Behavior Change Techniques in Physical Activity eHealth Interventions for People With Cardiovascular Disease: Systematic Review

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Abstract

Background

Cardiovascular disease (CVD) is the leading cause of premature death and disability in Europe, accounting for 4 million deaths per year and costing the European Union economy almost €196 billion annually. There is strong evidence to suggest that exercise-based secondary rehabilitation programs can decrease the mortality risk and improve health among patients with CVD. Theory-informed use of behavior change techniques (BCTs) is important in the design of cardiac rehabilitation programs aimed at changing cardiovascular risk factors. Electronic health (eHealth) is the use of information and communication technologies (ICTs) for health. This emerging area of health care has the ability to enhance self-management of chronic disease by making health care more accessible, affordable, and available to the public. However, evidence-based information on the use of BCTs in eHealth interventions is limited, and particularly so, for individuals living with CVD.

Objective

The aim of this systematic review was to assess the application of BCTs in eHealth interventions designed to increase physical activity (PA) in CVD populations.

Methods

A total of 7 electronic databases, including EBSCOhost (MEDLINE, PsycINFO, Academic Search Complete, SPORTDiscus with Full Text, and CINAHL Complete), Scopus, and Web of Science (Core Collection) were searched. Two authors independently reviewed references using the software package Covidence (Veritas Health Innovation). The reviewers met to resolve any discrepancies, with a third independent reviewer acting as an arbitrator when required. Following this, data were extracted from the papers that met the inclusion criteria. Bias assessment of the studies was carried out using the Cochrane Collaboration’s tool for assessing the risk of bias within Covidence; this was followed by a narrative synthesis.

Results

Out of the 987 studies that were identified, 14 were included in the review. An additional 9 studies were added following a hand search of review paper references. The average number of BCTs used across the 23 studies was 7.2 (range 1-19). The top three most frequently used BCTs included information about health consequences (78%, 18/23), goal setting (behavior; 74%, 17/23), and joint third, self-monitoring of behavior and social support (practical) were included in 11 studies (48%, 11/23) each.

Conclusions

This systematic review is the first to investigate the use of BCTs in PA eHealth interventions specifically designed for people with CVD. This research will have clear implications for health care policy and research by outlining the BCTs used in eHealth interventions for chronic illnesses, in particular CVD, thereby providing clear foundations for further research and developments in the area.

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Most cited references 26

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Program integrity in primary and early secondary prevention: are implementation effects out of control?

A John Dane, B. Schneider (1997)

We examined the extent to which program integrity (i.e., the degree to which programs were implemented as planned) was verified and promoted in evaluations of primary and early secondary prevention programs published between 1980 and 1994. Only 39 of 162 outcome studies featured specified procedures for the documentation of fidelity. Of these, only 13 considered variations in integrity in analyzing the effects of the program. Lowered adherence to protocol was often associated with poorer outcome. There was mixed evidence of dosage effects. The omission of integrity data, particularly measures of adherence, may compromise the internal validity of outcome studies in the prevention literature. We do not view procedures for integrity verification as inconsistent with the adaptation of interventions to the needs of receiving communities.

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Home based versus centre based cardiac rehabilitation: Cochrane systematic review and meta-analysis

Hasnain Dalal, Anna Zawada, Kate Jolly … (2010)

Objective To compare the effect of home based and supervised centre based cardiac rehabilitation on mortality and morbidity, health related quality of life, and modifiable cardiac risk factors in patients with coronary heart disease. Design Systematic review. Data sources Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, Medline, Embase, CINAHL, and PsycINFO, without language restriction, searched from 2001 to January 2008. Review methods Reference lists checked and advice sought from authors. Included randomised controlled trials that compared centre based cardiac rehabilitation with home based programmes in adults with acute myocardial infarction, angina, or heart failure or who had undergone coronary revascularisation. Two reviewers independently assessed the eligibility of the identified trials and extracted data independently. Authors were contacted when possible to obtain missing information. Results 12 studies (1938 participants) were included. Most studies recruited patients with a low risk of further events after myocardial infarction or revascularisation. No difference was seen between home based and centre based cardiac rehabilitation in terms of mortality (relative risk 1.31, 95% confidence interval 0.65 to 2.66), cardiac events, exercise capacity (standardised mean difference −0.11, −0.35 to 0.13), modifiable risk factors (weighted mean difference systolic blood pressure (0.58 mm Hg, −3.29 mm Hg to 4.44 mm Hg), total cholesterol (−0.13 mmol/l, −0.31 mmol/l to 0.05 mmol/l), low density lipoprotein cholesterol (−0.15 mmol/l, −0.31 mmol/l to 0.01 mmol/l), or relative risk for proportion of smokers at follow-up (0.98, 0.73 to 1.31)), or health related quality of life, with the exception of high density lipoprotein cholesterol (−0.06, −0.11 to −0.02) mmol/l). In the home based participants, there was evidence of superior adherence. No consistent difference was seen in the healthcare costs of the two forms of cardiac rehabilitation. Conclusions Home and centre based forms of cardiac rehabilitation seem to be equally effective in improving clinical and health related quality of life outcomes in patients with a low risk of further events after myocardial infarction or revascularisation. This finding, together with the absence of evidence of differences in patients’ adherence and healthcare costs between the two approaches, supports the further provision of evidence based, home based cardiac rehabilitation programmes such as the “Heart Manual.” The choice of participating in a more traditional supervised centre based or evidence based home based programme should reflect the preference of the individual patient.

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Exercise-based rehabilitation for heart failure: systematic review and meta-analysis

Viral A Sagar, Edward J Davies, Simon Briscoe … (2015)

Objective To update the Cochrane systematic review of exercise-based cardiac rehabilitation (CR) for heart failure. Methods A systematic review and meta-analysis of randomised controlled trials was undertaken. MEDLINE, EMBASE and the Cochrane Library were searched up to January 2013. Trials with 6 or more months of follow-up were included if they assessed the effects of exercise interventions alone or as a component of comprehensive CR programme compared with no exercise control. Results 33 trials were included with 4740 participants predominantly with a reduced ejection fraction (<40%) and New York Heart Association class II and III. Compared with controls, while there was no difference in pooled all-cause mortality between exercise CR with follow-up to 1 year (risk ratio (RR) 0.93; 95% CI 0.69 to 1.27, p=0.67), there was a trend towards a reduction in trials with follow-up beyond 1 year (RR 0.88; 0.75 to 1.02, 0.09). Exercise CR reduced the risk of overall (RR 0.75; 0.62 to 0.92, 0.005) and heart failure-specific hospitalisation (RR 0.61; 0.46 to 0.80, 0.0004) and resulted in a clinically important improvement in the Minnesota Living with Heart Failure questionnaire (mean difference: −5.8 points, −9.2 to −2.4, 0.0007). Univariate meta-regression analysis showed that these benefits were independent of the type and dose of exercise CR, and trial duration of follow- up, quality or publication date. Conclusions This updated Cochrane review shows that improvements in hospitalisation and health-related quality of life with exercise-based CR appear to be consistent across patients regardless of CR programme characteristics and may reduce mortality in the longer term. An individual participant data meta-analysis is needed to provide confirmatory evidence of the importance of patient subgroup and programme level characteristics (eg, exercise dose) on outcome.

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Author and article information

Contributors

Kieran A Moran:

School of Health and Human Performance and Insight Centre for Data AnalyticsDublin City UniversityRoom A246 (Albert College)School of Health and Human Performance, Dublin City UniversityDublin, D9Ireland353 1 700 ext 8011353 7008888kieran.moran@dcu.ie

ORCID: http://orcid.org/0000-0003-2015-8967

Journal

Journal ID (nlm-ta): J Med Internet Res

Journal ID (iso-abbrev): J. Med. Internet Res

Journal ID (publisher-id): JMIR

Title: Journal of Medical Internet Research

Publisher: JMIR Publications (Toronto, Canada )

ISSN (Print): 1439-4456

ISSN (Electronic): 1438-8871

Publication date Collection: August 2017

Publication date (Electronic): 02 August 2017

Volume: 19

Issue: 8

Electronic Location Identifier: e281

Affiliations

[1] ¹ MedEx Wellness School of Health and Human Performance and Insight Centre for Data Analytics Dublin City University Dublin Ireland

[2] ² Insight Centre for Data Analytics Dublin City University Dublin Ireland

[3] ³ School of Health and Human Performance and Insight Centre for Data Analytics Dublin City University Dublin Ireland

[4] ⁴ Department of Physical Education and Sport Sciences Faculty of Education and Health Sciences University of Limerick Limerick Ireland

Author notes

Corresponding Author: Kieran A Moran kieran.moran@ 123456dcu.ie

Author information

Orlaith Mairead Duff http://orcid.org/0000-0002-8121-5868

Deirdre MJ Walsh http://orcid.org/0000-0003-4255-299X

Bróna A Furlong http://orcid.org/0000-0003-4552-0555

Noel E O'Connor http://orcid.org/0000-0002-4033-9135

Kieran A Moran http://orcid.org/0000-0003-2015-8967

Catherine B Woods http://orcid.org/0000-0002-0892-6591

Article

Publisher ID: v19i8e281

DOI: 10.2196/jmir.7782

PMC ID: 5559649

PubMed ID: 28768610

SO-VID: a0591f3c-309f-4556-b591-7c7e1647f1be

Copyright © ©Orlaith Mairead Duff, Deirdre MJ Walsh, Bróna A Furlong, Noel E O'Connor, Kieran A Moran, Catherine B Woods. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 02.08.2017.

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

History

Date received : 30 March 2017

Date revision requested : 20 April 2017

Date revision received : 14 June 2017

Date accepted : 1 July 2017

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