A tailored internet-delivered mindfulness-based interventions for patients with hepatocellular carcinoma after TACE: A qualitative Study

A tailored internet-delivered mindfulness-based interventions for patients with hepatocellular carcinoma after TACE: A qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A tailored internet-delivered mindfulness-based interventions for patients with hepatocellular carcinoma after TACE: A qualitative Study Zengxia Liu, Min Li, Yong Jia, Lufang Zheng, Li Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4825350/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose The purpose of this study was to explore the true experiences of hepatocellular carcinoma (HCC) patients after TACE who participated the tailored internet-delivered mindfulness-based interventions (iMBIs). Methods From November 2020 to December 2022, 11 HCC patients after TACE who participated the tailored iMBIs were recruited from a tertiary hospital in Jilin Province by purposive sampling. Semi-structured interviews were performed to collect data, and qualitative content analysis was conducted to analyze the data. Results We identified five main categories from interviews, including mindfulness mindset, improvement of physical discomfort, resistance to mindfulness practice, support and encouragement, and accessibility and convenience. Each category can be divided into several general categories. Conclusions Participants reported subjective psychological and physical benefits. However, participants also had negative experiences in the process of mindfulness practice. While iMBIs gives participants a sense of convenience and accessibility, there are also issues with device usage limitations. interenet mindfulness hepatocellular carcinoma cancer qualitative study Background Primary liver cancer (PLC) is the third leading cause of cancer-related death. It is also one of the most common malignancies in the world, with China accounting for 45.27% of cases and 47.12% of deaths[ 1 ]. Hepatocellular carcinoma (HCC) is the most common histologic type of PLC, accounting for 75–85% of all cases[ 2 ]. Transcatheter arterial chemoembolization (TACE) is widely recognized as one of the local treatment methods for HCC and has become the preferred treatment for patients with non-surgical treatment of intermediate-stage HCC[ 3 , 4 ]. Patients often need to receive multiple TACE treatments to control the development of the disease, but they still face recurrence, metastasis and various complications after operation[ 5 ]. In addition, the efficacy of TACE will decrease with the increase of treatment times and repeated TACE treatment will aggravate liver damage[ 6 ]. HCC patients after TACE experience severe psychological distress[ 7 ], which seriously affects their treatment compliance and effectiveness[ 8 ]. The effectiveness of mindfulness-based interventions (MBIs) in improving psychological distress in cancer patients has been widely recognized[ 9 , 10 ]. Compared with other cancers, HCC patients after TACE have their special physiological and psychological characteristics. So it is necessary to develop a tailored MBIs for these patients. Despite documented efficacy, challenges remain to make MBIs available to patients in need because of limited number of trained therapists, costs, and restricted mobility and time constraints among cancer patients[ 11 ]. Compared with the traditional face-to-face intervention, internet-delivered interventions have many advantages. The intervention can be obtained online and can be arranged according to participants’ own time. Especially for HCC patients, it can reduce the practical barriers such as geographical distance, transportation issues, cancer-related illness, and limited mobility. Studies have demonstrated the effectiveness of internet-delivered mindfulness-based interventions (iMBIs) in improving participants' psychological distress[ 12 – 14 ]. Most studies use standardized questionnaires to investigate iMBIs in cancer patients[ 15 – 17 ]. However, these studies do not provide information on participants' experiences with iMBIs, which aspects of iMBIs are considered helpful and which are not, how mindfulness is integrated into private and work life, which ways of engaging with iMBIs are thought to affect patients psychologically and physiologically, what degree this approach to iMBIs would be perceived as relevant and appropriate by participants, and to what degree such content may be meaningfully administered electronically to this population. Therefore, the main objective of this qualitative study was to explore participants' experience and perceived effects of tailored iMBIs,further learns the feelings and experiences of participants, comprehensively explores the benefits and existing problems of interventions, and analyzes the influencing factors of participants' compliance. Materials and methods 1.1 Research design We conducted a qualitative interview study as part of a larger randomized controlled trial (RCT). A detailed description of the RCT can be found elsewhere[ 13 ]. 1.2 Research objects Inclusion criteria for research objects: (1) Age ≥ 18 years old; (2) For patients diagnosed with HCC, the diagnostic criteria of HCC are based on the criteria of European Association for the Study of the Liver (EASL)[ 18 ], including pathological diagnosis, positive lesions detected by at least two different imaging techniques, and imaging techniques combined with alpha fetoprotein > 400ng/ml; (3) receiving TACE; (4) Capable of operating smartphones and using WeChat frequently(5 times a week); (5) Ability to read, write and speak Chinese. (6) Informed consent and voluntary acceptance to cooperate with the implementation of this study. Exclusion criteria: (1) simultaneously diagnosed with other tumor types or mental stress disorders; (2) taking any psychotropic drugs during the study period; (3) received mindfulness intervention. (4) HCC patients who have poor health that affects normal communication. From November 2020 to December 2022, this study was conducted at the First Hospital of Jilin University. By evaluating and screening the medical records of patients, potential participants who met the inclusion criteria were invited to participate in mindfulness interventions, and interviewees were recruited from the participants who completed mindfulness interventions. The sample size was based on the saturation of the collected data. 1.3 Interventions Through preliminary cross-sectional surveys, it was found that trait mindfulness, perceived stress and experiential avoidance are potential psychological mechanisms that intervene in anxiety and depression in HCC patients after TACE. Therefore, based on the relevant content of MBSR[ 19 ], acceptance and commitment therapy[ 20 , 21 ] and mindfulness-based cancer rehabilitation, combined with the characteristics of HCC patients after TACE, a tailed mindfulness interventions program for HCC patients after TACE was developed. A self-service intervention approach is taken with WeChat groups and official accounts to push intervention content. The weekly intervention content will be converted into text, audio, video, pictures and other forms to create a WeChat official account. The intervention form for the first week is a face-to-face intervention within the hospital, while the second to sixth weeks are network-based interventions outside the hospital. The specific intervention methods are as follows: Face-to-face intervention in the hospital: The location is the classroom of the interventional department, with 5–8 participants in one group, each lasting 1-1.5 hours. The research team explains the purpose and content of the study to the participants through slides, introducing the content and role of mindfulness, and allowing participants to fully understand mindfulness and its attitude. The research team introduced the whole process and contents of the intervention to the participants, making them familiar with the relevant content of mindfulness intervention and self-service intervention methods, laying the foundation for the smooth implementation of out-of-hospital network-based intervention from the second to the sixth week. Out-of-hospital iMBIs: The intervention contents are converted into audio, video or pictures and pushed weekly via WeChat. Participants learn the intervention content and practice mindfulness for 20 minutes every day for at least 5 days a week, and practice their homework for about 10 minutes. The research team urged patients to complete the time and frequency of practice through WeChat and telephone, and encouraged participants to check in on mindfulness learning in the WeChat group every day to exchange experiences and feelings about mindfulness practice. The research team also shared knowledge through WeChat groups, including knowledge about mindfulness, HCC and TACE treatment, and answered participants' questions about diseases, mindfulness and other aspects. After discussion and modification by experts, a tailed mindfulness intervention program for HCC patients after TACE was developed. The specific contents are shown in Table 1 . Table 1 The tailored internet-delivered mindfulness-based interventions for HCC patients after TACE Week Theme of intervention Summary of contents Homework Intervention mode Week 1 Mindfulness and HCC, self-acceptance (1) Knowledge introduction : Introducing content related to mindfulness, HCC and TACE treatment, and the relationship between mindfulness and cancer. (2) Mindful breathing : Guide patients to practice mindful breathing and experience every detail of breathing. (3) "The Missing Piece" : Watch the video "The Missing Piece" to trigger participants' thinking about "unchangeable shortcomings". Mindful breathing Face-to-face intervention in the hospital, 5–8 participants per group, 1-1.5 hours per session, introducing the purpose and content of the study, and guiding the completion of the first session. Week 2 Cancer and stress, cognitive dissociation (1) Knowledge introduction : Describe knowledge related to cancer and stress, and typical stress reactions to cancer stress events. (2) Body scan : Introduce the connotation and requirements of body scan, and feel and experience the sensation of each part of the body in order from feet to head. (3) "I have such an idea now" : Guide participants to practice "I have such an idea now", Body scan Out-of-hospital online intervention, 20 minutes per day, at least 5 days per week, learn the intervention content via official account and WeChat, and 10 minutes of homework practice. Week 3 Identifying avoidance reactions and self-awareness (1) Meditation practice : Guide patients to practice mindful meditation and perform meditation exercises during meditation. (2) "Chessboard metaphor" : Guide participants to imagine a "chess game" and use the "chessboard metaphor" to guide participants no longer entangled in their inner struggles. Meditation practice Out-of-hospital online intervention, 20 minutes per day, at least 5 days per week, learn the intervention content via official account and WeChat, and 10 minutes of homework practice. Week 4 Practice mindfulness in life, focusing on the present (1) Mindfulness walking : Guide patients to practice mindfulness walking and feel the current movements while practicing. (2) Mindfulness eating : Guide patients to practice mindfulness eating. Mindful walking Week 5 Non-selective awareness, clear value (1) Awareness practice : Explain the key points of awareness practice to patients and be aware of everything around them. (2) “Compass” metaphor : Guide participants to think about the guiding role of the “compass” in the journey. Awareness practice Out-of-hospital online intervention, 20 minutes per day, at least 5 days per week, learn the intervention content via official account and WeChat, and 10 minutes of homework practice. Week 6 Grateful life, committed to action (1) Love meditation, good wishes : Cultivate compassionate mindfulness practice, and give your blessings to others during practice. Let participants be filled with tolerance and love in their hearts. (2) "Passengers on the Bus" : Through the short film "Passengers’ Practice on the Bus", guide participants to compare their lives to a bus, and think about the meaning of committed actions. Love meditation Abbreviations:HCC, hepatocellular carcinoma 1.4 Data collection Combined with the disease characteristics and treatment of HCC patients after TACE, a preliminary interview outline was formulated through a literature review and discussion among researchers. Before the formal interview, two participants were pre-interviewed, and the final interview outline was determined according to the problems encountered during the interview, as shown in Table 2 . Demographic information was collected prior to the interviews. Table 2 Interview Outline S/N Question 1 2 3 4 Why did you participate in this network-based mindfulness training? What are your experiences while participating in this training? What effects does network-based mindfulness training have on your body? How does the network-based mindfulness training affect you psychology? The two researchers agreed the interview time with the participants in advance, and chose a separate room of the hospital for face-to-face interviews. Before the interview, they introduced themselves to the interviewees, introduced the purpose, method and content of the interview, and told them that the whole interview process will be recorded in order to ensure the integrity and accuracy of the information, and signed the informed consent form after obtaining the consent. During the interview, the researchers used a neutral attitude and appropriate language to communicate with the participants, to avoid instructive words affecting the participants' answers, and data collection and analysis were carried out simultaneously. 1.5 Ethical considerations The research plan was approved by the Ethics Committee of the School of Nursing at Jilin University (2019112001) and registered with the Chinese Clinical Trial Registration Center (ChiCTR1900027976) On December 7, 2019. Before the interview, the researcher informed the participants of the research content and purpose, assured them that the relevant data would only be used for research and article publication, kept their personal information confidential, and promised them that they could withdraw from the research at any time. All participants signed an informed consent form before the study began. 1.6 Data analysis One researcher participating in the interview listened to the recordings repeatedly within 24 hours after each interview and transcribed them into text. Another researcher participating in the interview checked the transcribed text and imported it into NVivo 11 software for analysis. Qualitative content analysis[ 22 , 23 ] was used to analyze the data. Two researchers independently analyzed and transcribed the data. Research results 2.1 Characteristics of participants In this study, 9 participants were interviewed, and no new information emerged. To ensure that the data had reached saturation, 2 further participants were conducted, and no new information was found. Therefore, a total of 11 participants were interviewed in this study, and their basic characteristics are shown in Table 3 . Table 3 Characteristics of participants ( N = 11) Characteristic Category n (%) Age 18 ~ 44 years 3(27.3) 45 ~ 59 years 5(45.4) ≥ 60 years 3(27.3) Gender Male 6(54.5) Female 5(45.4) Education level Primary school or below 2(18.1) Senior high school 5(45.4) College or higher 4(36.4) Number of TACE 1 3(27.3) 2–6 5(45.4) > 6 3(27.3) HADS 0 ~ 20 5(45.4) 21 ~ 28 4(36.4) 29 ~ 42 2(18.1) Abbreviations: HADS, Hospital Anxiety and Depression Scale; 2.2 categories Through repeated analysis and sorting of data, the following five main categories corresponding to experiences of participants were extracted: mindfulness mindset, improvement of physical discomfort, resistance to mindfulness practice, support and encouragement, and accessibility and convenience. Each category can be divided into several general categories, as shown in Table 4 . Table 4 Relevant categories corresponding to experiences of participants Main Category General Category Subcategory 1 Mindful mindset 1.1 Acceptance 1.2 Calm 1.3 Mood Improvement 1.3.1 Relaxation 1.3.2 Gratitude 2 Improvement of physical discomfort 2.1 Improve Sleep 2.2 Pain Relief 2.3 Reduce gastrointestinal symptoms 2.4 Increase Activities 3 Mindfulness practice resistance 3.1 Lack of effect 3.2 Condition 3.2.1 Fatigue 3.3 Device Usage Restrictions 3.2.2 Pain 3.4 Difficulty Focusing 3.5 Lack of motivation to practice 4 Support and encourage 4.1 Social Support 4.2 Supervision and Guidance 5 Accessibility and convenience 5.1 Restore a sense of balance in your life 5.2 Practice Features Main category 1: Mindfulness mindset Mindfulness mentality refers to the ability of HCC patients after TACE to face HCC with a non-judgmental attitude and maintain a curious, open and accepting attitude toward their current feelings. General category 1.1 Acceptance Six participants expressed that they were able to face illness and various difficulties in life with an accepting attitude after practicing mindfulness. “My mother and I both have hepatitis, and my mother died of HCC, so I have always been worried about my health. I am scared every time I go to the hospital for a check-up. After doing this mindfulness exercise, my mentality changed, and I gradually realized that I should not think about it too much every day. Since I have got this disease, just follow the doctor’s instructions and receive treatment. Many treatments have good effects, but thinking too much is not conducive to my health.” (Interview ig4) General category 1.2 Calm Seven participants reported that after practicing mindfulness, their mentality became calm and they could feel the beauty of things around them better. "I have a much better mentality now. I can feel the things around me more calmly, and I can feel the bits and pieces of life more. I am more willing to take a walk, enjoy scenery and see the beauty of things around me, such as a tree and a flower on the roadside." (Interview ig9) General category 1.3 Mood improvement Subcategory 1.3.1 Relaxation Five participants reported that after mindfulness training, they could better regulate their emotions, no longer feel anxious and became relaxed. “Every time I went to the hospital for a check-up, I would be very nervous when I saw any change in any indicator. Sometimes even a slight change would make me nervous for a long time. Even if the doctor said there were no problems, I would search for a lot of information online. Now that I find myself anxious, I will adjust my emotions, relax my mentality, and not think about things that are not there every day. ” (Interview ig4) Subcategory 1.3.2 Gratitude Two participants mentioned gratitude. After practicing mindfulness, they can face the people and things around them with a grateful attitude. “I have always had a bad temper and am prone to getting angry. My family members gave in to me due to my poor health, which made me even more angry. After listening to that exercise, my mentality gradually improved, and I could calm down when encountering unpleasant things. I also knew that my family had sacrificed a lot for me, and my mentality had changed a lot, then the atmosphere at home was much better. " (Interview ig3) Main category 2: Improvement of physical discomfort Improvement of physical discomfort refers to the improvement of physical symptoms and reduction of discomfort in HCC patients after TACE. General category 2.1 Improvement of sleep Ten participants reported a significant improvement in their sleep after practice, reducing their pre-sleep woolgather and making it easier for them to fall asleep. "I have always had poor sleep, often lying in bed for a long time without falling asleep. The severer poor sleep, the more I become lost in my thoughts. However, since I started listening to this, I fell asleep shortly after listening to it. Listening to that will stop random thoughts." (Interview ig3) General category 2.2 Pain relief Three participants reported that mindfulness practice helped relieve pain and alleviate discomfort. "I used to feel uncomfortable all over and hurt everywhere. When doing this exercise, take a deep breath, relax, follow the teacher and slowly relax yourself. These uncomfortable feelings are no longer felt, and I feel much better!” (Interview ig6) General category 2.3 Alleviation of gastrointestinal symptoms Two participants reported that mindfulness exercises can alleviate gastrointestinal symptoms, improve appetite, and alleviate discomfort such as bloating. “I always have no appetite for anything, and feel uncomfortable after eating, and my stomach is bloated. Now I do this exercise every day, I feel better about these discomforts. When I sit there and relax every day, I feel less irritable and uncomfortable” (Interview ig1) General category 2.4 Add activities Two participants reported that mindfulness practice can alleviate fatigue and increase activity. "My whole body feels weak. Sitting there, lying there, and I don't want to do anything. Sometimes I lie there for a long time, just feeling fatigued. After starting this exercise, I practiced it on time every day. These simple movements gradually make me feel much better, I am willing to move, and I have something to do.” (Interview ig4) Main category 3: Resistance to mindfulness practice Resistance to mindfulness practice refers to the factors that hinder patients' normal participation and persistence in mindfulness practice during iMBIs for HCC patients after TACE. General category 3.1 Lack of effectiveness Two participants reported that the effect was not obvious and there were no obvious changes in psychology or physiology during the practice. "Anyway, with this disease, you are sentenced to death. Just make every possible effort. I planned to give up, but the family members insisted on continuing the treatment, the results would just be a loss of life and wealth, and any practice is useless.” (Interview ig1) General category 3.2 Conditions Subcategory 3.2.1 Fatigue Three participants reported that fatigue and discomfort caused by illness affected normal mindfulness practice. "I have a bad appetite, I do not feel like eating, with a little bit of energy every day. I feel uncomfortable everywhere, the treatment has no effect, and I don't want to do anything, I just want to lie down all day, without doing anything. It’s not easy to practice.” (Interview ig4) Subcategory 3.2.2 Pain Two participants reported that pain interfered with mindfulness practice. "This pain is torturing. I'm not in the mood to do anything, and I haven't seen any relief. When can I get better? This disease is torturing." (Interview ig6) General category 3.3 Equipment usage restrictions 2 participants reported that they were easily distracted by other messages during the use of cellphones and were unable to persist in completing the mindfulness exercises. "There are always all kinds of messages on my phone, and I'm frequently interrupted by them while practicing. It is difficult to keep quiet for a while to complete the practice. Now there are too many messy messages." (Interview ig10) General category 3.4 Difficulty in focusing Two participants reported that in the process of mindfulness practice, it was difficult to concentrate, and it was easy to get distracted, making it difficult to persist in mindfulness practice. "When practicing at home, I got lost while listening. For example, when I was asked to feel my abdomen, I would think of my illness and think about all the messy things. It was difficult to follow and stick to it completely." (Interview ig3) General category 3.5 Lack of motivation to practice Two participants said that during the mindfulness practice, they had difficulty completing it on time due to a lack of motivation to practice. "I feel irritable and tired every day. Alas, I don't want to do anything. I persisted for a while in the first few days, but later I felt that it didn't work. Many times I was too lazy to do this exercise." (Interview ig1) Main category 4: Support and encouragement Support and encouragement refer to the online or offline support and encouragement received by HCC patients after TACE during the process of receiving network-based mindfulness intervention. General category 4.1 Social support Two participants reported that their family members participated in mindfulness exercises and communicated with each other. At the same time, through WeChat groups, communication with patients and medical staff promoted their perseverance. "My wife has been practicing with me since I started practicing it in the hospital. She would also practice with me after I returned home. We share our feelings about practice. Sometimes I don't want to practice, and my wife will urge me. We practice together and gradually stick to it.” (Interview ig5) General category 4.2 Supervision and guidance Three participants reported that they saw patients checking in every day in the WeChat group, and they exchanged their feelings about mindfulness practice with each other, and the WeChat reminders from medical staff also promoted their persistence. “Every day in the WeChat group, everyone checked in and talked about their feelings. Seeing fellow patients who used to live in the same ward as me insisted on checking in every day and asking questions they encountered, I felt that I should also give it a try. After communicating more with everyone, I persevered.” (Interview ig2) Main category 5: Accessibility and convenience Accessibility and convenience refer to the recognition and perception of the convenience, ease, and accessibility of online self-help mindfulness interventions among HCC patients after TACE. General category 5.1 Restoring a sense of balance in life Three participants reported that practicing mindfulness at the same time or place every day made their lives more regular, and fulfilling, and restored a sense of balance, which promoted their persistence. "Since I was diagnosed with this disease, my family has taken special care of me. They won't let me do any housework, so I lie down every day. I feel like I'm going to be useless. With this practice, after practicing it every day, I feel like I've done something and I feel more energetic.” (Interview ig4) General category 5.2 Practice features Three participants mentioned their recognition of iMBIs, feeling that it is time-saving, effortless, and convenient, and this practice method has promoted their persistence. "I live in a rural area, and it's always difficult to come to the hospital. We also need family members to accompany us. Nowadays, this method is available online, and I can practice anytime after finding the audio. This method on WeChat is convenient. Sometimes when you feel down, or when you are idle, you can practice anytime you want. You don't have to have a fixed time, it's more free." (Interview ig11) Discussion This study shows that the participants' positive experience includes both physical and psychological aspects, and the physical positive experience is mainly the improvement of physical symptoms, which is mainly related to the fact that mindfulness intervention can solve the sleep problems of patients with cancer, relieve pain and increase the activity of participants. In terms of psychology, research by Eyles et al.[ 24 ]and Weitz et al. [ 25 ]show that an 8-week MBSR intervention can improve the mental state of breast cancer patients and enable them to live better in the present. Living in the present is seen as a way to let go of anxiety and rediscover happiness[ 20 ]. Mindfulness intervention can also cause changes in individual neurophysiological activities, brain structure and brain function, which is also the reason why mindfulness therapy can generate positive psychological experiences for patients with cancer[ 26 ]. The intervention plan of this study incorporates elements of acceptance and gratitude, allowing participants to continue to perceive and pay attention to current experiences with a more accepting and non-judgmental attitude, pay attention to some painful experiences with an open and accepting attitude, reduce empirical avoidance, and actively identify problems and adopt coping strategies. This study shows that the promoting factors of participants in practice include social support and supervision and guidance. Compared with face-to-face mindfulness intervention, iMBIs lack group communication and support. However, in this study, a WeChat group can provide a platform for mutual communication and sharing, so that everyone can exchange their feelings about mindfulness practice and their diseases. The participation of medical staff also enables patients to get professional answers in time, which increases their confidence and compliance in treatment. Participants' communication and check-in in WeChat groups can encourage other participants to complete mindfulness exercises on time every day, playing a role in mutual supervision. In this study, during the first in-hospital intervention, mindfulness intervention was introduced to patients and their families, encouraging them to complete mindfulness exercises together, which can make up for the shortcomings of online intervention. Research by Zulman et al.[ 27 ] shows that intervening in cancer patients and their caregivers as a whole can promote communication between both parties and increase mutual support. This study shows that the obstacles faced by participants during practice include lack of effectiveness, illness, equipment usage limitations, difficulty concentrating, difficulty completing on time, and lack of motivation to practice. Analyzing the reasons, it may be due to the relatively severe condition of HCC patients[ 28 ]. The disease and treatment have seriously affected the patient's body, which makes it difficult for patients to complete some exercises. Therefore, in future designs, attention should also be paid to the patient's condition and more targeted intervention plans should be designed. At the same time, it is also related to the lack of guidance from mindfulness professionals. As a new intervention method, online psychological intervention brings various conveniences to participants, but it also has disadvantages such as low compliance. Although this study regards medical staff as the instructors of iMBIs, they lack corresponding experience and pertinence in guiding mindfulness intervention, which is one of the reasons for the low compliance of intervention, and the decline of compliance is an important factor that weakens the effect of intervention. At the same time, it is also related to the inclusion criteria of participants. When the negative emotions of participants are too high or too low, it will affect the intervention effect. Compen et al.[ 12 ] used HADS score ≥ 11 points as the inclusion criteria for participants, and the intervention effect is significantly better than other iMBIs. When the patient is in a good psychological state, mindfulness intervention becomes a psychological suggestion to remind participants that they are the patient. Therefore, when the negative emotions of participants in mindfulness intervention are too high or too low, it may lead to the occurrence of a ceiling effect or floor effect. Setting reasonable inclusion criteria and screening procedures will better improve the effectiveness of the intervention. 3.4 Strengths and Limitations This study shows that participants not only felt the convenience and accessibility of online self-service intervention during the exercise but also experienced some inconvenience from the use of internet devices. Compared with traditional face-to-face intervention, iMBIs can reduce the economic burden on participants and is more accessible. The form of online interventions allow participants to complete interventions at home, reducing the inconvenience of travel and allowing them to freely arrange their time, leveraging the convenience of online intervention. The mindfulness intervention program in this study was pushed through a WeChat official account, which has limited functions and makes it difficult to meet the diverse needs of HCC patients after TACE. Therefore, before future product development, the individuality and common needs of users should be fully explored to improve the comfort and convenience of use. At the same time, comprehensive mobile medical products suitable for patients after TACE can be further comprehensively developed, such as the mindfulness application (APP) developed by Subnis et al[ 29 ], which supports personalized mindfulness exercises for participants through guided meditation, audio lectures, self-meditation timers, log functions, and other functions. At the same time, the APP also has a pressure measurement function, measuring pressure by extracting facial biosignals. It can save medical costs and meet the psychological needs of patients, providing a new platform for continuous psychological intervention for cancer survivors. Conclusion In this study, personal semi-structured interviews were used to learn the experiences of iMBIs participants. The results showed that participants subjectively felt benefits in many aspects, including psychological and physical, among which the improvement in psychological aspects was particularly obvious. However, participants also had negative experiences such as lack of obvious effects during mindfulness practice, and they hated being reminded that they were patients during practice. Restoring a sense of balance in life, supervision and guidance are factors that promote mindfulness practice. Lack of effectiveness, dislike of being reminded of being a patient during practice, difficulty concentrating, difficulty completing tasks on time, and lack of motivation to practice are factors that hinder mindfulness practice. While iMBIs gives participants a sense of convenience and accessibility, there are also issues with device usage limitations.In future promotions, the individuality and common needs of mindfulness participants should be fully explored, and software or APP with comprehensive functions should be developed to improve the comfort and convenience of participants. Declarations Author contributions statement Zengxia Liu: Conceptualization, Methodology, Formal analysis, Data curation, Writing -original draft, Writing-review & editing; Min Li: Methodology, Data curation; Yong Jia: Data curation, Writing-review & editing; Lufang Zheng: Data curation, Writing-review & editing; Li Chen: Funding acquisition, Project administration, Supervision. Funding Funding for this study was provided by University Natural Science Research Project of Anhui Provincial [grant number 2023AH050583]. Data availability statement The data are not publicly available because it contains information that could compromise the privacy of study participants. Ethics approval and consent to participate This study was approved by the Ethics Committee of Jilin University School of Nursing (2019112001).Informed consent was obtained from all subjects involvedin the study. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. Cancer J Clin. 2024;74(3):229–63. Hepatocellular carcinoma. Nat reviews Disease primers. 2021;7(1):7. Johnson BW, Wright GP. Regional therapies for the treatment of primary and metastatic hepatic tumors: A disease-based review of techniques and critical appraisal of current evidence. Am J Surg. 2019;217(3):541–5. Tang Z, Bai T, Wei T, Wang X, Chen J, Ye J, Li S, Wei M, Li X, Lin Y, et al. TACE combined Lenvatinib plus Camrelizumab versus TACE alone in efficacy and safety for unresectable hepatocellular carcinoma: a propensity score-matching study. BMC Cancer. 2024;24(1):717. Kim MS, Kang M, Park J, Ryu JM. Nurses' comfort care of transarterial chemoembolization patients based on their perceptions around postembolization syndrome and symptom interference. Nurs open. 2023;10(5):2877–85. Zhang L, Zhang X, Li Q, Makamure J, Liu Z, Zhao D, Li X, Shi H, Zheng C, Liu F, et al. Transarterial chemoembolization failure in patients with hepatocellular carcinoma: Incidence, manifestation and risk factors. Clin Res Hepatol Gastroenterol. 2023;47(2):102071. Lan SC, Lin YE, Chen SC, Lin YF, Wang YJ. Effects of acupressure on fatigue and depression in hepatocellular carcinoma patients treated with transcatheter arterial chemoembolization: a quasi-experimental study. Evidence-based complementary and alternative medicine: eCAM. 2015; 2015:496485. Cao W, Li J, Hu C, Shen J, Liu X, Xu Y, Ye Z. Symptom clusters and symptom interference of HCC patients undergoing TACE: a cross-sectional study in China. Supportive care cancer: official J Multinational Association Supportive Care Cancer. 2013;21(2):475–83. Kubo A, Kurtovich E, McGinnis M, Aghaee S, Altschuler A, Quesenberry C Jr., Kolevska T, Avins AL. A Randomized Controlled Trial of mHealth Mindfulness Intervention for Cancer Patients and Informal Cancer Caregivers: A Feasibility Study Within an Integrated Health Care Delivery System. Integr cancer Ther. 2019;18:1534735419850634. Goldin PR, Thurston M, Allende S, Moodie C, Dixon ML, Heimberg RG, Gross JJ. Evaluation of Cognitive Behavioral Therapy vs Mindfulness Meditation in Brain Changes During Reappraisal and Acceptance Among Patients With Social Anxiety Disorder: A Randomized Clinical Trial. JAMA psychiatry. 2021;78(10):1134–42. Martín J, García S, Anton-Ladislao A, Ferreiro J, Martín M, Padierna A, Quintana JM. Variables related to health-related quality of life among breast cancer survivors after participation in an interdisciplinary treatment combining mindfulness and physiotherapy. Cancer Med. 2023;12(12):13834–45. Compen F, Bisseling E, Schellekens M, Donders R, Carlson L, van der Lee M, Speckens A. Face-to-Face and Internet-Based Mindfulness-Based Cognitive Therapy Compared With Treatment as Usual in Reducing Psychological Distress in Patients With Cancer: A Multicenter Randomized Controlled Trial. J Clin Oncol. 2018;36(23):2413–21. Liu Z, Li M, Jia Y, Wang S, Zheng L, Wang C, Chen L. A randomized clinical trial of guided self-help intervention based on mindfulness for patients with hepatocellular carcinoma: effects and mechanisms. Jpn J Clin Oncol. 2022;52(3):227–36. Shao D, Zhang H, Cui N, Sun J, Li J, Cao F. The efficacy and mechanisms of a guided self-help intervention based on mindfulness in patients with breast cancer: A randomized controlled trial. Cancer. 2021;127(9):1377–86. Ireland MJ, Clough B, Gill K, Langan F, O'Connor A, Spencer L. A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners. Med Teach. 2017;39(4):409–14. Sommers-Spijkerman M, Austin J, Bohlmeijer E, Pots W. New Evidence in the Booming Field of Online Mindfulness: An Updated Meta-analysis of Randomized Controlled Trials. JMIR mental health. 2021;8(7):e28168. Nissen ER, O'Connor M, Kaldo V, Højris I, Borre M, Zachariae R, Mehlsen M. Internet-delivered mindfulness-based cognitive therapy for anxiety and depression in cancer survivors: A randomized controlled trial. Psycho-oncology. 2020;29(1):68–75. Bruix J, Sherman M, Llovet JM, Beaugrand M, Lencioni R, Burroughs AK, Christensen E, Pagliaro L, Colombo M, Rodés J. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver. Journal of hepatology. 2001; 35(3):421–430. Shapiro SL, Brown KW, Thoresen C, Plante TG. The moderation of Mindfulness-based stress reduction effects by trait mindfulness: results from a randomized controlled trial. J Clin Psychol. 2011;67(3):267–77. Finucane A, Mercer SW. An exploratory mixed methods study of the acceptability and effectiveness of Mindfulness-Based Cognitive Therapy for patients with active depression and anxiety in primary care. BMC Psychiatry. 2006;6:14. Fledderus M, Oude Voshaar MA, Ten Klooster PM, Bohlmeijer ET. Further evaluation of the psychometric properties of the Acceptance and Action Questionnaire-II. Psychol Assess. 2012;24(4):925–36. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88. Lindgren BM, Lundman B, Graneheim UH. Abstraction and interpretation during the qualitative content analysis process. Int J Nurs Stud. 2020;108:103632. Eyles C, Leydon GM, Hoffman CJ, Copson ER, Prescott P, Chorozoglou M, Lewith G. Mindfulness for the self-management of fatigue, anxiety, and depression in women with metastatic breast cancer: a mixed methods feasibility study. Integr cancer Ther. 2015;14(1):42–56. Weitz MV, Fisher K, Lachman VD. The journey of women with breast cancer who engage in mindfulness-based stress reduction: a qualitative exploration. Holist Nurs Pract. 2012;26(1):22–9. Hölzel BK, Carmody J, Vangel M, Congleton C, Yerramsetti SM, Gard T, Lazar SW. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Res. 2011;191(1):36–43. Zulman DM, Schafenacker A, Barr KL, Moore IT, Fisher J, McCurdy K, Derry HA, Saunders EW, An LC, Northouse L. Adapting an in-person patient-caregiver communication intervention to a tailored web-based format. Psycho-oncology. 2012;21(3):336–41. van den Hurk DG, Schellekens MP, Molema J, Speckens AE, van der Drift MA. Mindfulness-Based Stress Reduction for lung cancer patients and their partners: Results of a mixed methods pilot study. Palliat Med. 2015;29(7):652–60. Subnis UB, Farb NA, Piedalue KL, Speca M, Lupichuk S, Tang PA, Faris P, Thoburn M, Saab BJ, Carlson LE. A Smartphone App-Based Mindfulness Intervention for Cancer Survivors: Protocol for a Randomized Controlled Trial. JMIR Res protocols. 2020;9(5):e15178. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4825350","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":336644410,"identity":"529b2723-c1eb-4d5e-819d-fa5a8de8e14b","order_by":0,"name":"Zengxia Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYBACPmYog42BseFAQoUNDz9/A34tbAgtzI0PPpxJk5GccYCAFgSTvdlwZtthG4OGBAJa2HmMP3zcUZvYx36wTZqH7TyPAcMBxg8fc/A5jMfAcOaZ48ZsPIlALTy3ecyZG5glZ27DryWZt+2YHBsDSIvEbR7LhgNszLwEtBz+23aMh43/IVCLwTkegwMJBLUYNjO21cixSSQ2G85IOECMFrZixt62A8ZsEg+BgXwgmUdyxsFmvH7h5z+8+cPPtrrE+f3pDw4k/rOz5+dvPvjhIx4tUHAYmcPYQFA9ENQRo2gUjIJRMApGKgAASCRMxy6jAhEAAAAASUVORK5CYII=","orcid":"","institution":"Anhui medical University","correspondingAuthor":true,"prefix":"","firstName":"Zengxia","middleName":"","lastName":"Liu","suffix":""},{"id":336644411,"identity":"5538d656-9aa8-4fe5-88c8-8b0b50bb0afe","order_by":1,"name":"Min Li","email":"","orcid":"","institution":"First Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Li","suffix":""},{"id":336644413,"identity":"366f808e-b210-4e4a-8b12-ddbd592b46f1","order_by":2,"name":"Yong Jia","email":"","orcid":"","institution":"Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Jia","suffix":""},{"id":336644414,"identity":"6114f901-8a87-452a-bf4e-fd11a4d8ba7a","order_by":3,"name":"Lufang Zheng","email":"","orcid":"","institution":"Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Lufang","middleName":"","lastName":"Zheng","suffix":""},{"id":336644415,"identity":"007d77fe-6438-4613-902c-348387589aa3","order_by":4,"name":"Li Chen","email":"","orcid":"","institution":"Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-07-30 03:31:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4825350/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4825350/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83344996,"identity":"2d871d69-e149-4a4f-9f61-ae2dac63610c","added_by":"auto","created_at":"2025-05-23 11:53:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1001307,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4825350/v1/0ea8f6f0-7e5e-4509-b6e1-fc52d55d30ec.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A tailored internet-delivered mindfulness-based interventions for patients with hepatocellular carcinoma after TACE: A qualitative Study","fulltext":[{"header":"Background","content":"\u003cp\u003ePrimary liver cancer (PLC) is the third leading cause of cancer-related death. It is also one of the most common malignancies in the world, with China accounting for 45.27% of cases and 47.12% of deaths[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Hepatocellular carcinoma (HCC) is the most common histologic type of PLC, accounting for 75\u0026ndash;85% of all cases[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Transcatheter arterial chemoembolization (TACE) is widely recognized as one of the local treatment methods for HCC and has become the preferred treatment for patients with non-surgical treatment of intermediate-stage HCC[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Patients often need to receive multiple TACE treatments to control the development of the disease, but they still face recurrence, metastasis and various complications after operation[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In addition, the efficacy of TACE will decrease with the increase of treatment times and repeated TACE treatment will aggravate liver damage[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. HCC patients after TACE experience severe psychological distress[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], which seriously affects their treatment compliance and effectiveness[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe effectiveness of mindfulness-based interventions (MBIs) in improving psychological distress in cancer patients has been widely recognized[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Compared with other cancers, HCC patients after TACE have their special physiological and psychological characteristics. So it is necessary to develop a tailored MBIs for these patients. Despite documented efficacy, challenges remain to make MBIs available to patients in need because of limited number of trained therapists, costs, and restricted mobility and time constraints among cancer patients[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCompared with the traditional face-to-face intervention, internet-delivered interventions have many advantages. The intervention can be obtained online and can be arranged according to participants\u0026rsquo; own time. Especially for HCC patients, it can reduce the practical barriers such as geographical distance, transportation issues, cancer-related illness, and limited mobility. Studies have demonstrated the effectiveness of internet-delivered mindfulness-based interventions (iMBIs) in improving participants' psychological distress[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost studies use standardized questionnaires to investigate iMBIs in cancer patients[\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, these studies do not provide information on participants' experiences with iMBIs, which aspects of iMBIs are considered helpful and which are not, how mindfulness is integrated into private and work life, which ways of engaging with iMBIs are thought to affect patients psychologically and physiologically, what degree this approach to iMBIs would be perceived as relevant and appropriate by participants, and to what degree such content may be meaningfully administered electronically to this population. Therefore, the main objective of this qualitative study was to explore participants' experience and perceived effects of tailored iMBIs,further learns the feelings and experiences of participants, comprehensively explores the benefits and existing problems of interventions, and analyzes the influencing factors of participants' compliance.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Research design\u003c/h2\u003e \u003cp\u003eWe conducted a qualitative interview study as part of a larger randomized controlled trial (RCT). A detailed description of the RCT can be found elsewhere[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Research objects\u003c/h2\u003e \u003cp\u003eInclusion criteria for research objects: (1) Age\u0026thinsp;\u0026ge;\u0026thinsp;18 years old; (2) For patients diagnosed with HCC, the diagnostic criteria of HCC are based on the criteria of European Association for the Study of the Liver (EASL)[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], including pathological diagnosis, positive lesions detected by at least two different imaging techniques, and imaging techniques combined with alpha fetoprotein\u0026thinsp;\u0026gt;\u0026thinsp;400ng/ml; (3) receiving TACE; (4) Capable of operating smartphones and using WeChat frequently(5 times a week); (5) Ability to read, write and speak Chinese. (6) Informed consent and voluntary acceptance to cooperate with the implementation of this study. Exclusion criteria: (1) simultaneously diagnosed with other tumor types or mental stress disorders; (2) taking any psychotropic drugs during the study period; (3) received mindfulness intervention. (4) HCC patients who have poor health that affects normal communication.\u003c/p\u003e \u003cp\u003eFrom November 2020 to December 2022, this study was conducted at the First Hospital of Jilin University. By evaluating and screening the medical records of patients, potential participants who met the inclusion criteria were invited to participate in mindfulness interventions, and interviewees were recruited from the participants who completed mindfulness interventions. The sample size was based on the saturation of the collected data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Interventions\u003c/h2\u003e \u003cp\u003eThrough preliminary cross-sectional surveys, it was found that trait mindfulness, perceived stress and experiential avoidance are potential psychological mechanisms that intervene in anxiety and depression in HCC patients after TACE. Therefore, based on the relevant content of MBSR[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], acceptance and commitment therapy[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and mindfulness-based cancer rehabilitation, combined with the characteristics of HCC patients after TACE, a tailed mindfulness interventions program for HCC patients after TACE was developed.\u003c/p\u003e \u003cp\u003eA self-service intervention approach is taken with WeChat groups and official accounts to push intervention content. The weekly intervention content will be converted into text, audio, video, pictures and other forms to create a WeChat official account. The intervention form for the first week is a face-to-face intervention within the hospital, while the second to sixth weeks are network-based interventions outside the hospital. The specific intervention methods are as follows:\u003c/p\u003e \u003cp\u003eFace-to-face intervention in the hospital: The location is the classroom of the interventional department, with 5\u0026ndash;8 participants in one group, each lasting 1-1.5 hours. The research team explains the purpose and content of the study to the participants through slides, introducing the content and role of mindfulness, and allowing participants to fully understand mindfulness and its attitude. The research team introduced the whole process and contents of the intervention to the participants, making them familiar with the relevant content of mindfulness intervention and self-service intervention methods, laying the foundation for the smooth implementation of out-of-hospital network-based intervention from the second to the sixth week.\u003c/p\u003e \u003cp\u003eOut-of-hospital iMBIs: The intervention contents are converted into audio, video or pictures and pushed weekly via WeChat. Participants learn the intervention content and practice mindfulness for 20 minutes every day for at least 5 days a week, and practice their homework for about 10 minutes. The research team urged patients to complete the time and frequency of practice through WeChat and telephone, and encouraged participants to check in on mindfulness learning in the WeChat group every day to exchange experiences and feelings about mindfulness practice. The research team also shared knowledge through WeChat groups, including knowledge about mindfulness, HCC and TACE treatment, and answered participants' questions about diseases, mindfulness and other aspects.\u003c/p\u003e \u003cp\u003eAfter discussion and modification by experts, a tailed mindfulness intervention program for HCC patients after TACE was developed. The specific contents are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe tailored internet-delivered mindfulness-based interventions for HCC patients after TACE\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTheme of intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSummary of contents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHomework\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIntervention mode\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMindfulness and HCC, self-acceptance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(1) Knowledge introduction\u003c/b\u003e: Introducing content related to mindfulness, HCC and TACE treatment, and the relationship between mindfulness and cancer.\u003c/p\u003e \u003cp\u003e\u003cb\u003e(2) Mindful breathing\u003c/b\u003e: Guide patients to practice mindful breathing and experience every detail of breathing.\u003c/p\u003e \u003cp\u003e\u003cb\u003e(3) \"The Missing Piece\"\u003c/b\u003e: Watch the video \"The Missing Piece\" to trigger participants' thinking about \"unchangeable shortcomings\".\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMindful breathing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFace-to-face intervention in the hospital, 5\u0026ndash;8 participants per group, 1-1.5 hours per session, introducing the purpose and content of the study, and guiding the completion of the first session.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCancer and stress, cognitive dissociation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(1) Knowledge introduction\u003c/b\u003e: Describe knowledge related to cancer and stress, and typical stress reactions to cancer stress events.\u003c/p\u003e \u003cp\u003e\u003cb\u003e(2) Body scan\u003c/b\u003e: Introduce the connotation and requirements of body scan, and feel and experience the sensation of each part of the body in order from feet to head.\u003c/p\u003e \u003cp\u003e\u003cb\u003e(3) \"I have such an idea now\"\u003c/b\u003e: Guide participants to practice \"I have such an idea now\",\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBody scan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOut-of-hospital online intervention, 20 minutes per day, at least 5 days per week, learn the intervention content via official account and WeChat, and 10 minutes of homework practice.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIdentifying avoidance reactions and self-awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(1) Meditation practice\u003c/b\u003e: Guide patients to practice mindful meditation and perform meditation exercises during meditation.\u003c/p\u003e \u003cp\u003e\u003cb\u003e(2) \"Chessboard metaphor\"\u003c/b\u003e: Guide participants to imagine a \"chess game\" and use the \"chessboard metaphor\" to guide participants no longer entangled in their inner struggles.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMeditation practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOut-of-hospital online intervention, 20 minutes per day, at least 5 days per week, learn the intervention content via official account and WeChat, and 10 minutes of homework practice.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePractice mindfulness in life, focusing on the present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(1) Mindfulness walking\u003c/b\u003e: Guide patients to practice mindfulness walking and feel the current movements while practicing.\u003c/p\u003e \u003cp\u003e\u003cb\u003e(2) Mindfulness eating\u003c/b\u003e: Guide patients to practice mindfulness eating.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMindful walking\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-selective awareness, clear value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(1) Awareness practice\u003c/b\u003e: Explain the key points of awareness practice to patients and be aware of everything around them.\u003c/p\u003e \u003cp\u003e\u003cb\u003e(2) \u0026ldquo;Compass\u0026rdquo; metaphor\u003c/b\u003e: Guide participants to think about the guiding role of the \u0026ldquo;compass\u0026rdquo; in the journey.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAwareness practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOut-of-hospital online intervention, 20 minutes per day, at least 5 days per week, learn the intervention content via official account and WeChat, and 10 minutes of homework practice.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrateful life, committed to action\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(1) Love meditation, good wishes\u003c/b\u003e: Cultivate compassionate mindfulness practice, and give your blessings to others during practice. Let participants be filled with tolerance and love in their hearts.\u003c/p\u003e \u003cp\u003e\u003cb\u003e(2) \"Passengers on the Bus\"\u003c/b\u003e: Through the short film \"Passengers\u0026rsquo; Practice on the Bus\", guide participants to compare their lives to a bus, and think about the meaning of committed actions.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLove meditation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAbbreviations:HCC, hepatocellular carcinoma\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e1.4 Data collection\u003c/h2\u003e \u003cp\u003eCombined with the disease characteristics and treatment of HCC patients after TACE, a preliminary interview outline was formulated through a literature review and discussion among researchers. Before the formal interview, two participants were pre-interviewed, and the final interview outline was determined according to the problems encountered during the interview, as shown in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Demographic information was collected prior to the interviews.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterview Outline\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS/N\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuestion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhy did you participate in this network-based mindfulness training?\u003c/p\u003e \u003cp\u003eWhat are your experiences while participating in this training?\u003c/p\u003e \u003cp\u003eWhat effects does network-based mindfulness training have on your body?\u003c/p\u003e \u003cp\u003eHow does the network-based mindfulness training affect you psychology?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e The two researchers agreed the interview time with the participants in advance, and chose a separate room of the hospital for face-to-face interviews. Before the interview, they introduced themselves to the interviewees, introduced the purpose, method and content of the interview, and told them that the whole interview process will be recorded in order to ensure the integrity and accuracy of the information, and signed the informed consent form after obtaining the consent. During the interview, the researchers used a neutral attitude and appropriate language to communicate with the participants, to avoid instructive words affecting the participants' answers, and data collection and analysis were carried out simultaneously.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e1.5 Ethical considerations\u003c/h2\u003e \u003cp\u003e The research plan was approved by the Ethics Committee of the School of Nursing at Jilin University (2019112001) and registered with the Chinese Clinical Trial Registration Center (ChiCTR1900027976) On December 7, 2019. Before the interview, the researcher informed the participants of the research content and purpose, assured them that the relevant data would only be used for research and article publication, kept their personal information confidential, and promised them that they could withdraw from the research at any time. All participants signed an informed consent form before the study began.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e1.6 Data analysis\u003c/h2\u003e \u003cp\u003e One researcher participating in the interview listened to the recordings repeatedly within 24 hours after each interview and transcribed them into text. Another researcher participating in the interview checked the transcribed text and imported it into NVivo 11 software for analysis. Qualitative content analysis[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] was used to analyze the data. Two researchers independently analyzed and transcribed the data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Research results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Characteristics of participants\u003c/h2\u003e \u003cp\u003eIn this study, 9 participants were interviewed, and no new information emerged. To ensure that the data had reached saturation, 2 further participants were conducted, and no new information was found. Therefore, a total of 11 participants were interviewed in this study, and their basic characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of participants (\u003cem\u003eN\u003c/em\u003e = 11)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 ~ 44 years\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3(27.3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 ~ 59 years\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5(45.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e≥ 60 years\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3(27.3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6(54.5)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5(45.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary school or below\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2(18.1)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSenior high school\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5(45.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege or higher\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4(36.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of TACE\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3(27.3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2–6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5(45.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt; 6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3(27.3)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHADS\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 ~ 20\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5(45.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 ~ 28\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4(36.4)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 ~ 42\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2(18.1)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eAbbreviations: HADS, Hospital Anxiety and Depression Scale;\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.2 categories\u003c/h2\u003e \u003cp\u003eThrough repeated analysis and sorting of data, the following five main categories corresponding to experiences of participants were extracted: mindfulness mindset, improvement of physical discomfort, resistance to mindfulness practice, support and encouragement, and accessibility and convenience. Each category can be divided into several general categories, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelevant categories corresponding to experiences of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain Category\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral Category\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubcategory\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 Mindful mindset\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1 Acceptance\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.2 Calm\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3 Mood Improvement\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.3.1 Relaxation\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.3.2 Gratitude\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 Improvement of physical discomfort\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1 Improve Sleep\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.2 Pain Relief\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.3 Reduce gastrointestinal symptoms\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4 Increase Activities\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Mindfulness practice resistance\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1 Lack of effect\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.2 Condition\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2.1 Fatigue\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3 Device Usage Restrictions\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2.2 Pain\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.4 Difficulty Focusing\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5 Lack of motivation to practice\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 Support and encourage\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.1 Social Support\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.2 Supervision and Guidance\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5 Accessibility and convenience\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.1 Restore a sense of balance in your life\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.2 Practice Features\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMain category 1: Mindfulness mindset\u003c/h2\u003e \u003cp\u003eMindfulness mentality refers to the ability of HCC patients after TACE to face HCC with a non-judgmental attitude and maintain a curious, open and accepting attitude toward their current feelings.\u003c/p\u003e \u003cp\u003eGeneral category 1.1 Acceptance\u003c/p\u003e \u003cp\u003e Six participants expressed that they were able to face illness and various difficulties in life with an accepting attitude after practicing mindfulness.\u003c/p\u003e \u003cp\u003e \u003cem\u003e“My mother and I both have hepatitis, and my mother died of HCC, so I have always been worried about my health. I am scared every time I go to the hospital for a check-up. After doing this mindfulness exercise, my mentality changed, and I gradually realized that I should not think about it too much every day. Since I have got this disease, just follow the doctor’s instructions and receive treatment. Many treatments have good effects, but thinking too much is not conducive to my health.”\u003c/em\u003e (Interview ig4)\u003c/p\u003e \u003cp\u003eGeneral category 1.2 Calm\u003c/p\u003e \u003cp\u003e Seven participants reported that after practicing mindfulness, their mentality became calm and they could feel the beauty of things around them better.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I have a much better mentality now. I can feel the things around me more calmly, and I can feel the bits and pieces of life more. I am more willing to take a walk, enjoy scenery and see the beauty of things around me, such as a tree and a flower on the roadside.\"\u003c/em\u003e (Interview ig9)\u003c/p\u003e \u003cp\u003eGeneral category 1.3 Mood improvement\u003c/p\u003e \u003cp\u003eSubcategory 1.3.1 Relaxation\u003c/p\u003e \u003cp\u003e Five participants reported that after mindfulness training, they could better regulate their emotions, no longer feel anxious and became relaxed.\u003c/p\u003e \u003cp\u003e \u003cem\u003e“Every time I went to the hospital for a check-up, I would be very nervous when I saw any change in any indicator. Sometimes even a slight change would make me nervous for a long time. Even if the doctor said there were no problems, I would search for a lot of information online. Now that I find myself anxious, I will adjust my emotions, relax my mentality, and not think about things that are not there every day. ”\u003c/em\u003e(Interview ig4)\u003c/p\u003e \u003cp\u003eSubcategory 1.3.2 Gratitude\u003c/p\u003e \u003cp\u003e Two participants mentioned gratitude. After practicing mindfulness, they can face the people and things around them with a grateful attitude.\u003c/p\u003e \u003cp\u003e \u003cem\u003e“I have always had a bad temper and am prone to getting angry. My family members gave in to me due to my poor health, which made me even more angry. After listening to that exercise, my mentality gradually improved, and I could calm down when encountering unpleasant things. I also knew that my family had sacrificed a lot for me, and my mentality had changed a lot, then the atmosphere at home was much better. \"\u003c/em\u003e (Interview ig3)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMain category 2: Improvement of physical discomfort\u003c/h2\u003e \u003cp\u003eImprovement of physical discomfort refers to the improvement of physical symptoms and reduction of discomfort in HCC patients after TACE.\u003c/p\u003e \u003cp\u003eGeneral category 2.1 Improvement of sleep\u003c/p\u003e \u003cp\u003eTen participants reported a significant improvement in their sleep after practice, reducing their pre-sleep woolgather and making it easier for them to fall asleep.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I have always had poor sleep, often lying in bed for a long time without falling asleep. The severer poor sleep, the more I become lost in my thoughts. However, since I started listening to this, I fell asleep shortly after listening to it. Listening to that will stop random thoughts.\"\u003c/em\u003e (Interview ig3)\u003c/p\u003e \u003cp\u003eGeneral category 2.2 Pain relief\u003c/p\u003e \u003cp\u003e Three participants reported that mindfulness practice helped relieve pain and alleviate discomfort.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I used to feel uncomfortable all over and hurt everywhere. When doing this exercise, take a deep breath, relax, follow the teacher and slowly relax yourself. These uncomfortable feelings are no longer felt, and I feel much better!”\u003c/em\u003e(Interview ig6)\u003c/p\u003e \u003cp\u003eGeneral category 2.3 Alleviation of gastrointestinal symptoms\u003c/p\u003e \u003cp\u003e Two participants reported that mindfulness exercises can alleviate gastrointestinal symptoms, improve appetite, and alleviate discomfort such as bloating.\u003c/p\u003e \u003cp\u003e \u003cem\u003e“I always have no appetite for anything, and feel uncomfortable after eating, and my stomach is bloated. Now I do this exercise every day, I feel better about these discomforts. When I sit there and relax every day, I feel less irritable and uncomfortable”\u003c/em\u003e(Interview ig1)\u003c/p\u003e \u003cp\u003eGeneral category 2.4 Add activities\u003c/p\u003e \u003cp\u003eTwo participants reported that mindfulness practice can alleviate fatigue and increase activity.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"My whole body feels weak. Sitting there, lying there, and I don't want to do anything. Sometimes I lie there for a long time, just feeling fatigued. After starting this exercise, I practiced it on time every day. These simple movements gradually make me feel much better, I am willing to move, and I have something to do.”\u003c/em\u003e (Interview ig4)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMain category 3: Resistance to mindfulness practice\u003c/h2\u003e \u003cp\u003eResistance to mindfulness practice refers to the factors that hinder patients' normal participation and persistence in mindfulness practice during iMBIs for HCC patients after TACE.\u003c/p\u003e \u003cp\u003eGeneral category 3.1 Lack of effectiveness\u003c/p\u003e \u003cp\u003eTwo participants reported that the effect was not obvious and there were no obvious changes in psychology or physiology during the practice.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Anyway, with this disease, you are sentenced to death. Just make every possible effort. I planned to give up, but the family members insisted on continuing the treatment, the results would just be a loss of life and wealth, and any practice is useless.”\u003c/em\u003e (Interview ig1)\u003c/p\u003e \u003cp\u003eGeneral category 3.2 Conditions\u003c/p\u003e \u003cp\u003eSubcategory 3.2.1 Fatigue\u003c/p\u003e \u003cp\u003eThree participants reported that fatigue and discomfort caused by illness affected normal mindfulness practice.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I have a bad appetite, I do not feel like eating, with a little bit of energy every day. I feel uncomfortable everywhere, the treatment has no effect, and I don't want to do anything, I just want to lie down all day, without doing anything. It’s not easy to practice.”\u003c/em\u003e(Interview ig4)\u003c/p\u003e \u003cp\u003eSubcategory 3.2.2 Pain\u003c/p\u003e \u003cp\u003eTwo participants reported that pain interfered with mindfulness practice.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"This pain is torturing. I'm not in the mood to do anything, and I haven't seen any relief. When can I get better? This disease is torturing.\"\u003c/em\u003e (Interview ig6)\u003c/p\u003e \u003cp\u003eGeneral category 3.3 Equipment usage restrictions\u003c/p\u003e \u003cp\u003e 2 participants reported that they were easily distracted by other messages during the use of cellphones and were unable to persist in completing the mindfulness exercises.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"There are always all kinds of messages on my phone, and I'm frequently interrupted by them while practicing. It is difficult to keep quiet for a while to complete the practice. Now there are too many messy messages.\"\u003c/em\u003e (Interview ig10)\u003c/p\u003e \u003cp\u003eGeneral category 3.4 Difficulty in focusing\u003c/p\u003e \u003cp\u003e Two participants reported that in the process of mindfulness practice, it was difficult to concentrate, and it was easy to get distracted, making it difficult to persist in mindfulness practice.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"When practicing at home, I got lost while listening. For example, when I was asked to feel my abdomen, I would think of my illness and think about all the messy things. It was difficult to follow and stick to it completely.\"\u003c/em\u003e (Interview ig3)\u003c/p\u003e \u003cp\u003eGeneral category 3.5 Lack of motivation to practice\u003c/p\u003e \u003cp\u003e Two participants said that during the mindfulness practice, they had difficulty completing it on time due to a lack of motivation to practice.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I feel irritable and tired every day. Alas, I don't want to do anything. I persisted for a while in the first few days, but later I felt that it didn't work. Many times I was too lazy to do this exercise.\"\u003c/em\u003e (Interview ig1)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eMain category 4: Support and encouragement\u003c/h2\u003e \u003cp\u003eSupport and encouragement refer to the online or offline support and encouragement received by HCC patients after TACE during the process of receiving network-based mindfulness intervention.\u003c/p\u003e \u003cp\u003eGeneral category 4.1 Social support\u003c/p\u003e \u003cp\u003e Two participants reported that their family members participated in mindfulness exercises and communicated with each other. At the same time, through WeChat groups, communication with patients and medical staff promoted their perseverance.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"My wife has been practicing with me since I started practicing it in the hospital. She would also practice with me after I returned home. We share our feelings about practice. Sometimes I don't want to practice, and my wife will urge me. We practice together and gradually stick to it.”\u003c/em\u003e (Interview ig5)\u003c/p\u003e \u003cp\u003eGeneral category 4.2 Supervision and guidance\u003c/p\u003e \u003cp\u003e Three participants reported that they saw patients checking in every day in the WeChat group, and they exchanged their feelings about mindfulness practice with each other, and the WeChat reminders from medical staff also promoted their persistence.\u003c/p\u003e \u003cp\u003e \u003cem\u003e“Every day in the WeChat group, everyone checked in and talked about their feelings. Seeing fellow patients who used to live in the same ward as me insisted on checking in every day and asking questions they encountered, I felt that I should also give it a try. After communicating more with everyone, I persevered.”\u003c/em\u003e (Interview ig2)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMain category 5: Accessibility and convenience\u003c/h2\u003e \u003cp\u003eAccessibility and convenience refer to the recognition and perception of the convenience, ease, and accessibility of online self-help mindfulness interventions among HCC patients after TACE.\u003c/p\u003e \u003cp\u003eGeneral category 5.1 Restoring a sense of balance in life\u003c/p\u003e \u003cp\u003e Three participants reported that practicing mindfulness at the same time or place every day made their lives more regular, and fulfilling, and restored a sense of balance, which promoted their persistence.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Since I was diagnosed with this disease, my family has taken special care of me. They won't let me do any housework, so I lie down every day. I feel like I'm going to be useless. With this practice, after practicing it every day, I feel like I've done something and I feel more energetic.”\u003c/em\u003e (Interview ig4)\u003c/p\u003e \u003cp\u003eGeneral category 5.2 Practice features\u003c/p\u003e \u003cp\u003eThree participants mentioned their recognition of iMBIs, feeling that it is time-saving, effortless, and convenient, and this practice method has promoted their persistence.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I live in a rural area, and it's always difficult to come to the hospital. We also need family members to accompany us. Nowadays, this method is available online, and I can practice anytime after finding the audio. This method on WeChat is convenient. Sometimes when you feel down, or when you are idle, you can practice anytime you want. You don't have to have a fixed time, it's more free.\"\u003c/em\u003e (Interview ig11)\u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":"\u003cp\u003eThis study shows that the participants' positive experience includes both physical and psychological aspects, and the physical positive experience is mainly the improvement of physical symptoms, which is mainly related to the fact that mindfulness intervention can solve the sleep problems of patients with cancer, relieve pain and increase the activity of participants. In terms of psychology, research by Eyles et al.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]and Weitz et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]show that an 8-week MBSR intervention can improve the mental state of breast cancer patients and enable them to live better in the present. Living in the present is seen as a way to let go of anxiety and rediscover happiness[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Mindfulness intervention can also cause changes in individual neurophysiological activities, brain structure and brain function, which is also the reason why mindfulness therapy can generate positive psychological experiences for patients with cancer[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The intervention plan of this study incorporates elements of acceptance and gratitude, allowing participants to continue to perceive and pay attention to current experiences with a more accepting and non-judgmental attitude, pay attention to some painful experiences with an open and accepting attitude, reduce empirical avoidance, and actively identify problems and adopt coping strategies.\u003c/p\u003e\u003cp\u003eThis study shows that the promoting factors of participants in practice include social support and supervision and guidance. Compared with face-to-face mindfulness intervention, iMBIs lack group communication and support. However, in this study, a WeChat group can provide a platform for mutual communication and sharing, so that everyone can exchange their feelings about mindfulness practice and their diseases. The participation of medical staff also enables patients to get professional answers in time, which increases their confidence and compliance in treatment. Participants' communication and check-in in WeChat groups can encourage other participants to complete mindfulness exercises on time every day, playing a role in mutual supervision. In this study, during the first in-hospital intervention, mindfulness intervention was introduced to patients and their families, encouraging them to complete mindfulness exercises together, which can make up for the shortcomings of online intervention. Research by Zulman et al.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] shows that intervening in cancer patients and their caregivers as a whole can promote communication between both parties and increase mutual support.\u003c/p\u003e\u003cp\u003eThis study shows that the obstacles faced by participants during practice include lack of effectiveness, illness, equipment usage limitations, difficulty concentrating, difficulty completing on time, and lack of motivation to practice. Analyzing the reasons, it may be due to the relatively severe condition of HCC patients[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The disease and treatment have seriously affected the patient's body, which makes it difficult for patients to complete some exercises. Therefore, in future designs, attention should also be paid to the patient's condition and more targeted intervention plans should be designed. At the same time, it is also related to the lack of guidance from mindfulness professionals. As a new intervention method, online psychological intervention brings various conveniences to participants, but it also has disadvantages such as low compliance. Although this study regards medical staff as the instructors of iMBIs, they lack corresponding experience and pertinence in guiding mindfulness intervention, which is one of the reasons for the low compliance of intervention, and the decline of compliance is an important factor that weakens the effect of intervention. At the same time, it is also related to the inclusion criteria of participants. When the negative emotions of participants are too high or too low, it will affect the intervention effect. Compen et al.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] used HADS score ≥ 11 points as the inclusion criteria for participants, and the intervention effect is significantly better than other iMBIs. When the patient is in a good psychological state, mindfulness intervention becomes a psychological suggestion to remind participants that they are the patient. Therefore, when the negative emotions of participants in mindfulness intervention are too high or too low, it may lead to the occurrence of a ceiling effect or floor effect. Setting reasonable inclusion criteria and screening procedures will better improve the effectiveness of the intervention.\u003c/p\u003e\u003ch2\u003e3.4 Strengths and Limitations\u003c/h2\u003e\u003cp\u003eThis study shows that participants not only felt the convenience and accessibility of online self-service intervention during the exercise but also experienced some inconvenience from the use of internet devices. Compared with traditional face-to-face intervention, iMBIs can reduce the economic burden on participants and is more accessible. The form of online interventions allow participants to complete interventions at home, reducing the inconvenience of travel and allowing them to freely arrange their time, leveraging the convenience of online intervention.\u003c/p\u003e\u003cp\u003eThe mindfulness intervention program in this study was pushed through a WeChat official account, which has limited functions and makes it difficult to meet the diverse needs of HCC patients after TACE. Therefore, before future product development, the individuality and common needs of users should be fully explored to improve the comfort and convenience of use. At the same time, comprehensive mobile medical products suitable for patients after TACE can be further comprehensively developed, such as the mindfulness application (APP) developed by Subnis et al[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], which supports personalized mindfulness exercises for participants through guided meditation, audio lectures, self-meditation timers, log functions, and other functions. At the same time, the APP also has a pressure measurement function, measuring pressure by extracting facial biosignals. It can save medical costs and meet the psychological needs of patients, providing a new platform for continuous psychological intervention for cancer survivors.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e In this study, personal semi-structured interviews were used to learn the experiences of iMBIs participants. The results showed that participants subjectively felt benefits in many aspects, including psychological and physical, among which the improvement in psychological aspects was particularly obvious. However, participants also had negative experiences such as lack of obvious effects during mindfulness practice, and they hated being reminded that they were patients during practice. Restoring a sense of balance in life, supervision and guidance are factors that promote mindfulness practice. Lack of effectiveness, dislike of being reminded of being a patient during practice, difficulty concentrating, difficulty completing tasks on time, and lack of motivation to practice are factors that hinder mindfulness practice. While iMBIs gives participants a sense of convenience and accessibility, there are also issues with device usage limitations.In future promotions, the individuality and common needs of mindfulness participants should be fully explored, and software or APP with comprehensive functions should be developed to improve the comfort and convenience of participants.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eZengxia Liu:\u0026nbsp;\u003c/strong\u003eConceptualization, Methodology, Formal analysis, Data curation, Writing -original draft, Writing-review \u0026amp; editing;\u003cstrong\u003eMin Li:\u0026nbsp;\u003c/strong\u003eMethodology, Data curation;\u003cstrong\u003eYong Jia:\u0026nbsp;\u003c/strong\u003eData curation, Writing-review \u0026amp; editing;\u003cstrong\u003eLufang Zheng:\u0026nbsp;\u003c/strong\u003eData curation, Writing-review \u0026amp; editing;\u003cstrong\u003eLi Chen:\u003c/strong\u003e Funding acquisition, Project administration, Supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this study was provided by University Natural Science Research Project of Anhui Provincial\u0026nbsp;[grant number 2023AH050583].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data are not publicly available because it contains information that could compromise the privacy of study participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Jilin University School of Nursing (2019112001).Informed consent was obtained from all subjects involvedin the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. Cancer J Clin. 2024;74(3):229\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHepatocellular carcinoma. Nat reviews Disease primers. 2021;7(1):7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson BW, Wright GP. Regional therapies for the treatment of primary and metastatic hepatic tumors: A disease-based review of techniques and critical appraisal of current evidence. Am J Surg. 2019;217(3):541\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang Z, Bai T, Wei T, Wang X, Chen J, Ye J, Li S, Wei M, Li X, Lin Y, et al. TACE combined Lenvatinib plus Camrelizumab versus TACE alone in efficacy and safety for unresectable hepatocellular carcinoma: a propensity score-matching study. BMC Cancer. 2024;24(1):717.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim MS, Kang M, Park J, Ryu JM. Nurses' comfort care of transarterial chemoembolization patients based on their perceptions around postembolization syndrome and symptom interference. Nurs open. 2023;10(5):2877\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang L, Zhang X, Li Q, Makamure J, Liu Z, Zhao D, Li X, Shi H, Zheng C, Liu F, et al. Transarterial chemoembolization failure in patients with hepatocellular carcinoma: Incidence, manifestation and risk factors. Clin Res Hepatol Gastroenterol. 2023;47(2):102071.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLan SC, Lin YE, Chen SC, Lin YF, Wang YJ. Effects of acupressure on fatigue and depression in hepatocellular carcinoma patients treated with transcatheter arterial chemoembolization: a quasi-experimental study. \u003cem\u003eEvidence-based complementary and alternative medicine: eCAM.\u003c/em\u003e 2015; 2015:496485.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCao W, Li J, Hu C, Shen J, Liu X, Xu Y, Ye Z. Symptom clusters and symptom interference of HCC patients undergoing TACE: a cross-sectional study in China. Supportive care cancer: official J Multinational Association Supportive Care Cancer. 2013;21(2):475\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKubo A, Kurtovich E, McGinnis M, Aghaee S, Altschuler A, Quesenberry C Jr., Kolevska T, Avins AL. A Randomized Controlled Trial of mHealth Mindfulness Intervention for Cancer Patients and Informal Cancer Caregivers: A Feasibility Study Within an Integrated Health Care Delivery System. Integr cancer Ther. 2019;18:1534735419850634.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoldin PR, Thurston M, Allende S, Moodie C, Dixon ML, Heimberg RG, Gross JJ. Evaluation of Cognitive Behavioral Therapy vs Mindfulness Meditation in Brain Changes During Reappraisal and Acceptance Among Patients With Social Anxiety Disorder: A Randomized Clinical Trial. JAMA psychiatry. 2021;78(10):1134\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMart\u0026iacute;n J, Garc\u0026iacute;a S, Anton-Ladislao A, Ferreiro J, Mart\u0026iacute;n M, Padierna A, Quintana JM. Variables related to health-related quality of life among breast cancer survivors after participation in an interdisciplinary treatment combining mindfulness and physiotherapy. Cancer Med. 2023;12(12):13834\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCompen F, Bisseling E, Schellekens M, Donders R, Carlson L, van der Lee M, Speckens A. Face-to-Face and Internet-Based Mindfulness-Based Cognitive Therapy Compared With Treatment as Usual in Reducing Psychological Distress in Patients With Cancer: A Multicenter Randomized Controlled Trial. J Clin Oncol. 2018;36(23):2413\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Z, Li M, Jia Y, Wang S, Zheng L, Wang C, Chen L. A randomized clinical trial of guided self-help intervention based on mindfulness for patients with hepatocellular carcinoma: effects and mechanisms. Jpn J Clin Oncol. 2022;52(3):227\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShao D, Zhang H, Cui N, Sun J, Li J, Cao F. The efficacy and mechanisms of a guided self-help intervention based on mindfulness in patients with breast cancer: A randomized controlled trial. Cancer. 2021;127(9):1377\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIreland MJ, Clough B, Gill K, Langan F, O'Connor A, Spencer L. A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners. Med Teach. 2017;39(4):409\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSommers-Spijkerman M, Austin J, Bohlmeijer E, Pots W. New Evidence in the Booming Field of Online Mindfulness: An Updated Meta-analysis of Randomized Controlled Trials. JMIR mental health. 2021;8(7):e28168.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNissen ER, O'Connor M, Kaldo V, H\u0026oslash;jris I, Borre M, Zachariae R, Mehlsen M. Internet-delivered mindfulness-based cognitive therapy for anxiety and depression in cancer survivors: A randomized controlled trial. Psycho-oncology. 2020;29(1):68\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBruix J, Sherman M, Llovet JM, Beaugrand M, Lencioni R, Burroughs AK, Christensen E, Pagliaro L, Colombo M, Rod\u0026eacute;s J. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver. \u003cem\u003eJournal of hepatology.\u003c/em\u003e 2001; 35(3):421\u0026ndash;430.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShapiro SL, Brown KW, Thoresen C, Plante TG. The moderation of Mindfulness-based stress reduction effects by trait mindfulness: results from a randomized controlled trial. J Clin Psychol. 2011;67(3):267\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFinucane A, Mercer SW. An exploratory mixed methods study of the acceptability and effectiveness of Mindfulness-Based Cognitive Therapy for patients with active depression and anxiety in primary care. BMC Psychiatry. 2006;6:14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFledderus M, Oude Voshaar MA, Ten Klooster PM, Bohlmeijer ET. Further evaluation of the psychometric properties of the Acceptance and Action Questionnaire-II. Psychol Assess. 2012;24(4):925\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindgren BM, Lundman B, Graneheim UH. Abstraction and interpretation during the qualitative content analysis process. Int J Nurs Stud. 2020;108:103632.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEyles C, Leydon GM, Hoffman CJ, Copson ER, Prescott P, Chorozoglou M, Lewith G. Mindfulness for the self-management of fatigue, anxiety, and depression in women with metastatic breast cancer: a mixed methods feasibility study. Integr cancer Ther. 2015;14(1):42\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeitz MV, Fisher K, Lachman VD. The journey of women with breast cancer who engage in mindfulness-based stress reduction: a qualitative exploration. Holist Nurs Pract. 2012;26(1):22\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026ouml;lzel BK, Carmody J, Vangel M, Congleton C, Yerramsetti SM, Gard T, Lazar SW. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Res. 2011;191(1):36\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZulman DM, Schafenacker A, Barr KL, Moore IT, Fisher J, McCurdy K, Derry HA, Saunders EW, An LC, Northouse L. Adapting an in-person patient-caregiver communication intervention to a tailored web-based format. Psycho-oncology. 2012;21(3):336\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan den Hurk DG, Schellekens MP, Molema J, Speckens AE, van der Drift MA. Mindfulness-Based Stress Reduction for lung cancer patients and their partners: Results of a mixed methods pilot study. Palliat Med. 2015;29(7):652\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSubnis UB, Farb NA, Piedalue KL, Speca M, Lupichuk S, Tang PA, Faris P, Thoburn M, Saab BJ, Carlson LE. A Smartphone App-Based Mindfulness Intervention for Cancer Survivors: Protocol for a Randomized Controlled Trial. JMIR Res protocols. 2020;9(5):e15178.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"interenet, mindfulness, hepatocellular carcinoma, cancer, qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-4825350/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4825350/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe purpose of this study was to explore the true experiences of hepatocellular carcinoma (HCC) patients after TACE who participated the tailored internet-delivered mindfulness-based interventions (iMBIs).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e From November 2020 to December 2022, 11 HCC patients after TACE who participated the tailored iMBIs were recruited from a tertiary hospital in Jilin Province by purposive sampling. Semi-structured interviews were performed to collect data, and qualitative content analysis was conducted to analyze the data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe identified five main categories from interviews, including mindfulness mindset, improvement of physical discomfort, resistance to mindfulness practice, support and encouragement, and accessibility and convenience. Each category can be divided into several general categories.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eParticipants reported subjective psychological and physical benefits. However, participants also had negative experiences in the process of mindfulness practice. While iMBIs gives participants a sense of convenience and accessibility, there are also issues with device usage limitations.\u003c/p\u003e","manuscriptTitle":"A tailored internet-delivered mindfulness-based interventions for patients with hepatocellular carcinoma after TACE: A qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-27 07:07:33","doi":"10.21203/rs.3.rs-4825350/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aa5d2299-ddfc-44ad-b307-b28b2084f2f5","owner":[],"postedDate":"August 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-23T11:53:29+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-27 07:07:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4825350","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4825350","identity":"rs-4825350","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}