title: Content, Usability, and Utilization of Plain Language in Breast Cancer Mobile Phone Apps: A Systematic Analysis.
abstract: BACKGROUND
  Breast cancer is one of the leading contributors to preventable illness and death among women. Although mobile phone apps provide unprecedented opportunity to engage women along the cancer continuum, little is known about the availability, content, and usability of breast cancer mobile phone apps.
  
  
  OBJECTIVE
  This study analyzed the content and adherence to literate design standards of all breast cancer-related apps available on the App Store and Google Play, as well as the relationship between their content, user ratings, and price.
  
  
  METHODS
  Following identification and downloading of all available breast cancer mobile phone apps in October 2015, 101 apps were confirmed as focusing on breast cancer. Based on prior research, we adapted and applied a content analysis scheme that was specific to breast cancer apps, including their main purpose, relevance to the cancer care continuum, and adherence to usability standards outlined by the Institute of Medicine (IOM).
  
  
  RESULTS
  The most common aim of apps was educational (73/101, 72.3%), followed by behavior change (24/101, 23.9%), fundraising (20/101, 19.8%), and advocacy (14/101, 13.9%). On the cancer continuum, primary prevention (strategies to prevent cancer cells from occurring) was mentioned in almost one-third of the apps (30/101, 29.7%). Less than half of the apps (46/101, 45.5%) presented information about mammography and/or breast clinical exam, and 53 apps (52.5%) discussed breast self-exam (which is no longer recommended). Symptoms of cancer prediagnosis, such as a lump, were discussed in almost half of the apps (48/101, 47.5%) and a similar number of apps included information about genetic risk for breast cancer (47/101, 46.5%). Information about breast cancer diagnosis was included in 42 apps (41.58%) and 43 (42.6%) apps discussed treatment options. Survivorship issues were addressed in 17 (16.8%) apps. Only one (1.0%) app discussed hospice. Adherence to usability recommendations was low. The median composite score was 3 (mean 2.60, SD 1.20) of the six recommended usability items. With eight plain language items, the median of the composite health literacy score was 5 (mean 5.06, SD 2.00). Most apps did not use easy-to-understand words (44/101, 43.6%) and few (24/101, 23.8%) defined key terms.
  
  
  CONCLUSIONS
  Current breast cancer apps provide important information about breast cancer, but the most common topic covered is breast self-examination, a non-evidence-based screening strategy. Apps that focus on evidence-based strategies on the cancer continuum are needed, with a notable pressing need for apps that would address survivorship and end of life. Finally, developers of breast cancer apps should adhere to IOM standards to meet the needs of diverse populations and reduce current disparities.
authors.affiliation: Department of Communication and Journalism, University of New Mexico, Albuquerque, NM, United States.
authors.forename: Tamar
authors.identifier: http://orcid.org/0000-0002-0136-6675
authors.initials: T
authors.lastname: Ginossar
authors.affiliation: Department of Communication and Journalism, University of New Mexico, Albuquerque, NM, United States.
authors.forename: Sayyed Fawad Ali
authors.identifier: http://orcid.org/0000-0003-4380-7763
authors.initials: SF
authors.lastname: Shah
authors.affiliation: Department of Communication and Journalism, University of New Mexico, Albuquerque, NM, United States.
authors.forename: Andrew J
authors.identifier: http://orcid.org/0000-0001-6432-1856
authors.initials: AJ
authors.lastname: West
authors.affiliation: Department of Strategic Communication, Texas Christian University, Fort Worth, TX, United States.
authors.forename: Joshua M
authors.identifier: http://orcid.org/0000-0002-8391-6609
authors.initials: JM
authors.lastname: Bentley
authors.affiliation: Health Communication Research Laboratory, Brown School of Social Work, Washington University in Saint Louis, Saint Louis, MO, United States.
authors.forename: Charlene A
authors.identifier: http://orcid.org/0000-0001-8770-7989
authors.initials: CA
authors.lastname: Caburnay
authors.affiliation: Health Communication Research Laboratory, Brown School of Social Work, Washington University in Saint Louis, Saint Louis, MO, United States.
authors.forename: Matthew W
authors.identifier: http://orcid.org/0000-0001-7272-0785
authors.initials: MW
authors.lastname: Kreuter
authors.affiliation: Department of Internal Medicine, Health Science Center, University of New Mexico, Albuquerque, NM, United States.
authors.forename: Anita Y
authors.identifier: http://orcid.org/0000-0002-2996-9355
authors.initials: AY
authors.lastname: Kinney
keywords: breast cancer; cancer-related content; mobile apps; mobile phones