Comparative effect of eHealth interventions on hypertension management-related outcomes: A network meta-analysis

Effect of interactive digital counselling on risk factors and lifestyle in patients with coronary artery disease: a systematic review and meta-analysis

AIMS

Digital counselling has gained paramount importance for coronary artery disease (CAD) patients' treatment in recent years. It has been shown to provide a multitude of benefits, including improved risk factors and enhanced lifestyles. No previous reviews have emphasized the interactiveness of digital counselling. Consequently, the aim of this review is to determine whether interactive two-way digital counselling can provide effective secondary prevention as alternative or adjunct care compared with usual care, where patients visit a cardiac clinic and obtain verbal information and written recommendations of the risk factors without a digital intervention.

METHODS AND RESULTS

Studies that implemented digital interventions in patient counselling among CAD patients were identified by searching 10 electronic databases at the end of August 2022 and updated on 15 December 2023. The Joanna Briggs Institution (JBI) protocol was used for screening, quality assessment, data extraction, and meta-analysis. In total, 15 papers were identified that reported the effect of interactive digital counselling on risk factors and lifestyle changes in CAD patients. The results of the meta-analyses had neutral pre-defined outcomes and did not show any effect on cardiovascular risk factors or lifestyle changes.

CONCLUSION

There is a need for better descriptions of the content and delivery of interactive digital interventions in studies. In the future, digital interventions should be designed not only to focus on patient, but to incorporate social support, peer groups, and interactive tools on a digital platform. Social support has proved to be important in terms of adherence to treatment.

REGISTRATION

PROSPERO CRD42021247315.

Targeting Key Risk Factors for Cardiovascular Disease in At-Risk Individuals: Developing a Digital, Personalized, and Real-Time Intervention to Facilitate Smoking Cessation and Physical Activity

Health care is under pressure due to an aging population with an increasing prevalence of chronic diseases, including cardiovascular disease. Smoking and physical inactivity are 2 key preventable risk factors for cardiovascular disease. Yet, as with most health behaviors, they are difficult to change. In the interdisciplinary Perfect Fit project, scientists from different fields join forces to develop an evidence-based virtual coach (VC) that supports smokers in quitting smoking and increasing their physical activity. In this Viewpoint paper, intervention content, design, and implementation, as well as lessons learned, are presented to support other research groups working on similar projects. A total of 6 different approaches were used and combined to support the development of the Perfect Fit VC. The approaches used are (1) literature reviews, (2) empirical studies, (3) collaboration with end users, (4) content and technical development sprints, (5) interdisciplinary collaboration, and (6) iterative proof-of-concept implementation. The Perfect Fit intervention integrates evidence-based behavior change techniques with new techniques focused on identity change, big data science, sensor technology, and personalized real-time coaching. Intervention content of the virtual coaching matches the individual needs of the end users. Lessons learned include ways to optimally implement and tailor interactions with the VC (eg, clearly explain why the user is asked for input and tailor the timing and frequency of the intervention components). Concerning the development process, lessons learned include strategies for effective interdisciplinary collaboration and technical development (eg, finding a good balance between end users' wishes and legal possibilities). The Perfect Fit development process was collaborative, iterative, and challenging at times. Our experiences and lessons learned can inspire and benefit others. Advanced, evidence-based digital interventions, such as Perfect Fit, can contribute to a healthy society while alleviating health care burden.

Novel Multicomponent Digital Care Assistant and Support Program for People After Stroke or Transient Ischaemic Attack: A Pilot Feasibility Study

Evidence is increasing for digital health programs targeting the secondary prevention of stroke. We aimed to determine the feasibility of the novel Care Assistant and support Program for people after Stroke (CAPS) or transient ischaemic attack (TIA) by combining person-centred goal setting and risk-factor monitoring through a web-based clinician portal, SMS messages, a mobile application (app), and a wearable device. We conducted a 12-week mixed-methods, open-label feasibility study. Participants (6 months-3 years after stroke or TIA, access to the internet via a smartphone/tablet) were recruited via the Australian Stroke Clinical Registry. Participants set one or two secondary prevention goals with a researcher and provided access and training in technology use. Feasibility outcomes included recruitment, retention, usability, acceptability, and satisfaction. Secondary outcomes included goal attainment, health outcomes, and program costs. Following 600 invitations, 58 responded, 34/36 (94%) eligible participants commenced the program (one withdrawal; 97% retention), and 10 were interviewed. Participants (27% female, 33% TIA) generally rated the usability of the mobile application as 'Good' to 'Excellent' (System Usability Scale). Most (94%) agreed the program helped with engagement in health self-monitoring. Overall, 52 goals were set, predominantly regarding exercise (21/52), which were the most frequently achieved (9/21). At 12 weeks, participants reported significant improvements (p < 0.05) in self-efficacy (Cohen's d = 0.40), cardiovascular health (d = 0.71), and the mental health domain of the PROMIS GH (d = 0.63). CAPS was acceptable, with good retention and engagement of participants. Evaluation of this program in a randomised controlled trial is warranted.

Multicomponent Support Program for Secondary Prevention of Stroke Using Digital Health Technology: Co-Design Study With People Living With Stroke or Transient Ischemic Attack

BACKGROUND

Few individuals (<2%) who experience a stroke or transient ischemic attack (TIA) participate in secondary prevention lifestyle programs. Novel approaches that leverage digital health technology may provide a viable alternative to traditional interventions that support secondary prevention in people living with stroke or TIA. To be successful, these strategies should focus on user needs and preferences and be acceptable to clinicians and people living with stroke or TIA.

OBJECTIVE

This study aims to co-design, with people with lived experience of stroke or TIA (referred to as consumers) and clinicians, a multicomponent digital technology support program for secondary prevention of stroke.

METHODS

A consumer user needs survey (108 items) was distributed through the Australian Stroke Clinical Registry and the Stroke Association of Victoria. An invitation to a user needs survey (135 items) for clinicians was circulated via web-based professional forums and national organizations (eg, the Stroke Telehealth Community of Practice Microsoft Teams Channel) and the authors' research networks using Twitter (subsequently rebranded X, X Corp) and LinkedIn (LinkedIn Corp). Following the surveys, 2 rounds of user experience workshops (design and usability testing workshops) were completed with representatives from each end user group (consumers and clinicians). Feedback gathered after each round informed the final design of the digital health program.

RESULTS

Overall, 112 consumers (male individuals: n=63, 56.3%) and 54 clinicians (female individuals: n=43, 80%) responded to the survey; all items were completed by 75.8% (n=85) of consumers and 78% (n=42) of clinicians. Most clinicians (46/49, 94%) indicated the importance of monitoring health and lifestyle measures more frequently than current practice, particularly physical activity, weight, and sleep. Most consumers (87/96, 90%) and clinicians (41/49, 84%) agreed that providing alerts about potential deterioration in an individual's condition were important functions for a digital program. Intention to use a digital program for stroke prevention and discussing the data collected during face-to-face consultations was high (consumers: 79/99, 80%; clinicians 36/42, 86%). In addition, 7 consumers (male individuals: n=5, 71%) and 9 clinicians (female individuals: n=6, 67%) took part in the user experience workshops. Participants endorsed using a digital health program to help consumers manage stroke or TIA and discussed preferred functions and health measures in a digital solution for secondary prevention of stroke. They also noted the need for a mobile app that is easy to use. Clinician feedback highlighted the need for a customizable clinician portal that captures individual consumer goals.

CONCLUSIONS

Following an iterative co-design process, supported by evidence from user needs surveys and user experience workshops, a consumer-facing app that integrates wearable activity trackers and a clinician web portal were designed and developed to support secondary prevention of stroke. Feasibility testing is currently in progress to assess acceptability and use.

Efficacy of a Web-Based Home Blood Pressure Monitoring Program in Improving Predialysis Blood Pressure Control Among Patients Undergoing Hemodialysis: Randomized Controlled Trial

Background

Hypertension is highly prevalent among patients undergoing hemodialysis, with a significant proportion experiencing poorly controlled blood pressure (BP). Digital BP management in this population has been underused.

Objective

This study aimed to explore the efficacy of a web-based home BP monitoring (HBPM) program in improving predialysis BP control and enhancing knowledge, perception, and adherence to HBPM among patients with hypertension undergoing hemodialysis.

Methods

A multicenter, open-label, randomized controlled trial was conducted at 2 hemodialysis units. Patients were randomly allocated in a 1:1 ratio to either the web-based HBPM program as the intervention group or to usual care as the control group over a 6-month period. The primary outcomes were the predialysis BP control rate, defined as less than 140/90 mm Hg, and the predialysis systolic and diastolic BP, assessed from baseline to the 6-month follow-up. Secondary outcomes included patient knowledge, perception, and adherence to HBPM, evaluated using the HBPM Knowledge Questionnaire, HBPM Perception Scale, and HBPM Adherence Scale, respectively. A generalized estimating equations analysis was used to analyze the primary outcomes in the intention-to-treat analysis.

Results

Of the 165 patients enrolled in the program (n=84, 50.9% in the web-based HBPM group and n=81, 49.1% in the control group), 145 (87.9%) completed the follow-up assessment. During the follow-up period, 11 instances of hypotension occurred in 9 patients in the web-based HBPM group, compared to 15 instances in 14 patients in the control group. The predialysis BP control rate increased from 30% (25/84) to 48% (40/84) in the web-based HBPM group after the 6-month intervention, whereas in the control group, it decreased from 37% (30/81) to 25% (20/81; χ22=16.82, P<.001; odds ratio 5.11, 95% CI 2.14-12.23, P<.001). The web-based HBPM group demonstrated a significant reduction after the 6-month intervention in the predialysis systolic BP (t163=2.46, P=.02; β=-6.09, 95 % CI -10.94 to -1.24, P=.01) and the predialysis diastolic BP (t163=3.20, P=.002; β=-4.93, 95% CI -7.93 to -1.93, P=.001). Scores on the HBPM Knowledge Questionnaire (t163=-9.18, P<.001), HBPM Perception Scale (t163=-10.65, P<.001), and HBPM Adherence Scale (t163=-8.04, P<.001) were significantly higher after 6 months of intervention.

Conclusions

The implementation of a web-based HBPM program can enhance predialysis BP control and the knowledge, perception, and adherence to HBPM among patients undergoing hemodialysis. This web-based HBPM program should be promoted in appropriate clinical settings.

Effectiveness of eHealth Interventions in Improving Medication Adherence Among Patients With Cardiovascular Disease: Systematic Review and Meta-Analysis

BACKGROUND

Nonadherence to medication among patients with cardiovascular diseases undermines the desired therapeutic outcomes. eHealth interventions emerge as promising strategies to effectively tackle this issue.

OBJECTIVE

The aim of this study was to conduct a network meta-analysis (NMA) to compare and rank the efficacy of various eHealth interventions in improving medication adherence among patients with cardiovascular diseases (CVDs).

METHODS

A systematic search strategy was conducted in PubMed, Embase, Web of Science, Cochrane, China National Knowledge Infrastructure Library (CNKI), China Science and Technology Journal Database (Weipu), and WanFang databases to search for randomized controlled trials (RCTs) published from their inception on January 15, 2024. We carried out a frequentist NMA to compare the efficacy of various eHealth interventions. The quality of the literature was assessed using the risk of bias tool from the Cochrane Handbook (version 2.0), and extracted data were analyzed using Stata16.0 (StataCorp LLC) and RevMan5.4 software (Cochrane Collaboration). The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.

RESULTS

A total of 21 RCTs involving 3904 patients were enrolled. The NMA revealed that combined interventions (standardized mean difference [SMD] 0.89, 95% CI 0.22-1.57), telephone support (SMD 0.68, 95% CI 0.02-1.33), telemonitoring interventions (SMD 0.70, 95% CI 0.02-1.39), and mobile phone app interventions (SMD 0.65, 95% CI 0.01-1.30) were statistically superior to usual care. However, SMS compared to usual care showed no statistical difference. Notably, the combined intervention, with a surface under the cumulative ranking curve of 79.3%, appeared to be the most effective option for patients with CVDs. Regarding systolic blood pressure and diastolic blood pressure outcomes, the combined intervention also had the highest probability of being the best intervention.

CONCLUSIONS

The research indicates that the combined intervention (SMS text messaging and telephone support) has the greatest likelihood of being the most effective eHealth intervention to improve medication adherence in patients with CVDs, followed by telemonitoring, telephone support, and app interventions. The results of these network meta-analyses can provide crucial evidence-based support for health care providers to enhance patients' medication adherence. Given the differences in the design and implementation of eHealth interventions, further large-scale, well-designed multicenter trials are needed.

TRIAL REGISTRATION

INPLASY 2023120063; https://inplasy.com/inplasy-2023-12-0063/.

Effectiveness of m-health technology-enabled physical activity program on physical activity adoption and adherence in people with hypertension in India: A randomized controlled trial protocol

Background

Exercise and medication have similar benefits in reducing blood pressure (BP); however, hypertension management initiatives primarily focus on medicines. This is due to scarce research on the effectiveness of implementation strategies for optimal exercise adoption and adherence. Smartphones were found to be effective in delivering hypertension care and increase exercise adherence. Despite this, only a small number of research projects in India have used smartphones as a strategy for managing hypertension.

Methods

We hypothesized that smartphone application-based care would lead to higher exercise adherence among adults (30-79 years) with hypertension compared to those who receive usual care. It will be a multicentric, randomized controlled, parallel-design, superiority clinical trial. The outcome assessor and data analyst will be blinded to group allocation. Participants in the intervention group will receive mobile application-based care for 6 weeks. Participants in the usual care group will receive a standard intervention. Both groups will receive the same number of follow-ups.

Results

The primary outcome is the difference in the proportion of people adherent to the recommended level of physical activity evaluated using an exercise adherence rating scale in the intervention group and the control group. Exercise adoption will be measured as the percentage of eligible participants in each study setting willing to initiate the exercise program. The secondary outcome includes differences in systolic and diastolic BP and self-management (evaluated using the Hypertension Self-Care Profile). The trial outcome will be accompanied by a process evaluation.

Conclusions

This research will inform about the comparative effectiveness of conventional and m-health interventions for exercise adoption and adherence in people with hypertension in resource-constrained settings.

Needs and Demands for e-Health Symptom Management Interventions in Patients with Post-COVID-19 Condition: A User-Centered Design Approach

Introduction: Post-COVID-19 is an increasing chronic disease for which potential treatment options require further development and examination. A well-established approach to symptom management in post-COVID-19 patients could be e-Health interventions. To enhance the implementation and utilization of e-Health interventions, the needs and demands of patients should be taken into consideration. The aim of this study was to investigate needs and demands of post-COVID-19 patients concerning e-Health symptom management interventions. Methods: A total of 556 patients participated in this cross-sectional online survey study. Recruitment was performed from January 19 to May 24, 2022. Data related to the needs and demands for e-Health interventions were analyzed, along with medical and sociodemographic information. Results: The majority of the patients preferred interventions accessible on smartphones (95.3%). The favored content formats were applications (82.7%), interactive training (69.3%), or audio and video materials (61.1%). Furthermore, the preferred session length was about 10-20 min. The most desired topics included "quality of life," "information about how intensively I may exert myself or do sports," "adjustment to new life situation," and "handling physical changes." Conclusions: This study provides a detailed framework for the content and design of e-Health interventions to support patients managing their post-COVID-19 symptoms. The findings could significantly influence the further development of tailored e-Health interventions to address this pressing global health concern.

An evaluation of written materials for supporting hypertensive patient education and counselling when performing a new medicine service in Poland

BACKGROUND

The New Medicine Service (NMS) was developed in England more than ten years ago, as a three-stage consultation led by community pharmacists to support patients taking new medication for a chronic disease. In Poland, the scheme was officially introduced in January 2023. However, its implementation into common practice has been presented with various obstacles, including the need to develop relationships with general practitioners, resolve the payment structure, and provide training with adequate supporting materials. Hence, written materials have been designed for use as an optional tool for counselling patients receiving an NMS in community pharmacies.

METHODS

The present study evaluates the ability of these materials to inform patients about the need to adhere to anti-hypertensive medication. A group of 401 randomly-selected adult visitors to pharmacies and/or healthcare centres were surveyed; one third had hypertension in their history.

RESULTS

The structure, grammar and readability of the text achieved the required threshold of 40% according to the Plain Language Index. The designed materials effectively informed the patients about anti-hypertensive medication, reflected in an increased score in a knowledge test, and were rated positively regarding information level, comprehensibility and presentation.

CONCLUSION

The proposed material may serve as an additional, "patient-friendly" educational tool for use as part of an NMS.

Management of Hypertension in the Asia-Pacific Region: A Structured Review

This article reviews available evidence regarding hypertension management in the Asia-Pacific region, focussing on five research questions that deal with specific aspects: blood pressure (BP) control, guideline recommendations, role of renin-angiotensin-aldosterone system (RAAS) inhibitors in clinical practice, pharmacological management and real-world adherence to guideline recommendations. A PubMed search identified 2537 articles, of which 94 were considered relevant. Compared with Europeans, Asians have higher systolic/diastolic/mean arterial BP, with a stronger association between BP and stroke. Calcium channel blockers are the most-commonly prescribed monotherapy in Asia, with significant variability between countries in the rates of angiotensin-converting enzyme inhibitors (ACEis)/angiotensin-receptor blockers (ARBs) and single-pill combination (SPC) use. In clinical practice, ARBs are used more commonly than ACEis, despite the absence of recommendation from guidelines and clinical evidence supporting the use of one class of drug over the other. Ideally, antihypertensive treatment should be tailored to the individual patient, but currently there are limited data on the characteristics of hypertension in Asia-Pacific individuals. Large outcome studies assessing RAAS inhibitor efficacy and safety in multi-national Asian populations are lacking. Among treated patients, BP control rates were ~ 35 to 40%; BP control in Asia-Pacific is suboptimal, and disproportionately so compared with Western nations. Strategies to improve the management of hypertension include wider access/availability of affordable treatments, particularly SPCs (which improve adherence), effective public health screening programs targeting patients to drive health-seeking behaviours, an increase in physician/patient awareness and early implementation of lifestyle changes. A unified Asia-Pacific guideline on hypertension management with pragmatic recommendations, particularly in resource-limited settings, is essential.

Applications of digital health approaches for cardiometabolic diseases prevention and management in the Western Pacific region

Cardiometabolic diseases (CMDs) are the major types of non-communicable diseases, contributing to huge disease burdens in the Western Pacific region (WPR). The use of digital health (dHealth) technologies, such as wearable gadgets, mobile apps, and artificial intelligence (AI), facilitates interventions for CMDs prevention and treatment. Currently, most studies on dHealth and CMDs in WPR were conducted in a few high- and middle-income countries like Australia, China, Japan, the Republic of Korea, and New Zealand. Evidence indicated that dHealth services promoted early prevention by behavior interventions, and AI-based innovation brought automated diagnosis and clinical decision-support. dHealth brought facilitators for the doctor-patient interplay in the effectiveness, experience, and communication skills during healthcare services, with rapidly development during the pandemic of coronavirus disease 2019. In the future, the improvement of dHealth services in WPR needs to gain more policy support, enhance technology innovation and privacy protection, and perform cost-effectiveness research.

Remote follow-up by pharmacists for blood pressure control in patients with hypertension: a systematic review and a meta-analysis of randomized controlled trials

Hypertension is a major cause of cardiovascular diseases. Several recent studies reported that pharmacists' remote follow-up reduced hypertension patients' blood pressure (BP). This meta-analysis aims to verify whether remote follow-up by pharmacists improves BP levels and reveal the factors that make the intervention effective. The search, conducted using PubMed/Medline, Embase, and Cochrane Library from June to July 2023, targeted articles published between October 1982 and June 2023, using terms including "pharmacist", "hypertension", and "randomized controlled trial (RCT)". The inclusion criteria were: (a) RCTs involving hypertension patients with or without comorbidities, (b) pharmacists using remote communication tools to conduct follow-up encounter during the intervention period, (c) reporting systolic blood pressure (SBP) at baseline and during intervention. SBP was the primary outcome for the meta-analysis. Thirteen studies (3969 participants) were included in this meta-analysis. The mean difference of SBP between intervention group and control group was - 7.35 mmHg (P < 0.0001). Subgroup analyses showed the greater reduction of SBP in the "regularly scheduled follow-up cohort" (- 8.89 mmHg) compared with the "as needed follow-up cohort" (- 3.23 mmHg, P < 0.0001). The results revealed that remote follow-up by pharmacists reduced SBP levels in hypertension patients and scheduled remote follow-up may contribute to the effectiveness.

Developing cue-behavior association for habit formation: A qualitative study to explore the role of avatar in hypertension

Background

Electronic health (eHealth) has been widely adopted in chronic disease management. Prior studies focused on time-based reminders as a cue to facilitate behavior change intentions, ignoring the development of automatic cue-behavior associations via other cue types.

Objective

Hence, this study utilized avatar appearance as a visual-based cue to help establish the automatic association between appearance transformation and health behavior to form habits without intention.

Methods

To better understand users' attitudes and experiences toward applying changes in avatar appearance to develop cue-behavior associations for hypertensive patients. Fifteen participants were recruited in a 14-day experiment. After excluding one participant who dropped out of the experiment, others were randomly assigned to two groups. One group consisted of a visual-based cue (a virtual plant) and basic behavior change techniques (BCTs). The other group only included basic BCTs. Attitudes and experience outcomes were collected by interview, and qualitative data were analyzed using thematic analysis.

Results

57% of participants had been diagnosed with hypertension for more than five years, and more than 50% of participants have experience using mobile apps or wearables. 66% of participants did physical activity more than three times every week. The result shows that tailored time-based reminders, blood pressure monitoring, and daily dietary intake were the most attractive features. Additionally, hypertensive participants have positive attitudes toward avatar appearance as a visual-based cue to develop cue-behavior association, which enhances self-management motivation.

Conclusion

This study proposes a visual-based cue design for habit formation and conducts a qualitative method to explore hypertensive patients' perceptions. The findings offer insights from user's perspectives into hypertensive patients' attitudes toward visual-based cues and perception of the connection between avatar appearance and health behavior for self-management. Subsequent discussions present eHealth design guidelines of habit formation from intention, automatic cue-behavior association, and self-management perspectives.

Development and validation of D-PATH website to improve hypertension management among hypertensive patients in Malaysia

Objective

This study aimed at developing and validating a web application on hypertension management called the D-PATH website.

Methods

The website development involved three stages: content analysis, web development, and validation. The model of Internet Intervention was used to guide the development of the website, in addition to other learning and multimedia theories. The content was developed based on literature reviews and clinical guidelines on hypertension. Then, thirteen experts evaluated the website using Fuzzy Delphi Technique.

Results

The website was successfully developed and contains six learning units. Thirteen experts rated the website based on content themes, presentation, interactivity, and instructional strategies. All experts reached a consensus that the web is acceptable to be used for nutrition education intervention.

Conclusion

D-PATH is a valid web-based educational tool ready to be used to help disseminate information on dietary and physical activity to manage hypertension. This web application was suitable for sharing information on dietary and physical activity recommendations for hypertension patients.

A Scoping Review of mHealth Interventions for Secondary Prevention of Stroke: Implications for Policy and Practice

Secondary prevention is a major priority for those living with stroke and may be improved through the use of mobile Health (mHealth) interventions. While evidence for the effectiveness of mHealth interventions for secondary prevention of stroke is growing, little attention has been given to the translation of these interventions into real-world use. In this review, we aimed to provide an update on the effectiveness of mHealth interventions for secondary prevention of stroke, and investigate their translation into real-world use. Four electronic databases and the gray literature were searched for randomized controlled trials of mHealth interventions for secondary prevention of stroke published between 2010 and 2023. Qualitative and mixed-methods evaluations of the trials were also included. Data were extracted regarding study design, population, mHealth technology involved, the intervention, and outcomes. Principal researchers from these trials were also contacted to obtain further translational information. From 1151 records, 13 randomized controlled trials and 4 evaluations were identified; sample sizes varied widely (median, 56; range, 24-4298). Short message service messages (9/13) and smartphone applications (6/13) were the main technologies used to deliver interventions. Primary outcomes of feasibility of the intervention were achieved in 4 trials, and primary outcomes of changes in risk factors, lifestyle behaviors, and adherence to medication improved in 6 trials. Only 1 trial had a hard end point (ie, stroke recurrence) as a primary outcome, and no significant differences were observed between groups. There was evidence for only 1 intervention being successfully translated into real-world use. Further evidence is required on the clinical effectiveness of mHealth interventions for preventing recurrent stroke, and the associated delivery costs and cost-effectiveness, before adoption into real-world settings.

Efficacy of Robot-Assisted and Virtual Reality Interventions on Balance, Gait, and Daily Function in Patients With Stroke: A Systematic Review and Network Meta-analysis

OBJECTIVE

This study aimed to evaluate the comparative effectiveness and ranking of robot-assisted training, virtual reality, and robot-assisted rehabilitation combined with virtual reality in improving balance, gait, and daily function in patients with stroke.

DATA SOURCES

PubMed, EMBASE, the Cochrane Library, Physiotherapy Evidence Database, CINAHL, Web of Science, and ProQuest Dissertations and Theses abstracting and indexing databases were comprehensively searched to include randomized controlled trials published through August 31, 2022.

STUDY SELECTION

Randomized controlled trials comparing robot-assisted training, virtual reality, robot-assisted rehabilitation combined with virtual reality, and conventional therapy to assess the effects on balance, gait, and daily function of patients with stroke.

DATA EXTRACTION

The risk of bias was assessed using the Cochrane Risk of Bias tool and the methodological quality of the studies was assessed using the Physiotherapy Evidence Database scale. A network meta-analysis of random effects models was performed for direct and indirect effects. Data were analyzed using Stata SE 17.0 and R 4.2.1.

DATA SYNTHESIS

A total of 52 randomized controlled trials involving 1,559 participants were included in this study. Based on the ranking probabilities, robot-assisted rehabilitation combined with virtual reality was most effective in improving balance (surface under the cumulative ranking curve [SUCRA]=82.0%; mean difference [MD]=4.10; 95% confidence interval [CI], 0.43 to 7.67). Virtual reality was most effective in improving velocity (SUCRA=97.8%; MD=-0.15; 95% CI, -0.24 to -0.06) and daily function (SUCRA=92.1%; MD=-7.85; 95% CI, -15.18 to -1.07).

CONCLUSIONS

Compared to robot-assisted training and conventional therapy, robot-assisted training combined virtual reality was most likely the best intervention for balance, and virtual reality might be the most helpful in improving daily function for patients after stroke. Further studies are needed to clarify the specific efficacy of robot-assisted training combined with virtual reality and virtual reality on gait.

Assessing the Effectiveness of mHealth Interventions for Diabetes and Hypertension Management in Africa: Systematic Review and Meta-Analysis

Background

Mobile health (mHealth) interventions are effective in improving chronic disease management, mainly in high-income countries. However, less is known about the efficacy of mHealth interventions for the reduction of cardiovascular risk factors, including for hypertension and diabetes, which are rapidly increasing in low- and middle-income countries.

Objective

This study aimed to assess the efficacy of mHealth interventions for diabetes and hypertension management in Africa.

Methods

We searched PubMed, Cochrane Library, Google Scholar, African Journals Online, and Web of Science for relevant studies published from inception to July 2022. The main outcomes of interest were changes in hemoglobin A1c (HbA1c), systolic blood pressure, and diastolic blood pressure. The random or fixed effect model was used for the meta-analysis, and the I2 statistic was used to gauge study heterogeneity. Z tests and P values were used to evaluate the effect of mHealth interventions on HbA1c and blood pressure levels.

Results

This review included 7 studies (randomized controlled trials) with a total of 2249 participants. Two studies assessed the effect of mHealth on glycemic control, and 5 studies assessed the effect of mHealth on blood pressure control. The use of mHealth interventions was not associated with significant reductions in HbA1c levels (weighted mean difference [WMD] 0.20, 95% CI -0.40 to 0.80; P=.51) among patients with diabetes and systolic blood pressure (WMD -1.39, 95% CI -4.46 to 1.68; P=.37) and diastolic blood pressure (WMD 0.36, 95% CI -1.37 to 2.05; P=.69) among patients with hypertension. After conducting sensitivity analyses using the leave-one-out method, the Kingue et al study had an impact on the intervention, resulting in a 2 mm Hg reduction in systolic blood pressure (WMD -2.22, 95% CI -3.94 to -0.60; P=.01) but was nonsignificant for diastolic blood pressure and HbA1c levels after omitting the study.

Conclusions

Our review provided no conclusive evidence for the effectiveness of mHealth interventions in reducing blood pressure and glycemic control in Africa among persons with diabetes and hypertension. To confirm these findings, larger randomized controlled trials are required.

Effectiveness of educational interventions on hypertensive patients' self-management behaviours: an umbrella review protocol

BACKGROUND

Although different educational interventions have been widely used to manage and treat hypertension, alone or in combination with other interventions, there is a significant variation in their claimed effectiveness.

REVIEW QUESTION/OBJECTIVE

The objective of this umbrella review is to determine the effectiveness of educational interventions, alone or in combination with other interventions, for improving blood pressure control and self-management practices among hypertensive patients. The review question is: Do educational interventions, alone or in combination with other interventions, improve self-management practices among patients with hypertension?

METHODS

We will conduct a review of systematic reviews involving studies that implemented educational interventions, alone or in combination with other interventions, designed to change self-care practices among hypertensive patients who are 18 years and above, regardless of their sex and ethnicity. Following the guidelines set forth in the Preferred Reporting Items for Systematic Review and Meta-Analysis statement, a comprehensive literature search will be conducted from September to December 2023 on six electronic databases: MEDLINE, Embase, PsycINFO, CINAHL, Web of Science Core Collection and Google Scholar. Search terms will be developed using database-specific indexed terms and text words derived from the review aim. We will present the effects of the educational interventions, alone or in combination with other interventions, on hypertension self-management practices. We will report the outcome data with 95% CIs for each study. Relative risk, mean differences or ORs will be used, depending on the measuring indices in each study.

ETHICS AND DISSEMINATION

Ethical approval is not required as this study will use aggregated data from previously published systematic reviews. However, we have registered the protocol in PROSPERO. We confirm that all methods will be performed following the guidelines of the Declaration of Helsinki. The findings from this study will be disseminated through presentations at academic conferences and publication in peer-reviewed international journals.

PROSPERO REGISTRATION NUMBER

CRD42022375581.

Using Ballistocardiogram and Impedance Plethysmogram for Minimal Contact Measurement of Blood Pressure Based on a Body Weight-Fat Scale

Electronic health (eHealth) is a strategy to improve the physical and mental condition of a human, collecting daily physiological data and information from digital apparatuses. Body weight and blood pressure (BP) are the most popular and important physiological data. The goal of this study is to develop a minimal contact BP measurement method based on a commercial body weight-fat scale, capturing biometrics when users stand on it. The pulse transit time (PTT) is extracted from the ballistocardiogram (BCG) and impedance plethysmogram (IPG), measured by four strain gauges and four footpads of a commercial body weight-fat scale. Cuffless BP measurement using the electrocardiogram (ECG) and photoplethysmogram (PPG) serves as the reference method. The BP measured by a commercial BP monitor is considered the ground truth. Twenty subjects participated in this study. By the proposed model, the root-mean-square errors and correlation coefficients (r2s) of estimated systolic blood pressure and diastolic blood pressure are 7.3 ± 2.1 mmHg and 4.5 ± 1.8 mmHg, and 0.570 ± 0.205 and 0.284 ± 0.166, respectively. This accuracy level achieves the C grade of the corresponding IEEE standard. Thus, the proposed method has the potential benefit for eHealth monitoring in daily application.

Effect of health coaching on blood pressure control and behavioral modification among patients with hypertension: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Health coaching has emerged as a potential supporting tool for improving hypertension health behavior. However, health coaching efficacy on hypertension has not been reviewed systematically.

OBJECTIVE

To evaluate the effects of health coaching on blood pressure and behavioral changes among patients with hypertension in randomized controlled trials.

DESIGN

A systematic review and meta-analysis.

METHODS

We searched Medline (via PubMed), Web of Science, Embase, Cochrane Central Register of Controlled Trials, Proquest, and Scopus from inception to November 30, 2021. All randomized controlled trials that estimated the effects of health coaching on blood pressure and behavioral changes in adults with hypertension were included. The Cochrane risk-of-bias tool was used to evaluate the quality of the included studies. Standardized mean differences (SMD) and 95 % confidence intervals (CIs) were calculated using random-effects or fixed-effects meta-analysis. Sensitivity analysis and subgroup analysis were also conducted.

RESULTS

A total of 1655 studies were screened and 12 randomized controlled trials were selected for inclusion, with 2497 participants were included. Most of the studies were at low risk of bias and the quality of evidence was high. The meta-analysis demonstrated that health coaching could significantly reduce systolic blood pressure (SMD: -0.26, 95 % CI: -0.39, -0.13, p < 0.001) and diastolic blood pressure in hypertension (SMD: -0.13, 95 % CI: -0.22, -0.03, p = 0.009). In addition, health coaching showed statistically significant positive effects on dietary behaviors (SMD: 0.76, 95 % CI: 0.08, 1.44, p = 0.02) and self-efficacy (SMD: 0.39, 95 % CI: 0.05, 0.73, p = 0.02). Subgroup analysis indicated that the most common and effective type of health coaching was the phone-based interventions (systolic blood pressure: SMD: -0.27, 95 % CI: -0.44, -0.10, p = 0.002; diastolic blood pressure: SMD: -0.14, 95 % CI: -0.25, -0.03, p = 0.02). The effects of nurse-delivered interventions were larger than other health care professionals (systolic blood pressure: SMD: -0.42, 95 % CI: -0.68, -0.16, p = 0.002; diastolic blood pressure: SMD: -0.19, 95 % CI: -0.35, -0.04, p = 0.02).

CONCLUSION

Current evidence suggested that health coaching could reduce blood pressure, improve dietary behaviors, and increase self-efficacy among patients with hypertension and thus could be an effective and alternative method in the management of hypertension. The most common and effective types of health coaching were phone-based and nurse-delivered interventions. Thus, more strategies and policies may be needed to implement these types of interventions to more patients with hypertension.

[Adherence, barriers, and facilitators for the treatment of systemic arterial hypertension: rapid review of evidenceAdhesión, obstáculos y elementos facilitadores en relación con el tratamiento de la hipertensión: revisión rápida de la evidencia]

Objective

To identify strategies to increase adherence to systemic arterial hypertension (SAH) treatment and describe the barriers and facilitators for implementing these strategies in primary health care (PHC).

Method

A rapid evidence review was performed. We included systematic reviews with or without meta-analyses, published in English, Spanish or Portuguese, covering adults (age 18 to ≤ 60 years) with SAH followed in the PHC. Searches were performed in nine databases in December 2020 and updated in April 2022. The systematic reviews were assessed for methodological quality using the AMSTAR 2 tool.

Results

Fourteen systematic reviews on treatment adherence strategies and three on barriers and facilitators for implementation were included. Regarding methodological quality, one systematic review was classified as moderate, four as low, and the others as critically low. Four strategies were identified as options for health policies: actions performed by pharmacists; actions performed by non-pharmaceutical health professionals; self-monitoring, use of mobile apps, and text messages; and subsidies for the purchase of medicines. Low digital literacy, limited access to the internet, work process and incipient training were barriers for professionals. The users' educational and health literacy levels, accessibility to health services and good relationships with professionals were facilitators.

Conclusions

Positive effects of strategies related to pharmaceutical care, self-monitoring, and the use of cell phone applications and text messages were identified to increase adherence to the treatment of SAH in the context of PHC. However, for implementation purposes, it is necessary to consider barriers and facilitators, in addition to the methodological limitations of the analyzed systematic reviews.

The Interplay of Work, Digital Health Usage, and the Perceived Effects of Digitalization on Physicians' Work: Network Analysis Approach

Background

In health care, the benefits of digitalization need to outweigh the risks, but there is limited knowledge about the factors affecting this balance in the work environment of physicians. To achieve the benefits of digitalization, a more comprehensive understanding of this complex phenomenon related to the digitalization of physicians’ work is needed.

Objective

The aim of this study was to examine physicians’ perceptions of the effects of health care digitalization on their work and to analyze how these perceptions are associated with multiple factors related to work and digital health usage.

Methods

A representative sample of 4630 (response rate 24.46%) Finnish physicians (2960/4617, 64.11% women) was used. Statements measuring the perceived effects of digitalization on work included the patients’ active role, preventive work, interprofessional cooperation, decision support, access to patient information, and faster consultations. Network analysis of the perceived effects of digitalization and factors related to work and digital health usage was conducted using mixed graphical modeling. Adjusted and standardized regression coefficients are denoted by b. Centrality statistics were examined to evaluate the relative influence of each variable in terms of node strength.

Results

Nearly half of physicians considered that digitalization has promoted an active role for patients in their own care (2104/4537, 46.37%) and easier access to patient information (1986/4551, 43.64%), but only 1 in 10 (445/4529, 9.82%) felt that the impact has been positive on consultation times with patients. Almost half of the respondents estimated that digitalization has neither increased nor decreased the possibilities for preventive work (2036/4506, 45.18%) and supportiveness of clinical decision support systems (1941/4458, 43.54%). When all variables were integrated into the network, the most influential variables were purpose of using health information systems, employment sector, and specialization status. However, the grade given to the electronic health record (EHR) system that was primarily used had the strongest direct links to faster consultations (b=0.32) and facilitated access to patient information (b=0.28). At least 6 months of use of the main EHR was associated with facilitated access to patient information (b=0.18).

Conclusions

The results highlight the complex interdependence of multiple factors associated with the perceived effects of digitalization on physicians’ work. It seems that a high-quality EHR system is critical for promoting smooth clinical practice. In addition, work-related factors may influence other factors that affect digital health success. These factors should be considered when developing and implementing new digital health technologies or services for physicians’ work. The adoption of digital health is not just a technological project but a project that changes existing work practices.

Electronic health strategies to improve medication adherence in patients with cardiometabolic disease: current status and future directions

PURPOSE OF REVIEW

Enabled by widespread technological advancements, electronic health (eHealth) strategies have expanded rapidly over the last decade, presenting opportunities to support self-management including medication adherence for cardiometabolic disease control. eHealth can minimize access barriers to medications, enable timely assessment and shared decision-making, and provide medication reminders and health data feedback. This review summarizes current evidence for effectiveness of eHealth strategies for improving medication adherence in patients with hypertension, type 2 diabetes, and/or hyperlipidemia, and identifies priorities for future research.

RECENT FINDINGS

Current research supports the effectiveness of eHealth strategies to improve medication adherence and clinical outcomes for cardiometabolic disease. Although patient acceptability of eHealth strategies is generally high, engagement may decline over time. In addition, differences in effectiveness across intervention characteristics and sociodemographic groups are understudied, limiting generalizability and tailoring of interventions to local health system resources, culture, and patient needs or preferences.

SUMMARY

eHealth is a promising tool for addressing low medication adherence. Further work incorporating rigorous evaluation, assessment of patient engagement over time and effectiveness of intervention characteristics and components, and a health equity lens addressing eHealth use in vulnerable groups will increase understanding of the full potential of eHealth for improving medication adherence in diverse patients with cardiometabolic disease.