guidance, follow‐up care, and self‐management functionalities tailored to the needs of Iranian patients. The primary focus of this app's design was on content that aligns with the latest guidelines for managing breast cancer [67, 68, 69, 70]. MAUQ results showed acceptable to good usability, indicating patients could effectively use the app. This culturally adapted Persian mHealth solution addresses postoperative needs and adds to international evidence on digital tools for breast cancer care, while filling a local gap in Iran.

Digital health interventions have gained widespread support as effective tools for improving health behavior and self‐management [71]. Ponder et al. [14] evaluated the feasibility of Manage My Surgery (MMS), a mobile health application designed as a perioperative tool to enhance patient education and gather outcomes reported by individuals undergoing breast cancer surgery. Their study demonstrated that patients found the application helpful in preparing for surgery and engaging with educational content. While the MMS application focused on the perioperative phase, our approach extends this by specifically targeting the postoperative period with detailed, guideline‐based resources on topics such as wound care, lymphedema prevention, and exercise, drawing from reputable sources including the WHO and the American Cancer Society [59, 60, 61]. This method ensures that the application's content is clinically applicable and aligns with research indicating that applications lacking such scientific foundations experience lower adoption rates [72].

A key principle in app's design was the delivery of tailored information in the right format and at the right time, as emphasized by Ormel et al. [23]. To accommodate diverse user needs, the PostSurgCare app uses multimedia resources, including text, videos, and images demonstrating proper techniques for lymphedema prevention, drain care, and postoperative exercises. While several existing mHealth applications support breast cancer patients through symptom monitoring [73, 74] or education [47, 75, 76], relatively few appear to focus on structured postoperative self‐management [22, 77, 78]. The PostSurgCare app was designed to support postoperative self‐management for breast cancer patients, addressing their recovery needs.

The educational component covers not only surgical aftercare but also extended treatment support, including detailed information on chemotherapy, radiotherapy, and hormone therapy, such as treatment schedules, potential side effects, and medication management. Additionally, the app integrates social resources like support organizations and FAQs, a feature consistently highlighted as valuable in prior research [14, 79]. Hou et al. [80] and Ahmadi et al. [32] demonstrated the effectiveness of apps focusing on physical activity, nutrition, and lymphedema management, while Harder et al. [81] and Miranda et al. [75] validated the importance of shoulder/arm exercise modules and breast reconstruction education, respectively. A focus group study on the bWell app conducted by Harder et al. [81] highlighted the importance of a “notes” feature for symptom tracking and self‐evaluation. Similarly, our app incorporates this feature, allowing users to create, edit, and store notes to document their emotional and psychological status, dietary habits, physical activities, and more.

Another key feature of the application developed in our study was the use of reminders. This functionality allows patients to log medications, medical appointments, exercise sessions, and paraclinical services. The app then provides timely notifications to ensure adherence and facilitate the management of these scheduled activities. Reminders play an important role in guiding behavior change and enhancing adherence to medication, treatment, and appointment attendance [82]. Moreover, reminders can reduce the need to memorize, reduce the number of missed drug doses, reduce treatment interruptions, and perform laboratory tests on time [82, 83]. Ponder et al. [14] developed the MMS application, which incorporates a reminder feature designed to prompt patients for tasks such as confirming appointments and completing preoperative screenings. The significance of the reminder feature has been emphasized in other studies as well [21, 45, 84, 85].

Heuristic evaluation on mHealth prototypes has been used before to address usability concerns of newly developed apps before user interaction [86, 87, 88, 89]. The heuristic evaluation of the PostSurgCare app revealed 130 problems. A significant finding of this research was that most identified problems were classified as minor. Additionally, the average severity score for the discovered problems was 1.56, falling within the minor problem category. The application exhibited restricted user control and freedom, characterized by the lack of confirmation steps for irreversible actions and the inability to transition between sections without incurring data loss. Additionally, the error prevention mechanisms were found to be insufficient, permitting erroneous data entry without validation or confirmation prompts prior to the deletion of information. The heuristic evaluation led to valuable improvements, such as adding a confirmation step and measures to prevent incorrect data entry, ultimately enhancing the app's overall user experience.

Data from the MAUQ showed that patients considered the PostSurgCare app to have acceptable usability. Among the three primary usability criteria, users expressed the highest satisfaction with the application's interface and overall experience (5.98 ± 0.71), likely due to features that effectively met participants' expectations. The results of this study are comparable to those obtained by Rezaee et al. [90], who evaluated the usability of an mHealth application using MAUQ and reported that the interface and user satisfaction received the highest average score. These results are consistent with the study by Saeidnia et al. [91], which highlighted that interface and user satisfaction are key factors in the effective use of mHealth applications for self‐managing health issues.

Future studies may explore iterative refinements of the PostSurgCare application and evaluate its usability and potential benefits over longer follow‐up periods. Although the app was developed for Iranian breast cancer patients, the general development approach could be adapted for use in other settings, particularly in middle‐income countries, provided that appropriate linguistic, clinical, and cultural modifications are undertaken.

5. Limitations

This study has several limitations. Although patient needs were considered, a fully user‐centered design approach with direct patient involvement was not applied during the early requirements‐gathering phase, and needs were primarily identified through literature review and expert consensus. The use of convenience sampling for expert recruitment may have introduced sampling bias. In addition, the usability evaluation was conducted with a relatively small sample size and over a short period. Finally, the application was developed and evaluated within a single institutional context and on the Android platform only, which may limit generalizability.

6. Conclusion

This study describes the development and usability evaluation of PostSurgCare, a Persian‐language mobile application intended to support postoperative self‐management among breast cancer patients. The usability findings suggest that the application was generally acceptable and easy to use for participating patients. By offering culturally adapted postoperative information and basic self‐management support, PostSurgCare may serve as a preliminary step toward improving supportive care for breast cancer patients in Iran.

Author Contributions

Seyed Mohsen Laal Mousavi: conceptualization, writing – original draft, writing – review and editing, visualization, validation, methodology, software, data curation, project administration, supervision. Corneel Vandelanotte: conceptualization, validation, writing – original draft, writing – review and editing. Mohammad Beheshti: visualization, formal analysis, writing – original draft, writing – review and editing. Saman Khalesi: conceptualization, validation, writing – original draft, writing – review and editing. Maryam Alidadi: methodology, writing – review and editing, writing – original draft, data curation, visualization, software, supervision. Zahra Shafiei Bafti: data curation, writing – original draft, writing – review and editing.

Funding

The authors have nothing to report.

Ethics Statement

This study received approval from the Research Ethics Committee of Shahid Beheshti University of Medical Sciences in Tehran, Iran (ethical code: IR.SBMU.RETECH.REC.1402.336). Patient privacy was ensured using non‐identifiable information, and informed consent is used for all participants prior to their involvement. The study ensured voluntary participation, maintained confidentiality, and respected participants' right to withdraw at any time. All procedures followed applicable guidelines, regulations, and ethical standards. The research did not modify existing standards of care practices. The study adheres to the Declaration of Helsinki.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix A. Results of the Delphi Process

Category	Data element/function		No.	CVR	Delphi round 1 mean	Delphi round 2 mean	Standard deviation	Status
Demographic information	Patient name		1	0.8	4.2	—	0.7	Accepted
	Last name		2	0.8	4.2	—	0.59	Accepted
	Age		3	0.8	4.2	—	0.56	Accepted
	Education		4	0.6	—	—	—	Rejected
	Occupation		5	0.8	2.8	2.4	0.68	Rejected
	Marital status		6	1	4.3	—	0.62	Accepted
	Weight		7	1	4.6	—	0.51	Accepted
	Height		8	1	4.6	—	0.35	Accepted
	Age at diagnosis		9	1	4.2	—	0.56	Accepted
	Comorbid conditions		10	0.4	—	—	—	Rejected
	Surgery date		11	1	4.4	—	0.51	Accepted
	Attending physician's name		12	0.2	—	—	—	Rejected
	Number of children		13	1	3.8	—	0.41	Accepted
	Total years of breastfeeding		14	1	3.9	—	0.59	Accepted
	Age at first pregnancy		15	1	4.6	—	0.70	Accepted
Post‐surgical instructions	Dressing removal time		16	0.8	3.3	2.2	0.82	Rejected
	First bathing time		17	0.8	3.4	2.4	0.49	Rejected
	Arm exercises		18	1	4.6	—	0.52	Accepted
	Wound care		19	1	4.6	—	0.49	Accepted
	Seroma		20	1	4.8	—	0.35	Accepted
	Infection		21	0.8	2.2	—	0.35	Rejected
	Pain management		22	0.8	4.4	—	0.46	Accepted
	Use of a bra		23	1	3.8	—	0.63	Accepted
	Emergency conditions		24	1	4.2	—	0.56	Accepted
Post‐surgical chemotherapy	Definition of chemotherapy		25	0.8	4.5	—	0.59	Accepted
	Frequency and duration		26	1	4.6	—	0.52	Accepted
	Use of other medications during chemotherapy		27	1	3.7	—	0.51	Accepted
	Side effects	Hair loss	28	1	4.6	—	0.46	Accepted
		Nausea and vomiting	29	1	4.2	—	0.49	Accepted
		Skin and nail changes	30	1	4.6	—	0.88	Accepted
		Constipation and diarrhea	31	1	4.6	—	0.49	Accepted
		Appetite loss	32	1	3.8	—	0.63	Accepted
		Weight changes	33	1	3.7	—	0.83	Accepted
		Fatigue	34	1	3.9	—	0.80	Accepted
		Temporary or permanent menopause	35	1	4.6	—	0.70	Accepted
		Fertility impact	36	1	4.6	—	0.49	Accepted
		Mouth and lip ulcers	37	1	4.2	—	0.62	Accepted
		Anemia	38	1	3.8	—	0.88	Accepted
		Bruising and bleeding	39	0.6	—	—	—	Rejected
		Fever	40	0.6	—	—	—	Rejected
		Low white, red blood cells, or platelets	41	0.6	—	—	—	Rejected
		Sore throat	42	0.6	—	—	—	Rejected
		Cardiac complications	43	1	4.6	—	0.59	Accepted
Musculoskeletal Pain		44	1	3.8	—	0.74	Accepted
Numbness and tingling in hands/feet	45	1	4.6	—	0.53	Accepted
Post‐surgical radiotherapy	Definition of radiotherapy		46	1	4.5	—	0.63	Accepted
	Frequency and duration of treatment		47	1	4.6	—	0.52	Accepted
	Care during and after radiotherapy		48	1	3.6	—	0.59	Accepted
	Necessary care for using creams and gels		49	1	4.6	—	0.49	Accepted
	Side effects	Skin burns in the radiotherapy area	50	1	3.8	—	0.68	Accepted
		Swelling and heaviness in the breast	51	1	3.7	—	0.74	Accepted
		Pain in the chest area	52	1	4.2	—	0.46	Accepted
		Fatigue	53	1	4.6	—	0.68	Accepted
		Pain and swelling in the arm	54	1	4.2	—	0.49	Accepted
Post‐surgical hormone therapy	Definition of hormone therapy		55	0.8	4.5	—	0.77	Accepted
	Medications and duration of use		56	1	4.2	—	0.64	Accepted
	Importance of exercise and physical activity		57	0.8	3	2.4	0.70	Rejected
	Side effects	Menopause symptoms	58	0.8	4.5	—	0.76	Accepted
		Vaginal dryness	59	0.8	3.8	—	0.52	Accepted
		Muscle and joint stiffness and pain	60	1	4.6	—	0.74	Accepted
		Osteoporosis	61	1	3.6	—	0.51	Accepted
		Heart disease and hypertension	62	1	3.8	—	0.62	Accepted
		Blood clots	63	1	4.6	—	0.52	Accepted
		Liver disorders	64	0.8	2.4	—	0.51	Rejected
		Bone pain	65	1	4.6	—	0.68	Accepted
		Obesity	66	1	4.2	—	0.63	Accepted
		Endometrial cancer and uterine sarcoma	67	0.8	2.4	—	0.88	Rejected
Follow‐ups	Surgeon and oncologist visits		68	0.8	4.5	—	0.51	Accepted
	Breast imaging (mammography)		69	0.8	4.5	—	0.35	Accepted
	Pelvic examinations (gynecologist visit)		70	1	4.6	—	0.41	Accepted
	Bone scan		71	1	4.6	—	0.72	Accepted
	PET scan		72	0.8	2.2	—	0.74	Rejected
	Uterine and ovarian ultrasound		73	1	4.4	—	0.68	Accepted
	CT scan and abdominal/pelvic ultrasound		74	1	3.7	—	0.52	Accepted
	Chest X‐ray		75	0.8	2.2	—	0.59	Rejected
	Blood tests (tumor markers)		76	0.8	2.4	—	1.01	Rejected
Lifestyle	Nutrition and diet		77	1	4.2	—	0.83	Accepted
	Vitamin D intake		78	0.8	4.5	—	0.77	Accepted
	Physical activity		79	0.8	4.5	—	0.52	Accepted
	Work‐related issues and level of activity		80	0.4	—	—	—	Rejected
	Weight management		81	1	4.6	—	0.74	Accepted
	Management of comorbid conditions	Blood pressure	82	1	4.4	—	0.63	Accepted
		Diabetes	83	1	4.6	—	0.74	Accepted
		Increased cholesterol levels	84	1	4.2	—	0.49	Accepted
		Thyroid disorders	85	1	3.7	—	0.80	Accepted
	Management of depression and anxiety		86	1	4.6	—	0.59	Accepted
	Pregnancy and breastfeeding		87	1	3.8	—	0.49	Accepted
	Early menopause/symptoms		88	1	3.7	—	0.83	Accepted
	Physical appearance changes		89	0.8	4.5	—	0.70	Accepted
	Prevention of recurrence		90	1	4.2	—	0.52	Accepted
	Lymphedema		91	1	4.6	—	0.46	Accepted
	Breast reconstruction		92	0.8	3.7	—	0.63	Accepted
App functions	Reminders	Medications	93	1	4.6	—	0.80	Accepted
		Doctor visits	94	1	4.4	—	0.63	Accepted
		Exercise	95	1	4.2	—	0.51	Accepted
		Paraclinical services	96	1	4.6	—	0.88	Accepted
	Warning about BMI increase		97	1	4.4	—	0.62	Accepted
	Notes		98	0.8	4.5	—	0.63	Accepted
	Contact information for doctors and list of treatment centers		99	0.8	4.5	—	0.52	Accepted
	Frequently asked questions (FAQ)		100	0.8	3.8	—	0.64	Accepted

Appendix B. User Interface of the Application in Persian (Farsi)

FIGURE B1.

The application's main and login screens. The application interface is originally developed in Persian (Farsi). For readability and clarity for international readers, the screenshots presented in this manuscript have been translated into English.

FIGURE B2.

Education information. Exercise module of the app showing postoperative shoulder and arm exercises. Educational video module of the app demonstrating postoperative drain care.

FIGURE B3.

Reminders and alerts.

FIGURE B4.

Updated prototype screens after heuristic evaluation.

Data Availability Statement

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.