Associations Between Psychological Factors and Adherence to Health Behaviors After Percutaneous Coronary Intervention: The Role of Cardiac Rehabilitation.

BACKGROUND: Cardiac rehabilitation (CR) participation after percutaneous coronary intervention (PCI) for coronary heart disease lowers the disease burden and risk of recurrent cardiac events. Examining psychological factors may improve post-PCI health behavior adherence. PURPOSE: To determine whether psychological factors are associated with post-PCI health behavior adherence, and the role of CR participation. METHODS: Data from 1,682 patients (22.1% female, Mage = 64.0, SDage = 10.5 years) from the THORESCI cohort were included. Adjusted mixed models were used to examine associations between psychological factors and the 1-year course of health behaviors, using interactions to test for moderation by CR participation. RESULTS: Psychological factors were associated with the trajectories of adherence to medical advice, exercise, and diet. The strongest association found was between optimism and the trajectory of dietary adherence (B: = -0.09, p = .026). Patients with high optimism levels had a worse trajectory of dietary adherence compared to patients with low to middle optimism levels. Participation in CR buffered the associations of high anxiety, pessimism, and low to middle resilience, but strengthened the associations of high stress in the past year with the probability of smoking. CONCLUSIONS: Psychological factors are associated with post-PCI health behavior adherence, but the pattern of associations is complex. Patients with high levels of anxiety, pessimism, and low to middle resilience levels may disproportionately benefit from CR. Cardiac rehabilitation programs could consider this to improve post-PCI health behavior adherence. CLINICAL TRIALS REGISTRATION #: NCT02621216.

For patients with coronary heart disease who have undergone percutaneous coronary intervention (PCI), participating in cardiac rehabilitation (CR) reduces the disease burden and the risk of future cardiac events. However, adherence to the health behaviors targeted in CR could be improved. Using data from 1,682 patients included in the THORESCI study, we explored whether psychological factors could predict health behavior adherence and the role of participation in CR. Results revealed that psychological factors were linked to adherence to medical advice, exercise, and diet. Overall, patients with low to moderate optimism levels exhibited more favorable changes in healthy dietary habits than patients with high levels of optimism. Participation in CR made the link between high anxiety, pessimism, low to moderate resilience, and lower adherence to health behaviors less strong. Cardiac rehabilitation programs could use these results to enhance the health behavior adherence of patients who have undergone PCI.

Patient-reported preferences in eHealth-based cardiac rehabilitation: A qualitative investigation of behavior change techniques, barriers and facilitators.

Background: Cardiac rehabilitation (CR) reduces recurrent cardiac events and mortality in patients with cardiovascular diseases (CVD). Innovative eHealth methods can facilitate CR uptake and effectiveness by addressing barriers associated with clinic-based rehabilitation. Tailoring eHealth-based CR to patient preferences is needed to further enhance CR. Purpose: To identify preferred behavior change techniques (BCTs) as well as barriers and facilitators for the different health behaviors targeted in eHealth-based CR among patients who have been referred to CR. Methods: Thirty-nine patients were interviewed in nine focus groups in The Netherlands, Germany, and Spain. A thematic analysis, using a combined deductive and inductive approach to coding, was conducted to identify BCTs and barriers and facilitators to behavior change. Behaviors under investigation included physical activity, medication adherence, eating a cardiac healthy-diet, stress reduction and smoking cessation. Results: The perceived helpfulness of BCTs depended on the specific behavior targeted. Common barriers were negative emotional state and physical limitations. A desire to feel physically or mentally well and having experienced a cardiac life event were the most common facilitators across health behaviors. Specific BCTs, barriers and facilitators were found for each of the health behavior. Conclusions: Behavior change techniques that patients preferred for each health behavior targeted in eHealth-based CR were identified. A negative emotional state, experiencing a life event, and improving physical functioning are important barriers and facilitators in multiple behaviors targeted in eHealth-based CR programs. Additional tailoring of interventions to patient preferences for BCTs and patient-specific barriers and facilitators per health behavior could lead to further improvement of eHealth-based CR.

Living Lab Data of Patient Needs and Expectations for eHealth-Based Cardiac Rehabilitation in Germany and Spain From the TIMELY Study: Cross-Sectional Analysis.

BACKGROUND: The use of eHealth technology in cardiac rehabilitation (CR) is a promising approach to enhance patient outcomes since adherence to healthy lifestyles and risk factor management during phase III CR maintenance is often poorly supported. However, patients' needs and expectations have not been extensively analyzed to inform the design of such eHealth solutions. OBJECTIVE: The goal of this study was to provide a detailed patient perspective on the most important functionalities to include in an eHealth solution to assist them in phase III CR maintenance. METHODS: A guided survey as part of a Living Lab approach was conducted in Germany (n=49) and Spain (n=30) involving women (16/79, 20%) and men (63/79, 80%) with coronary artery disease (mean age 57 years, SD 9 years) participating in a structured center-based CR program. The survey covered patients' perceived importance of different CR components in general, current usage of technology/technical devices, and helpfulness of the potential features of eHealth in CR. Questionnaires were used to identify personality traits (psychological flexibility, optimism/pessimism, positive/negative affect), potentially predisposing patients to acceptance of an app/monitoring devices. RESULTS: All the patients in this study owned a smartphone, while 30%-40% used smartwatches and fitness trackers. Patients expressed the need for an eHealth platform that is user-friendly, personalized, and easily accessible, and 71% (56/79) of the patients believed that technology could help them to maintain health goals after CR. Among the offered components, support for regular physical exercise, including updated schedules and progress documentation, was rated the highest. In addition, patients rated the availability of information on diagnosis, current medication, test results, and risk scores as (very) useful. Of note, for each item, except smoking cessation, 35%-50% of the patients indicated a high need for support to achieve their long-term health goals, suggesting the need for individualized care. No major differences were detected between Spanish and German patients (all P>.05) and only younger age (P=.03) but not sex, education level, or personality traits (all P>.05) were associated with the acceptance of eHealth components. CONCLUSIONS: The patient perspectives collected in this study indicate high acceptance of personalized user-friendly eHealth platforms with remote monitoring to improve adherence to healthy lifestyles among patients with coronary artery disease during phase III CR maintenance. The identified patient needs comprise support in physical exercise, including regular updates on personalized training recommendations. Availability of diagnoses, laboratory results, and medications, as part of a mobile electronic health record were also rated as very useful. TRIAL REGISTRATION: ClinicalTrials.gov NCT05461729; https://clinicaltrials.gov/study/NCT05461729.

eHealth for maintenance cardiovascular rehabilitation: a systematic review and meta-analysis.

AIMS: To provide a quantitative analysis of eHealth-supported interventions on health outcomes in cardiovascular rehabilitation (CR) maintenance (phase III) in patients with coronary artery disease (CAD) and to identify effective behavioural change techniques (BCTs). METHODS AND RESULTS: A systematic review was conducted (PubMed, CINAHL, MEDLINE, and Web of Science) to summarize and synthesize the effects of eHealth in phase III maintenance on health outcomes including physical activity (PA) and exercise capacity, quality of life (QoL), mental health, self-efficacy, clinical variables, and events/rehospitalization. A meta-analysis following the Cochrane Collaboration guidelines using Review Manager (RevMan5.4) was performed. Analyses were conducted differentiating between short-term (≤6 months) and medium/long-term effects (>6 months). Effective behavioural change techniques were defined based on the described intervention and coded according to the BCT handbook. Fourteen eligible studies (1497 patients) were included. eHealth significantly promoted PA (SMD = 0.35; 95%CI 0.02-0.70; P = 0.04) and exercise capacity after 6 months (SMD = 0.29; 95%CI 0.05-0.52; P = 0.02) compared with usual care. Quality of life was higher with eHealth compared with care as usual (SMD = 0.17; 95%CI 0.02-0.32; P = 0.02). Systolic blood pressure decreased after 6 months with eHealth compared with care as usual (SMD = -0.20; 95%CI -0.40-0.00; P = 0.046). There was substantial heterogeneity in the adapted BCTs and type of intervention. Mapping of BCTs revealed that self-monitoring of behaviour and/or goal setting as well as feedback on behaviour were most frequently included. CONCLUSION: eHealth in phase III CR is effective in stimulating PA and improving exercise capacity in patients with CAD while increasing QoL and decreasing systolic blood pressure. Currently, data of eHealth effects on morbidity, mortality, and clinical outcomes are scarce and should be investigated in future studies. REGISTRATION: PROSPERO: CRD42020203578.

KEY FINDINGS: • eHealth interventions in cardiovascular rehabilitation maintenance may be used to increase physical activity and exercise capacity as well as quality of life while reducing systolic blood pressure.• Effective behavioural change techniques used in eHealth interventions may include self-monitoring of behaviour, goal setting, and feedback on behaviour; thus, future studies are needed to define effective eHealth components based on behavioural change theories and associated behavioural change techniques to assist patients with coronary artery disease.

• This paper reviews the impact of eHealth-supported interventions on health outcomes during cardiovascular rehabilitation maintenance phase III for patients with coronary artery disease, with a meta-analysis performed to differentiate between short-term (≤6 months) and medium/long-term effects (>6 months).

Developmental pathway of orthorexia nervosa: Factors contributing to progression from healthy eating to excessive preoccupation with healthy eating. Experiences of Dutch health professionals.

Orthorexia nervosa (ON) has in recent years attracted attention, but the scarcity of empirical research on the matter generates uncertainty about its progression. This study aims to gain insight into the developmental pathway of ON and factors contributing to it, to establish its etiology. In order to gain insights into health professionals' experience with patients that they identified as suffering from ON, this study adopted mixed methods, with a sequential exploratory design: first, semi-structured interviews (n = 10) were conducted; following, a questionnaire (n = 101) was administered online. Nutritionists, psychologists, psychotherapists, and support workers with experience in treating eating disorders in the Netherlands were the study's target group. Results shed light on environmental factors influencing the development of ON (e.g. pseudoscientific nutritional experts on social media), baseline risks (e.g. high level of education), initiating events (e.g. experiencing a break up), symptoms (e.g. feelings of depression and anxiety), diagnosis and type of treatment administered (e.g. cognitive-behavioral therapy). The current study is unique in its use of health professionals' experiential knowledge to assess how ON develops and who typically develops it. Furthermore, it contributes to the sparse literature on potential ways to treat ON. More top-down investigations into health professionals' experiences are encouraged as the literature on ON thickens.