Key features in telehealth-delivered cardiac rehabilitation required to optimize cardiovascular health in coronary heart disease: a systematic review and realist synthesis.

Telehealth-delivered cardiac rehabilitation (CR) programmes can potentially increase participation rates while delivering equivalent outcomes to facility-based programmes. However, key components of these interventions that reduce cardiovascular risk factors are not yet distinguished. This study aims to identify features of telehealth-delivered CR that improve secondary prevention outcomes, exercise capacity, participation, and participant satisfaction and develop recommendations for future telehealth-delivered CR. The protocol for our review was registered with the Prospective Register of Systematic Reviews (#CRD42021236471). We systematically searched four databases (PubMed, Scopus, EMBASE, and Cochrane Database) for randomized controlled trials comparing telehealth-delivered CR programmes to facility-based interventions or usual care. Two independent reviewers screened the abstracts and then full texts. Using a qualitative review methodology (realist synthesis), included articles were evaluated to determine contextual factors and potential mechanisms that impacted cardiovascular risk factors, exercise capacity, participation in the intervention, and increased satisfaction. We included 37 reports describing 26 randomized controlled trials published from 2010 to 2022. Studies were primarily conducted in Europe and Australia/Asia. Identified contextual factors and mechanisms were synthesized into four theories required to enhance participant outcomes and participation. These theories are as follows: (i) early and regular engagement; (ii) personalized interventions and shared goals; (iii) usable, accessible, and supported interventions; and (iv) exercise that is measured and monitored. Providing a personalized approach with frequent opportunities for bi-directional interaction was a critical feature for success across telehealth-delivered CR trials. Real-world effectiveness studies are now needed to complement our findings.

Evaluating a Remotely Delivered Cardio-Oncology Rehabilitation Intervention for Patients With Breast Cancer (REMOTE-COR-B): Protocol for a Single-Arm Feasibility Trial.

BACKGROUND: Exercise rehabilitation is a promising strategy for reducing cardiovascular disease risk among patients with breast cancer. However, the evidence is primarily derived from programs based at exercise centers with in-person supervised delivery. Conversely, most patients report a preference for home-based rehabilitation. As such, there is a clear need to explore strategies that can provide real-time supervision and coaching while addressing consumer preferences. Evidence from cardiac rehabilitation has demonstrated the noninferiority of a smartphone-based telerehabilitation approach (REMOTE-CR) to improve cardiorespiratory fitness in people with cardiovascular disease compared to a center-based program. OBJECTIVE: This study aims to assess the feasibility, safety, and preliminary efficacy of the REMOTE-CR program adapted for patients with breast cancer at risk of cardiotoxicity (REMOTE-COR-B). We will also assess the satisfaction and usability of REMOTE-COR-B. METHODS: We will conduct a single-arm feasibility study of the REMOTE-COR-B program among patients with stage I-III breast cancer who are at risk of cardiotoxicity (taking treatment type and dose, as well as other common cardiovascular disease risk factors into account) and who are within 24 months of completing primary definitive treatment. Participants (target sample size of 40) will receive an 8-week smartphone-based telerehabilitation exercise program involving remotely delivered real-time supervision and behavior change support. The platform comprises a smartphone and wearable heart rate monitor, as well as a custom-built smartphone app and web application. Participants will be able to attend remotely monitored exercise sessions during set operating hours each week, scheduled in both the morning and evening. Adherence is the primary outcome of the trial, assessed through the number of remotely monitored exercise sessions attended compared to the trial target (ie, 3 sessions per week). Secondary outcomes include additional trial feasibility indicators (eg, recruitment and retention), safety, satisfaction, and usability, and objective and patient-reported efficacy outcomes (cardiovascular fitness, quality of life, fatigue, self-reported exercise, self-efficacy, habit strength, and motivation). Adherence, feasibility, and safety outcomes will be assessed during the intervention period; intervention satisfaction and usability will be assessed post intervention; and objective and patient-reported efficacy outcomes will be assessed at baseline, post intervention (2-month postbaseline assessment), and at follow-up (5-month postbaseline assessment). RESULTS: Recruitment for this trial commenced in March 2023, and 7 participants had been recruited as of the submission of the manuscript. The estimated completion date for the project is October 2024, with results expected to be published in mid-2025. CONCLUSIONS: The REMOTE-COR-B intervention is a novel and promising approach to providing exercise therapy to patients with breast cancer at risk of cardiotoxicity who have unique needs and heightened safety risks. This project will provide important information on the extent to which this approach is satisfactory to patients with breast cancer, safe, and potentially effective, which is necessary before larger-scale research or clinical projects. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12621001557820; www.anzctr.org.au/ACTRN12621001557820.aspx. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53301.

Co-design of a personalised digital intervention to improve vegetable intake in adults living in Australian rural communities.

BACKGROUND: Diets low in vegetables are a main contributor to the health burden experienced by Australians living in rural communities. Given the ubiquity of smartphones and access to the Internet, digital interventions may offer an accessible delivery model for a dietary intervention in rural communities. However, no digital interventions to address low vegetable intake have been co-designed with adults living in rural areas. This paper describes the co-design of a digital intervention to improve vegetable intake with rural community members and research partners. METHODS: Active participants in the co-design process were adults ≥ 18 years living in three rural Australian communities (total n = 57) and research partners (n = 4) representing three local rural governments and one peak non-government health organisation. An iterative co-design process was undertaken to understand the needs (pre-design phase) and ideas (generative phase) of the target population. Eight online workshops and a community survey were conducted between July and December 2021. The MoSCoW prioritisation method was used to help participants identify the 'Must-have, Should-have, Could-have, and Won't-have or will not have right now' features and functions of the digital intervention. Workshops were transcribed and inductively analysed using NVivo. Convergent and divergent themes were identified between the workshops and community survey to identify how to implement the digital intervention in the community. RESULTS: Consensus was reached on a concept for a digital intervention that addressed individual and food environment barriers to vegetable intake, specific to rural communities. Implementation recommendations centred on (i) food literacy approaches to improve skills via access to vegetable-rich recipes and healthy eating resources, (ii) access to personalisation options and behaviour change support, and (iii) improving the community food environment by providing information on and access to local food initiatives. CONCLUSIONS: Rural-dwelling adults expressed preferences for personalised intervention features that can enhance food literacy and engagement with community food environments. This research will inform the development of the prototyping (evaluation phase) and feasibility testing (post-design phase) of this intervention.

A Bluetooth-Enabled Device for Real-Time Detection of Sitting, Standing, and Walking: Cross-Sectional Validation Study.

BACKGROUND: This study assesses the accuracy of a Bluetooth-enabled prototype activity tracker called the Sedentary behaviOR Detector (SORD) device in identifying sedentary, standing, and walking behaviors in a group of adult participants. OBJECTIVE: The primary objective of this study was to determine the criterion and convergent validity of SORD against direct observation and activPAL. METHODS: A total of 15 healthy adults wore SORD and activPAL devices on their thighs while engaging in activities (lying, reclining, sitting, standing, and walking). Direct observation was facilitated with cameras. Algorithms were developed using the Python programming language. The Bland-Altman method was used to assess the level of agreement. RESULTS: Overall, 1 model generated a low level of bias and high precision for SORD. In this model, accuracy, sensitivity, and specificity were all above 0.95 for detecting sitting, reclining, standing, and walking. Bland-Altman results showed that mean biases between SORD and direct observation were 0.3% for sitting and reclining (limits of agreement [LoA]=-0.3% to 0.9%), 1.19% for standing (LoA=-1.5% to 3.42%), and -4.71% for walking (LoA=-9.26% to -0.16%). The mean biases between SORD and activPAL were -3.45% for sitting and reclining (LoA=-11.59% to 4.68%), 7.45% for standing (LoA=-5.04% to 19.95%), and -5.40% for walking (LoA=-11.44% to 0.64%). CONCLUSIONS: Results suggest that SORD is a valid device for detecting sitting, standing, and walking, which was demonstrated by excellent accuracy compared to direct observation. SORD offers promise for future inclusion in theory-based, real-time, and adaptive interventions to encourage physical activity and reduce sedentary behavior.

Determining the feasibility of a codesigned and personalised intervention (Veg4Me) to improve vegetable intake in young adults living in rural Australian communities: protocol for a randomised controlled trial.

INTRODUCTION: Diets low in vegetables are a main contributor to the health burden experienced by young adults in rural communities. Digital health interventions provide an accessible delivery model that can be personalised to meet the diverse preferences of young adults. A personalisable digital vegetable intake intervention (Veg4Me) was codesigned to meet the needs of young adults living in rural communities. This study will determine the feasibility of delivering a personalised Veg4Me programme and compare preliminary effects with a non-personalised Veg4Me (control). METHODS AND ANALYSIS: A 12-week assessor-blinded, two-arm, parallel randomised controlled trial will be undertaken from August 2023 until April 2024. A total of 150 eligible and consenting young adults (18-35 years; eat<5 serves of vegetables/day; have an internet connected mobile device/computer) living in Loddon Campaspe or Colac Otway Shire in Victoria, Australia, will be randomised to receive 12 weeks of personalised (intervention) or non-personalised (control) support to increase vegetable intake via a free web application (app; Veg4Me). The primary outcome is feasibility (recruitment, participation and retention rates). Secondary outcomes are user engagement, usability and experience, as well as vegetable intake, eating habits and digital health equity. Process evaluation will be conducted in a subsample of participants using semistructured interviews. Descriptive statistics will be presented for the personalised and non-personalised groups at baseline and 12 weeks. Generalised linear models will be used to evaluate group differences in outcomes. Interviews will be transcribed and analysed thematically. ETHICS AND DISSEMINATION: All procedures involving human subjects were approved by Deakin University's Human Ethics Advisory Group-Health (HEAG-H 06_2023) on 6 March 2023. Dissemination events will be held in the City of Greater Bendigo and the Colac Otway Shire. Summaries of the results will be disseminated to participants via email. Results will be disseminated to the scientific community through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: Australia New Zealand Clinical Trials Registry, ACTRN12623000179639p, prospectively registered on 21 February 2023, according to the World Health Organizational Trial Registration Data Set. Universal Trial Number U1111-1284-9027.

Self-efficacy, motivation, and habits: psychological correlates of exercise among women with breast cancer.

PURPOSE: The purpose of this analysis was to explore associations between exercise behaviour among breast cancer survivors and three behavioural constructs from distinct theories: self-efficacy from social cognitive theory, motivation from self-determination theory, and habits from habit theory. METHODS: Breast cancer survivors (n = 204) completed a cross-sectional survey that collected demographic and disease characteristics, exercise levels, and self-efficacy, motivation, and habits. Multivariable linear regression models were used to identify constructs associated with total activity and resistance training. RESULTS: Participants were a mean (SD) age of 57.3 (10.8) years and most were diagnosed with early-stage disease (72%) and engaged in sufficient levels of total activity (94%), though only 45% completed ≥ 2 resistance training sessions/week. Identified motivation (ꞵ[95% CI] = 7.6 [3.9-11.3]) and habits (ꞵ[95% CI] = 4.4 [1.4-7.4]) were significantly associated with total activity (as were body mass index and disease stage), whilst identified motivation (ꞵ[95% CI] = 0.6 [0.3-0.9]) and coping self-efficacy (ꞵ[95% CI] = 0.02 [< 0.01-0.03]) were significantly associated with resistance training. The models explained 27% and 16% of variance in total activity and resistance training behaviour, respectively. CONCLUSION: Results suggest that incorporating strategies that support identified motivation, habits, and coping self-efficacy in future interventions could promote increased exercise behaviour among breast cancer populations. Future longitudinal research should examine associations with exercise in a more representative, population-based sample.

Development of a Mobile Health Snacktivity App to Promote Physical Activity in Inactive Adults (SnackApp): Intervention Mapping and User Testing Study.

BACKGROUND: Despite the unequivocal evidence demonstrating the benefits of being physically active, many people do not meet the recommended guidelines of at least 150 minutes of moderate- to vigorous-intensity physical activity per week. This can be changed with the development and implementation of innovative interventions. The use of mobile health (mHealth) technologies has been suggested as a mechanism to offer people innovative health behavior change interventions. OBJECTIVE: This study aims to outline the systematic, theory-driven processes and user testing applied to the development of a smartphone-based physical activity app (SnackApp) to promote participation in a novel physical activity intervention called Snacktivity. The acceptability of the app was explored and reported. METHODS: Intervention mapping involves a 6-step process, the first 4 of which were presented in this study. These steps were used to develop the SnackApp for use within the Snacktivity intervention. The first step involved a needs assessment, which included composing an expert planning group, patient and public involvement group, and gathering the views of the public on Snacktivity and the public perception of the use of wearable technology to support Snacktivity. This first step aimed to determine the overall purpose of the Snacktivity intervention. Steps 2 to 4 involved determining the intervention objectives, the behavior change theory and techniques on which the intervention is based, and the development of the intervention resources (ie, SnackApp). After the completion of steps 1 to 3 of the intervention mapping process, the SnackApp was developed and linked to a commercial physical activity tracker (Fitbit Versa Lite) for the automated capture of physical activity. SnackApp includes provisions for goal setting, activity planning, and social support. Stage 4 involved users (inactive adults, N=15) testing the SnackApp for 28 days. App engagement (mobile app use analytics) was analyzed to determine app use and to inform the further development of SnackApp. RESULTS: Over the study period (step 4), participants engaged with SnackApp an average of 77 (SD 80) times. On average, participants used the SnackApp for 12.6 (SD 47) minutes per week, with most of the time spent on the SnackApp dashboard and engaging, on average, 14 (SD 12.1) times, lasting 7 to 8 minutes per week. Overall, male participants used the SnackApp more than female participants did. The app rating score was 3.5 (SD 0.6) out of 5, suggesting that SnackApp was rated as fair to good. CONCLUSIONS: This study outlines and reports data regarding the development of an innovative mHealth app using a systematic, theory-driven framework. This approach can guide the development of future mHealth programs. User testing of the SnackApp suggested that physically inactive adults will engage with the SnackApp, indicating its applicability of use in the Snacktivity physical activity intervention.

Digital behaviour change interventions to increase vegetable intake in adults: a systematic review.

BACKGROUND: Digital interventions may help address low vegetable intake in adults, however there is limited understanding of the features that make them effective. We systematically reviewed digital interventions to increase vegetable intake to 1) describe the effectiveness of the interventions; 2) examine links between effectiveness and use of co-design, personalisation, behavioural theories, and/or a policy framework; and 3) identify other features that contribute to effectiveness. METHODS: A systematic search strategy was used to identify eligible studies from MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Library, INFORMIT, IEEE Xplore and Clinical Trial Registries, published between January 2000 and August 2022. Digital interventions to increase vegetable intake were included, with effective interventions identified based on statistically significant improvement in vegetable intake. To identify policy-action gaps, studies were mapped across the three domains of the NOURISHING framework (i.e., behaviour change communication, food environment, and food system). Risk of bias was assessed using Cochrane tools for randomized, cluster randomized and non-randomized trials. RESULTS: Of the 1,347 records identified, 30 studies were included. Risk of bias was high or serious in most studies (n = 25/30; 83%). Approximately one quarter of the included interventions (n = 8) were effective at improving vegetable intake. While the features of effective and ineffective interventions were similar, embedding of behaviour change theories (89% vs 61%) and inclusion of stakeholders in the design of the intervention (50% vs 38%) were more common among effective interventions. Only one (ineffective) intervention used true co-design. Although fewer effective interventions included personalisation (67% vs 81%), the degree of personalisation varied considerably between studies. All interventions mapped across the NOURISHING framework behaviour change communication domain, with one ineffective intervention also mapping across the food environment domain. CONCLUSION: Few digital interventions identified in this review were effective for increasing vegetable intake. Embedding behaviour change theories and involving stakeholders in intervention design may increase the likelihood of success. The under-utilisation of comprehensive co-design methods presents an opportunity to ensure that personalisation approaches better meet the needs of target populations. Moreover, future digital interventions should address both behaviour change and food environment influences on vegetable intake.

Sustaining telehealth among cardiac and pulmonary rehabilitation services: a qualitative framework study.

AIMS: As we move into a new phase of the COVID-19 pandemic, cardiac and pulmonary services are considering how to sustain telehealth modalities long-term. It is important to learn from services that had greater telehealth adoption and determine factors that support sustained use. We aimed to describe how telehealth has been used to deliver cardiac and pulmonary rehabilitation services across Queensland, Australia. METHODS AND RESULTS: Semi-structured interviews (n = 8) and focus groups (n = 7) were conducted with 27 cardiac and pulmonary clinicians and managers from health services across Queensland between June and August 2021. Interview questions were guided by Greenhalgh's Non-adoption, Abandonment, Scale-up, Spread, and Sustainability framework. Hybrid inductive/deductive framework analysis elicited six main themes: (i) Variable levels of readiness; (ii) Greater telehealth uptake in pulmonary vs. cardiac rehabilitation; (iii) Safety and risk management; (iv) Client willingness-targeted support required; (v) Equity and access; and (vi) New models of care. We found that sustained integration of telehealth in cardiac and pulmonary rehabilitation will require contributions from all stakeholders: consumers (e.g. co-design), clinicians (e.g. shared learning), health services (e.g. increasing platform functionality), and the profession (e.g. sharing resources). CONCLUSION: There are opportunities for telehealth programmes servicing large geographic areas and opportunities to increase programme participation rates more broadly. Centralized models of care serving large geographic areas could maximize sustainability with current resource limitations; however, realizing the full potential of telehealth will require additional funding for supporting infrastructure and workforce. Individuals and organizations both have roles to play in sustaining telehealth in cardiac and pulmonary services.

Understanding Australian adolescent girls' use of digital technologies for healthy lifestyle purposes: a mixed-methods study.

BACKGROUND: Little is known about girls' use of a broad range of digital technologies to support a healthy lifestyle, particularly during the later adolescent years when they are expected to take greater responsibility for individually managing their health and wellbeing. The present study was designed to gain an in-depth understanding of adolescent girls', 15 to 17 years of age, use of a broad range of digital technologies to support multiple healthy lifestyle purposes. METHODS: This study used a mixed-methods sequential research design (i.e. quantitative and qualitative data in two consecutive phases). A quantitative online survey was conducted to determine the use of digital technologies for healthy lifestyle purposes. Qualitative semi-structured interviews were conducted with a subset of survey respondents to explore factors influencing their technology use and preferences. RESULTS: Descriptive analysis of survey data (online survey, n = 336) demonstrated the popularity of social media and online video sharing platforms, with evidence that the use of digital technologies does not occur in isolation and girls draw on several resources simultaneously to achieve their desired healthy lifestyle outcomes. Thematic analysis of interview data (semi-structured interviews, n = 29) revealed seven interrelated themes around factors influencing girls' use of, and satisfaction with, different digital technologies: accessibility, social connectivity, credibility, relatability, inspiration, safety, and customisability. CONCLUSIONS: The findings reiterate that one size doesn't fit all girls, and often one size might not even fit one girl, and thus highlight the challenge of catering to such varied use cases. Overall, it appears that current digital technology offerings meet the needs and preferences of adolescent girls for healthy lifestyle purposes, however there may be benefit in allowing greater customisation of use, and consumer driven tailoring of content, according to personal preferences and changing circumstances.

Consensus on Recommended Functions of a Smart Home System to Improve Self-Management Behaviors in People With Heart Failure: A Modified Delphi Approach.

Background: Smart home systems could enhance clinical and self-management of chronic heart failure by supporting health monitoring and remote support, but evidence to guide the design of smart home system functionalities is lacking. Objective: To identify consensus-based recommendations for functions of a smart home system that could augment clinical and self-management for people living with chronic heart failure in the community. Methods: Healthcare professionals caring for people living with chronic heart failure participated in a two-round modified Delphi survey and a consensus workshop. Thirty survey items spanning eight chronic health failure categories were derived from international guidelines for the management of heart failure. In survey Round 1, participants rated the importance of all items using a 9-point Liket scale and suggested new functions to support people with chronic heart failure in their homes using a smart home system. The Likert scale scores ranged from 0 (not important) to 9 (very important) and scores were categorized into three groups: 1-3 = not important, 4-6 = important, and 7-9 = very important. Consensus agreement was defined a priori as ≥70% of respondents rating a score of ≥7 and ≤ 15% rating a score ≤ 3. In survey Round 2, panel members re-rated items where consensus was not reached, and rated the new items proposed in earlier round. Panel members were invited to an online consensus workshop to discuss items that had not reached consensus after Round 2 and agree on a set of recommendations for a smart home system. Results: In Round 1, 15 experts agreed 24/30 items were "very important", and suggested six new items. In Round 2, experts agreed 2/6 original items and 6/6 new items were "very important". During the consensus workshop, experts endorsed 2/4 remaining items. Finally, the expert panel recommended 34 items as "very important" for a smart home system including, healthy eating, body weight and fluid intake, physical activity and sedentary behavior, heart failure symptoms, tobacco cessation and alcohol reduction, medication adherence, physiological monitoring, interaction with healthcare professionals, and mental health among others. Conclusion: A panel of healthcare professional experts recommended 34-item core functions in smart home systems designed to support people with chronic heart failure for self-management and clinical support. Results of this study will help researchers to co-design and protyping solutions with consumers and healthcare providers to achieve these core functions to improve self-management and clinical outcomes in people with chronic heart failure.

Effects of exercise-based cardiac rehabilitation delivery modes on exercise capacity and health-related quality of life in heart failure: a systematic review and network meta-analysis.

BACKGROUND: This review aimed to compare the relative effectiveness of different exercise-based cardiac rehabilitation (ExCR) delivery modes (centre-based, home-based, hybrid and technology-enabled ExCR) on key heart failure (HF) outcomes: exercise capacity, health-related quality of life (HRQoL), HF-related hospitalisation and HF-related mortality. METHODS AND RESULTS: Randomised controlled trials (RCTs) published through 20 June 2021 were identified from six databases, and reference lists of included studies. Risk of bias and certainty of evidence were evaluated using the Cochrane tool and Grading of Recommendations Assessment, Development and Evaluation, respectively. Bayesian network meta-analysis was performed using R. Continuous and binary outcomes are reported as mean differences (MD) and ORs, respectively, with 95% credible intervals (95% CrI). One-hundred and thirty-nine RCTs (n=18 670) were included in the analysis. Network meta-analysis demonstrated improvements in VO2peak following centre-based (MD (95% CrI)=3.10 (2.56 to 3.65) mL/kg/min), home-based (MD=2.69 (1.67 to 3.70) mL/kg/min) and technology-enabled ExCR (MD=1.76 (0.27 to 3.26) mL/kg/min). Similarly, 6 min walk distance was improved following hybrid (MD=84.78 (31.64 to 138.32) m), centre-based (MD=50.35 (30.15 to 70.56) m) and home-based ExCR (MD=36.77 (12.47 to 61.29) m). Incremental shuttle walk distance did not improve following any ExCR delivery modes. Minnesota living with HF questionnaire improved after centre-based (MD=-10.38 (-14.15 to -6.46)) and home-based ExCR (MD=-8.80 (-13.62 to -4.07)). Kansas City Cardiomyopathy Questionnaire was improved following home-based ExCR (MD=20.61 (4.61 to 36.47)), and Short Form Survey 36 mental component after centre-based ExCR (MD=3.64 (0.30 to 6.14)). HF-related hospitalisation and mortality risks reduced only after centre-based ExCR (OR=0.41 (0.17 to 0.76) and OR=0.42 (0.16 to 0.90), respectively). Mean age of study participants was only associated with changes in VO2peak. CONCLUSION: ExCR programmes have broader benefits for people with HF and since different delivery modes were comparably effective for improving exercise capacity and HRQoL, the selection of delivery modes should be tailored to individuals' preferences.

Telehealth is here to stay but not without challenges: a consultation of cardiac rehabilitation clinicians during COVID-19 in Victoria, Australia.

AIMS: Delivery of cardiac rehabilitation (CR) was challenged during the pandemic caused by the Coronavirus disease (COVID-19), due to government stay-at-home directives which restricted in-person programmes. The Australian state of Victoria experienced the longest and most severe COVID-19 restrictions and was in lockdown for ∼6 months of 2020. We aimed to explore (i) clinicians' experiences and perceptions and (ii) identify barriers and enablers, for delivering CR during the COVID-19 pandemic. METHODS AND RESULTS: Victorian members of the Australian Cardiovascular Health and Rehabilitation Association (ACRA) were invited to attend an exploratory qualitative online consultation in November 2020. An inductive thematic analysis was undertaken, before deductively applying the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework to identify barriers and enablers for technology adoption in CR. Thirty members participated in a 106-min consultation. Seventeen members who provided demographics represented multiple disciplines (nursing n = 13, exercise physiology n = 3, and physiotherapy n = 1) and geographical settings (metropolitan n = 10, regional n = 4, and rural n = 3). Four main themes were inductively identified: consequences of change; use of technology; capacity; and the way forward. The deductive NASSS analysis demonstrated the main challenges of continuing remotely delivered CR lie with adopters (staff, patients, and carers) and with organizations. CONCLUSION: The COVID-19 pandemic expedited significant changes to CR delivery models. While clinicians are eager to retain technology-enabled delivery in addition to resuming in-person CR, it is now timely to review remote models of care, tools used and plan how they will be integrated with traditional in-person programmes.

Implementation of Telerehabilitation Interventions for the Self-Management of Cardiovascular Disease: Systematic Review.

BACKGROUND: Coronary heart disease (CHD) is a leading cause of disability and deaths worldwide. Secondary prevention, including cardiac rehabilitation (CR), is crucial to improve risk factors and to reduce disease burden and disability. Accessibility barriers contribute to underutilization of traditional center-based CR programs; therefore, alternative delivery models, including cardiac telerehabilitation (ie, delivery via mobile, smartphone, and/or web-based apps), have been tested. Experimental studies have shown cardiac telerehabilitation to be effective and cost-effective, but there is inadequate evidence about how to translate this research into routine clinical practice. OBJECTIVE: This systematic review aimed to synthesize research evaluating the effectiveness of implementing cardiac telerehabilitation interventions at scale in routine clinical practice, including factors underlying successful implementation processes, and experimental research evaluating implementation-related outcomes. METHODS: MEDLINE, Embase, PsycINFO, and Global Health databases were searched from 1990 through November 9, 2018, for studies evaluating the implementation of telerehabilitation for the self-management of CHD. Reference lists of included studies and relevant systematic reviews were hand searched to identify additional studies. Implementation outcomes of interest included acceptability, appropriateness, adoption, feasibility, fidelity, implementation cost, penetration, and sustainability. A narrative synthesis of results was carried out. RESULTS: No included studies evaluated the implementation of cardiac telerehabilitation in routine clinical practice. A total of 10 studies of 2250 participants evaluated implementation outcomes, including acceptability (8/10, 80%), appropriateness (9/10, 90%), adoption (6/10, 60%), feasibility (6/10, 60%), fidelity (7/10, 70%), and implementation cost (4/10, 40%), predominantly from the participant perspective. Cardiac telerehabilitation interventions had high acceptance among the majority of participants, but technical challenges such as reliable broadband internet connectivity can impact acceptability and feasibility. Many participants considered telerehabilitation to be an appropriate alternative CR delivery model, as it was convenient, flexible, and easy to access. Participants valued interactive intervention components, such as real-time exercise monitoring and feedback as well as individualized support. The penetration and sustainability of cardiac telerehabilitation, as well as the perspectives of CR practitioners and health care organizations, have received little attention in existing cardiac telerehabilitation research. CONCLUSIONS: Experimental trials suggest that participants perceive cardiac telerehabilitation to be an acceptable and appropriate approach to improve the reach and utilization of CR, but pragmatic implementation studies are needed to understand how interventions can be sustainably translated from research into clinical practice. Addressing this gap could help realize the potential impact of telerehabilitation on CR accessibility and participation as well as person-centered, health, and economic outcomes. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019124254; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=124254.

Toward a Digital Platform for the Self-Management of Noncommunicable Disease: Systematic Review of Platform-Like Interventions.

BACKGROUND: Digital interventions are effective for health behavior change, as they enable the self-management of chronic, noncommunicable diseases (NCDs). However, they often fail to facilitate the specific or current needs and preferences of the individual. A proposed alternative is a digital platform that hosts a suite of discrete, already existing digital health interventions. A platform architecture would allow users to explore a range of evidence-based solutions over time to optimize their self-management and health behavior change. OBJECTIVE: This review aims to identify digital platform-like interventions and examine their potential for supporting self-management of NCDs and health behavior change. METHODS: A literature search was conducted in January 2020 using EBSCOhost, PubMed, Scopus, and EMBASE. No digital platforms were identified, so criteria were broadened to include digital platform-like interventions. Eligible platform-like interventions offered a suite of discrete, evidence-based health behavior change features to optimize self-management of NCDs in an adult population and provided digitally supported guidance for the user toward the features best suited to their needs and preferences. Data collected on interventions were guided by the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile Health Applications and Online Telehealth) checklist, including evaluation data on effectiveness and process outcomes. The quality of the included literature was assessed using the Mixed Methods Appraisal Tool. RESULTS: A total of 7 studies were included for review. Targeted NCDs included cardiovascular diseases (CVD; n=3), diabetes (n=3), and chronic obstructive pulmonary disease (n=1). The mean adherence (based on the number of follow-up responders) was 69% (SD 20%). Of the 7 studies, 4 with the highest adherence rates (80%) were also guided by behavior change theories and took an iterative, user-centered approach to development, optimizing intervention relevance. All 7 interventions presented algorithm-supported user guidance tools, including electronic decision support, smart features that interact with patterns of use, and behavior change stage-matching tools. Of the 7 studies, 6 assessed changes in behavior. Significant effects in moderate-to-vigorous physical activity were reported, but for no other specific health behaviors. However, positive behavior change was observed in studies that focused on comprehensive behavior change measures, such as self-care and self-management, each of which addresses several key lifestyle risk factors (eg, medication adherence). No significant difference was found for psychosocial outcomes (eg, quality of life). Significant changes in clinical outcomes were predominately related to disease-specific, multifaceted measures such as clinical disease control and cardiovascular risk score. CONCLUSIONS: Iterative, user-centered development of digital platform structures could optimize user engagement with self-management support through existing, evidence-based digital interventions. Offering a palette of interventions with an appropriate degree of guidance has the potential to facilitate disease-specific health behavior change and effective self-management among a myriad of users, conditions, or stages of care.

High-intensity interval training improves cardiorespiratory fitness in cancer patients and survivors: A meta-analysis.

OBJECTIVE: The primary objective of this systematic review and meta-analysis was to compare the effects of high-intensity interval training (HIIT) versus moderate-intensity continuous training (MICT) and usual care (UC) on cardiorespiratory fitness (peak V̇O2 ) in cancer patients and survivors. Secondary objectives were to compare the effects of HIIT versus MICT and UC on other cardiopulmonary exercise testing (CPET) indices. Safety and adherence to HIIT were also evaluated. METHODS: A systematic review and meta-analysis of controlled trials were undertaken using eligible studies from electronic database searching (inception-December 2019). Mean differences (MD) with 95% confidence intervals (CI) were compared and heterogeneity assessed using Cochran's Q and I2 statistic. RESULTS: Twelve eligible studies included 516 participants with post-intervention CPET data. No serious adverse events occurred. Adherence to HIIT ranged between 71.2% and 95.6%. HIIT had significantly higher peak V̇O2 compared with UC (MD = 2.11 ml kg-1  min-1 , 95% CI 0.75-3.47, p = .002). No significant difference was found between HIIT and MICT (MD = 2.03 ml kg-1  min-1 , 95%CI -0.75-4.83, p = .15). HIIT was more effective than UC to improve peak oxygen pulse (MD = 1.59 ml/beat, 95%CI 0.06-3.12, p = .04). CONCLUSIONS: Quantitative assessment of HIIT studies indicates good compliance, with a significant effect on peak V̇O2 and peak oxygen pulse compared with UC in cancer patients and survivors. HIIT demonstrates a comparable effect with MICT to improve peak V̇O2 .

mHealth Interventions for Exercise and Risk Factor Modification in Cardiovascular Disease.

Exercise and lifestyle risk factor management are critical for the secondary prevention of cardiovascular disease but are poorly adhered to. Mobile health interventions could enhance engagement; however, a one-size intervention approach cannot meet the needs of all people. We hypothesize a unifying digital platform that enables choice from a suite of evidence-based programs will enhance access, delivery, and engagement.

End Users Want Alternative Intervention Delivery Models: Usability and Acceptability of the REMOTE-CR Exercise-Based Cardiac Telerehabilitation Program.

OBJECTIVE: Evaluate user experiences of an exercise-based cardiac telerehabilitation intervention (REMOTE-CR) that provided near universal access to real-time remote coaching and behavioral support from exercise specialists. DESIGN: Secondary analysis (12-week follow-up) of a parallel group, single blind, randomized controlled noninferiority trial (ACTRN12614000843651). SETTING: Community-based cardiac rehabilitation. PARTICIPANTS: Adults (N=162) with coronary heart disease who were eligible for outpatient cardiac rehabilitation. Eighty-two of 162 trial participants were randomized to receive REMOTE-CR; 67 completed usability and acceptability assessment at 12-week follow-up. INTERVENTION: REMOTE-CR comprised 12 weeks of individualized exercise prescription, real-time physiological monitoring, coaching, and behavioral support, delivered via a bespoke telerehabilitation platform. OUTCOMES: Ease of use, satisfaction with the technology platform and intervention content, and demand for real-world implementation as an alternative to traditional center-based programs were assessed at 12-week follow-up. RESULTS: Components of usability and acceptability were positively evaluated by most participants (44-66 of 67, 66%-99%). Fifty-eight of 67 (87%) would choose REMOTE-CR if it was available as a usual care service, primarily because it provides convenient and flexible access to real-time individualized support from exercise specialists. Technology challenges were rare and had little effect on user experiences or demand for REMOTE-CR. CONCLUSIONS: REMOTE-CR can extend the reach and impact of existing cardiac rehabilitation services by overcoming traditional participation barriers while preserving expert oversight. Adoption of emerging technologies should be accelerated to support dynamic, engaging, individualized intervention delivery models, but optimizing overall cardiac rehabilitation participation rates will require multiple delivery models that are tailored to satisfy diverse participant preferences.

Text4Heart II - improving medication adherence in people with heart disease: a study protocol for a randomized controlled trial.

BACKGROUND: Cardiac rehabilitation (CR) is an essential component of contemporary management for patients with coronary heart disease, including following an acute coronary syndrome (ACS). CR typically involves education and support to assist people following an ACS to make lifestyle changes and prevent subsequent events. Despite its benefits, uptake and participation in tradition CR programs is low. The use of mobile technologies (mHealth) offers the potential to improve reach, access, and delivery of CR support. We aim to determine the effectiveness and cost-effectiveness of a text-messaging intervention (Text4Heart II) to improve adherence to medication and lifestyle change in addition to usual care in people following an ACS. A second aim is to use the RE-AIM framework to inform the potential implementation of Text4Heart II within health services in New Zealand. METHODS: Text4Heart II is a two-arm, parallel, superiority randomized controlled trial conducted in two large metropolitan hospitals in Auckland, New Zealand. Three hundred and thirty participants will be randomized to either a 24-week theory- and evidence-based personalized text message program to support self-management in addition to usual CR, or usual CR alone (control). Outcomes are assessed at 6 and 12 months. The primary outcome is the proportion of participants adhering to medication at 6 months as measured by dispensed records. Secondary outcomes include medication adherence at 12 months, the proportion of participants adhering to self-reported healthy behaviors (physical activity, fruit and vegetable consumption, moderating alcohol intake and smoking status) measured using a composite health behavior score, self-reported medication adherence, cardiovascular risk factors (lipids, blood pressure), readmissions and related hospital events at 6 and 12 months. A cost-effectiveness analysis will also be conducted. Using the RE-AIM framework, we will determine uptake and sustainability of the intervention. DISCUSSION: The Text4Heart II trial will determine the effectiveness of a text-messaging intervention to improve adherence to medication and lifestyle behaviors at both 6 and 12 months. Using the RE-AIM framework this trial will provide much needed data and insight into the potential implementation of Text4Heart II. This trial addresses many limitations/criticisms of previous mHealth trials; it builds on our Text4Heart pilot trial, it is adequately powered, has sufficient duration to elicit behavior change, and the follow-up assessments (6 and 12 months) are long enough to determine the sustained effect of the intervention. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ID: ACTRN12616000422426 . Registered retrospectively on 1 April 2016.