Participants were recruited via Facebook advertisements and completed an online screening survey to assess eligibility. Following the completion of the online screening survey, research staff contacted potential participants by telephone. Inclusion criteria required that participants (1) were ≥18 years of age, (2) had a prior diagnosis of stage I-IV invasive BC, (3) self-reported poor sleep defined as a >4 global score on the Shortened Pittsburgh Sleep Quality Index [30], and (4) had an Eastern Cooperative Oncology Group Performance Status of 0 to 2 (indicating the ability to perform activities of daily living) [31]. The exclusion criteria were (1) a prior diagnosis of restless legs syndrome, periodic leg movement disorder, narcolepsy, rapid eye movement sleep behavior disorder, or sleep-related breathing disorder; or (2) active receipt of chemotherapy or radiation (endocrine therapy permitted). Sixty-four individuals filled out the initial screener. Of these, 22 participants provided consent, while 4 declined participation, 7 were found ineligible, and 31 were lost to follow-up due to being unreachable. Among those who consented, 2 participants withdrew after enrollment and 4 could not be scheduled for focus groups or interviews. Ultimately, a total of 16 BC survivors experiencing current sleep disturbances were included.

Three online focus groups and 3 individual online interviews were conducted from May 2020 to March 2021. Two groups consisted of 4 participants each, while the third group comprised 5 participants. Individual interviews were conducted with 3 participants who had difficulty scheduling focus group times. All discussions were conducted and recorded via Zoom (Zoom Video Communications, Inc), and each discussion lasted approximately 60 minutes.

The focus groups were led by 2 authors (KWR and WS), and the individual interviews were conducted by WS. Group discussions were framed by semistructured subject guides (Table 1). The first section of each focus group and individual interview explored participants’ experiences with sleep disturbances and their coping strategies. Next, participants were asked about their preferences regarding potential features of sleep-related technology interventions, including the use of physical activity as one potential strategy to improve sleep.

Data saturation was assessed retrospectively following the completion of 3 focus groups and 3 individual interviews. The analysis showed consistent themes across sessions, with no new codes or conceptual categories identified in later transcripts. Consequently, no further data collection was required.

The study was reviewed and approved by the University of Washington Institutional Review Board (approval number 9642). All participants provided verbal informed consent, as written informed consent was waived. Since all the discussions were conducted and recorded via Zoom, participants were informed that sessions would be audio recorded. All transcripts were deidentified before data analysis. All participants received a $25 gift card as compensation.

Three focus groups and 3 individual interviews were conducted with a total of 16 BC survivors experiencing sleep disturbances. The characteristics of the participants are summarized in Table 2. The participants were aged between 41 and 72 years; the average age was 59.3 (SD 8.9) years. Most of the participants were White (14/16, 87.5%), while the remainder were Black (2/16, 12.5%). Participants had varying levels of education, with 68.8% (11/16) holding a bachelor’s degree or higher; they also had varying stages of BC, with 50% (8/16) diagnosed with stage II BC. The majority had received chemotherapy, radiation, and/or hormone therapy.

Three themes emerged from the analysis: (1) attitudes toward the use of technology-based tools for promoting sleep and physical activity, (2) specific user needs for future SMS text messaging–based interventions, and (3) technology usage habits and preferences. Table 3 provides an outline of the themes, subthemes, and definitions of the themes.

In our focus groups and individual interviews, we explored BC survivors’ perspectives on various approaches to delivering SMS text messaging–based mobile health interventions targeting sleep and physical activity. This included ascertaining the intervention’s format and potential functionalities. Three areas were focused upon in this study: attitudes toward SMS text messaging–based mobile interventions, technology preferences, and specific user needs.

To address sleep disturbances and improve physical activities, participants stated the need for an efficient intervention and expressed a positive attitude toward trying new approaches. Some participants mentioned that they were still seeking effective strategies. These findings highlighted the significance that participants attributed to sleep health and emphasized the need for suitable sleep-related interventions. Most participants exhibited a high level of acceptance toward technology, such as SMS text messaging and mobile apps, and they incorporated it into their daily lives. Prior studies showed that smartphone ownership among older adults increased significantly from 18% in 2013 to 83% for individuals aged 50 to 64 years and 61% for those aged 65 years and older in 2021 [33]. A survey from the American Association of Retired Persons in 2023 revealed that 94% of adults aged 50 years and above in the United States use SMS text messaging to maintain social connections [34]. This finding aligns with the usage habits reported by most of our interview participants. In combination with commonly used devices (eg, smartphones) and communication habits, this suggests that designing conversational interventions, such as interactive SMS text messaging or chatbots, is potentially feasible within this population.

In terms of features, incorporating a reminder related to sleep and physical activity was mentioned most frequently. A systematic review reported that personalized push reminders can positively influence users’ adherence [35]. Participants proposed that incorporating bedtime and relaxation exercise reminders could be helpful and that daily reminders, or notifications an hour before bed, would be acceptable. A systematic review paper regarding electronic health interventions in patients with BC indicates that users exhibited the most engagement with supportive features, including SMS text messaging, chat functions, and health reminders [36]. On the other hand, a significant decline in user engagement over time is also a common phenomenon [36]. A study with older patients with cancer suggested that customization features, such as the ability to ignore reminders, which give users more control, might enhance adherence to digital health interventions [37]. Consequently, when developing reminder features, user control and customization options should be considered fundamental components. The desire expressed by participants for mindfulness meditation tools aligns with literature, showing that mindfulness is effective for enhancing sleep quality among adults. Previous studies suggested that mindfulness meditation significantly improves sleep quality and reduces sleep-related daytime impairment [38,39]. Mindfulness meditation is thought to regulate arousal and neurocognitive processes, thereby mediating the link between how stimuli are perceived and how they are appraised [39]. Furthermore, a study implemented a meditation app to improve sleep in adults with sleep disturbances, resulting in significant reductions in presleep arousal and improvements in depression and anxiety [40]. Additionally, a qualitative study demonstrated that a mobile meditation tool to improve sleep quality is acceptable and feasible among adults, with tailoring needs varying by race and ethnicity [41].

Tracking features were also discussed in focus group interviews. The tracking feature can assist users in adhering to their goals, evaluating their progress, and motivating them to maintain healthy habits. In previous studies on technology-based interventions related to physical activity for the population with BC, tracking features have often been requested or incorporated [42,43]. Although there is a lack of studies specifically on the tracking features of sleep-related interventions for the population with BC, evidence from other clinical populations suggests potential benefits. A study with multiple sclerosis patients found that self-tracking tools helped clarify patterns related to symptoms, physical activity, and sleep quality and had a motivational effect on changing behavior [44]. Another research study focused on the general population indicated that routine self-tracking is more likely to provide positive modifications in health management strategies compared to event-triggered tracking [45]. In addition, the mindsets of users may influence the evaluation of self-tracking performance and affect the dynamics of the relationship formed with the tool [46]. If future studies incorporate self-tracking features into sleep-related interventions, researchers could evaluate their potential to enhance users’ motivation for lifestyle modifications and subsequently improve sleep quality.

In terms of technology preferences, both SMS text messaging and applications were mentioned as acceptable choices, with a shared consensus that mobile phones are the most convenient tool. According to prior studies, several sleep-related applications have been developed, some of which incorporate CBTi principles. These applications include features such as personalized sleep feedback, a sleep diary, and reminders [47]. However, there has been a lack of interventions delivered via SMS text messaging with interactive features, especially in the cancer survivors’ population. Participants who preferred SMS text messaging found texts to be easy to read and simple to operate, suggesting that this format holds potential as an effective intervention.

One such potential approach involves a conversational agent, including chatbots or other conversational interfaces, which mimic human conversation through spoken language or SMS text messaging [48]. Conversational agents are increasingly utilized in health care [49], and recent advances in large language models have also enabled an increasing use of conversational agents to support personal sleep wellness, for instance, by delivering CBTi–based interventions [50]. A customized SMS text messaging–based conversational agent tailored to this population could provide targeted support in real-time, delivering reminders, relaxation exercises, or sleep hygiene tips that are particularly relevant to their lived experiences. A growing body of research has emphasized the potential of SMS text messaging–based conversational agents in clinical practice and psychotherapy [51,52]. However, the application of such technology in addressing sleep and physical activity among BC survivors remains limited. We also asked participants about their perspectives on these developing technologies. Some participants expressed interest in using novel technologies such as SMS text messaging–based conversational agents for health interventions. Although novel technologies were regarded as acceptable in this study, one recent article discussed potential risks associated with chatbots. For instance, chatbots utilizing generative artificial intelligence may generate responses that cause psychological harm, provide misleading or inappropriate information, or lead the users overrely on them [53]. Therefore, these potential risks should be considered while developing the tools.

One participant expressed concerns regarding the use of electronic devices before bed. Prior research has shown that using smartphones in bed may negatively impact sleep quality, especially games that overload certain memory and cognitive functions. Conversely, smartphones used outside of bed do not decrease sleep quality [54]. Another research study also highlighted the complexity of the relationship between sleep quality and smartphone use. While screen use before bed may negatively affect sleep, if digital tools are used appropriately, some features, such as reminders, tailored recommendations, or other CBTi-related features, may still support users’ sleep and improve engagement [55]. Overall, this aspect should be considered when designing sleep-related digital tools to avoid any potential negative impact of technology on sleep.

The long-term goal of this research is to help BC survivors improve their sleep and overall health. Accomplishing this goal will require a 2-fold effort: first, to develop an effective SMS text messaging–based mobile health intervention with strong adherence, such as a conversational agent, and second, to make this intervention widely available to the over 1 million BC survivors with insomnia living in the United States. The perspectives of BC survivors will be essential to each of the steps to determine where, when, and how an SMS text messaging–based mobile health intervention would be most useful as well as how to anticipate and address barriers and facilitators to access. To support the implementation and scalability of this intervention, we will also need to engage with BC clinicians to develop strategies to integrate the intervention into clinical practice.

In line with current technological trends, future interventions may leverage emerging technologies, such as conversational generative artificial intelligence and large language models, which have the potential to deliver personalized support tailored to BC survivors’ needs. Future research is needed to develop and evaluate the feasibility, acceptability, and effectiveness of this type of tool.

One limitation of this study is that the demographic composition of the sample mainly comprised older adults with higher levels of education, and the majority of participants self-identified as White. In addition, most participants were based in the United States, with recruitment primarily targeted in Washington State. The lack of a diverse population included in this study may limit the generalizability of the findings to broader populations. Moreover, this study used social media for recruitment, and the interviews were conducted virtually via Zoom. As a result, most of the participants were likely to have a greater degree of knowledge and familiarity with using technology. The perspectives of groups less familiar with using technology were not included. However, the findings could still provide meaningful insights into the specific group perspectives and serve as a foundation for developing SMS text messaging–based mobile health interventions to promote sleep and physical activity. We also recommend that future research be expanded to include more diverse populations to enhance the breadth of perspectives represented in the findings.

We gathered perspectives from BC survivors to inform the design of an SMS text messaging–based mobile health intervention, which incorporated common sleep-related interventions such as CBTi and physical activity. The participants generally expressed openness to SMS text messaging–based mobile interventions and potential features such as tracking and reminders. The preference for delivery modes such as SMS text messaging could serve as a reference for tailoring interventions to this population.