Effects of a Novel Contextual Just-In-Time Mobile App Intervention (LowSalt4Life) on Sodium Intake in Adults With Hypertension: Pilot Randomized Controlled Trial

Effectiveness of digital health interventions on adherence and control of hypertension: a systematic review and meta-analysis

BACKGROUND

Hypertension, a risk factor for developing cardiovascular disease, is becoming increasingly prevalent worldwide. Digital health is now widely utilized for hypertension management, and numerous studies have assessed its effectiveness.

OBJECTIVE

The review aims to analyse the effectiveness of digital health (i.e., mobile health (mHealth), telehealth, and the combination of mHealth & telehealth) on hypertensive patients, concerning three key areas: clinical outcomes, medication adherence, and adherence to lifestyle changes, as compared to standard care.

METHODS

The review followed the PRISMA framework. Eight electronic databases were scanned for randomized control trials focusing on the effects of mHealth or telehealth on hypertensive patients, published between 2010 and 2023. All processes were conducted by the first two authors independently. A meta-analysis was conducted for quantitative data, while a narrative synthesis was conducted for qualitative data.

RESULTS

In total, 74 studies involving 92 686 participants were identified. The meta-analysis favoured the interventions, revealing a significant decrease in systolic blood pressure and diastolic blood pressure for mHealth, telehealth and mHealth & telehealth groups. Nevertheless, medication adherence showed improvement only in the mHealth group, while blood pressure control showed improvement in both mHealth and mHealth & telehealth groups, and BMI showed improvement only in the mHealth group. Evidence for adherence to physical activity and DASH diet/salt intake remained inconclusive.

CONCLUSION

In general, mHealth and telehealth have demonstrated their merits in improving the clinical outcomes of hypertensive patients.

Evaluation of Daily Eating Patterns on Overall Diet Quality using Decision Tree Analyses

BACKGROUND

Preliminary evidence suggests that meal timing is associated with higher quality diets. Less is known about whether types of food consumed during specific eating episodes (i.e., day-level eating patterns) predict diet quality.

OBJECTIVE

We investigated the association between day-level eating patterns and diet quality.

METHODS

Decision tree models were built using 24-hour dietary recall data from the NHANES 2015 and 2017 cycles in a cross-sectional study. Sixteen food groups and 12 eating episodes (e.g., breakfast, lunch) were included as input parameters. Diet quality was scored using the Healthy Eating Index (HEI)-2020 and categorized as higher or lower quality diets based on the median score. Mean decrease in impurity (MDI) ± standard deviation determined the relative contribution that day-level eating patterns had on diet quality; higher values represented greater contributions.

RESULTS

We analyzed 12,597 dietary recalls from 9,347 U.S. adults who were aged 18 years and older with at least one complete recall. Meals (breakfast, lunch, dinner) and respective snacking episodes had the greatest variety of dietary groups that contributed to the HEI-2020 score. Any whole grain intake at breakfast predicted a higher quality diet (MDI = 0.08 ± 0.00), followed by lower solid fat intake (<8.94 grams; MDI = 0.07 ± 0.00) and any plant protein intake at dinner (MDI = 0.05 ± 0.00).

CONCLUSIONS

Day-level eating patterns were associated with diet quality, emphasizing the relevance of both food type and timing in relation to a high-quality diet. Future interventions should investigate the potential impact of targeting food type and timing to improve diet quality.

Effect of m-Health-Based Interventions on Blood Pressure: An Updated Systematic Review with Meta-Analysis

Background: In recent years, the integration of mobile health (m-Health) interventions has garnered increasing attention as a potential means to improve blood pressure (BP) management in adults. This updated systematic review with meta-analysis aimed to identify the effect of m-Health-based interventions on BP in adults and to evaluate the effect of m-Health on BP according to the characteristics of subjects, interventions, and countries. Methods: The search was carried out in PubMed, Embase, ResearchGate, and Cochrane databases in January 2022. Study selection and data extraction were performed by two independent reviewers. For analysis, random effects models were used with a confidence interval (CI) of 95% and p < 0.05. Results: Fifty studies were included in this review and in the meta-analysis. Interventions with m-Health reduced systolic BP in 3.5 mmHg (95% CI -4.3; -2.7; p < 0.001; I2 = 85.8%) and diastolic BP in 1.8 mmHg (95% CI -2.3; -1.4; p < 0.001; I2 = 78.9%) compared to usual care. The effects of m-Health interventions on BP were more evident in men and in older adults, in interventions lasting 6-8 weeks, with medication reminders, with the possibility of insertion of BP values (p < 0.05). Conclusion: The results of this study support the effectiveness of m-Health in reducing BP when compared to standard care. However, these effects are dependent on the characteristics of the subjects and interventions. Given the substantial heterogeneity among the results of this systematic review with meta-analysis, its interpretation should be cautious. Future research on this topic is warranted.

A Community Participatory Approach to Creating Contextually Tailored mHealth Notifications: myBPmyLife Project

Just-in-time adaptive interventions (JITAIs) are a novel approach to mobile health (mHealth) interventions, sending contextually tailored behavior change notifications to participants when they are more likely to engage, determined by data from wearable devices. We describe a community participatory approach to JITAI notification development for the myBPmyLife Project, a JITAI focused on decreasing sodium consumption and increasing physical activity to reduce blood pressure. Eighty-six participants were interviewed, 50 at a federally qualified health center (FQHC) and 36 at a university clinic. Participants were asked to provide encouraging physical activity and low-sodium diet notifications and provided feedback on researcher-generated notifications to inform revisions. Participant notifications were thematically analyzed using an inductive approach. Participants noted challenging vocabulary, phrasing, and culturally incongruent suggestions in some of the researcher-generated notifications. Community-generated notifications were more direct, used colloquial language, and contained themes of grace. The FQHC participants' notifications expressed more compassion, religiosity, and addressed health-related social needs. University clinic participants' notifications frequently focused on office environments. In summary, our participatory approach to notification development embedded a distinctive community voice within our notifications. Our approach may be generalizable to other communities and serve as a model to create tailored mHealth notifications to their focus population.

Technology-supported behavior change interventions for reducing sodium intake in adults: a systematic review and meta-analysis

The effects of technology-supported behavior change interventions for reducing sodium intake on health outcomes in adults are inconclusive. Effective intervention characteristics associated with sodium reduction have yet to be identified. A systematic review and meta-analysis were conducted, searching randomized controlled trials (RCTs) published between January 2000 and April 2023 across 5 databases (PROSPERO: CRD42022357905). Meta-analyses using random-effects models were performed on 24-h urinary sodium (24HUNa), systolic blood pressure (SBP), and diastolic blood pressure (DBP). Subgroup analysis and meta-regression of 24HUNa were performed to identify effective intervention characteristics. Eighteen RCTs involving 3505 participants (51.5% female, mean age 51.6 years) were included. Technology-supported behavior change interventions for reducing sodium intake significantly reduced 24HUNa (mean difference [MD] -0.39 gm/24 h, 95% confidence interval [CI] -0.50 to -0.27; I2 = 24%), SBP (MD -2.67 mmHg, 95% CI -4.06 to -1.29; I2 = 40%), and DBP (MD -1.39 mmHg, 95% CI -2.31 to -0.48; I2 = 31%), compared to control conditions. Interventions delivered more frequently (≤weekly) were associated with a significantly larger effect size in 24HUNa reduction compared to less frequent interventions (>weekly). Other intervention characteristics, such as intervention delivery via instant messaging and participant-family dyad involvement, were associated with larger, albeit non-significant, effect sizes in 24HUNa reduction when compared to other subgroups. Technology-supported behavior change interventions aimed at reducing sodium intake were effective in reducing 24HUNa, SBP, and DBP at post-intervention. Effective intervention characteristics identified in this review should be considered to develop sodium intake reduction interventions and tested in future trials, particularly for its long-term effects.

Effectiveness and Feasibility of Telehealth-Based Dietary Interventions Targeting Cardiovascular Disease Risk Factors: Systematic Review and Meta-Analysis

BACKGROUND

Telehealth-based dietary interventions were recommended for cardiovascular disease (CVD) management during the COVID-19 pandemic; however, data regarding their effectiveness and feasibility are limited.

OBJECTIVE

We aimed to examine (1) the effectiveness of telehealth-based dietary interventions in improving clinical CVD risk factors and (2) the feasibility of these interventions among individuals with CVD.

METHODS

To conduct this systematic review and meta-analysis of randomized controlled trials (RCTs), 2 investigators searched PubMed, Cochrane Library, Web of Science, and ClinicalTrials.gov databases based on predetermined search terms and included English-language RCTs published between January 2000 and July 2022. The Cochrane Risk of Bias tool was used to assess RCT quality. To evaluate intervention effectiveness, weight, BMI, systolic and diastolic blood pressure, and levels of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, or blood glucose were compared postintervention in telehealth and usual care (UC) groups. Feasibility was determined through the number of participants retained in intervention and UC groups. Pooled data for each CVD outcome were analyzed using a random effects model. Mean difference (MD), standardized MD, or risk ratio were calculated using R software.

RESULTS

A total of 13 RCTs with 3013 participants were included in the analysis to assess the effectiveness and feasibility of telehealth-based dietary interventions among individuals with CVD. Participants had a mean age of 61.0 (SD 3.7) years, and 18.5% (n=559) were women. Approximately one-third of RCTs were conducted in the United States (n=4, 31%). Included studies used telephone, app, text, audio-visual media, or website-based interventions. Of the 13 included studies, 3 were of high quality, 9 were of moderate quality, and only 1 was of low quality. Pooled estimates showed systolic blood pressure (MD -2.74, 95% CI -4.93 to -0.56) and low-density lipoprotein cholesterol (standardized MD -0.11, 95% CI -0.19 to -0.03) to be significantly improved among individuals with CVD as a result of telehealth-based dietary interventions compared to UC. No significant difference in effectiveness was detected for weight, BMI, and levels of diastolic blood pressure, total cholesterol, high-density lipoprotein, and triglycerides between telehealth-based dietary interventions and UC among those with CVD. There was no significant difference between the feasibility of telehealth-based dietary interventions versus UC. Significant I2 indicated moderate to considerable heterogeneity.

CONCLUSIONS

Telehealth-based dietary interventions show promise in addressing CVD risk factors.

A Physical Activity and Diet Just-in-Time Adaptive Intervention to Reduce Blood Pressure: The myBPmyLife Study Rationale and Design

BACKGROUND

Smartphone applications and wearable devices are promising mobile health interventions for hypertension self-management. However, most mobile health interventions fail to use contextual data, potentially diminishing their impact. The myBPmyLife Study is a just-in-time adaptive intervention designed to promote personalized self-management for patients with hypertension.

METHODS AND RESULTS

The study is a 6-month prospective, randomized-controlled, remotely administered trial. Participants were recruited from the University of Michigan Health in Ann Arbor, Michigan or the Hamilton Community Health Network, a federally qualified health center network in Flint, Michigan. Participants were randomized to a mobile application with a just-in-time adaptive intervention promoting physical activity and lower-sodium food choices as well as weekly goal setting or usual care. The mobile study application encourages goal attainment through a central visualization displaying participants' progress toward their goals for physical activity and lower-sodium food choices. Participants in both groups are followed for up for 6 months with a primary end point of change in systolic blood pressure. Exploratory analyses will examine the impact of notifications on step count and self-reported lower-sodium food choices. The study launched on December 9, 2021, with 484 participants enrolled as of March 31, 2023. Enrollment of participants was completed on July 3, 2023. After 6 months of follow-up, it is expected that results will be available in the spring of 2024.

CONCLUSIONS

The myBPmyLife study is an innovative mobile health trial designed to evaluate the effects of a just-in-time adaptive intervention focused on improving physical activity and dietary sodium intake on blood pressure in diverse patients with hypertension.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05154929.

The use of internet-based smartphone apps consistently improved consumers' healthy eating behaviors: a systematic review of randomized controlled trials

Introduction

Digital tools, such as mobile apps and the Internet, are being increasingly used to promote healthy eating habits. However, there has been inconsistent reporting on the effectiveness of smartphones and web-based apps in influencing dietary behaviors. Moreover, previous reviews have been limited in scope, either by focusing on a specific population group or by being outdated. Therefore, the purpose of this review is to investigate the impacts of smartphone- and web-based dietary interventions on promoting healthy eating behaviors worldwide.

Methods

A systematic literature search of randomized controlled trials was conducted using databases such as Google Scholar, PubMed, Global Health, Informit, Web of Science, and CINAHL (EBSCO). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to prepare the entire document. EndNote (version 20) was used for reference management. The risk of bias in the articles was assessed using the "Revised Cochrane Risk of Bias tool for randomized trials (RoB 2.0)" by the Cochrane Collaboration. Narrative synthesis, using text and tables, was used to present the results. The study was registered in PROSPERO under protocol number CRD42023464315.

Results

This review analyzed a total of 39 articles, which consisted of 25 smartphone-based apps and 14 web-based apps. The studies involved a total of 14,966 participants. Out of the 25 studies, 13 (52%) showed that offline-capable smartphone apps are successful in promoting healthier eating habits. The impact of smartphone apps on healthy adults has been inconsistently reported. However, studies have shown their effectiveness in chronically ill patients. Likewise, internet-based mobile apps, such as social media or nutrition-specific apps, have been found to effectively promote healthy eating behaviors. These findings were consistent across 14 studies, which included healthy adults, overweight or obese adults, chronically ill patients, and pregnant mothers.

Conclusion

Overall, the findings suggest that smartphone apps contribute to improving healthy eating behaviors. Both nutrition-specific and social media-based mobile apps consistently prove effective in promoting long-term healthy eating habits. Therefore, policymakers in the food system should consider harnessing the potential of internet-based mobile apps and social media platforms to foster sustainable healthy eating behaviors.

A Behaviorally Informed Mobile App to Improve the Nutritional Quality of Grocery Shopping (SwapSHOP): Feasibility Randomized Controlled Trial

BACKGROUND

Interventions targeting the nutritional quality of grocery shopping have the potential to help improve diet and health outcomes.

OBJECTIVE

This study aims to assess the feasibility and acceptability of receiving advice on healthier food purchases through SwapSHOP, a behaviorally informed smartphone app that allows users to scan barcodes of grocery products from the United Kingdom, providing nutritional information and personalized swap suggestions to encourage healthier purchases.

METHODS

We randomized adult volunteers in a 6-arm parallel-group controlled feasibility trial. Participants used the SwapSHOP app to record their grocery shopping during a 2-week run-in period and were individually randomized in a 3:1 ratio to either intervention or control arms within 3 strata related to a nutrient of concern of their choice: saturated fat (SFA), sugar, or salt. Participants randomized to the intervention received the SwapSHOP app with a healthier swap function, goal setting, and personalized feedback. Participants in the control group were instructed to use a simpler version of the app to log all their food purchases without receiving any guidance or advice. The primary outcome was the feasibility of progression to a full trial, including app use and follow-up rates at 6 weeks. The secondary outcomes included other feasibility outcomes, process and qualitative measures, and exploratory effectiveness outcomes to assess changes in the nutrient content of the purchased foods.

RESULTS

A total of 112 participants were randomized into 3 groups: SFA (n=38 intervention and n=13 control), sugar (n=40 intervention and n=15 control), and salt (n=5 intervention and n=1 control, not analyzed). The 2 progression criteria were met for SFA and sugar: 81% (30/37) and 87% (34/39) of intervention participants in the SFA and sugar groups, respectively, used the app to obtain healthier swaps, and 89% (68/76) of intervention participants and 96% (23/24) of control participants completed follow-up by scanning all purchases over the follow-up period. The process and qualitative outcomes suggested that the intervention was acceptable and has the potential to influence shopping behaviors. There were reductions of -0.56 g per 100 g (95% CI -1.02 to -0.19) in SFA and -1 g per 100 g (95% CI -1.97 to -0.03) in total sugars across all food purchases in the intervention groups.

CONCLUSIONS

People were willing to use the SwapSHOP app to help reduce sugar and SFA (but not salt) in their grocery shopping. Adherence and follow-up rates suggest that a full trial is feasible. Given the suggestive evidence indicating that the intervention resulted in reductions in sugars and SFA, a definitive trial is necessary to target improvements in health outcomes.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN13022312; https://doi.org/10.1186/ISRCTN13022312.

Digital Tool-Assisted Hospitalization Detection in the Tailored Antiplatelet Initiation to Lessen Outcomes due to Decreased Clopidogrel Response After Percutaneous Coronary Intervention Study Compared to Traditional Site-Coordinator Ascertainment: Intervention Study

BACKGROUND

Accurate, timely ascertainment of clinical end points, particularly hospitalizations, is crucial for clinical trials. The Tailored Antiplatelet Initiation to Lessen Outcomes Due to Decreased Clopidogrel Response after Percutaneous Coronary Intervention (TAILOR-PCI) Digital Study extended the main TAILOR-PCI trial's follow-up to 2 years, using a smartphone-based research app featuring geofencing-triggered surveys and routine monthly mobile phone surveys to detect cardiovascular (CV) hospitalizations. This pilot study compared these digital tools to conventional site-coordinator ascertainment of CV hospitalizations.

OBJECTIVE

The objectives were to evaluate geofencing-triggered notifications and routine monthly mobile phone surveys' performance in detecting CV hospitalizations compared to telephone visits and health record reviews by study coordinators at each site.

METHODS

US and Canadian participants from the TAILOR-PCI Digital Follow-Up Study were invited to download the Eureka Research Platform mobile app, opting in for location tracking using geofencing, triggering a smartphone-based survey if near a hospital for ≥4 hours. Participants were sent monthly notifications for CV hospitalization surveys.

RESULTS

From 85 participants who consented to the Digital Study, downloaded the mobile app, and had not previously completed their final follow-up visit, 73 (85.8%) initially opted in and consented to geofencing. There were 9 CV hospitalizations ascertained by study coordinators among 5 patients, whereas 8 out of 9 (88.9%) were detected by routine monthly hospitalization surveys. One CV hospitalization went undetected by the survey as it occurred within two weeks of the previous event, and the survey only allowed reporting of a single hospitalization. Among these, 3 were also detected by the geofencing algorithm, but 6 out of 9 (66.7%) were missed by geofencing: 1 occurred in a participant who never consented to geofencing, while 5 hospitalizations occurred among participants who had subsequently turned off geofencing prior to their hospitalization. Geofencing-detected hospitalizations were ascertained within a median of 2 (IQR 1-3) days, monthly surveys within 11 (IQR 6.5-25) days, and site coordinator methods within 38 (IQR 9-105) days. The geofencing algorithm triggered 245 notifications among 39 participants, with 128 (52.2%) from true hospital presence and 117 (47.8%) from nonhospital health care facility visits. Additional geofencing iterative improvements to reduce hospital misidentification were made to the algorithm at months 7 and 12, elevating the rate of true alerts from 35.4% (55 true alerts/155 total alerts before month 7) to 78.7% (59 true alerts/75 total alerts in months 7-12) and ultimately to 93.3% (14 true alerts/5 total alerts in months 13-21), respectively.

CONCLUSIONS

The monthly digital survey detected most CV hospitalizations, while the geofencing survey enabled earlier detection but did not offer incremental value beyond traditional tools. Digital tools could potentially reduce the burden on study coordinators in ascertaining CV hospitalizations. The advantages of timely reporting via geofencing should be weighed against the issue of false notifications, which can be mitigated through algorithmic refinements.

Use of geofencing interventions in population health research: a scoping review

OBJECTIVES

Technological advancements that use global positioning system (GPS), such as geofencing, provide the opportunity to examine place-based context in population health research. This review aimed to systematically identify, assess and synthesise the existing evidence on geofencing intervention design, acceptability, feasibility and/or impact.

DESIGN

Scoping review, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidance for reporting.

DATA SOURCES

PubMed, CINAHL, EMBASE, Web of Science, Cochrane and PsycINFO for articles in English published up to 31 December 2021.

ELIGIBILITY CRITERIA

Articles were included if geofencing was used as a mechanism for intervention delivery.

EXCLUSION CRITERIA

(1) a component or combination of GPS, geographical information system or ecological momentary assessment was used without delivery of an intervention; (2) did not include a health or health-related outcome from the geofencing intervention; or (3) was not a peer-reviewed study.

DATA EXTRACTION AND SYNTHESIS

Several researchers independently reviewed all abstracts and full-text articles for final inclusion.

RESULTS

A total of 2171 articles were found; after exclusions, nine studies were included in the review. The majority were published in 5 years preceding the search (89%). Geofences in most studies (n=5) were fixed and programmed in the mobile application carried by participants without their input. Mechanisms of geofencing interventions were classified as direct or indirect, with five studies (56%) using direct interventions. There were several different health outcomes (from smoking to problematic alcohol use) across the five studies that used a direct geofencing intervention.

CONCLUSIONS

This scoping review found geofencing to be an emerging technology that is an acceptable and feasible intervention applied to several different populations and health outcomes. Future studies should specify the rationale for the locations that are geofenced and user input. Moreover, attention to mechanisms of actions will enable scientists to understand not only whether geofencing is an appropriate and effective intervention but why it works to achieve the outcomes observed.

Assessment of US Food and Drug Administration-Approved Digital Medical Devices for Just-in-Time Interventions: A Systematic Review

Importance

Just-in-time interventions (JITIs) are a type of digital therapeutic intervention that combines remote monitoring tools and algorithms to personalize the delivery of specific interventions at the right time. The US Food and Drug Administration (FDA) regulatory approval documents are often the only available source of information on the effectiveness of therapeutic interventions based on these devices.

Objective

To systematically review the publicly available information from the FDA on all recently approved medical devices used in JITIs to (1) assess how they operate to deliver JITIs and (2) appraise the evidence supporting their performance and clinical effectiveness.

Evidence Review

Two reviewers systematically searched the Premarket Notifications (510(k)), Premarket Approvals, De Novo, and Humanitarian Device Exemption databases from January 2019 to December 2021 for all entries associated with devices that monitored patients' data over time to personalize the delivery of interventions to treat, prevent, or mitigate health conditions or events. They assessed whether the product summaries (1) enabled an understanding of how the device operated to deliver a JITI (eg, the nature, type, and frequency of the monitoring, the nature of the decision algorithm, and the nature and intended receiver of the intervention); (2) informed about the performance and effectiveness of the JITI; and (3) included information on data security and ownership.

Findings

In total, 38 devices were included in this review. These were mainly intended for cardiac conditions (12 [31.6%]), diabetes (10 [26.3%]), and neurological diseases (4 [10.5%]). Monitoring devices ranged from wearable (18 of 28 [64.4%]; eg, smartwatches) to implanted sensors (6 of 28 [21.4%]; eg, inserted electrocardiographic sensors). Only 10 of 38 product summaries (26.3%) allowed a full understanding of how the device operated to deliver a JITI. Similarly, only 12 of 28 (42.9%), 12 of 36 (33.3%), and 5 of 38 (13.2%) reported the assessment of the performance of the monitoring device, assessment of the decision algorithm, and results of clinical studies assessing the effectiveness of the JITI, respectively. Finally, 14 of 36 product summaries (38.9%) included some information on data security, but none included information on data ownership.

Conclusion and Relevance

The results of this systematic review suggest that the information publicly available in the FDA databases on the performance and effectiveness of digital medical devices used in JITIs is heterogeneous.

Impact of mHealth Interventions on Supporting Dietary Adherence in Cardiovascular Disease: A Systematic Review

INTRODUCTION

A systematic review was conducted to determine if mobile health (mHealth) interventions, and which intervention characteristics, effectively support dietary adherence and reduce risk factors in patients with cardiovascular disease (CVD).

METHOD

Using 7 databases, studies involving adult participants with specific CVD diagnoses, mHealth intervention testing, and dietary adherence assessment were identified. Systematic reviews, qualitative studies, or studies testing interventions involving open dialogue between participants and health care providers or researchers were excluded. Two independent reviewers conducted screening and assessed the risk of bias.

RESULTS

Thirteen studies involved participants with prehypertension (n = 1), hypertension (n = 9), coronary artery disease (n = 2), and heart failure (n = 1). mHealth interventions in 8 studies improved dietary adherence, 4 showed mixed results, and 1 showed no improvements. Eight studies found interactive text and/or application-based mHealth intervention features effectively improved dietary adherence. One study had a low risk of bias, 2 had some concerns/moderate risk, and 10 had a high/critical or serious risk.

DISCUSSION

In most included studies, mHealth interventions positively impacted dietary adherence for patients with CVD.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Clinicians may recommend mHealth interventions to support nutrition education and self-management for their patients with CVD.

Effectiveness, reach, uptake, and feasibility of digital health interventions for adults with hypertension: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Digital health interventions are effective for hypertension self-management, but a comparison of the effectiveness and implementation of the different modes of interventions is not currently available. This study aimed to compare the effectiveness of SMS, smartphone application, and website interventions on improving blood pressure in adults with hypertension, and to report on their reach, uptake, and feasibility.

METHODS

In this systematic review and meta-analysis we searched CINAHL Complete, Cochrane Central Register of Controlled Trials, Ovid Embase, Ovid MEDLINE, and APA PsycInfo on May 25, 2022, for randomised controlled trials (RCTs) published in English from Jan 1, 2009, that examined the effectiveness of digital health interventions on reducing blood pressure in adults with hypertension. Screening was carried out using Covidence, and data were extracted following Cochrane's guidelines. The primary endpoint was change in the mean of systolic blood pressure. Risk of bias was assessed with Cochrane Risk of Bias 2. Data on systolic and diastolic blood pressure reduction were synthesised in a meta-analysis, and data on reach, uptake and feasibility were summarised narratively. Grading of Recommendations, Assessment, Development, and Evaluation criteria were used to evaluate the level of evidence. The study was registered with PROSPERO CRD42021247845.

FINDINGS

Of the 3235 records identified, 29 RCTs from 13 regions (n=7592 participants) were included in the systematic review, and 28 of these RCTs (n=7092 participants) were included in the meta-analysis. 11 studies used SMS as the primary mode of delivery of the digital health intervention, 13 used smartphone applications, and five used websites. Overall, digital health intervention group participants had a -3·62 mm Hg (95% CI -5·22 to -2·02) greater reduction in systolic blood pressure, and a -2·45 mm Hg (-3·83 to -1·07) greater reduction in diastolic blood pressure, compared with control group participants. No statistically significant differences between the three different modes of delivery were observed for both the systolic (p=0·73) and the diastolic blood pressure (p=0·80) outcomes. Smartphone application interventions had a statistically significant reduction in diastolic blood pressure (-2·45 mm Hg [-4·15 to -0·74]); however, there were no statistically significant reductions for SMS interventions (-1·80 mm Hg [-4·60 to 1·00]) or website interventions (-3·43 mm Hg [-7·24 to 0·38]). Due to the considerable heterogeneity between included studies and the high risk of bias in some, the level of evidence was assigned a low overall score. Interventions were more effective among people with greater severity of hypertension at baseline. SMS interventions reported higher reach and smartphone application studies reported higher uptake, but differences were not statistically significant.

INTERPRETATION

SMS, smartphone application, and website interventions were associated with statistically and clinically significant systolic and diastolic blood pressure reductions, compared with usual care, regardless of the mode of delivery of the intervention. This conclusion is tempered by the considerable heterogeneity of included studies and the high risk of bias in most. Future studies need to describe in detail the mediators and moderators of the effectiveness and implementation of these interventions, to both further improve their effectiveness as well as increase their reach, uptake, and feasibility.

FUNDING

European Union's Horizon 2020 Research and Innovation Programme.

Using a complexity science approach to evaluate the effectiveness of just-in-time adaptive interventions: A meta-analysis

Objective

Just-in-time adaptive interventions (JITAIs), which allow individuals to receive the right amount of tailored support at the right time and place, hold enormous potential for promoting behavior change. However, research on JITAIs' implementation and evaluation is still in its early stages, and more empirical evidence is needed. This meta-analysis took a complexity science approach to evaluate the effectiveness of JITAIs that promote healthy behaviors and assess whether key design principles can increase JITAIs' impacts.

Methods

We searched five databases for English-language papers. Study eligibility required that interventions objectively measured health outcomes, had a control condition or pre-post-test design, and were conducted in the real-world setting. We included randomized and non-randomized trials. Data extraction encompassed interventions' features, methodologies, theoretical foundations, and delivery modes. RoB 2 and ROBINS-I were used to assess risk of bias.

Results

The final analysis included 21 effect sizes with 592 participants. All included studies used pre- and post-test design. A three-level random meta-analytic model revealed a medium effect of JITAIs on objective behavior change (g = 0.77 (95% confidence interval (CI); 0.32 to 1.22), p < 0.001). The summary effect was robust to bias. Moderator analysis indicated that design principles, such as theoretical foundations, targeted behaviors, and passive or active assessments, did not moderate JITAIs' effects. Passive assessments were more likely than a combination of passive and active assessments to relate to higher intervention retention rates.

Conclusions

This review demonstrated some evidence for the efficacy of JITAIs. However, high-quality randomized trials and data on non-adherence are needed.

Effectiveness of dietary interventions delivered by digital health to adults with chronic conditions: Systematic review and meta-analysis

BACKGROUND

Digital health interventions may facilitate management of chronic conditions; however, no reviews have systematically assessed the effectiveness of dietary interventions delivered by digital health platforms for improving dietary intake and clinical outcomes for adults with diet-related chronic conditions.

METHODS

Databases CINAHL, CENTRAL, Embase and MEDLINE were searched from inception to April 2021 to identify controlled trials for dietary education delivered by digital health (mobile or electronic health) to adults with diet-related chronic conditions. Random effects analysis was performed for diet quality, food groups, nutrients and clinical outcomes. Screening, data extraction and quality checking were completed in duplicate.

RESULTS

Thirty-nine studies were included involving 7333 participants. Significant changes were found for Mediterranean diet adherence score (standardised mean difference [SMD] = 0.79; 95% confidence interval [CI] = 0.18 to 1.40), overall fruit and vegetable intake (mean difference [MD]: 0.63 serves/day; 95% CI = 0.27-0.98), fruit intake alone (MD = 0.58 serves/day; 95% CI = 0.39 to 0.77) and sodium intake (SMD = -0.22; 95% CI = -0.44 to -0.01). Improvements were also found for waist circumference [MD = -2.24 centimetres; 95% CI = -4.14 to -0.33], body weight (MD = -1.94 kg; 95% CI = -2.63 to -1.24) and haemoglobin A1c (MD = -0.17%; 95% CI = -0.29 to -0.04). Validity of digital assessment tools to measure dietary intake were not reported. The quality of evidence was considered to have low to moderate certainty.

CONCLUSIONS

Modest improvements in diet and clinical outcomes may result from intervention via digital health for those with diet-related chronic conditions. However, additional robust trials with better reporting of digital dietary assessment tools are needed to support implementation within clinical practice.

Effect of salt reduction interventions in lowering blood pressure: A comprehensive systematic review and meta-analysis of controlled clinical trials

BACKGROUND

Excessive salt intake results in hypertension (HTN), which is a major risk factor for cardiovascular disease (CVD). This review and meta-analysis aimed to evaluate the effect of salt reduction interventions on systolic blood pressure (SBP) and diastolic blood pressure (DBP).

METHODS

Studies were identified via systematic searches of the databases, including PubMed, Embase, Scopus, and Web of Science. All the studies examining the effectiveness of salt reduction interventions on blood pressure (BP), regardless of age, sex, and HTN status, were included in the systematic review, and eligible studies were used in the meta-analysis. A random-effect model was applied for quantitative data synthesis.

RESULTS

A total of 50 trials extracted from 40 articles (21 trials on nutrition education,10 on self-help materials,17 on salt substitutes, and 2 on food reformulation) were included in the systematic review. The pooled results of 44 eligible trials showed that salt substitution and nutrition education interventions had significant effects on both SBP (WMD: -7.44 mmHg, P<0.001 and WMD: -2.75 mmHg, P<0.001, respectively), and DBP (WMD: -3.77 mmHg, P<0.001 and WMD: -2.11 mmHg, P<0.001, respectively). Furthermore, using self-help materials led to a significant reduction in SBP among subjects aged 25-60 years (WMD: -2.60 mmHg, P = 0.008); it also decreased both SBP and DBP among those who were hypertensive (WMD: -3.87 mmHg, P = 0.003 and WMD: -2.91 mmHg, P<0.001, respectively).

CONCLUSION

Our results supported that salt substitution and nutrition education are effective nutrition strategies to lower BP. It seems that multi-component approaches could be more effective in improving BP status. However, further trials are required.

An Overview of Innovative Approaches to Support Timely and Agile Health Communication Research and Practice

Innovative approaches are needed to make health communication research and practice more timely, responsive, and effective in a rapidly changing information ecosystem. In this paper we provide an overview of strategies that can enhance the delivery and effectiveness of health communication campaigns and interventions, as well as research approaches that can generate useful data and insights for decisionmakers and campaign designers, thereby reducing the research-to-practice gap. The discussion focuses on the following approaches: digital segmentation and microtargeting, social media influencer campaigns, recommender systems, adaptive interventions, A/B testing, efficient message testing protocols, rapid cycle iterative message testing, megastudies, and agent-based modeling. For each method highlighted, we also outline important practical and ethical considerations for utilizing the approach in the context of health communication research and practice, including issues related to transparency, privacy, equity, and potential for harm.

The Association Between Smartphone App–Based Self-monitoring of Hypertension-Related Behaviors and Reductions in High Blood Pressure: Systematic Review and Meta-analysis

Background

Self-monitoring of behavior can support lifestyle modifications; however, we do not know whether such interventions are effective in supporting positive changes in hypertension-related health behaviors and thus in reducing blood pressure in patients treated for hypertension.

Objective

This systematic literature review evaluates the extent to which smartphone app–based self-monitoring of health behavior supports reductions in blood pressure and changes in hypertension-related behaviors. It also explores the behavioral components that might explain intervention effectiveness.

Methods

A systematic search of 7 databases was conducted in August 2021. Article screening, study and intervention coding, and data extraction were completed independently by reviewers. The search strategy was developed using keywords from previous reviews and relevant literature. Trials involving adults, published after the year 2000, and in the English language were considered for inclusion. The random-effects meta-analysis method was used to account for the distribution of the effect across the studies.

Results

We identified 4638 articles, of which 227 were included for full-text screening. A total of 15 randomized controlled trials were included in the review. In total, 7415 patients with hypertension were included in the meta-analysis. The results indicate that app-based behavioral self-monitoring interventions had a small but significant effect in reducing systolic blood pressure (SBP), on average, by 1.64 mmHg (95% CI 2.73-0.55, n=7301; odds ratio [OR] 1.60, 95% CI 0.74-3.42, n=114) and in improving changes in medication adherence behavior (standardized mean difference [SMD] 0.78, 95% CI 0.22-1.34) compared to usual care or minimal intervention. The review found the intervention had a small effect on supporting improvements in healthy diet by changing habits related to high sodium food (SMD –0.44, 95% CI –0.79 to –0.08) and a trend, although insignificant, toward supporting smoking cessation, low alcohol consumption, and better physical activity behaviors. A subgroup analysis found that behavioral self-monitoring interventions combined with tailored advice resulted in higher and significant changes in both SBP and diastolic blood pressure (DBP) in comparison to those not providing tailored advice (SBP: –2.92 mmHg, 95% CI –3.94 to –1.90, n=3102 vs –0.72 mmHg, 95% CI –1.67 to 0.23, n=4199, χ²=9.65, P=.002; DBP: –2.05 mmHg, 95% CI –3.10 to –1.01, n=968 vs 1.54 mmHg, 95% CI –0.53 to 3.61, n=400, χ²=9.19, P=.002).

Conclusions

Self-monitoring of hypertension-related behaviors via smartphone apps combined with tailored advice has a modest but potentially clinically significant effect on blood pressure reduction. Future studies could use rigorous methods to explore its effects on supporting changes in both blood pressure and hypertension-related health behaviors to inform recommendations for policy making and service provision.

Trial Registration

PROSPERO CRD42019136158; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=136158

EatWellNow: Formative Development of a Place-Based Behavioral "Nudge" Technology Intervention to Promote Healthier Food Purchases among Army Soldiers

Approximately 17% of military service members are obese. Research involving army soldiers suggests a lack of awareness of healthy foods on post. Innovative approaches are needed to change interactions with the military food environment. Two complementary technological methods to raise awareness are geofencing (deliver banner ads with website links) and Bluetooth beacons (real-time geotargeted messages to mobile phones that enter a designated space). There is little published literature regarding the feasibility of this approach to promote healthy behaviors in retail food environments. Thus, we conducted a formative feasibility study of a military post to understand the development, interest in, and implementation of EatWellNow, a multi-layered interactive food environment approach using contextual messaging to improve food purchasing decisions within the military food environment. We measured success based on outcomes of a formative evaluation, including process, resources, management, and scientific assessment. We also report data on interest in the approach from a Fort Bragg community health assessment survey (n = 3281). Most respondents agreed that they were interested in receiving push notifications on their phone about healthy options on post (64.5%) and that receiving these messages would help them eat healthier (68.3%). EatWellNow was successfully developed through cross-sector collaboration and was well received in this military environment, suggesting feasibility in this setting. Future work should examine the impact of EatWellNow on military service food purchases and dietary behaviors.

A Physical Activity Just-in-time Adaptive Intervention Designed in Partnership With a Predominantly Black Community: Virtual, Community-Based Participatory Design Approach

Background

Black people are disproportionally impacted by hypertension. New approaches for encouraging healthy lifestyles are needed to reduce hypertension and promote health equity in Black communities.

Objective

In this report, we describe the early-stage, virtual design of a just-in-time adaptive intervention (JITAI) to increase physical activity in partnership with members of a low-income, predominantly Black community.

Methods

The hallmark of JITAIs is highly contextualized mobile app push notifications. Thus, understanding participants' context and determinants of physical activity are critical. During the height of the COVID-19 pandemic, we conducted virtual discovery interviews and analysis guided by the Behavior Change Wheel (which focuses on participants' capacity, opportunity, and motivation to engage in physical activity), as well as empathy mapping. We then formed a community-academic participatory design team that partnered in the design sprint, storyboarding, and paper prototyping.

Results

For this study, 5 community members participated in the discovery interviews, 12 stakeholders participated in the empathy mapping, 3 community members represented the community on the design team, and 10 community members provided storyboard or paper prototyping feedback. Only one community member had used videoconferencing prior to partnering with the academic team, and none had design experience. A set of 5 community-academic partner design principles were created: (1) keep users front and center, (2) tailor to the individual, (3) draw on existing motivation, (4) make physical activity feel approachable, and (5) make data collection transparent yet unobtrusive. To address community-specific barriers, the community-academic design team decided that mobile app push notifications will be tailored to participants’ baseline mobility level and community resources (eg, local parks and events). Push notifications will also be tailored based on the day (weekday versus weekend), time of day, and weather. Motivation will be enhanced via adaptive goal setting with supportive feedback and social support via community-generated notifications.

Conclusions

We completed early-stage virtual design of a JITAI in partnership with community participants and a community design team with limited design and videoconferencing experience. We found that designing JITAIs with the community enables these interventions to address community-specific needs, which may lead to a more meaningful impact on users' health.

Interventions That Successfully Reduced Adults Salt Intake-A Systematic Review

Background: Adequate sodium intake is important for lowering blood pressure and thus reducing cardiovascular disease risk and other complications. The aim of this review is to identify recent interventions around the world that have been successful in reducing salt intake. Methods: A search in the PubMed, Web of Science and Scopus databases was performed. We include studies published in the last 10 years; randomized trials, pilot intervention without a control arm or experimental study; adult participants; and interventions that successfully reduced salt intake. Study quality was assessed. Results: We included 21 studies, 16 randomized intervention trials and five nonrandomized intervention studies. Eleven interventions described health and nutritional education, seven interventions described nutritional education plus other interventions, and three studies used salt meters to reduce sodium intake. Conclusion: Health and nutritional education, nutritional education plus other interventions and estimates of salt intake showed success in the reduction of salt consumption. There is no evidence that one type of intervention analyzed is more effective than other in reducing salt consumption, so we must analyze each in which individuals or subpopulations will have the intervention performed and use the most suitable approaches to lead to better results.

Reducing salt intake: a systematic review and meta-analysis of behavior change interventions in adults

CONTEXT

Prolonged high salt (sodium) intake can increase the risk of hypertension and cardiovascular disease. Behavioral interventions may help reduce sodium intake at the population level.

OBJECTIVE

The effectiveness of behavior change interventions to reduce sodium intake in adults was investigated in this systematic review and meta-analysis.

DATA SOURCE

The PubMed, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and EMBASE databases were searched.

DATA EXTRACTION

Narrative synthesis and random-effects meta-analyses were used to determine intervention efficacy. A total of 61 trials (46 controlled trials and 15 quasi-experimental studies) were included.

RESULTS

Behavior change interventions resulted in significant improvements in salt consumption behavior (eg, decrease in purchase of salty foods; increase in use of salt substitutes), leading to reductions in sodium intake as measured by urinary sodium in 32 trials (N = 7840 participants; mean difference, -486.19 mg/d [95%CI, -669.44 to -302.95]; P < 0.001; I2 = 92%) and dietary sodium in 19 trials (N = 3750 participants; mean difference -399.86 mg/d [95%CI, -581.51 to -218.20]; P < 0.001; I2 = 96%), equivalent to a reduction of >1 g of salt intake daily. Effects were not significantly different based on baseline sodium intakes, blood pressure status, disease status, the use of behavior change theories, or the main method of intervention delivery (ie, online vs face-to-face).

CONCLUSION

Behavior change interventions are effective at improving salt consumption practices and appear to reduce salt intake by >1 g/d.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020185639.

The Effects of the ManageHF4Life Mobile App on Patients With Chronic Heart Failure: Randomized Controlled Trial

Background

The successful management of heart failure (HF) involves guideline-based medical therapy as well as self-management behavior. As a result, the management of HF is moving toward a proactive real-time technological model of assisting patients with monitoring and self-management.

Objective

The aim of this paper was to evaluate the efficacy of enhanced self-management via a mobile app intervention on health-related quality of life, self-management, and HF readmissions.

Methods

A single-center randomized controlled trial was performed. Participants older than 45 years and admitted for acute decompensated HF or recently discharged in the past 4 weeks were included. The intervention group (“app group”) used a mobile app, and the intervention prompted daily self-monitoring and promoted self-management. The control group (“no-app group”) received usual care. The primary outcome was the change in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score from baseline to 6 and 12 weeks. Secondary outcomes were the Self-Care Heart Failure Index (SCHFI) questionnaire score and recurrent HF admissions.

Results

A total of 83 participants were enrolled and completed all baseline assessments. Baseline characteristics were similar between the groups except for the prevalence of ischemic HF. The app group had a reduced MLHFQ at 6 weeks (mean 37.5, SD 3.5 vs mean 48.2, SD 3.7; P=.04) but not at 12 weeks (mean 44.2, SD 4 vs mean 45.9, SD 4; P=.78), compared to the no-app group. There was no effect of the app on the SCHFI at 6 or 12 weeks. The time to first HF readmission was not statistically different between the app group and the no-app group (app group 11/42, 26% vs no-app group 12/41, 29%; hazard ratio 0.89, 95% CI 0.39-2.02; P=.78) over 12 weeks.

Conclusions

The adaptive mobile app intervention, which focused on promoting self-monitoring and self-management, improved the MLHFQ at 6 weeks but did not sustain its effects at 12 weeks. No effect was seen on HF self-management measured by self-report. Further research is needed to enhance engagement in the app for a longer period and to determine if the app can reduce HF readmissions in a larger study.

Trial Registration

ClinicalTrials.gov NCT03149510; https://clinicaltrials.gov/ct2/show/NCT03149510

A Mobile Health Salt Reduction Intervention for People With Hypertension: Results of a Feasibility Randomized Controlled Trial

BACKGROUND

A high-salt diet is a risk factor for hypertension and cardiovascular disease; therefore, reducing dietary salt intake is a key part of prevention strategies. There are few effective salt reduction interventions suitable for delivery in the primary care setting, where the majority of the management and diagnosis of hypertension occurs.

OBJECTIVE

The aim of this study is to assess the feasibility of a complex behavioral intervention to lower salt intake in people with elevated blood pressure and test the trial procedures for a randomized controlled trial to investigate the intervention's effectiveness.

METHODS

This feasibility study was an unblinded, randomized controlled trial of a mobile health intervention for salt reduction versus an advice leaflet (control). The intervention was developed using the Behavior Change Wheel and comprised individualized, brief advice from a health care professional with the use of the SaltSwap app. Participants with an elevated blood pressure recorded in the clinic were recruited through primary care practices in the United Kingdom. Primary outcomes assessed the feasibility of progression to a larger trial, including follow-up attendance, fidelity of intervention delivery, and app use. Secondary outcomes were objectively assessed using changes in salt intake (measured via 24-hour urine collection), salt content of purchased foods, and blood pressure. Qualitative outcomes were assessed using the think-aloud method, and the process outcomes were evaluated.

RESULTS

A total of 47 participants were randomized. All progression criteria were met: follow-up attendance (45/47, 96%), intervention fidelity (25/31, 81%), and app use (27/31, 87%). There was no evidence that the intervention significantly reduced the salt content of purchased foods, salt intake, or blood pressure; however, this feasibility study was not powered to detect changes in secondary outcomes. Process and qualitative outcomes demonstrated that the trial design was feasible and the intervention was acceptable to both individuals and practitioners and positively influenced salt intake behaviors.

CONCLUSIONS

The intervention was acceptable and feasible to deliver within primary care; the trial procedures were practicable, and there was sufficient signal of potential efficacy to change salt intake. With some improvements to the intervention app, a larger trial to assess intervention effectiveness for reducing salt intake and blood pressure is warranted.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN): 20910962; https://www.isrctn.com/ISRCTN20910962.