Developing a digital health intervention for the secondary prevention of cardiovascular disease

Background: Secondary prevention is an important strategy to reduce the burden of cardiovascular disease (CVD). While guidelines recommend that secondary prevention should start as early as possible following a CVD diagnosis, referral to and uptake of secondary prevention programmes such as cardiac rehabilitation (CR) remains persistently poor. Digital health interventions (DHIs) including mobile apps have the potential to offer innovative, scalable approaches that improve the provision of timely secondary prevention. However, despite these potential benefits, adoption of DHIs into routine clinical practice has been slow. Furthermore, although secondary prevention DHIs such as CR have been compared to traditional in-person programmes, there has been little research focusing on the development of these DHIs, with limited use of co-design to approaches. There is also a lack of understanding of the systems required to support implementation, scalability, and sustainability. Aim: The overall aim of this research was to advance knowledge on the development of DHIs for the secondary prevention of CVD. In line with this aim, the research included in this thesis sought to: (i) examine current practice, by assessing the outcomes of a multicomponent digital CR intervention delivered in Ireland during the COVID-19 pandemic, (ii) to identify factors influencing implementation of this digital CR programme from the perspective of health workers, and (iii) to use the resulting evidence to inform the development of a DHI known as “INTERCEPT” for the secondary prevention of CVD that could be provided to patients with coronary heart disease(CHD) at the time of their diagnosis and prior to their discharge from hospital. Methods: Using a mixed methods approach, this research was underpinned by the UK Medical Research Council (MRC) framework for developing and evaluating complex interventions. In the first study, a single-centre observational study was conducted to examine the outcomes (lifestyle, risk factor, therapeutic goals and quality of life) of a digital CR programme called “Croí MySláinte”. To help identify the contextual factors influencing implementation of secondary prevention DHIs, a qualitative analysis of health worker perspectives on this programme was conducted in Study 2. In Study 3, a person-based, co-design approach to the development of INTERCEPT, inclusive of usability testing was adopted. Findings: The observational study of Croí MySláinte (Study 1) showed that multicomponent digital CR can be successfully implemented to help patients achieve guideline recommended lifestyle, medical and therapeutic targets that are comparable to in-person CR programmes. Insights from the qualitative analysis of health worker perspectives on digital CR (Study 2) revealed that factors influencing implementation of DHIs relate to: intervention characteristics and technical considerations; individuals (workforce and patients); the healthcare ecosystem; and the broader extrinsic ecosystem within which they operate. Then, in Study 3, the needs of the end user, key design principles, and the desired app features and content were established through the use of co-design. Through an iterative process, including usability testing, this facilitated the development of a theory informed intervention, which comprised of a mobile Health app linked to a health care professional portal and wearable technology. Conclusion: Increasing emphasis is being placed on prioritising the development of DHIs for the secondary prevention of CVD. This research contributes to the evidence base for the development of such interventions by examining real world evidence including clinical outcomes and contextual factors influencing implementation and integrating these findings with the use of co-design to inform the development of INTERCEPT. By adopting a mixed method, theory based, approach to the development of the INTERCEPT DHI, this programme of research has paved the way for next step feasibility testing and definitive evaluation of effectiveness and future replication.

Funder

Health Research Board

Publisher

University of Galway

Rights

Attribution-NonCommercial-NoDerivatives 4.0 International

cbn

Collections

University of Galway Theses (PhD Theses)