Combining users' needs with health behavior models in designing an internet- and mobile-based intervention for physical activity in cardiac rehabilitation

Konstantinos Antypas, Silje C Wangberg, Konstantinos Antypas, Silje C Wangberg

Abstract

Background: Internet-based physical activity interventions have great potential in supporting patients in cardiac rehabilitation. Health behavior change theories and user input are identified as important contributors in the effectiveness of the interventions, but they are rarely combined in a systematic way in the design of the interventions.

Objective: The aim of this study is to identify the appropriate theoretical framework, along with the needs of the users of a physical activity intervention for cardiac rehabilitation, and to combine them into an effective Internet- and mobile-based intervention.

Methods: We explain the theoretical framework of the intervention in a narrative overview of the existing health behavior change literature as it applies to physical activity. We also conducted a focus group with 11 participants of a cardiac rehabilitation program and used thematic analysis to identify and analyze patterns of meaning in the transcribed data.

Results: We chose stage-based approaches, specifically the transtheoretical model and the health action process approach as our main framework for tailoring, supplemented with other theoretical concepts such as regulatory focus within the appropriate stages. From the thematic analysis of the focus group data, we identified seven themes: (1) social, (2) motivation, (3) integration into everyday life, (4) information, (5) planning, (6) monitoring and feedback, and (7) concerns and potential problems. The final design of the intervention was based on both the theoretical review and the user input, and it is explained in detail.

Conclusions: We applied a combination of health behavioral theory and user input in designing our intervention. We think this is a promising design approach with the potential to combine the high efficacy of theory-based interventions with the higher perceived usefulness of interventions designed according to user input.

Trial registration: Clinicaltrials.gov NCT01223170; https://ichgcp.net/clinical-trials-registry/NCT01223170 (Archived by WebCite at http://www.webcitation.org/6M5FqT9Q2).

Keywords: Internet; SMS; cardiac rehabilitation; design methodology; focus group; health behavior models; physical activity; smoking cessation; tailoring; user involvement; user needs.

Conflict of interest statement

Conflicts of Interest: The authors have participated in the design of the interventions mentioned in the manuscript.

Figures

Figure 1
Figure 1
Thematic map of the focus group themes.
Figure 2
Figure 2
The profile page (My Page).
Figure 3
Figure 3
Weekly overview of the planned activities of the activity calendar.
Figure 4
Figure 4
Planning of an activity in the activity calendar.
Figure 5
Figure 5
SMS before and after planned activity: "Remember Ball game, football/handball at 17:50 (second SMS from below)," "Did you do the activity Ball game, football/handball?" "If so, you can confirm it by following the link [unique URL]" (first SMS from below).
Figure 6
Figure 6
Mobile page for confirming the completed activity. Questions about the intensity of the activity, actual duration of the activity, and free text comment field (left image). The intensity of the activity according to Borg’s scale (right image).
Figure 7
Figure 7
The discussion forum.

References

    1. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, Amann M, Anderson HR, Andrews KG, Aryee M, Atkinson C, Bacchus LJ, Bahalim AN, Balakrishnan K, Balmes J, Barker-Collo S, Baxter A, Bell ML, Blore JD, Blyth F, Bonner C, Borges G, Bourne R, Boussinesq M, Brauer M, Brooks P, Bruce NG, Brunekreef B, Bryan-Hancock C, Bucello C, Buchbinder R, Bull F, Burnett RT, Byers TE, Calabria B, Carapetis J, Carnahan E, Chafe Z, Charlson F, Chen H, Chen JS, Cheng AT, Child JC, Cohen A, Colson KE, Cowie BC, Darby S, Darling S, Davis A, Degenhardt L, Dentener F, Des Jarlais DC, Devries K, Dherani M, Ding EL, Dorsey ER, Driscoll T, Edmond K, Ali SE, Engell RE, Erwin PJ, Fahimi S, Falder G, Farzadfar F, Ferrari A, Finucane MM, Flaxman S, Fowkes FG, Freedman G, Freeman MK, Gakidou E, Ghosh S, Giovannucci E, Gmel G, Graham K, Grainger R, Grant B, Gunnell D, Gutierrez HR, Hall W, Hoek HW, Hogan A, Hosgood HD, Hoy D, Hu H, Hubbell BJ, Hutchings SJ, Ibeanusi SE, Jacklyn GL, Jasrasaria R, Jonas JB, Kan H, Kanis JA, Kassebaum N, Kawakami N, Khang YH, Khatibzadeh S, Khoo JP, Kok C, Laden F, Lalloo R, Lan Q, Lathlean T, Leasher JL, Leigh J, Li Y, Lin JK, Lipshultz SE, London S, Lozano R, Lu Y, Mak J, Malekzadeh R, Mallinger L, Marcenes W, March L, Marks R, Martin R, McGale P, McGrath J, Mehta S, Mensah GA, Merriman TR, Micha R, Michaud C, Mishra V, Mohd Hanafiah K, Mokdad AA, Morawska L, Mozaffarian D, Murphy T, Naghavi M, Neal B, Nelson PK, Nolla JM, Norman R, Olives C, Omer SB, Orchard J, Osborne R, Ostro B, Page A, Pandey KD, Parry CD, Passmore E, Patra J, Pearce N, Pelizzari PM, Petzold M, Phillips MR, Pope D, Pope CA, Powles J, Rao M, Razavi H, Rehfuess EA, Rehm JT, Ritz B, Rivara FP, Roberts T, Robinson C, Rodriguez-Portales JA, Romieu I, Room R, Rosenfeld LC, Roy A, Rushton L, Salomon JA, Sampson U, Sanchez-Riera L, Sanman E, Sapkota A, Seedat S, Shi P, Shield K, Shivakoti R, Singh GM, Sleet DA, Smith E, Smith KR, Stapelberg NJ, Steenland K, Stöckl H, Stovner LJ, Straif K, Straney L, Thurston GD, Tran JH, Van Dingenen R, van Donkelaar A, Veerman JL, Vijayakumar L, Weintraub R, Weissman MM, White RA, Whiteford H, Wiersma ST, Wilkinson JD, Williams HC, Williams W, Wilson N, Woolf AD, Yip P, Zielinski JM, Lopez AD, Murray CJ, Ezzati M, AlMazroa MA, Memish ZA. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 Dec 15;380(9859):2224–2260. doi: 10.1016/S0140-6736(12)61766-8.
    1. Illman J. WHO's plan to police health websites rejected. BMJ. 2000 Nov 25;321(7272):1308–1308. doi: 10.1136/bmj.321.7272.1308/b.
    1. Omboni S, Gazzola T, Carabelli G, Parati G. Clinical usefulness and cost effectiveness of home blood pressure telemonitoring: Meta-analysis of randomized controlled studies. J Hypertens. 2013 Mar;31(3):455–467. doi: 10.1097/HJH.0b013e32835ca8dd.
    1. Samoocha D, Bruinvels DJ, Elbers NA, Anema JR, van der Beek AJ. Effectiveness of web-based interventions on patient empowerment: A systematic review and meta-analysis. J Med Internet Res. 2010 Jun;12(2):e23. doi: 10.2196/jmir.1286.
    1. Murray E, Burns J, See TS, Lai R, Nazareth I. Interactive Health Communication Applications for people with chronic disease. Cochrane Database Syst Rev. 2005;(4):CD004274. doi: 10.1002/14651858.CD004274.pub4.
    1. Jackson CL, Bolen S, Brancati FL, Batts-Turner ML, Gary TL. A systematic review of interactive computer-assisted technology in diabetes care. Interactive information technology in diabetes care. J Gen Intern Med. 2006 Feb;21(2):105–110. doi: 10.1111/j.1525-1497.2005.00310.x.
    1. Fanning J, Mullen SP, McAuley E. Increasing physical activity with mobile devices: A meta-analysis. J Med Internet Res. 2012;14(6):e161. doi: 10.2196/jmir.2171.
    1. Lau PW, Lau EY, Wong del P, Ransdell L. A systematic review of information and communication technology-based interventions for promoting physical activity behavior change in children and adolescents. J Med Internet Res. 2011;13(3):e48. doi: 10.2196/jmir.1533.
    1. McLean S, Nurmatov U, Liu JL, Pagliari C, Car J, Sheikh A. Telehealthcare for chronic obstructive pulmonary disease: Cochrane Review and meta-analysis. Br J Gen Pract. 2012 Nov;62(604):e739–749. doi: 10.3399/bjgp12X658269.
    1. Laplante C, Peng W. A systematic review of e-health interventions for physical activity: An analysis of study design, intervention characteristics, and outcomes. Telemed J E Health. 2011 Sep;17(7):509–523. doi: 10.1089/tmj.2011.0013.
    1. Ritterband LM, Thorndike FP, Cox DJ, Kovatchev BP, Gonder-Frederick LA. A behavior change model for Internet interventions. Ann Behav Med. 2009 Aug;38(1):18–27. doi: 10.1007/s12160-009-9133-4.
    1. Murray E. Web-based interventions for behavior change and self-management: Potential, pitfalls, and progress. Med 2.0. 2012 Aug 14;1(2):e3. doi: 10.2196/med20.1741.
    1. Neville LM, O'Hara B, Milat A. Computer-tailored physical activity behavior change interventions targeting adults: A systematic review. Int J Behav Nutr Phys Act. 2009;6:30. doi: 10.1186/1479-5868-6-30.
    1. Revere D, Dunbar PJ. Review of computer-generated outpatient health behavior interventions: Clinical encounters "in absentia". J Am Med Inform Assoc. 2001;8(1):62–79.
    1. Kelders SM, Kok RN, Ossebaard HC, Van Gemert-Pijnen JE. Persuasive system design does matter: A systematic review of adherence to web-based interventions. J Med Internet Res. 2012;14(6):e152. doi: 10.2196/jmir.2104.
    1. Strecher VJ, Shiffman S, West R. Moderators and mediators of a web-based computer-tailored smoking cessation program among nicotine patch users. Nicotine Tob Res. 2006 Dec;8 Suppl 1:S95–101.
    1. Brug J, Steenhuis I, van Assema P, Glanz K, De Vries H. Computer-tailored nutrition education: Differences between two interventions. Health Educ Res. 1999 Apr;14(2):249–256.
    1. Dijkstra A. Working mechanisms of computer-tailored health education: Evidence from smoking cessation. Health Educ Res. 2005 Oct;20(5):527–539. doi: 10.1093/her/cyh014.
    1. Brug J, Campbell M, van Assema P. The application and impact of computer-generated personalized nutrition education: A review of the literature. Patient Educ Couns. 1999 Feb;36(2):145–156.
    1. Campbell MK, DeVellis BM, Strecher VJ, Ammerman AS, DeVellis RF, Sandler RS. Improving dietary behavior: The effectiveness of tailored messages in primary care settings. Am J Public Health. 1994 May;84(5):783–787.
    1. de Nooijer J, Lechner L, de Vries H. Tailored versus general information on early detection of cancer: A comparison of the reactions of Dutch adults and the impact on attitudes and behaviors. Health Educ Res. 2002 Apr;17(2):239–252.
    1. Oenema A, Brug J, Lechner L. Web-based tailored nutrition education: Results of a randomized controlled trial. Health Educ Res. 2001 Dec;16(6):647–660.
    1. Webb MS, Simmons VN, Brandon TH. Tailored interventions for motivating smoking cessation: Using placebo tailoring to examine the influence of expectancies and personalization. Health Psychol. 2005 Mar;24(2):179–188. doi: 10.1037/0278-6133.24.2.179.
    1. Webb MS, Hendricks PS, Brandon TH. Expectancy priming of smoking cessation messages enhances the placebo effect of tailored interventions. Health Psychol. 2007 Sep;26(5):598–609. doi: 10.1037/0278-6133.26.5.598.
    1. Kreuter MW, Holt CL. How do people process health information? Applications in an age of individualized communication. Current Directions in Psychol Sci. 2001 Dec;10(6):206–209. doi: 10.1111/1467-8721.00150.
    1. Schwarzer R. Modeling health behavior change: How to predict and modify the adoption and maintenance of health behaviors. Applied Psychology. 2008 Jan;57(1):1–29. doi: 10.1111/j.1464-0597.2007.00325.x.
    1. Velicer WF, Prochaska JO. Stage and non-stage theories of behavior and behavior change: A comment on Schwarzer. Applied Psychology. 2008 Jan;57(1):75–83. doi: 10.1111/j.1464-0597.2007.00327.x.
    1. Sheeran P. Intention–behavior relations: A conceptual and empirical review. In: Stroebe Wolfgang, Hewstone Miles., editors. European review of social psychology. Chichester, UK: John Wiley & Sons, Ltd; 2005. pp. 1–36.
    1. Miller WR, Rollnick S. Motivational interviewing, third edition: Helping people change (applications of motivational interviewing) New York, NY: The Guilford Press; 2012.
    1. Martins RK, McNeil DW. Review of motivational interviewing in promoting health behaviors. Clin Psychol Rev. 2009 Jun;29(4):283–293. doi: 10.1016/j.cpr.2009.02.001.
    1. Lundahl BW, Kunz C, Brownell C, Tollefson D, Burke BL. A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice. 2010 Jan 11;20(2):137–160. doi: 10.1177/1049731509347850.
    1. Hardcastle SJ, Taylor AH, Bailey MP, Harley RA, Hagger MS. Effectiveness of a motivational interviewing intervention on weight loss, physical activity and cardiovascular disease risk factors: A randomised controlled trial with a 12-month post-intervention follow-up. Int J Behav Nutr Phys Act. 2013;10:40. doi: 10.1186/1479-5868-10-40.
    1. Hardcastle S, Taylor A, Bailey M, Castle R. A randomised controlled trial on the effectiveness of a primary health care based counselling intervention on physical activity, diet, and CHD risk factors. Patient Educ Couns. 2008 Jan;70(1):31–39. doi: 10.1016/j.pec.2007.09.014.
    1. Hardcastle S, Hagger MS. "You can't do it on your own": Experiences of a motivational interviewing intervention on physical activity and dietary behaviour. Psychology of Sport and Exercise. 2011 Jun;12(3):314–323. doi: 10.1016/j.psychsport.2011.01.001.
    1. Hardcastle S, Blake N, Hagger MS. The effectiveness of a motivational interviewing primary-care based intervention on physical activity and predictors of change in a disadvantaged community. J Behav Med. 2012 Jun;35(3):318–333. doi: 10.1007/s10865-012-9417-1.
    1. Noar SM, Benac CN, Harris MS. Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. Psychol Bull. 2007 Jul;133(4):673–693. doi: 10.1037/0033-2909.133.4.673.
    1. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12(1):38–48.
    1. Adams J, White M. Why don't stage-based activity promotion interventions work? Health Educ Res. 2005 Apr;20(2):237–243. doi: 10.1093/her/cyg105.
    1. Marcus BH, Selby VC, Niaura RS, Rossi JS. Self-efficacy and the stages of exercise behavior change. Res Q Exerc Sport. 1992 Mar;63(1):60–66.
    1. Higgins ET. Beyond pleasure and pain. Am Psychol. 1997 Dec;52(12):1280–1300.
    1. Higgins ET, Friedman RS, Harlow RE, Idson LC, Ayduk ON, Taylor A. Achievement orientations from subjective histories of success: Promotion pride versus prevention pride. Eur. J. Soc. Psychol. 2001 Jan;31(1):3–23. doi: 10.1002/ejsp.27.
    1. Bandura A. Self-efficacy mechanism in human agency. American Psychologist. 1982 Apr 22;37(2):122–147. doi: 10.1037/0003-066X.37.2.122.
    1. Gollwitzer PM. Implementation intentions: Strong effects of simple plans. American Psychologist. 1999;54(7):493–503. doi: 10.1037/0003-066X.54.7.493.
    1. Latimer AE, Rivers SE, Rench TA, Katulak NA, Hicks A, Hodorowski JK, Higgins ET, Salovey P. A field experiment testing the utility of regulatory fit messages for promoting physical activity. J Exp Soc Psychol. 2008 May;44(3):826–832. doi: 10.1016/j.jesp.2007.07.013.
    1. Latimer AE, Williams-Piehota P, Katulak NA, Cox A, Mowad L, Higgins ET, Salovey P. Promoting fruit and vegetable intake through messages tailored to individual differences in regulatory focus. Ann Behav Med. 2008 Jun;35(3):363–369. doi: 10.1007/s12160-008-9039-6.
    1. Prochaska JO, Velicer WF, Rossi JS, Goldstein MG, Marcus BH, Rakowski W, Fiore C, Harlow LL, Redding CA, Rosenbloom D. Stages of change and decisional balance for 12 problem behaviors. Health Psychol. 1994 Jan;13(1):39–46.
    1. Cancer Prevention Research Center. [2013-04-10]. Exercise: Decisional balance cancer prevention research center .
    1. Schwarzer R. Self-efficacy in the adoption maintenance of health behaviors: Theoretical approaches a new model. In: Schwarzer R, editor. Self-efficacy: Thought control of action. Washington, DC: Hemisphere; 1992. pp. 217–242.
    1. Sniehotta FF, Scholz U, Schwarzer R. Action plans and coping plans for physical exercise: A longitudinal intervention study in cardiac rehabilitation. Br J Health Psychol. 2006 Feb;11(Pt 1):23–37. doi: 10.1348/135910705X43804.
    1. Sniehotta FF, Schwarzer R, Scholz U, Schüz B. Action planning and coping planning for long-term lifestyle change: Theory and assessment. Eur. J. Soc. Psychol. 2005 Jul;35(4):565–576. doi: 10.1002/ejsp.258.
    1. Terry DJ, O'Leary JE. The theory of planned behaviour: The effects of perceived behavioural control and self-efficacy. Br J Soc Psychol. 1995 Jun;34 (Pt 2):199–220.
    1. Trafimow D, Sheeran P, Conner M, Finlay KA. Evidence that perceived behavioural control is a multidimensional construct: Perceived control and perceived difficulty. Br J Soc Psychol. 2002 Mar;41(Pt 1):101–121.
    1. Barrera M. Distinctions between social support concepts, measures, and models. Am J Commun Psychol. 1986 Aug;14(4):413–445. doi: 10.1007/BF00922627.
    1. Wagner J, Burg M, Sirois B. Social support and the transtheoretical model: Relationship of social support to smoking cessation stage, decisional balance, process use, and temptation. Addict Behav. 2004 Jul;29(5):1039–1043. doi: 10.1016/j.addbeh.2004.02.058.
    1. Marlatt GA, George WH. Relapse prevention: Introduction and overview of the model. Br J Addict. 1984 Sep;79(3):261–273.
    1. Hajek P, Stead LF, West R, Jarvis M, Hartmann-Boyce J, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane Database Syst Rev. 2013;8:CD003999. doi: 10.1002/14651858.CD003999.pub4.
    1. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377–381.
    1. Antypas K, Wangberg SC. E-Rehabilitation - an Internet and mobile phone based tailored intervention to enhance self-management of cardiovascular disease: Study protocol for a randomized controlled trial. BMC Cardiovasc Disord. 2012;12:50. doi: 10.1186/1471-2261-12-50.
    1. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, Nieman DC, Swain DP, American College of Sports Medicine American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports Exerc. 2011 Jul;43(7):1334–1359. doi: 10.1249/MSS.0b013e318213fefb.
    1. Stevens VJ, Funk KL, Brantley PJ, Erlinger TP, Myers VH, Champagne CM, Bauck A, Samuel-Hodge CD, Hollis JF. Design and implementation of an interactive website to support long-term maintenance of weight loss. J Med Internet Res. 2008;10(1):e1. doi: 10.2196/jmir.931.
    1. van Weert JC, van Noort G, Bol N, van Dijk L, Tates K, Jansen J. Tailored information for cancer patients on the Internet: Effects of visual cues and language complexity on information recall and satisfaction. Patient Educ Couns. 2011 Sep;84(3):368–378. doi: 10.1016/j.pec.2011.04.006.
    1. Lehto T, Oinas-Kukkonen H. Persuasive features in web-based alcohol and smoking interventions: A systematic review of the literature. J Med Internet Res. 2011;13(3):e46. doi: 10.2196/jmir.1559.
    1. Harris PR, Sillence E, Briggs P. The effect of credibility-related design cues on responses to a web-based message about the breast cancer risks from alcohol: Randomized controlled trial. J Med Internet Res. 2009;11(3):e37. doi: 10.2196/jmir.1097.
    1. Irvin JE, Bowers CA, Dunn ME, Wang MC. Efficacy of relapse prevention: A meta-analytic review. J Consult Clin Psychol. 1999 Aug;67(4):563–570.
    1. Kahn EB, Ramsey LT, Brownson RC, Heath GW, Howze EH, Powell KE, Stone EJ, Rajab MW, Corso P. The effectiveness of interventions to increase physical activity. A systematic review. Am J Prev Med. 2002 May;22(4 Suppl):73–107.
    1. Glanz K, Rimer BK, Viswanath K. Health behavior and health education: theory, research, and practice. San Francisco: Jossey-Bass; 2008. [2013-12-31]. Ecological models of health behavior .
    1. Bandura A. Health promotion from the perspective of social cognitive theory. Psychology & Health. 1998 Jul;13(4):623–649. doi: 10.1080/08870449808407422.
    1. Baranowski T, Anderson C, Carmack C. Mediating variable framework in physical activity interventions. How are we doing? How might we do better? Am J Prev Med. 1998 Nov;15(4):266–297.
    1. Rothman AJ. "Is there nothing more practical than a good theory?": Why innovations and advances in health behavior change will arise if interventions are used to test and refine theory. Int J Behav Nutr Phys Act. 2004 Jul 27;1(1):11. doi: 10.1186/1479-5868-1-11.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe