Background
Methods
Framework for intervention development
Step 1: needs assessment
Literature review
In-depth interview and focus group discussion
Reasons of choosing CAM model to guide the design of the intervention
Step 2: development of a matrix of objectives for diet and physical activity change
Step 3: formulation of evidence-based methods and strategies, and practical applications
Defining criteria for the selection of evidence-based methods
Reviewing existing evidence-based methods and strategies
Selecting effective evidence-based methods and strategies
Translating evidence-based methods into practical applications
Formulating of iCARE interventions
Results
Needs assessment
Topic | Summary of findings |
---|---|
Contents of the intervention | 1. Providing food and exercise suggestions that are relevant, personalized, and actionable 2. Providing knowledge that healthy lifestyle and behavior change is clear, accurate, valid, and reliable 3. Specific physical activity plans 4. Follow-up tailored messages 5. Feedback about progress and individual barriers |
Presentation modes of the intervention | 1. Text message is presented in a variety font 2. Attention getting pictures and/or videos |
Functional features of the app | 1. Communication with doctors 2. Self-risk assessment 3. Tailored education 4. Blood pressure management 5. Health status recording/monitoring activity without user’s interaction 6. Reminders 7. Being active with friends or families 8. Data sharing ability |
Patients’ needs of the content of mHealth intervention
I had no idea of how to keep healthy after I had a PCI. Although I know that I should eat healthier, but I don’t know the specific knowledge about eating healthily after having PCI. [P4, Male, 41 years old]
What I want from the App exactly is a simple and practical action plan based on my own health problem related data. I don’t like complicated information, I love simplicity. I prefer multiple action plans so that I can choose the most appropriate one. For instance, if my blood sugar keeps increasing for several days, then I want to receive a message like: ‘Your blood sugar has increased by 2 mmol/L recently. There are several options for you, such as eating less or walking 5 kilometers.’ [P1, Male, 34 years old]
Patients’ needs of the presentation modes of mHealth intervention
I prefer information presented in large font, a humous tone, and muted color. Voice and video are more suitable for me. [P2, Female, 52 years old]
Patients’ needs of functional features of the app for CHD
I need to monitor my blood pressure and blood glucose every day. I think a healthcare App should be linked to some other monitoring devices. It will be much more convenient if the device is directly connected to the App and the data is transferred to the App directly, so that I don’t need to input the blood glucose by myself. [P1, Male, 34 years old]
I think a reminder is particularly important for both young patients and old patients. Young patients like me are busy working, older people may not have a good memory. For me, reminding me to measure blood pressure on time is necessary. [P1, Male, 34 years old]
One day, when I rested in bed after mountain climbing with my friends, my heart felt uncomfortable. I was afraid that I had a heart attack. I felt helpless at that time. If there was a doctor who could tell me that it was not a heart attack, I would feel at ease. I really hope the App has a service that I can use to consult with the doctors when I feel uncomfortable. [P5, Male, 55 years old]
I think it is important that we (patients) can communicate with each other. For example, I do not know whether the slight pain in my heart is normal after the operation (PCI). When I talked to my wardmate, he said he also had the same feeling. Then I realized this is normal. [P4, Male, 41 years old]
Matrix of objectives for diet and physical activity changes
Performance Objectives (PO) | Mediators | Moderators | Proximal performance objectives (PPOs) |
---|---|---|---|
PO1: Building intention to change | Motivation | Risk perception | PPO1: Promoting patients to identify cardiovascular risk factors |
PPO2: Increasing patients’ awareness of the adverse consequences related to these risk factors | |||
PPO3: Increasing patients’ awareness of the severity of coronary heart disease | |||
Outcome expectations | PPO4: Increasing patients’ perception of the benefits for adoption of healthy diet and regular physical activity | ||
PPO5: Increasing patients’ decisiveness and supporting them in establishing an intention to adopt healthy diet and regular physical activity | |||
PO2: Building and enhancing motivation of action taking | Motivation | Action Self-efficacy | PPO6: Helping patients to uncover barriers of diet and physical activity changes |
PPO7: Increasing patients’ confidence in diet and physical activity changes through role-modeling | |||
PPO8: Increasing knowledge and skills related to healthy diet and physical activity | |||
PPO9: Correcting patients’ misunderstanding about changing unhealthy diet and physical inactivity | |||
PPO10: Helping patients to recognize their ability to change | |||
PPO11: Decreasing patients’ fear of difficulty in diet and physical activity changes | |||
PPO12: Increasing social support | |||
Action planning | PPO13: Making a specific and individualized action plan for diet and physical activity changes with patients, and ensuring patients confirm and accept it. | ||
PPO14: Promoting patients to implement the action plan | |||
PO3: Building and enhancing volition of action maintaining | Volition | Maintenance Self-efficacy | PPO15: Increasing patients’ confidence in maintaining healthy diet and regular physical activity |
PPO16: Increasing patients’ perception of physiological responses | |||
PPO17: Helping patients to uncover the barriers in maintaining healthy diet and regular physical activity | |||
PPO18: Increasing patients’ perception of positive experience from healthy diet and regular physical activity changing | |||
PPO19: Increasing patients’ awareness of progress in healthy diet and regular physical activity | |||
Coping planning | PPO20: Promoting patients coping with the barriers of maintaining healthy diet and regular physical activity | ||
Behavioral enjoyment | PPO18: Increasing patients’ perception of healthy diet and regular physical activity induced positive experience | ||
Effectiveness perception | PPO21: Increasing patients’ perceptions about the improvements in physiological indexes from diet and physical activity changes | ||
Social support | PPO22: Increasing family-support | ||
PPO23: Increasing peer-support | |||
PPO24: Increasing professional-support |
Evidence-based methods, strategies, and practical applications formulated
Criteria for the selection of evidence-based methods defined
Inclusion criteria | Source |
---|---|
General criteria | |
1. Focus on diet change or physical activity change | Research team discussion |
2. Safe for the target patients (1) The intensity, frequency, content of the intervention should be certified by experts. (2) The intervention will not increase the rate of acute cardiovascular events. (3) Strategies to protect patients’ privacy are covered in the study. | Literature review, research team discussion |
3. Feasible to implement (1) Affordable to implement. (2) Practical with limited human resources | Literature review, focus group |
Desirable criteria | |
4. With high effectiveness in diet change or physical activity change (1) internal validity: •Odds ratio > 0.8 •Effect size (r > 0.3 or d > 0.2) (2) external validity: Intervention were found to be effectiveness in many literatures | Literature review/expert consultation |
5. Consider the circumstances | In-depth interview, focus group |
6. Met patients’ needs | In-depth interview |
7. Culturally appropriate | In-depth interview, literature review |
8. More attention to life | In-depth interview |
9. Simple | In-depth interview |
10. Clear | In-depth interview |
11. Easy to understand | In-depth interview |
12. Appropriate for patients with coronary heart disease | In-depth interview |
13. Enjoyable | In-depth interview |
14. Personalized | In-depth interview, focus group, literature review |
15. Considerate | In-depth interview |
16. Accept interruption | In-depth interview |
17. With incentive | In-depth interview |
18. Visible | In-depth interview |
19. Appropriate frequency | In-depth interview, focus group |
20. Continuous | In-depth interview, focus group |
21. Self-monitoring functions available | Literature review |
22. Alert functions available | Research team discussion, literature |
23. Interactive function available | In-depth interview, focus group, Literature review |
Evidence-based methods and strategies selected
Strategies | Strategies derived from BCT or IM taxonomy | Precontemplation Stage | Contemplation Stage | Action stage and Maintenance stage | Number of evidence-based methods (N = 61) | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
BCT | IM Taxonomy | Risk perception | Outcome expectation | Action planning | Action self-efficacy | Coping self-efficacy | Coping planning | Behavioral enjoyment | Effectiveness perception | Social support | Maintenance self-efficacy | |||
1 | Psychological cues | √ | √ | √ | √ | √ | √ | 12 | ||||||
2 | Visualization | √ | √ | √ | √ | 6 | ||||||||
3 | Peer impact | √ | √ | √ | 5 | |||||||||
4 | Fear arousal | √ | √ | √ | 5 | |||||||||
5 | Dynamic monitoring and individualized, immediate feedback | √ | √ | √ | √ | √ | 2 | |||||||
6 | Increase knowledge interestingly | √ | √ | √ | 2 | |||||||||
7 | Re-attribution | √ | √ | √ | 1 | |||||||||
8 | Personalized action planning | √ | √ | 1 | ||||||||||
9 | Friendly reminders | √ | 1 | |||||||||||
10 | Role model/modelling | √ | √ | √ | √ | √ | 5 | |||||||
11 | Authority influence | √ | 1 | |||||||||||
12 | Comparison of behavior | √ | 1 | |||||||||||
13 | Decisional balance | √ | 1 | |||||||||||
14 | Easy-to-do | √ | 1 | |||||||||||
15 | Encourage | √ | 1 | |||||||||||
16 | Increase self-control | √ | 1 | |||||||||||
17 | Self-affirmation | √ | √ | 1 | ||||||||||
18 | Self-reevaluation | √ | √ | 1 | ||||||||||
19 | Social support | √ | √ | 2 | ||||||||||
20 | Increase sense of control | √ | 3 | |||||||||||
21 | Public commitment | √ | √ | 1 | ||||||||||
22 | Step by step | √ | 1 | |||||||||||
23 | Experience of success or enjoyment | √ | √ | √ | √ | 4 | ||||||||
24 | Accept | √ | √ | 1 | ||||||||||
25 | Increase sense of experience | √ | √ | 3 | ||||||||||
26 | Increase sense of gain | √ | √ | 1 | ||||||||||
27 | Increase sense of success | √ | √ | 1 | ||||||||||
28 | Individualization | √ | 1 | |||||||||||
29 | Considerate service | √ | 1 | |||||||||||
30 | Family impact | √ | 1 | |||||||||||
31 | Stimulate interest | 1 |
Phases of change | POs | Mediators | Moderators | PPOs | Strategies | Theory-based Methods | IF | AND | THEN: Practical applications | Mode |
---|---|---|---|---|---|---|---|---|---|---|
Precontemplation | PO1 | Motivation | Risk Perception | PPO1 | Dynamic monitoring and individualized, immediate feedback | Monitor and provide feedback on performance (e.g. salt intake) of the behavior. Monitor and provide feedback on the outcome (e.g. blood pressure) of the behavior. | Salt intake >5 g/d | Cooked soil intake < 25 g/d | Mr. Wang, we found that you have very good control of your lipid and cholesterol levels, which is good for your health. Your health would improve if you decreased your sodium intake, because a salty diet may increase the risk of developing hypertension. | Text- messaging with trend graph |
Contemplation | PO2 | Motivation | Action Planning | PPO13 | Personalized action plan | Provide a personalized action plan based on the patient’s health condition and preferences. Patient can modify the action plan if they disagree with the plan. | Salt intake >5 g/d and Cooked oil intake > 25 g/d | Have an intention to change | Mr. Wang, here is the action plan we recommend for you to maintain a healthy diet. What do you think of it? If you accept it, please click the accept button. If not, you can click the edit button to change the plan and then submit it. | Text-messaging with a link to review action plan |
Action | PO3 | Volition | Self-Efficacy | PPO17 | Psychological cues | Psychometric tests: To uncover the obstacles in the maintenance of healthy behavior change and to provide tailored feedbacks and suggestions. | Salt intake >5 g/d and Soil intake > 25 g/d | Action plan has been made | If you have a dietary action plan, but you can’t stick to it, please complete this questionnaire to tell us your experience. | Text-messaging with a link to Psychological test |
Maintenance | PO3 | Volition | Social Support | PPO23 | Role model | Patients who maintain healthy behavior for more than 6 months, will serve as role models. Regular group discussions will be facilitated by the role models for other patients who encounter difficulties in the process of behavior change to help them learn coping strategies | Salt intake >5 g/d and Soil intake > 25 g/d | Maintaining healthy diet for 6 months or above | The topics of the group discussions are: (1) experiences shared by the role model, and (2) the role model answering the questions from other patients. | Group discussion in the app |
Phases of change | POs | Mediators | Moderators | PPOs | Strategies | Evidence-based Methods | IF | AND | THEN-Interventions | Mode |
---|---|---|---|---|---|---|---|---|---|---|
Precontemplation | PO1 | Motivation | Risk Perception | PPO2 | Dynamic monitoring and individualized, immediate feedback | Monitor and provide feedback on performance (e.g. salt intake) of the behavior. Monitor and provide feedback on the outcome (e.g. blood pressure) of the behavior. | PA frequency < 5 times a week or PA time < 15 min a day or patients’ steps < 6500 steps a day | Fasting blood glucose > 7.0 mmol/L or arbitrary blood glucose > 11.1 mmol/L | Mr. Wang, You have a bad control in blood glucose at present. Regular physical activity can effectively reduce blood glucose. Do you know the risk of Hyperglycemia for coronary heart disease? This video will tell you. | Video |
Contemplation | PO2 | Motivation | Self-Efficacy | PPO7 | Role model | Use the story of a role model who has healthy behaviors | PA frequency < 5 times a week or PA time < 15 min a day or patients’ steps < 6500 steps a day | Making a specific and individualized PA action plans | Do you remember Mr. Zhang, he was in the hospital near your bed in the same ward, whose illness and age are similar to yours? Mr. Zhang has kept a regular PA. His blood pressure and blood glucose level are now normal. We believe you could do equally well. Keep it up! | Text with voice |
Action | PO3 | Volition | Coping Planning | PPO20 | Individualization | Provide personalized coping strategies according to barriers patients meet during the process of behavior change | Regular PA for several days but patients’ steps < 6500 steps today | Making a specific and individualized PA action planning | Mr. Wang, your physical activity report shows that you have done well in recent days. But you did not make much progress today. I guess there were some causes for this. Please answer the questionnaire and so we can try to understand the reason that you did not keep up with your regular physical activity. | text-messaging and a link to a questionnaire |
Maintenance | PO3 | Volition | Behavioral enjoyment | PPO18 | Experience of success or enjoyment | Material rewards will be given to the participants after each goal is completed, such as scores, small red packets (or coupons) which can be exchanged for gifts. | PA frequency > 5 times a week and PA time > 15 min a day or patients’ steps > 6500 steps a day | Maintaining regular PA for 6 months or above | Scores + 60, Rank + 3, monetary incentives sent at random | System setting |