Patients' views and experiences of technology based self-management tools for the treatment of hypertension in the community: A qualitative study

Study protocol: Collaboration Oriented Approach to Controlling High blood pressure (COACH) in adults - a randomised controlled trial

INTRODUCTION

Hypertension, the clinical condition of persistent high blood pressure (BP), is preventable yet remains a significant contributor to poor cardiovascular outcomes. Digital self-management support tools can increase patient self-care behaviours to improve BP. We created a patient-facing and provider-facing clinical decision support (CDS) application, called the Collaboration Oriented Approach to Controlling High BP (COACH), to integrate home BP data, guideline recommendations and patient-centred goals with primary care workflows. We leverage social cognitive theory principles to support enhanced engagement, shared decision-making and self-management support. This study aims to measure the effectiveness of the COACH intervention and evaluate its adoption as part of BP management.

METHODS AND ANALYSIS

The study design is a multisite, two-arm hybrid type III implementation randomised controlled trial set within primary care practices across three health systems. Randomised participants are adults with high BP for whom home BP monitoring is indicated. The intervention arm will receive COACH, a digital web-based intervention with effectively enhanced alerts and displays intended to drive engagement with BP lowering; the control arm will receive COACH without the alerts and a simple display. Outcome measures include BP lowering (primary) and self-efficacy (secondary). Implementation preplanning and postevaluation use the Consolidated Framework for Implementation Research and Reach-Effectiveness-Adoption-Implementation-Maintenance metrics with iterative cycles for qualitative integration into the trial and its quantitative evaluation. The trial analysis includes logistic regression and constrained longitudinal data analysis.

ETHICS AND DISSEMINATION

The trial is approved under a single IRB through the University of Missouri-Columbia, #2091483. Dissemination of the intervention specifications and results will be through open-source mechanisms.

TRIAL REGISTRATION NUMBER

NCT06124716.

An Integrated Community-Based Blood Pressure Telemonitoring Program - A Population-Based Observational Study

BACKGROUND

Home blood pressure telemonitoring (BPT) has been shown to improve blood pressure control. A community-based BPT program (the Health+ program) was launched in 2015 in an urban area around a medical center.

OBJECTIVES

To examine the impact of the BPT program on the use of medical resources.

METHODS

We conducted a retrospective propensity-score (PS)-matched observational cohort study using the National Health Insurance Research Database (NHIRD) 2013-2016 in Taiwan. A total of 9,546 adults with a high risk of cardiovascular disease participated in the integrated BPT program, and 19,082 PS-matched controls were identified from the NHIRD. The primary and secondary outcome measures were changes in 1-year emergency department visit rate, hospitalization rate, duration of hospital stay, and healthcare costs.

RESULTS

The number of emergency department visits in the Health+ group significantly reduced (0.8 to 0.6 per year vs. 0.8 to 0.9 per year, p < 0.0001) along with a significant decrease in hospitalization rate (43.7% to 21.3% vs. 42.7% to 35.3%, p < 0.001). The duration of hospital stay was also lower in the Health+ group (4.3 to 3.3 days vs. 5.3 to 6.5 days, p < 0.0001). The annual healthcare costs decreased more in the Health+ group (USD 1642 to 1169 vs. 1466 to 1393 per year, p < 0.001), compared with the controls. Subgroup analysis of the Health+ group revealed that the improvements in outcomes were significantly greater among those who were younger and had fewer comorbidities, especially without diabetes or hypertension.

CONCLUSIONS

A community-based integrated BPT program may improve patients' health outcomes and reduce healthcare costs.

Choice of home blood pressure monitoring device: the role of device characteristics among Alaska Native and American Indian peoples

BACKGROUND

Home blood pressure monitoring (HBPM) is an effective tool in treatment and long-term management of hypertension. HBPM incorporates more data points to help patients and providers with diagnosis and management. The characteristics of HBPM devices matter to patients, but the relative importance of the characteristics in choosing a device remains unclear.

METHODS

We used data from a randomized cross-over pilot study with 100 Alaska Native and American Indian (ANAI) people with hypertension to assess the choice of a wrist or arm HBPM device. We use a random utility framework to evaluate the relationship between stated likely use, perceived accuracy, ease of use, comfort, and participant characteristics with choice of device. Additional analyses examined willingness to change to a more accurate device.

RESULTS

Participants ranked the wrist device higher compared to the arm on a 5-point Likert scale for likely use, ease of use, and comfort (0.3, 0.5, 0.8 percentage points, respectively). Most participants (66%) choose the wrist device. Likely use (wrist and arm devices) was related to the probability of choosing the wrist (0.7 and - 1.4 percentage points, respectively). Independent of characteristics, 75% of participants would be willing to use the more accurate device. Ease of use (wrist device) and comfort (arm device) were associated with the probability of changing to a more accurate device (- 1.1 and 0.5 percentage points, respectively).

CONCLUSION

Usability, including comfort, ease, and likely use, appeared to discount the relative importance of perceived accuracy in the device choice. Our results contribute evidence that ANAI populations value accurate HBPM, but that the devices should also be easy to use and comfortable to facilitate long-term management.

A model of integrated remote monitoring and behaviour change for osteoarthritis

Background

The National Institute for Health and Care Excellence recommends the use of digital and mobile health technologies to facilitate behaviour change interventions. Due to its high prevalence and dependence upon patient self-management strategies, osteoarthritis is one musculoskeletal condition which may benefit from such approaches. This is particularly pertinent due to the increasing use of remote monitoring technologies to collect patient data and facilitate self-management in individuals outside of hospital clinics. In practice however, application of digital behaviour change interventions is difficult due to insufficient reporting of behaviour change theories in the current literature. When digital technologies are employed to alter behaviour change in osteoarthritis, they often focus on physical activity. Currently, such interventions focus of self-efficacy but do not often explicitly report the behaviour change techniques they use to facilitate these changes.

Methods

This paper proposes a new model of integrating specific behaviour change principles (persuasive design) in an integrated model of remote monitoring and digital behaviour change interventions for osteoarthritis.

Results

There is potential to combine remote monitoring systems of patient data through digital and mobile technologies with behaviour change principles to improve physical activity behaviours in individuals with osteoarthritis. The use of persuasive design principles (e.g. prompts or nudges) through mobile notifications and strategic system design can be directed to enhance behaviour change. A validated measure of behaviour change, such as the patient activation measure, will allow effective evaluation of such systems.

Conclusions

Digital behaviour change interventions should be directed towards the underlying principles of behaviour change they employ, although this is not commonly reported in practice. Such interventions can be integrated within remote monitoring pathways using persuasive design techniques to enhance patient activation. This approach can enhance self-management in individuals with musculoskeletal conditions, such as osteoarthritis.

Assessing Data Adequacy for High Blood Pressure Clinical Decision Support: A Quantitative Analysis

OBJECTIVE

This study examines guideline-based high blood pressure (HBP) and hypertension recommendations and evaluates the suitability and adequacy of the data and logic required for a Fast Healthcare Interoperable Resources (FHIR)-based, patient-facing clinical decision support (CDS) HBP application. HBP is a major predictor of adverse health events, including stroke, myocardial infarction, and kidney disease. Multiple guidelines recommend interventions to lower blood pressure, but implementation requires patient-centered approaches, including patient-facing CDS tools.

METHODS

We defined concept sets needed to measure adherence to 71 recommendations drawn from eight HBP guidelines. We measured data quality for these concepts for two cohorts (HBP screening and HBP diagnosed) from electronic health record (EHR) data, including four use cases (screening, nonpharmacologic interventions, pharmacologic interventions, and adverse events) for CDS.

RESULTS

We identified 102,443 people with diagnosed and 58,990 with undiagnosed HBP. We found that 21/35 (60%) of required concept sets were unused or inaccurate, with only 259 (25.3%) of 1,101 codes used. Use cases showed high inclusion (0.9-11.2%), low exclusion (0-0.1%), and missing patient-specific context (up to 65.6%), leading to data in 2/4 use cases being insufficient for accurate alerting.

DISCUSSION

Data quality from the EHR required to implement recommendations for HBP is highly inconsistent, reflecting a fragmented health care system and incomplete implementation of standard terminologies and workflows. Although imperfect, data were deemed adequate for two test use cases.

CONCLUSION

Current data quality allows for further development of patient-facing FHIR HBP tools, but extensive validation and testing is required to assure precision and avoid unintended consequences.

The Role of Health Care Quality in Hypertension Self-Management: A Qualitative Study of the Experience of Patients in a Public Hospital, North-West Ethiopia

Purpose

Hypertension is becoming a global epidemic in all population groups. For its effective management and control, patients should have enhanced self-management skills and get adequate support from care providers. Although the quality of health care is critical in enhancing self-management behaviors of patients with hypertension, the issue has not been fully explored in the Ethiopian context. Therefore, the purpose of this study was to explore the experience of hypertensive patients on the quality of health care and the self-management practice in a public hospital in North-west Ethiopia.

Patients and Methods

This qualitative study involves a phenomenological approach. Participants were hypertension patients who are on treatment follow-up. They were recruited purposively with maximum variation approach. Eleven in-depth interviews and two key informant interviews were undertaken using a semi-structured interview guide with hypertensive patients and nurses respectively. Interviews were audio recorded, transcribed verbatim, translated into English, and then analyzed thematically by the investigators.

Results

The analysis identified two main themes and seven sub-themes. The first theme “experience in self-management practice” describes medication adherence, lifestyle modification, and self-monitoring of blood pressure. The second theme “experience in the quality of health care” discusses access to health services, patient-centered care, behavior of health care providers, and time and patient flow management.

Conclusion

The self-management practice of hypertensive patients is sub-optimal. Although several individual patient issues were identified, facility-level problems are mainly responsible for poor self-management practice. The main facility-level barriers, as reported by participants, include shortage of medicines, high cost of medicines, busyness of doctors due to high patient load, lack of appropriate education and counseling services, poor patient-provider interaction, and long waiting times. Intervention areas should focus on providing appropriate training for health care providers to enhance the patient–provider relationship. Improving the supply of hypertensive medications is also paramount for better medication adherence.

Patients' Experiences of Using Smartphone Apps to Support Self-Management and Improve Medication Adherence in Hypertension: Qualitative Study

BACKGROUND

Worldwide, hypertension control rates remain suboptimal despite clinically effective antihypertensive drug therapy. Patient failure to take medication as prescribed (ie, nonadherence) is the most important factor contributing to poor control. Smartphone apps can facilitate the delivery of evidence-based behavior change techniques to improve adherence and may provide a scalable, usable, and feasible method to deliver self-management support.

OBJECTIVE

The aim of this study is to explore patients' experiences of the usability and feasibility of smartphone apps to support self-management and improve medication adherence in hypertension.

METHODS

A qualitative descriptive study was conducted. A total of 11 people living with hypertension from the West of Ireland were sampled purposively and interviewed about their experience of using a self-management app for a 4-week period, which included two key functionalities: self-monitoring of blood pressure (BP) and medication reminders. Thematic analysis was carried out on the semistructured interview data.

RESULTS

Participants' age ranged from 43 to 74 years (mean 62 years, SD 9.13). Three themes were identified: digital empowerment of self-management, human versus digital systems, and digital sustainability. Although patients' experience of using the technology to self-monitor BP was one of empowerment, characterized by an enhanced insight and understanding into their condition, control, and personal responsibility, the reminder function was only feasible for patients who reported unintentional nonadherence to treatment. Patients experienced the app as a sustainable tool to support self-management and found it easy to use, including those with limited technological competence.

CONCLUSIONS

The study's findings provide new insights into the experience of using apps to support medication adherence in hypertension. Overall, the data support apps as a usable and feasible method to aid self-management of hypertension and highlight the need for personalized functionality, particularly with regard to medication adherence reminder strategies. The study's findings challenge the perspective that the use of these technologies to support self-management can inevitably add to the burden of treatment experienced by patients.

Adherence with blood pressure monitoring wearable device among the elderly with hypertension: The case of rural China

INTRODUCTION

Wearable blood pressure (BP) monitor devices are increasingly adopted owing to the promotion of hypertension management program. However, little is known about the adherence and its associated factors in older adults (OAs) with hypertension.

METHODS

The aim of this study was to determine factors associated with adherence to wearable BP monitor. In total, 212 OAs with hypertension in a remote rural area in China were asked to wear a BP monitor over 1-month period. The following information on associated factors for adherence was collected, including demographic characteristics, cardiovascular health measurements, technology fluency, the Compliance of Hypertensive Patients' Scale, and the Health-related Quality of Life Survey. As a result, the mean age of the 212 hypertension participants was 71.32 years (SD = 6.81).

RESULTS

During the 30-day survey, 50.94% of the participants with daily recoded BP wristband data were assigned as "BP device users." The binary logistic regression model revealed that lower lifestyle compliance, lower medication compliance and higher total hypertension compliance were significant predictors for adherence. However, there were no differences concerning cardiovascular health factors, technology fluency, and health-related quality of life between device users and nonusers.

CONCLUSION

Individuals reporting a higher level of total compliance in hypertension management were more likely to wear a BP monitor device among OAs with hypertension. In addition, further research is needed to determine how wearable mHealth technology can be used to develop better hypertension self-management education programs for this population.

Users' acceptance of electronic patient portals in Lebanon

Background

Acceptance of Electronic patient portal (EPP) is instrumental for its success. Studies on users’ acceptance in the Middle East region are scarce. This study aims to use the TAM as a framework to quantitatively describe potential users, diabetic and chronic high blood pressure patients and their providers, intention to use and factors influencing the intention to use EPP at AUBMC-FMC We concurrently test the internal construct validity and the reliability of the TAM.

Methods

A cross-sectional survey design and the vignette approach were used. For validation, we needed a minimum of 180 patients; all 35 attending physicians and 11 registered nurses were targeted. We used descriptive statistics to calculate the intention to use EPP and its determinants based on the TAM constructs. Exploratory factor analysis (EFA) and structural equation modeling (SEM) were employed to estimate significant path coefficients for patients only as the sample size of providers was too small.

Results

We had 199 patients, half intended to use EPP; 73% of providers (N = 17) intended to use EPP. Perceived ease of use and privacy concerns were significantly higher among providers than patients (Mean (M) = 0.77 vs M = 0.42 (CI: − 0.623; − 0.081)) and (M = 3.67 vs M = 2.13, CI: − 2.16; − 0.91) respectively; other constructs were not significantly different. Reliability of TAM revealed a Cronbach Alpha of α=.91. EFA showed that three components explained 73.48% of the variance: Behavioral Intention of Use (14.9%), Perceived Ease of Use (50.74%), Perceived Usefulness (7.84%). SEM found that perceived ease of use increased perceived usefulness (standardized regression weight = 0.49); perceived usefulness (0.51) had more predictive value than perceived ease of use (0.27) to explain the behavioral intention of use of the EPP.

Conclusions

We found that providers valued the usefulness of EPP and were mostly intending to use it. This finding has yet to be tested in future studies testing actual use as intention and actual use may not be concordant. The intention to use among patients was lower than those reported in developed countries. We identified two factors that we need to address to increase use, namely perceived ease and usefulness, and proposed practical implications to address them; future research directions were also discussed.

The Potential of mHealth Applications in Improving Resistant Hypertension Self-Assessment, Treatment and Control

PURPOSE OF REVIEW

To review the evidence supporting the use of mobile health (mHealth) apps to improve resistant hypertension self-assessment, treatment and control.

RECENT FINDINGS

mHealth apps have been used to directly measure blood pressure (BP) levels, either using the oscillometric method with automated inflatable cuffs or using pulse wave signals detected by smartphone technology without the need for cuffs. These app-based BP monitors tend to over or underestimate BP levels when compared to a gold standard aneroid sphygmomanometer. However, the differences in BP measurements are within the acceptable range of 5 mmHg pre-defined by the European Society of Hypertension International Protocol Revision 2010. mHealth apps are also used as tools to support physicians in improving hypertension treatment. App-based clinical decision support systems are innovative solutions, in which patient information is entered in the app and management algorithms provide recommendations for hypertension treatment. The use of these apps has been shown to be feasible and easily integrated into the workflow of healthcare professionals, and, therefore particularly useful in resource-limited settings. In addition, apps can be used to improve hypertension control by facilitating regular BP monitoring, communication between patients and health professionals, and patient education; as well as by reinforcing behaviours through reminders, including medication-taking and appointment reminders. Several studies provided evidence supporting the use of apps for hypertension control. Although some of the results are promising, there is still limited evidence on the benefits of using such mHealth tools, as these studies are relatively small and with a short-term duration. Recent research has shown that mHealth apps can be beneficial in terms of improving hypertension self-assessment, treatment and control, being especially useful to help differentiate and manage true and pseudo-resistant hypertension. However, future research, including large-scale randomised clinical trials with user-centred design, is crucial to further evaluate the potential scalability and effectiveness of such mHealth apps in the resistant hypertension context.

Persuasive design features within a consumer-focused eHealth intervention integrated with the electronic health record: A mixed methods study of effectiveness and acceptability

INTRODUCTION

eHealth strategies targeting health-related behaviour often incorporate persuasive software design. To further engage patients with their overall health management, consumer-facing web portals may be integrated with data from one or more care providers. This study aimed to explore effectiveness for healthier behaviour of persuasive design characteristics within a web application integrated with the primary health care electronic record; also patient and general practitioner (GP) preferences for future integrated records.

METHODS

Mixed methods study within the Consumer Navigation of Electronic Cardiovascular Tools randomised controlled trial. Participants were patients with moderate-high risk of cardiovascular disease, and their GPs. Survey and web analytic data were analysed with descriptive statistics. Interview and focus group transcripts were recorded, transcribed, coded and analysed for themes.

RESULTS

Surveys (n = 397) received from patients indicated improved medication adherence (31.8%); improved mental health and well-being (40%); higher physical activity (47%); and healthier eating (61%). Users of the interactive features reported benefiting from personalised cardiovascular disease risk score (73%); goal tracking (69%); risk factor self-monitoring (52%) and receipt of motivational health tips (54%). Focus group and interview participants (n = 55) described customisations that would increase portal appeal and relevance, including more provider interaction. Of the GP survey respondents (n = 38), 74% reported increased patient attendance and engagement with their care. For future integrated portals, 94% of GPs were in favour and key themes among interviewees (n = 17) related to design optimisation, impact on workflow and data security.

CONCLUSION

Intervention features reflecting the persuasive design categories of Primary Task support, Dialogue support and System Credibility support facilitated healthier lifestyle behaviour. Patients valued customisable functions and greater patient-provider interactivity. GPs identified system challenges but saw advantages for patients and the health care relationship. Future studies could further elucidate the persuasive design principles that are at play and which may promote adoption of EHR-integrated consumer portals.

Perceptions and use of technology in older people with ophthalmic conditions

Background: Technologies such as mobile applications are increasingly being developed for patients to help manage their clinical conditions. However there is a paucity of information confirming the capacity or willingness of older patients with ophthalmic complaints to engage with such computer applications. The aim of this paper is to assess the perception and use of a range of common computing technologies by older ophthalmic patients, in order to guide future ophthalmology-specific development and clinical use.

Methods: Patients attending Manchester Royal Eye Hospital were surveyed with questions designed to measure their perceptions, attitudes and experiences of using technology.  Inclusion criteria included any patient aged 40 or over who attended the ophthalmology outpatients department.

Results: A total of 300 patients completed the questionnaire. The male-to-female ratio was 128:169. The majority of patients owned predominantly mobile forms of technology such as tablets and smart phones. The most common uses of technology were for communicating with friends, watching television and gathering information. Patients aged over 80 had particular difficulty using technology and used it less regularly. Less than 10% overall stated eyesight as a reason for stopping using technology.

Conclusions: Technology is used regularly by a large proportion of older ophthalmic patients, with numbers reducing significantly only in those aged 80 years or over. There appears to be potential for further medical use, though developers and clinicians should consider the perceptions and challenges highlighted through this survey.

Integrating Behavioral Science With Mobile (mHealth) Technology to Optimize Health Behavior Change Interventions

Abstract. Recent rapid advances in technology have provided us with a golden opportunity to effect change in health-related outcomes for chronic disease by employing digital technologies to encourage and support behavior change to promote and maintain health. Behavior change theories are the bedrock to developing evidence-based mHealth interventions. Digital technologies enable researchers to empirically test behavioral theories in “real-world” contexts using behavior change techniques ( Hekler, Michie, et al., 2016 ). According to the European Commission (2014) among the world’s population of 7 billion, there are over 5 billion mobile devices and over 90% of the users have their mobile device near them 24 hr a day. This provides a huge opportunity for behavior change and one that health psychologists have already begun to address. However, while a novel and exciting area of research, many early studies have been criticized for lacking a strong evidence base in both design and implementation. The European Commission conducted a public consultation in 2016 on the issues surrounding the use of mHealth tools (e.g., apps) and found a lack of global standards was a significant barrier. Recently, the World Health Organization (WHO) mHealth Technical Evidence Review Group developed the mHealth evidence reporting and assessment (mERA) checklist for specifying the content of mHealth interventions. Health psychologists play a key role in developing mHealth interventions, particularly in the management of chronic disease. This article discusses current challenges facing widespread integration of mobile technology into self-management of chronic disease including issues around security and regulation, as well as investigating mechanisms to overcoming these barriers.

New self-management technologies for the treatment of hypertension: general practitioners' perspectives

BACKGROUND

Digital health interventions, such as those that can be delivered via smartphone applications (apps) or wireless blood pressure monitors, offer a new, scalable and potentially cost-effective way to improve hypertension self-management. In Ireland, as is common in the UK, the majority of hypertension management occurs in general practice. Therefore, it is crucial to investigate how general practitioners (GPs) feel about and engage with the growth of these new methods of self-management of blood pressure.

AIM

To explore GPs' perspectives of self-management technology to support medication adherence and blood pressure control in patients with hypertension.

DESIGN AND SETTING

This was a qualitative interview study based in the West of Ireland. Ten GPs who were purposively sampled participated in semi-structured interviews. Thematic analysis was carried out on the data.

RESULTS

Three major themes were identified: current reach and future potential, empowerment and responsibility.

CONCLUSIONS

GPs could see the benefit of using these technologies, such as more accurate blood pressure data and potential to engage patients in self-management. Concerns relating to the increased workload associated with a potentially unmanageable quantity of information and an increase in healthcare use among the 'worried well' also emerged strongly from the data.

Experiences of Using Web-Based and Mobile Technologies to Support Self-Management of Type 2 Diabetes: Qualitative Study

Background

The prevalence of type 2 diabetes is rising, placing increasing strain on health care services. Web-based and mobile technologies can be an important source of information and support for people with type 2 diabetes and may prove beneficial with respect to reducing complications due to mismanagement. To date, little research has been performed to gain an insight into people’s perspectives of using such technologies in their daily management.

Objective

The purpose of this study was to understand the impact of using Web-based and mobile technologies to support the management of type 2 diabetes.

Methods

In-depth interviews were conducted with 15 people with type 2 diabetes to explore experiences of using Web-based and mobile technologies to manage their diabetes. Transcripts were analyzed using the framework method.

Results

Technology supported the users to maintain individualized and tailored goals when managing their health. A total of 7 themes were identified as important to participants when using technology to support self-management: (1) information, (2) understanding individual health and personal data, (3) reaching and sustaining goals, (4) minimizing disruption to daily life, (5) reassurance, (6) communicating with health care professionals, and (7) coordinated care.

Conclusions

Patients need to be supported to manage their condition to improve well-being and prevent diabetes-related complications from arising. Technologies enabled the users to get an in-depth sense of how their body reacted to both lifestyle and medication factors—something that was much more difficult with the use of traditional standardized information alone. It is intended that the results of this study will inform a new questionnaire designed to assess self-management in people using Web-based and mobile technology to manage their health.

Intervention planning for a digital intervention for self-management of hypertension: a theory-, evidence- and person-based approach

Background

This paper describes the intervention planning process for the Home and Online Management and Evaluation of Blood Pressure (HOME BP), a digital intervention to promote hypertension self-management. It illustrates how a Person-Based Approach can be integrated with theory- and evidence-based approaches. The Person-Based Approach to intervention development emphasises the use of qualitative research to ensure that the intervention is acceptable, persuasive, engaging and easy to implement.

Methods

Our intervention planning process comprised two parallel, integrated work streams, which combined theory-, evidence- and person-based elements. The first work stream involved collating evidence from a mixed methods feasibility study, a systematic review and a synthesis of qualitative research. This evidence was analysed to identify likely barriers and facilitators to uptake and implementation as well as design features that should be incorporated in the HOME BP intervention. The second work stream used three complementary approaches to theoretical modelling: developing brief guiding principles for intervention design, causal modelling to map behaviour change techniques in the intervention onto the Behaviour Change Wheel and Normalisation Process Theory frameworks, and developing a logic model.

Results

The different elements of our integrated approach to intervention planning yielded important, complementary insights into how to design the intervention to maximise acceptability and ease of implementation by both patients and health professionals. From the primary and secondary evidence, we identified key barriers to overcome (such as patient and health professional concerns about side effects of escalating medication) and effective intervention ingredients (such as providing in-person support for making healthy behaviour changes). Our guiding principles highlighted unique design features that could address these issues (such as online reassurance and procedures for managing concerns). Causal modelling ensured that all relevant behavioural determinants had been addressed, and provided a complete description of the intervention. Our logic model linked the hypothesised mechanisms of action of our intervention to existing psychological theory.

Conclusion

Our integrated approach to intervention development, combining theory-, evidence- and person-based approaches, increased the clarity, comprehensiveness and confidence of our theoretical modelling and enabled us to ground our intervention in an in-depth understanding of the barriers and facilitators most relevant to this specific intervention and user population.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0553-4) contains supplementary material, which is available to authorized users.