Evaluating the Impact of the HeartHab App on Motivation, Physical Activity, Quality of Life, and Risk Factors of Coronary Artery Disease Patients: Multidisciplinary Crossover Study
Supraja Sankaran, Paul Dendale, Karin Coninx, Supraja Sankaran, Paul Dendale, Karin Coninx
Abstract
Background: Telerehabilitation approaches have been successful in supporting coronary artery disease (CAD) patients to rehabilitate at home after hospital-based rehabilitation. However, on completing a telerehabilitation program, the effects are not sustained beyond the intervention period because of the lack of lifestyle adaptations. Furthermore, decline in patients' motivation lead to recurrence of disease and increased rehospitalization rates. We developed HeartHab, using persuasive design principles and personalization, to enable sustenance of rehabilitation effects beyond the intervention period. HeartHab promotes patients' understanding, motivates them to reach personalized rehabilitation goals, and helps to maintain positive lifestyle adaptations during telerehabilitation.
Objective: This study aimed to investigate the impact of the HeartHab app on patients' overall motivation, increasing physical activities, reaching exercise targets, quality of life, and modifiable risk factors in patients with CAD during telerehabilitation. The study also investigated carryover effects to determine the maintenance of effects after the conclusion of the intervention.
Methods: A total of 32 CAD patients were randomized on a 1:1 ratio to telerehabilitation or usual care. We conducted a 4-month crossover study with a crossover point at 2 months using a mixed-methods approach for evaluation. We collected qualitative data on users' motivation, user experience, and quality of life using questionnaires, semistructured interviews and context-based sentiment analysis. Quantitative data on health parameters, exercise capacity, and risk factors were gathered from blood tests and ergo-spirometry tests. Data procured during the app usage phase were compared against baseline values to assess the impact of the app on parameters such as motivation, physical activity, quality of life, and risk factors. Carryover effects were used to gather insights on the maintenance of effects.
Results: The qualitative data showed that 75% (21/28) of patients found the HeartHab app motivating and felt encouraged to achieve their rehabilitation targets. 84% (21/25) of patients either reached or exceeded their prescribed physical activity targets. We found positive significant effects on glycated hemoglobin (P=.01; d=1.03; 95% CI 0.24-1.82) with a mean decrease of 1.5 mg/dL and high-density lipoprotein (HDL) cholesterol (P=.04; d=0.78; 95% CI 0.02-1.55) with a mean increase of 0.61 mg/dL after patients used the HeartHab app. We observed significant carryover effects on weight, HDL cholesterol, and maximal oxygen consumption (VO2 max), indicating the maintenance of effects.
Conclusions: Persuasive design techniques integrated in HeartHab and tailoring of exercise targets were effective in motivating patients to reach their telerehabilitation targets. This study demonstrated significant effects on glucose and HDL cholesterol and positive carryover effects on weight, HDL cholesterol, and VO2 max. There was also a perceived improvement in quality of life. A longer-term evaluation with more patients could possibly reveal effectiveness on other risk factors and maintenance of the positive health behavior change.
Trial registration: ClinicalTrials.gov NCT03102671; https://ichgcp.net/clinical-trials-registry/NCT03102671 (Archived by WebCite at http://www.webcitation.org/76gzI9Pvd).
Keywords: cardiac rehabilitation; evaluation studies; heart diseases; human factors engineering; mobile app; multidisciplinary research; telerehabilitation.
Conflict of interest statement
Conflicts of Interest: None declared.
©Supraja Sankaran, Paul Dendale, Karin Coninx. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 04.04.2019.
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References
- Kotseva K, Wood D, De Bacquer D, De Backer G, Rydén L, Jennings C, Gyberg V, Amouyel P, Bruthans J, Castro CA, Cífková R, Deckers J, De SJ, Dilic M, Dolzhenko M, Erglis A, Fras Z, Gaita D, Gotcheva N, Goudevenos J, Heuschmann P, Laucevicius A, Lehto S, Lovic D, Miličić D, Moore D, Nicolaides E, Oganov R, Pajak A, Pogosova N, Reiner Z, Stagmo M, Störk S, Tokgözo?lu L, Vulic D. EUROASPIRE IV: a European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol Internet. 2016 Apr;:16. doi: 10.1177/2047487315569401.
- Anderson L, Oldridge N, Thompson DR, Zwisler A, Rees K, Martin N, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol. 2016 Jan 5;67(1):1–12. doi: 10.1016/j.jacc.2015.10.044.
- Hansen D, Dendale P, Raskin A, Schoonis A, Berger J, Vlassak I, Meeusen R. Long-term effect of rehabilitation in coronary artery disease patients: randomized clinical trial of the impact of exercise volume. Clin Rehabil. 2010 Apr;24(4):319–27. doi: 10.1177/0269215509353262.
- Turk-Adawi KI, Oldridge NB, Tarima SS, Stason WB, Shepard DS. Cardiac rehabilitation patient and organizational factors: what keeps patients in programs? J Am Heart Assoc. 2013 Oct 21;2(5):e000418. doi: 10.1161/JAHA.113.000418.
- Piepoli M, Corrà U, Dendale P, Frederix I, Prescott E, Schmid J, Cupples M, Deaton C, Doherty P, Giannuzzi P, Graham I, Hansen T, Jennings C, Landmesser U, Marques-Vidal P, Vrints C, Walker D, Bueno H, Fitzsimons D, Pelliccia A. Challenges in secondary prevention after acute myocardial infarction: a call for action. Eur J Prev Cardiol. 2016 Dec;23(18):1994–2006. doi: 10.1177/2047487316663873.
- Piotrowicz E, Piotrowicz R. Cardiac telerehabilitation: current situation and future challenges. Eur J Prev Cardiol. 2013 Jun;20(2 Suppl):12–6. doi: 10.1177/2047487313487483c.
- Piepoli M, Corrà U, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D, McGee H, Mendes M, Niebauer J, Zwisler A, Schmid J, Cardiac Rehabilitation Section of the European Association of Cardiovascular PreventionRehabilitation Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2010 Feb;17(1):1–17. doi: 10.1097/HJR.0b013e3283313592.
- Jolly K, Taylor R, Lip G, Stevens A. Home-based cardiac rehabilitation compared with centre-based rehabilitation and usual care: a systematic review and meta-analysis. Int J Cardiol. 2006 Aug 28;111(3):343–51. doi: 10.1016/j.ijcard.2005.11.002.
- Frederix I, Hansen D, Coninx K, Vandervoort P, Vandijck D, Hens N, Van Craenenbroeck E, Van Driessche N, Dendale P. Effect of comprehensive cardiac telerehabilitation on one-year cardiovascular rehospitalization rate, medical costs and quality of life: a cost-effectiveness analysis. Eur J Prev Cardiol. 2016 May;23(7):674–82. doi: 10.1177/2047487315602257.
- Sankaran S, Frederix I, Haesen M, Dendale P, Luyten K, Coninx K. A Grounded Approach for Applying Behavior Change Techniques in Mobile Cardiac Tele-Rehabilitation. Proceedings of the 9th ACM International Conference on PErvasive Technologies Related to Assistive Environments; PETRA'16; June 29-July 1, 2016; Corfu Island, Greece. New York, NY, USA: ACM; 2016.
- Kraal JJ, Peek N, Van den Akker-Van Marle ME, Kemps HM. Effects of home-based training with telemonitoring guidance in low to moderate risk patients entering cardiac rehabilitation: short-term results of the FIT@Home study. Eur J Prev Cardiolog. 2014 Oct 29;21(2_suppl):26–31. doi: 10.1177/2047487314552606.
- Hwang R, Bruning J, Morris N, Mandrusiak A, Russell T. A systematic review of the effects of telerehabilitation in patients with cardiopulmonary diseases. J Cardiopulm Rehabil Prev. 2015;35(6):380–9. doi: 10.1097/HCR.0000000000000121.
- Frederix I, Vanhees L, Dendale P, Goetschalckx K. A review of telerehabilitation for cardiac patients. J Telemed Telecare. 2015 Jan;21(1):45–53. doi: 10.1177/1357633X14562732.
- Frederix I, Solmi F, Piepoli M, Dendale P. Cardiac telerehabilitation: a novel cost-efficient care delivery strategy that can induce long-term health benefits. Eur J Prev Cardiol. 2017 Dec;24(16):1708–17. doi: 10.1177/2047487317732274.
- Thaler R, Sunstein C. Nudge: Improving Decisions About Health, Wealth, And Happiness. London, England: Penguin Books; 2008.
- Michie S, Yardley L, West R, Patrick K, Greaves F. Developing and evaluating digital interventions to promote behavior change in health and health care: recommendations resulting from an international workshop. J Med Internet Res. 2017 Dec 29;19(6):e232. doi: 10.2196/jmir.7126.
- Stawarz K, Cox A, Blandford A. Beyond Self-Tracking and Reminders: Designing Smartphone Apps That Support Habit Formation. Proceedings of the 33rd Annual ACM Conference on Human Factors in Computing Systems; CHI'15; April 18-23, 2015; Seoul, Republic of Korea. New York, NY, USA: ACM; 2015.
- Fogg BJ. A behavior model for persuasive design. Proceedings of the 4th International Conference on Persuasive Technology; Persuasive'09; April 26-29, 2009; Claremont, California, USA. New York, NY, USA: ACM; 2009.
- Oinas-Kukkonen H, Harjumaa M. Persuasive systems design: key issues, process model, and system features. Comm Assoc Inf Syst. 2009;24:500. doi: 10.17705/1CAIS.02428.
- Fogg BJ, Hreha J. Behavior wizard: a method for matching target behaviors with solutions. Proceedings of the 5th international conference on Persuasive Technology; PERSUASIVE'10; June 7-10, 2010; Copenhagen, Denmark. 2010. pp. 117–131.
- Sankaran S, Frederix I, Haesen M, Dendale P, Luyten K, Coninx K. A Grounded Approach for Applying Behavior Change Techniques in Mobile Cardiac Tele-Rehabilitation. 9th ACM International Conference on PErvasive Technologies Related to Assistive Environments; June 29 - July 01, 2016; Corfu island, Greece. New York, NY, USA: ACM; 2016.
- Sankaran S, Luyten K, Hansen D, Dendale P, Hospital J, Coninx K. Have You Met Your METs?- Enhancing Patient Motivation to Achieve Physical Activity Targets in Cardiac Tele-rehabilitation. Proceedings of the 32nd International BCS Human Computer Interaction Conference; HCI 2018; July 4-6, 2018; Belfast, UK. London, UK: BCS Learning and Development Ltd; 2018.
- Sankaran S, Bonneux C, Dendale P, Coninx K. Bridging Patients' Needs and Caregivers' Perspectives to Tailor Information Provisioning during Cardiac Rehabilitation. Proceedings of the 32nd International BCS Human Computer Interaction Conference; HCI'18; July 4-6, 2018; Belfast, UK. London, UK: BCS Learning and Development Ltd; 2018.
- Richards L. Using NVIVO in Qualitative Research. London, UK: Sage Publications; 1999.
- Welsh E. Dealing with data: using NVivo in the qualitative data analysis process. Forum Qual Soc Res. 2002;3(2) doi: 10.17169/fqs-3.2.865.
- Pawar AB, Jawale MA, Kyatanavar DN. Fundamentals of sentiment analysis: concepts and methodology. In: Pedrycz W, Chen SM, editors. Sentiment Analysis and Ontology Engineering. Switzerland: Springer; 2016. pp. 25–48.
- International Physical Activity Questionnaire. [2018-02-19]. .
- Oldridge N. Heartqol Questionnaire: a new patient-reported outcome in cardiology. Eur Heal Psychol. 2014;16:379.
- EuroQol Research Foundation. Rotterdam, Netherlands: 2017. [2018-02-19]. EQ-5D-5L | About
- Google Docs. 2005. [2019-03-05]. Guidelines for Data Processing and Analysis of the International Physical Activity Questionnaire (IPAQ) .
- Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ, O'Brien WL, Bassett DR, Schmitz KH, Emplaincourt PO, Jacobs DR, Leon AS. Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc. 2000 Sep;32(9 Suppl):S498–504. doi: 10.1097/00005768-200009001-00009.
- Hansen D, Dendale P, Coninx K, Vanhees L, Piepoli M, Niebauer J, Cornelissen V, Pedretti R, Geurts E, Ruiz G, Corrà U, Schmid J, Greco E, Davos C, Edelmann F, Abreu A, Rauch B, Ambrosetti M, Braga S, Barna O, Beckers P, Bussotti M, Fagard R, Faggiano P, Garcia-Porrero E, Kouidi E, Lamotte M, Neunhäuserer D, Reibis R, Spruit M, Stettler C, Takken T, Tonoli C, Vigorito C, Völler H, Doherty P. The European Association of Preventive Cardiology Exercise Prescription in Everyday Practice and Rehabilitative Training (EXPERT) tool: A digital training and decision support system for optimized exercise prescription in cardiovascular disease. Concept, definitions and construction methodology. Eur J Prev Cardiol. 2017 Dec;24(10):1017–31. doi: 10.1177/2047487317702042.
- van Reenen M, Janssen B. EuroQol Research Foundation. 2015. [2019-03-05]. EQ-5D-5L User guide .
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