The effect of a smartphone-based coronary heart disease prevention (SBCHDP) programme on awareness and knowledge of CHD, stress, and cardiac-related lifestyle behaviours among the working population in Singapore: a pilot randomised controlled trial

Baseline data were acquired from a total of 80 working adults. The majority of the participants were Chinese (n = 61, 76.3%), female (n = 52, 65%), aged between 21 and 40 years old (n = 62, 77.5%), and at least college-educated (n = 62, 77.5%). More than half were married (n = 42, 52.5%) and had less than 10 years of working experience (n = 46, 57.6%). Nearly half of the participants (n = 35, 43.8%) worked in an information technology- or engineering-related field, 37.5% (n = 30) of the participants had other occupations, 15% (n = 12) of the participants worked in clerical services, and 3.8% (n = 3) of the participants worked in the teaching profession. There were no significant differences between the intervention and control groups in terms of the baseline socio-demographic data (Table 1).

Regarding the awareness of CHD, there was no significant difference between the intervention and control groups at baseline. There were significantly more participants in the intervention group who were aware that ‘CHD is the second leading cause of death in Singapore’ (X ²  = 6.486, p = 0.039) after the 4-week SBCHDP programme.

Table 2 shows the comparisons of CHD knowledge assessed using the HDFQ-2 between the intervention and control groups. At baseline, a significant difference was found in the total HDFQ-2 mean scores, with significantly better scores being reported by the participants in the control group (t = -2.118; p = 0.038). In contrast, the participants in the intervention group had significantly better scores than those in the control group (t = 3.171; p = 0.002) after the intervention. Specifically, there were significantly more participants in the intervention group who reported the right answers for the following four statements: (1) A family history of heart disease increases the risk of CHD (X ² = 3.914, p = 0.048); (2) The risk of heart disease will be reduced if sugar levels are under control (X ²  = 5.165, p = 0.023); (3) People with diabetes tend to have low HDL cholesterol (X ²  = 7.366, p = 0.007); and (4) Diabetic people can reduce their risk of developing heart disease if they keep their weight under control (X ² = 5.333, p = 0.021).

Table 3 represents the comparisons of perceived stress levels and lifestyle behaviours related to CHD between the intervention and control groups. There were no significant differences at baseline between the two groups. After intervention, there were no significant differences in the perceived stress levels assessed using the PSS-10 between the two groups (p = 0.911). With regard to the BRFSS, there were no significant differences in the lifestyle behaviours between the two groups after intervention, with the exception of behaviours related to blood cholesterol control (X ²  = 4.54, p = 0.033). At follow-up, there was a significantly greater proportion of participants in the control group (n = 14, 37.8%) who reported that they were informed that their blood cholesterol was high by healthcare professionals compared to those in the intervention group (n = 5, 15.2%).

The results of the feedback regarding the SBCHDP programme from the participants in the intervention group are summarised in Table 4. The majority of the participants agreed/strongly agreed that the SBCHDP programme improved their knowledge of CHD and that the newly developed Care4Heart app was easy to use and was convenient to access. In addition, the qualitative data from the open-ended question “What ways can the app be improved based on your experience?” indicated that the participants perceived that the SBCHDP programme was informative (e.g., “good information app”), feasible (e.g., “app is just nice and convenient to use”), and applicable (e.g., “increasing the popularity of the app will benefit more people”). The participants also commented that the areas to improve on included developing the app to be available in multiple languages, adding more pictures, and providing information regarding strategies for the management of heart disease.

This study is the first study conducted in Singapore to examine an mHealth approach to educating the working population about CHD prevention. The results from the current study revealed that, compared to the control group, there were more participants in the intervention group who were aware that CHD is the second leading cause of death in Singapore. This partly affirmed the feasibility of disseminating disease prevention messages to a wide audience by mHealth. However, awareness of gender risk and CHD mortality rate was not found to be significantly different between the two groups after the SBCHDP programme. In the current study, since the participants in the control group were provided with the website addresses of the SHF and the HPB, they had access to similar disease prevention information via those two websites.

In addition, while the Care4Heart mobile app and SMS intervention appeared to be an alternative method for delivering CHD educational content, websites perform a similar function and are also accessible from mobile devices. In this case, participants in the control group may have had increased access to the web-based content via their mobile devices. Overall, the sample size in the present pilot study may be underpowered for the detection of the intervention effect.

The results from the current study showed that the participants in both the intervention and control groups generally had good baseline knowledge regarding CHD risk factors, which was independent of the participants’ socio-demographic characteristics, such as educational level, age, ethnicity, marital status, occupation, medical history, or family history of heart diseases. While this was inconsistent with the findings of several previous studies [45], it may reflect the impact from the collaborative efforts of various governmental and non-governmental organisations in the prevention and control of CVD in Singapore. Many strategic health education campaigns and events that specifically target different populations have been launched and are implemented by the HPB at various locations, including workplaces, industries, and communities [46‐49]. Those programmes were organised and delivered with a long-term perspective on how to reduce lifestyle risks to improve the health of the general population [50]. In addition, currently, many commercial enterprises have used the health promotion concept in their advertising efforts to promote the sale of their products. Therefore, the amount of available health promotion and disease prevention messages could be rather saturated in the public arena. Many of our study participants may have already come across this information before taking part in the study.

Nevertheless, the results from the current study revealed that the participants from the intervention group further advanced their CHD knowledge after the mHealth intervention, specifically, regarding the following points: 1) a family history of heart disease is a risk factor; 2) controlling blood glucose level helps reduce cardiac risk; 3) diabetic people tend to have low HDL but high cardiac risk; and 4) cardiac risk can be reduced by controlling one’s body weight within a normal range. These findings suggest that the mHealth and Care4Heart apps can be used as new and effective ways to supplement the existing programmes and services, provide disease prevention education to the public, and address some of the knowledge gaps. The revolution of mobile technology has changed how people share and consume data, from a passive receiver to a more active user. The Care4Heart app allowed users to obtain the right amount of information from the right sources and in a more accessible and convenient way, therefore enhancing their understanding and information retention. Furthermore, sending a daily SMS with healthy tips may have also contributed to some of the success of the intervention. An SMS is the least sophisticated and yet the most commonly used tool for transmitting simple information to end users [51]. It has been well established that SMS facilitate patient-provider communication and medication adherence as well as patient education and motivation [51].

In this study, differences were not found between the intervention group and the control group regarding the knowledge of other CHD risk factors, which included fatty foods, cholesterol level, exercise, gender, and smoking. This reflected the need for further app content modifications to better attract the users’ attention and support the uptake of additional information.

Our study indicated that there was no statistically significant difference in the perceived stress level between the two groups after the intervention. However, the participants in the intervention group had a lower mean PSS-10 score compared to their baseline, while the participants in the control group had a higher mean PSS score compared to their baseline. This may reflect a certain degree of usefulness for the relaxation exercise and stress management content included in the Care4Heart app in lowering the participants’ stress level. Nonetheless, four weeks may be too short to observe any changes in their coping style. Therefore, a longer study period should be considered to further validate such an effect. There were no significant differences in cardiac-related lifestyle behaviours between the two groups after the intervention, except for cholesterol control behaviour. Both groups seemed to improve their health screening behaviours regarding blood pressure and blood cholesterol during the four-week study period. This could be due to the increased awareness of CHD by taking part in the study, therefore leading to more screening behaviours at the beginning of the study. Both groups deteriorated in several health behaviours (e.g., regular exercise and alcohol consumption) after four weeks, but this was more pronounced in the control group. The percentage of participants from the intervention group that were exercising decreased from 62.5% (n = 25) to 60% (n = 24) while those from control group decreased from 77.5% (n = 33) to 65% (n = 26). In contrast to the health screening behaviours, which require relatively less individual effort, disease prevention behaviours that involve a change of lifestyle habits are much more difficult to implement. It requires more personal effort and self-discipline. Butland et al. [52] suggested that an effective behavioural change is normally assisted by a synergy of various interventions that are delivered over a sufficient period of time with a corresponding modification to the targeted variables. For this reason, the 4-week study period was rather short for lifestyle behavioural change and therefore was not sufficient to initiate other behavioural changes for the participants in both groups. Additionally, the content of our Care4Heart app was information-based, and information alone is not enough to bring about behavioural changes. A more interactive feature with real-time monitoring, sharing (socially), and feedback will be preferable in the future design of the mobile app, as this could increase the users’ self-awareness of their behaviour. For example, a patient’s physical activity levels can be assessed by an accelerometer or a heart rate monitor that is synchronised to their mobile phones. Patients can upload their training and physical activity data weekly and receive feedback from their healthcare providers [53] and their friends. The emergence of a social presence in the mobile app could help prompt behavioural changes.

In addition to the current primary management programmes of the SHF and the HPB, the SBCHDP programme provided a new and potentially effective way to engage people and increase their knowledge regarding CHD and its prevention. It permits more accessible opportunities for self-directed learning and relearning. The growing popularity of mHealth is evident because it promotes better acceptability and higher treatment adherence [28, 29]. It also has the potential to disseminate health information related to primary and secondary disease prevention to a larger population at a lower manpower cost. In the long run, with increased awareness and knowledge of CHD and its prevention, one hopes that more working adults will practise healthy behaviours and maintain a better health status. Consequently, with a healthier workforce, work productivity will increase.

This pilot RCT has partially demonstrated the effects of a 4-week SBCHDP programme in improving awareness and knowledge of CHD as well as changing cholesterol control behaviour among the working population in Singapore. This study contributed some evidence to the mHealth research field and further affirmed that chronic disease prevention via mobile devices is feasible and effective due to its convenience. It represents a convenient, affordable, and accessible method for a substantial proportion of the population. In addition, our findings suggest that the SBCHDP programme can be provided to occupational health teams of different organisations as an educational programme for the prevention of CHD.