A process evaluation, with mediation analysis, of a web-based intervention to augment primary care exercise referral schemes: the e-coachER randomised controlled trial

Current Implementation of Digital Health in Chronic Disease Management: Scoping Review

BACKGROUND

Approximately 1 in 3 adults live with multiple chronic diseases. Digital health is being harnessed to improve continuity of care and management of chronic diseases. However, meaningful uptake of digital health for chronic disease management remains low. It is unclear how these innovations have been implemented and evaluated.

OBJECTIVE

This scoping review aims to identify how digital health innovations for chronic disease management have been implemented and evaluated: what implementation frameworks, methods, and strategies were used; how successful these strategies were; key barriers and enablers to implementation; and lessons learned and recommendations shared by study authors.

METHODS

We used the Joanna Briggs Institute methodology for scoping reviews. Five databases were searched for studies published between January 2015 and March 2023: PubMed, Scopus, CINAHL, PsycINFO, and IEEE Xplore. We included primary studies of any study design with any type of digital health innovations for chronic diseases that benefit patients, caregivers, or health care professionals. We extracted study characteristics; type of digital health innovation; implementation frameworks, strategies, and outcome measures used; barriers and enablers to implementation; lessons learned; and recommendations reported by study authors. We used established taxonomies to synthesize extracted data. Extracted barriers and enablers were grouped into categories for reporting. Descriptive statistics were used to consolidate extracted data.

RESULTS

A total of 252 studies were included, comprising mainly mobile health (107/252, 42.5%), eHealth (61/252, 24.2%), and telehealth (97/252, 38.5%), with some studies involving more than 1 innovation. Only 23 studies (23/252, 9.1%) reported using an implementation science theory, model, or framework; the most common were implementation theories, classic theories, and determinant frameworks, with 7 studies each. Of 252 studies, 144 (57.1%) used 2 to 5 implementation strategies. Frequently used strategies were "obtain and use patient or consumer feedback" (196/252, 77.8%); "audit and provide feedback" (106/252, 42.1%); and piloting before implementation or "stage implementation scale-up" (85/252, 33.7%). Commonly measured implementation outcomes were acceptability, feasibility, and adoption of the digital innovation. Of 252 studies, 247 studies (98%) did not measure service outcomes, while patient health outcomes were measured in 89 studies (35.3%). The main method used to assess outcomes was surveys (173/252, 68.7%), followed by interviews (95/252, 37.7%). Key barriers impacting implementation were data privacy concerns and patient preference for in-person consultations. Key enablers were training for health care workers and personalization of digital health features to patient needs.

CONCLUSIONS

This review generated a summary of how digital health in chronic disease management is currently implemented and evaluated and serves as a useful resource for clinicians, researchers, health system managers, and policy makers planning real-world implementation. Future studies should investigate whether using implementation science frameworks, including how well they are used, would yield better outcomes compared to not using them.

Mechanisms of impact of web-based support and self-monitoring to augment and maintain physical activity levels: a qualitative study exploring participants' interactions with the e-coachER, a web-based support programme for people attending exercise referral schemes

OBJECTIVES

e-coachER was a web-based intervention designed to support uptake and maintenance of physical activity for people attending exercise referral schemes (ERS) for weight loss, diabetes, hypertension, osteoarthritis or a history of depression/low mood. The aim of this study was to explore the mechanisms of impact of the e-coachER intervention, specifically how participants interacted with e-coachER and the key mediators of increased physical activity.

DESIGN

This was a qualitative one-on-one interview study. Interviews were audio-recorded and transcribed and analysed using thematic analysis.

SETTING

UK primary care ERS.

PARTICIPANTS

A purposive sample of adult patients randomised to the intervention arm of the e-coachER randomised controlled trial.

RESULTS

Twenty-six participants (20 female), who had logged on to e-coachER at least once were recruited, resulting in a total of 38 interviews (mean duration 48 min). Four broad, inter-related themes were generated from the data (1) catalyst for change, (2) goals and aspirations, (3) support and (4) engagement with the e-coachER programme. Most participants who took part in e-coachER were already motivated to improve their health and perceived e-coachER as an additional source of motivation and accountability. Many felt that the opportunity to set goals and self-monitor supported participant's competence and autonomy by enabling them to progress at their own pace. Many participants reported on how e-coachER helped them to foster a sense of relatedness by encouraging them to seek support from others. Finally, e-coachER was regarded as being generally accessible and engaging. Despite this, some found it too simplistic, and others found it hard to maintain engagement over time.

CONCLUSIONS

The e-coachER intervention seemed to be generally motivating in the early stages of initiating behaviour change, but engagement waned over time. Our findings highlight how important an online package might be in supporting behaviour change while also highlighting the challenges of achieving sustained physical activity changes.

TRIAL REGISTRATION NUMBER

ISRCTN15644451.

A systematic review and narrative synthesis of physical activity referral schemes' components

BACKGROUND

Physical activity referral schemes (PARS) are complex multicomponent interventions that represent a promising healthcare-based concept for physical activity (PA) promotion. This systematic review and narrative synthesis aimed to identify the constitutive components of PARS and provide an overview of their effectiveness.

METHODS

Following a published protocol, we conducted a systematic search of PubMed, Scopus, Web of Science, CINAHL, ScienceDirect, SpringerLink, HTA, Wiley Online Library, SAGE Journals, Taylor & Francis, Google Scholar, OpenGrey, and CORE from 1990 to January 2023. We included experimental, quasi-experimental, and observational studies that targeted adults participating in PARS and reported PA outcomes, scheme uptake, or adherence rates. We performed an intervention components analysis using the PARS taxonomy to identify scheme components and extracted data related to uptake, adherence, and PA behavior change. We combined these to provide a narrative summary of PARS effectiveness.

RESULTS

We included 57 studies reporting on 36 PARS models from twelve countries. We identified 19 PARS components: a patient-centered approach, individualized content, behavior change theory and techniques, screening, brief advice, written materials, a written prescription, referral, baseline and exit consultation, counselling support session(s), PA sessions, education session(s), action for non-attendance, structured follow-up, a PA network, feedback for the referrer, and exit strategies/routes. The PARS models contained a mean of 7 ± 2.9 components (range = 2-13). Forty-five studies reported PA outcome data, 28 reported uptake, and 34 reported adherence rates. Of these, approximately two-thirds of studies reported a positive effect on participant PA levels, with a wide range of uptake (5.7-100.0%) and adherence rates (8.5-95.0%).

CONCLUSIONS

Physical activity referral scheme components are an important source of complexity. Despite the heterogeneous nature of scheme designs, our synthesis was able to identify 19 components. Further research is required to determine the influence of these components on PARS uptake, adherence, and PA behavior change. To facilitate this, researchers and scheme providers must report PARS designs in more detail. Process evaluations are also needed to examine implementation and increase our understanding of what components lead to which outcomes. This will facilitate future comparisons between PARS and enable the development of models to maximize impact.

Dietary Barriers Appear to Influence the Effects of a Dyadic Web-Based Lifestyle Intervention on Caloric Intake and Adiposity: A Mediation Analysis of the DUET Trial

Mechanisms that explain behavior change within web-based lifestyle interventions are not well-studied. This secondary analysis explores whether the effects of the DUET web-based lifestyle intervention on diet, physical activity, and/or adiposity are mediated through changes in self-efficacy, social support, and perceived barriers (key constructs of social cognitive theory). Data on mediators, diet quality, caloric intake, moderate-to-vigorous physical activity (MVPA), weight, and waist circumference (WC) were analyzed from 112 cancer survivors and their partners enrolled in the DUET intervention. Mediation analyses were performed using Mplus to execute regression analyses and determine associations. Mediation analyses supported an effect of the intervention on caloric intake (-3.52, 95% CI [-8.08 to -0.84]), weight (-1.60, CI [-3.84 to -0.47]), and WC (-0.83, CI [-1.77 to -0.18]), interpreting these negative associations as intervention induced reductions in dietary barriers. Higher social support was significantly and positively associated with, but not a mediator for, improvements in self-reported and accelerometry-measured MVPA (b = 0.69, CI [0.19, 1.24]) and (b = 0.55, CI [0.15, 1.00]), respectively. Self-efficacy did not appear to mediate the intervention's effects. Findings suggest that the effects of the DUET intervention on diet and adiposity stem from reducing perceived barriers to a healthful, low-calorie diet.

"Own doctor" presence in a web-based lifestyle intervention for adults with obesity and hypertension: A randomized controlled trial

Introduction

Online interventions have long been shown to be an effective means to promote a healthy lifestyle, thereby helping to control body weight and blood pressure figures. Likewise, using video modeling is also considered an effective way to guide patients through behavioral interventions. Nonetheless, to the best of our knowledge, this study is the first to analyze how the presence of patients' "own doctor" in the audiovisual content of a web-based lifestyle program ("Living Better") aimed at promoting regular physical exercise and healthy eating behavior, compared with an "unknown doctor," influences the outcomes of adults with obesity and hypertension.

Materials and methods

A total of 132 patients were randomly assigned either to the experimental (n = 70) or control (n = 62) group ("own doctor" or "unknown doctor", respectively). The body mass index, systolic and diastolic blood pressure, number of antihypertensive drugs used, physical activity level, and quality of life was assessed and compared at baseline and post-intervention (12 weeks).

Results

The intention-to-treat analysis showed intragroup significant improvements in both groups in terms of the body mass index (control group: mean difference -0.3, 95% CI [-0.5, -0.1], p = 0.002; experimental group: -0.4 [-0.6, -0.2], p < 0.001) and systolic blood pressure (control group: -2.3 [-4.4, -0.2], p = 0.029; experimental group: -3.6 [-5.5, -1.6], p< 0.001). In addition, there were also significant improvements in the experimental group for the diastolic blood pressure (-2.5 [-3.7, -1.2], p < 0.001), physical activity (479 [9, 949], p = 0.046), and quality of life (5.2 [2.3, 8.2], p = 0.001). However, when comparing the experimental with the control group, no between-group significant differences were found in these variables.

Conclusions

This study suggests that the presence of patients' "own doctor" in the audiovisual content of a web-based intervention, aimed at promoting a healthy lifestyle among adults with obesity and hypertension, do not show significant additional benefits over the efficacy of e-counseling.

Trial registration

ClinicalTrials.gov NCT04426877. First Posted: 11/06/2020. https://clinicaltrials.gov/ct2/show/NCT04426877.