Reduction of cardiovascular disease (CVD) is a worldwide health priority and innovative uses of technology-based interventions may assist patients with improving prevention behaviours. Targeting ...these interventions to recipients most likely to benefit requires understanding how contexts of use influence responsiveness to the intervention, and how this interaction favours or discourages health behaviour. Using a realist evaluation approach, the aim of this study was to examine the contextual factors influencing behaviour change within a multi-feature eHealth intervention with personalised data integration from the primary care electronic health record (EHR).
Realist evaluation of qualitative data from the Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) randomised trial (N = 934). Thirty-six participants from the intervention group (N = 486) who had completed 12 months of study follow-up were interviewed. Coding of transcripts was structured around configurations of contexts, mechanisms, and outcomes of intervention use. Contextual narratives were derived from thematic analysis of the interviews.
Mechanisms favouring positive health behaviour occurred when participants responded to four interactive features of the intervention. Facilitating mechanisms included greater cognitive engagement whereby participants perceived value and benefit, and felt motivated, confident and incentivised. Participants moved from being unconcerned (or unaware) to more task-oriented engagement with personal CVD risk profile and prevention. Increased personalisation occurred when modifiable CVD risk factors became relatable to lifestyle behaviour; and experiences of feeling greater agency/self-efficacy emerged. Use and non-use of the intervention were influenced by four overarching narratives within the individual's micro-level and meso-level environments: illness experiences; receptiveness to risk and prevention information; history of the doctor-patient relationship; and relationship with technology.
Intervention-context interactions are central to understanding how change mechanisms activate within complex interventions to exert their impact on recipients. Intervention use and non-use were context-dependent, underscoring the need for further research to target eHealth innovations to those most likely to benefit.
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eHealth strategies targeting health-related behaviour often incorporate persuasive software design. To further engage patients with their overall health management, consumer-facing web portals may be ...integrated with data from one or more care providers. This study aimed to explore effectiveness for healthier behaviour of persuasive design characteristics within a web application integrated with the primary health care electronic record; also patient and general practitioner (GP) preferences for future integrated records.
Mixed methods study within the Consumer Navigation of Electronic Cardiovascular Tools randomised controlled trial. Participants were patients with moderate-high risk of cardiovascular disease, and their GPs. Survey and web analytic data were analysed with descriptive statistics. Interview and focus group transcripts were recorded, transcribed, coded and analysed for themes.
Surveys (n = 397) received from patients indicated improved medication adherence (31.8%); improved mental health and well-being (40%); higher physical activity (47%); and healthier eating (61%). Users of the interactive features reported benefiting from personalised cardiovascular disease risk score (73%); goal tracking (69%); risk factor self-monitoring (52%) and receipt of motivational health tips (54%). Focus group and interview participants (n = 55) described customisations that would increase portal appeal and relevance, including more provider interaction. Of the GP survey respondents (n = 38), 74% reported increased patient attendance and engagement with their care. For future integrated portals, 94% of GPs were in favour and key themes among interviewees (n = 17) related to design optimisation, impact on workflow and data security.
Intervention features reflecting the persuasive design categories of Primary Task support, Dialogue support and System Credibility support facilitated healthier lifestyle behaviour. Patients valued customisable functions and greater patient-provider interactivity. GPs identified system challenges but saw advantages for patients and the health care relationship. Future studies could further elucidate the persuasive design principles that are at play and which may promote adoption of EHR-integrated consumer portals.
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Background:
Coronary heart disease (CHD) is a major cause of death worldwide. Cardiac rehabilitation, an evidence-based CHD secondary prevention programme, remains underutilized. Telehealth may offer ...an innovative solution to overcome barriers to cardiac rehabilitation attendance. We aimed to determine whether contemporary telehealth interventions can provide effective secondary prevention as an alternative or adjunct care compared with cardiac rehabilitation and/or usual care for patients with CHD.
Methods:
Relevant randomized controlled trials evaluating telehealth interventions in CHD patients with at least three months’ follow-up compared with cardiac rehabilitation and/or usual care were identified by searching electronic databases. We checked reference lists, relevant conference lists, grey literature and keyword searching of the Internet. Main outcomes included all-cause mortality, rehospitalization/cardiac events and modifiable risk factors. (PROSPERO registration number 77507.)
Results:
In total, 32 papers reporting 30 unique trials were identified. Telehealth was not significant associated with a lower all-cause mortality than cardiac rehabilitation and/or usual care (risk ratio (RR)=0.60, 95% confidence interval (CI)=0.86 to 1.24, p=0.42). Telehealth was significantly associated with lower rehospitalization or cardiac events (RR=0.56, 95% CI=0.39 to 0.81, p<0.0001) compared with non-intervention groups. There was a significantly lower weighted mean difference (WMD) at medium to long-term follow-up than comparison groups for total cholesterol (WMD= −0.26 mmol/l, 95% CI= −0.4 to −0.11, p <0.001), low-density lipoprotein (WMD= −0.28, 95% CI = −0.50 to −0.05, p=0.02) and smoking status (RR=0.77, 95% CI =0.59 to 0.99, p=0.04.
Conclusions:
Telehealth interventions with a range of delivery modes could be offered to patients who cannot attend cardiac rehabilitation, or as an adjunct to cardiac rehabilitation for effective secondary prevention.
Many studies have now demonstrated the efficacy of text messaging in positively changing behaviours. We aimed to identify features and factors that explain the effectiveness of a successful text ...messaging program in terms of user engagement, perceived usefulness, behavior change and program delivery preferences.
Mixed methods qualitative design combining four data sources; (i) analytic data extracted directly from the software system, (ii) participant survey, (iii) focus groups to identify barriers and enablers to implementation and mechanisms of effect and (iv) recruitment screening logs and text message responses to examine engagement. This evaluation was conducted within the TEXT ME trial-a parallel design, single-blind randomized controlled trial (RCT) of 710 patients with coronary heart disease (CHD). Qualitative data were interpreted using inductive thematic analysis.
307/352 (87% response rate) of recruited patients with CHD completed the program evaluation survey at six months and 25 participated in a focus group. Factors increasing engagement included (i) ability to save and share messages, (ii) having the support of providers and family, (iii) a feeling of support through participation in the program, (iv) the program being initiated close to the time of a cardiovascular event, (v) personalization of the messages, (vi) opportunity for initial face-to-face contact with a provider and (vii) that program and content was perceived to be from a credible source. Clear themes relating to program delivery were that diet and physical activity messages were most valued, four messages per week was ideal and most participants felt program duration should be provided for at least for six months or longer.
This study provides context and insight into the factors influencing consumer engagement with a text message program aimed at improving health-related behavior. The study suggests program components that may enhance potential success but will require integration at the development stage to optimize up-scaling.
Australia and New Zealand Clinical Trials Registry, ACTRN12611000161921.
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Participation in cardiac rehabilitation (CR) benefits patients with coronary heart disease (CHD), yet worldwide only some 15–30% of those eligible attend. To improve understanding of the reasons for ...poor participation we undertook a systematic review and meta-synthesis of the qualitative literature.
Qualitative studies identifying patient barriers and enablers to attendance at CR were identified by searching multiple electronic databases, reference lists, relevant conference lists, grey literature, and keyword searching of the Internet (1990–2010). Studies were selected if they included patients with CHD and reviewed experience or understanding about CR. Meta-synthesis was used to review the papers and to synthesize the data.
From 1165 papers, 34 unique studies were included after screening. These included 1213 patients from eight countries. Study methodology included interviews (n = 25), focus groups (n = 5), and mixed-methods (n = 4). Key reasons for not attending CR were physical barriers, such as lack of transport, or financial cost, and personal barriers, such as embarrassment about participation, or misunderstanding the reasons for onset of CHD or the purpose of CR.
There is a vast amount of qualitative research which investigates patients’ reasons for non-attendance at CR. Key issues include system-level and patient-level barriers, which are potentially modifiable. Future research would best be directed at investigating strategies to overcome these barriers.
There are a growing number of mobile phone apps available to support people in taking their medications and to improve medication adherence. However, little is known about how these apps differ in ...terms of features, quality, and effectiveness.
We aimed to systematically review the medication reminder apps available in the Australian iTunes store and Google Play to assess their features and their quality in order to identify high-quality apps.
This review was conducted in a similar manner to a systematic review by using a stepwise approach that included (1) a search strategy; (2) eligibility assessment; (3) app selection process through an initial screening of all retrieved apps and full app review of the included apps; (4) data extraction using a predefined set of features considered important or desirable in medication reminder apps; (5) analysis by classifying the apps as basic and advanced medication reminder apps and scoring and ranking them; and (6) a quality assessment by using the Mobile App Rating Scale (MARS), a reliable tool to assess mobile health apps.
We identified 272 medication reminder apps, of which 152 were found only in Google Play, 87 only in iTunes, and 33 in both app stores. Apps found in Google Play had more customer reviews, higher star ratings, and lower cost compared with apps in iTunes. Only 109 apps were available for free and 124 were recently updated in 2015 or 2016. Overall, the median number of features per app was 3.0 (interquartile range 4.0) and only 18 apps had ≥9 of the 17 desirable features. The most common features were flexible scheduling that was present in 56.3% (153/272) of the included apps, medication tracking history in 54.8% (149/272), snooze option in 34.9% (95/272), and visual aids in 32.4% (88/272). We classified 54.8% (149/272) of the included apps as advanced medication reminder apps and 45.2% (123/272) as basic medication reminder apps. The advanced apps had a higher number of features per app compared with the basic apps. Using the MARS instrument, we were able to identify high-quality apps that were rated as being very interesting and entertaining, highly interactive and customizable, intuitive, and easy to use and to navigate as well as having a high level of visual appeal and good-quality information.
Many medication reminder apps are available in the app stores; however, the majority of them did not have many of the desirable features and were, therefore, considered low quality. Through a systematic stepwise process, we were able to identify high-quality apps to be tested in a future study that will provide evidence on the use of medication reminder apps to improve medication adherence.
Youth Advisory Groups (YAGs) represent a promising method to engage adolescents in research of relevance to them and their peers. However, YAGs are rarely implemented or evaluated in chronic disease ...prevention research. The aims of this study were firstly, to evaluate the effect of participation in a 12-month YAG on adolescents' leadership skills and perceptions related to chronic disease prevention research and secondly, to evaluate the process of establishing and facilitating a 12-month YAG and identify barriers and enablers to establishment and facilitation.
This study was a 12-month pre-post study. Eligible participants were adolescents (13-18-years) and current members of an established YAG. Data collection involved online surveys and semi-structured interviews at baseline, six-months and 12-months follow-up. Participatory outcomes such as self-efficacy, leadership skills, and collective participation were derived from Youth Participatory Action Research Principles (YPAR), and the Lansdown-UNICEF conceptual framework for measuring outcomes of adolescent participation. Process evaluation data were captured via meeting minutes, Slack metrics and researcher logs. Quantitative data was analysed using descriptive statistics and qualitative data was thematically analysed using a reflexive thematic analysis approach.
Thirteen (13/16) YAG youth advisors consented to participate in the evaluation study (mean age 16.0 years, SD 1.3; 62% (8/13) identified as female). Survey data assessing participatory outcomes found an increase in leadership and life skills scores over 12-months (+ 8.90 points). Semi-structured interview data collected over the 12-month term revealed three key themes namely: influence, empowerment, and contribution. Comparison of pre-post themes determined a positive trend at follow-ups, demonstrating improved participatory outcomes. Process indicators revealed that at 12-month follow-up the YAG was implemented as planned. Semi-structured interview data determined barriers to YAG facilitation included time and limited face-to-face components, while enablers to YAG facilitation included flexibility, accessible delivery methods, and a supportive adult facilitator.
This study found that a YAG fostered positive participatory outcomes and unique opportunities for youth participants. A successful YAG based on YPAR principles requires researchers to ensure YAG establishment and facilitation is an iterative process. Taking into consideration important barriers and enablers to YAG facilitation ensures adolescent engagement in a YAG is both meaningful and impactful.
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The demand for convenience and the increasing role of digital technology in everyday life has fueled the use of online food delivery services (OFD's), of which young people are the largest users ...globally. OFD's are disrupting traditional food environments, yet research evaluating the public health implications of such services is lacking. We evaluated the characteristics and nutritional quality of popular food outlets on a market-leading platform (UberEATS
) in a cross-sectional observational study conducted in two international cities: Sydney (Australia) and Auckland (New Zealand). A systematic search using publicly available population-level data was used to identify geographical areas with above-average concentrations (>30%) of young people (15-34-years). A standardized data extraction protocol was used to identify the ten most popular food outlets within each area. The nutritional quality of food outlets was assessed using the Food Environment Score (FES) (range: -10 'unhealthiest' to 10 'healthiest'). Additionally, the most popular menu items from each food outlet were classified as discretionary or core foods/beverages according to the Australian Dietary Guidelines. The majority of popular food outlets were classified as 'unhealthy' (FES range -10 to -5; 73.5%, 789/1074) and were predominately takeaway franchise stores (59.6%, 470/789, e.g., McDonald's
). 85.9% of all popular menu items were discretionary (n = 4958/5769). This study highlights the pervasion and accessibility of discretionary foods on OFD's. This study demonstrated that the most popular food outlets on the market-leading online food delivery service are unhealthy and popular menu items are mostly discretionary foods; facilitating the purchase of foods of poor nutritional quality. Consideration of OFD's in public health nutrition strategies and policies in critical.
Electronic health (eHealth) strategies are evolving making it important to have valid scales to assess eHealth and health literacy. Item response theory methods, such as the Rasch measurement model, ...are increasingly used for the psychometric evaluation of scales. This paper aims to examine the internal construct validity of an eHealth and health literacy scale using Rasch analysis in a population with moderate to high cardiovascular disease risk.
The first 397 participants of the CONNECT study completed the electronic health Literacy Scale (eHEALS) and the Health Literacy Questionnaire (HLQ). Overall Rasch model fit as well as five key psychometric properties were analysed: unidimensionality, response thresholds, targeting, differential item functioning and internal consistency.
The eHEALS had good overall model fit (χ2 = 54.8, p = 0.06), ordered response thresholds, reasonable targeting and good internal consistency (person separation index (PSI) 0.90). It did, however, appear to measure two constructs of eHealth literacy. The HLQ subscales (except subscale 5) did not fit the Rasch model (χ2: 18.18-60.60, p: 0.00-0.58) and had suboptimal targeting for most subscales. Subscales 6 to 9 displayed disordered thresholds indicating participants had difficulty distinguishing between response options. All subscales did, nonetheless, demonstrate moderate to good internal consistency (PSI: 0.62-0.82).
Rasch analyses demonstrated that the eHEALS has good measures of internal construct validity although it appears to capture different aspects of eHealth literacy (e.g. using eHealth and understanding eHealth). Whilst further studies are required to confirm this finding, it may be necessary for these constructs of the eHEALS to be scored separately. The nine HLQ subscales were shown to measure a single construct of health literacy. However, participants' scores may not represent their actual level of ability, as distinction between response categories was unclear for the last four subscales. Reducing the response categories of these subscales may improve the ability of the HLQ to distinguish between different levels of health literacy.
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