Targeting behavioral factors with digital health and shared decision-making to promote cardiac rehabilitation-a narrative review.

Cardiac rehabilitation (CR) represents an important steppingstone for many cardiac patients into a more heart-healthy lifestyle to prevent premature death and improve quality of life years. However, CR is underutilized worldwide. In order to support the development of targeted digital health interventions, this narrative review (I) provides understandings of factors influencing CR utilization from a behavioral perspective, (II) discusses the potential of digital health technologies (DHTs) to address barriers and reinforce facilitators to CR, and (III) outlines how DHTs could incorporate shared decision-making to support CR utilization. A narrative search of reviews in Web of Science and PubMed was conducted to summarize evidence on factors influencing CR utilization. The factors were grouped according to the Behaviour Change Wheel. Patients' Capability for participating in CR is influenced by their disease knowledge, awareness of the benefits of CR, information received, and interactions with healthcare professionals (HCP). The Opportunity to attend CR is impacted by healthcare system factors such as referral processes and HCPs' awareness, as well as personal resources including logistical challenges and comorbidities. Patients' Motivation to engage in CR is affected by emotions, factors such as gender, age, self-perception of fitness and control over the cardiac condition, as well as peer comparisons. Based on behavioral factors, this review identified intervention functions that could support an increase of CR uptake: Future DHTs aiming to support CR utilization may benefit from incorporating information for patients and HCP education, enabling disease management and collaboration along the patient pathway, and enhancing social support from relatives and peers. To conclude, considerations are made how future innovations could incorporate such functions.

Making it transparent: A worked example of articulating programme theory for a digital health application using Intervention Mapping.

Objective: Digital health interventions for behaviour change are usually complex interventions, and intervention developers should 'articulate programme theory', that is, they should offer detailed descriptions of individual intervention components and their proposed mechanisms of action. However, such detailed descriptions often remain lacking. The objective of this work was to provide a conceptual case study with an applied example of 'articulating programme theory' for a newly developed digital health intervention. Methods: Intervention Mapping methodology was applied to arrive at a detailed description of programme theory for a newly developed digital health intervention that aims to support cardiac rehabilitation patients in establishing heart-healthy physical activity habits. Based on a Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) logic model of the problem, a logic model of change was developed. The proposed mechanisms of action were visualised in an acyclic behaviour change diagram. Results: Programme theory for this digital health intervention includes 4 sub-behaviours of the main target behaviour (i.e. habitual heart-healthy physical activity), 8 personal determinants and 12 change objectives (i.e. changes needed at the determinant level to achieve the sub-behaviours). These are linked to 12 distinct features of the digital health intervention and 12 underlying behaviour change methods. Conclusions: This case study offers a worked example of articulating programme theory for a digital health intervention using Intervention Mapping. Intervention developers and researchers may draw on this example to replicate the method, or to reflect on most suitable approaches for their own behaviour change interventions.

Usability Testing of a Multi-Level Modeling Framework for Just-in-Time Adaptive Interventions (JITAIs) in Mobile Health.

The JITAI is an intervention design to support health behavior change. We designed a multi-level modeling framework for JITAIs and developed a proof-of-concept prototype (POC). This study aimed at investigating the usability of the POC by conducting two usability tests with students. We assessed the usability and the students' workload and success in completing tasks. In the second usability test, however, they faced difficulties in completing the tasks. We will work on hiding the complexity of the framework as well as improving the frontend and the instructions.

Multi-Stakeholder Design for Complex Digital Health Systems: Development of a Modular Open Research Platform (MORE).

BACKGROUND: The Modular Open Research Platform (MORE) is being developed as an open-source platform for long-term situated digital health (DH) research and observations with the potential to facilitate studies, evaluations of DH interventions, and remote telehealth monitoring. OBJECTIVES: To implement an iterative development approach that integrates multi-stakeholder perspectives to support a single platform development process. METHOD: Capture, fulfil and balance the requirements of a multi-disciplinary group of stakeholders interacting with the system through a Delphi-inspired, iterative and participatory design process encompassing a series of workshops and online surveys. RESULTS: Through interaction with a multi-disciplinary group of key platform stakeholders, diverse feedback and requirements for the design and development process were elicited and integrated. CONCLUSION: Findings from the initial rounds of stakeholder involvement lay the stepping stone towards further iterations in the process. Experts who participated in the process reported being generally supportive of and feeling involved in the development process.

Investigating shared decision-making during the use of a digital health tool for physical activity planning in cardiac rehabilitation.

Background: Shared decision making (SDM) between healthcare professionals and persons with CVD can have a positive impact on motivation, adherence, or sustainability regarding long-term goals and integration of cardiovascular disease (CVD) rehabilitation in the everyday lives of persons with CVD. SDM can foster the transition between regular heart-healthy activity at rehabilitation facilities and more independent activity at home, but it is often challenging to implement SDM given limited time and resources, e.g., in the daily practice of rehabilitation. Digital tools can help but must be appropriately tailored for situated use and user needs. Objective: We aimed to (1) describe in how far SDM is manifested in the situated context when using a digital tool developed by our group, and, based on that, (2) reflect on how digital health tools can be designed to facilitate and improve the SDM process. Methods: In the context of a field study, we investigated how SDM is already naturally applied and manifested when using a digital tool for joint physical activity planning in cardiac rehabilitation in clinical practice. In a two-week qualitative study, we collected data on expectations, experiences and interactions during the use of a digital health tool by seven persons with CVD and five healthcare professionals. Data was collected by means of observations, interviews, questionnaires and a self-reported diary, and analysed with a particular focus on episodes related to SDM. Results: We found that SDM was manifested in the situated context to limited extent. For example, we identified high improvement potential for more structured goal-setting and more explicit consideration of preferences and routines. Based on mapping our findings to temporal phases where SDM can be adopted, we highlight implications for design to further support SDM in clinical practice. We consider this as "SDM supportive design in digital health apps," suggesting for example step-by-step guidance to be used during the actual consultation. Conclusion: This study contributes to further understanding and integration of SDM in digital health tools with a focus on rehabilitation, to empower and support both persons with CVD and healthcare professionals.

The Development of a Digital Tool for Planning Physical Exercise Training During Cardiac Rehabilitation.

In this work, we describe the conceptualization and development of a digital tool to support patients in adhering to prescription of physical exercise training during cardiac rehabilitation. To meet the need for an individual and trackable heart-healthy training plan - which became even more evident during the Coronavirus pandemic - the Activity Planning Tool was developed within a user-centered design process. Tackling the relationship between rehabilitation professional and patient, it allows to jointly set up, monitor, and regularly review a personalized physical activity plan.

General Data Protection Regulation (GDPR) Toolkit for Digital Health.

The General Data Protection Regulation (GDPR) entered into force on May 25, 2018. Compliance with GDPR is especially relevant to the Digital Health (DH) domain, as it is common to process highly sensitive personal data regarding a person's health. However, GDPR compliance is a very challenging process since it requires implementing several technical and organizational measures to maintain compliance. With the aim to facilitate this process, we reviewed the published best practices in GDPR compliance. Then, we customized the findings to fit into the DH domain and created a toolkit for GDPR implementation and compliance. The Activity Planning Tool (APT) is provided as an example of how this toolkit could be utilized in new application development in mobile health in Austria. In the case of our APT, the toolkit was very helpful in integrating the GDPR technical requirements in addition to creating the corresponding compliance impact assessment, processing agreements, privacy policy, data flowcharts, and compliance checklists.

Outpatient Cardiac Rehabilitation Closure and Home-Based Exercise Training During the First COVID-19 Lockdown in Austria: A Mixed-Methods Study.

OBJECTIVE: To assess the impact of the closure of group-based cardiac rehabilitation (CR) training during the first COVID-19 lockdown in spring 2020 on patients' physical activity, cardiorespiratory fitness, and cardiovascular risk, and to describe the patient experience of lockdown and home-based exercise training during lockdown. DESIGN: Mixed methods study. Prospectively collected post-lockdown measurements were compared to pre-lockdown medical record data. Quantitative measurements were supplemented with qualitative interviews about the patient experience during lockdown. SETTING: Outpatient CR centre in Salzburg, Austria. PARTICIPANTS: Twenty-seven patients [six female, mean (SD) age 69 (7.4) years] who attended weekly CR training sessions until the first COVID-19 lockdown in March 2020. OUTCOME MEASURES: Quantitative: exercise capacity (maximal ergometer test, submaximal ergometer training), cardiovascular risk (Framingham risk score, blood pressure, body mass index, lipids). Qualitative: individual semi-structured interviews. RESULTS: Exercise capacity had significantly reduced from pre- to post-lockdown: mean (SD) power (W) in maximal ergometry 165 (70) vs. 151 (70), p < 0.001; submaximal ergometer training 99 (40) vs. 97 (40), p = 0.038. There was no significant difference in Framingham risk score and other cardiovascular risk factors. Qualitative data showed that almost all patients had kept physically active during lockdown, but 17 (63%) said they had been unable to maintain their exercise levels, and 15 (56%) felt their cardiorespiratory fitness had deteriorated. Many patients missed the weekly CR training and the motivation and sense of community from training together with others. Several patients stated that without professional supervision they had felt less confident to carry out home-based exercise training at high intensity. CONCLUSION: This study highlights the importance of group-based supervised exercise training for patients who engage well in such a setting, and the detrimental impact of disruption to this type of CR service on physical activity levels and exercise capacity. Additionally, learning from the COVID-19 pandemic may inform the development and implementation of remote CR modalities going forward.

Viewing experience of 3DTV: An exploration of the feeling of sickness and presence in a shopping mall.

The adoption and deployment of 3DTV can be seen as a major step in the history of television, comparable to the transition from analogue to digital and standard to high definition TV. Although 3D is expected to emerge from the cinema to peoples' home, there is still a lack of knowledge on how people (future end users) perceive 3DTV and how this influences their viewing experience as well as their acceptance of 3DTV. Within this paper, findings from a three-day field evaluation study on people's 3DTV experiences, focusing on the feeling of sickness and presence, are presented. Contrary to the traditional controlled laboratory setting, the study was conducted in the public setting of a shopping center and involved 700 participants. The study revealed initial insights on users' feeling of presence and sickness when watching 3DTV content. Results from this explorative study show that most of the participants reported symptoms of sickness after watching 3DTV with an effect of gender and age on the reported feeling of sickness. Our results further suggest that the users' previous experience with 3D content has an influence on how realistic people rate the viewing experience and how involved they feel. The particularities of the study environment, a shopping mall, are reflected in our findings and future research directions and action points for investigating people's viewing experiences of 3DTV are summarized.