How Behavior Change Strategies are Used to Design Digital Interventions to Improve Medication Adherence and Blood Pressure Among Patients With Hypertension: Systematic Review

Improving medication adherence in cardiovascular disease

Non-adherence to medication is a global health problem with far-reaching individual-level and population-level consequences but remains unappreciated and under-addressed in the clinical setting. With increasing comorbidity and polypharmacy as well as an ageing population, cardiovascular disease and medication non-adherence are likely to become increasingly prevalent. Multiple methods for detecting non-adherence exist but are imperfect, and, despite emerging technology, a gold standard remains elusive. Non-adherence to medication is dynamic and often has multiple causes, particularly in the context of cardiovascular disease, which tends to require lifelong medication to control symptoms and risk factors in order to prevent disease progression. In this Review, we identify the causes of medication non-adherence and summarize interventions that have been proven in randomized clinical trials to be effective in improving adherence. Practical solutions and areas for future research are also proposed.

Effects of a medication adherence app among medically underserved adults with chronic illness: a randomized controlled trial

For individuals living with a chronic illness who require use of long-term medications, adherence is a vital aspect of successful symptom management and outcomes. This study investigated the effect of a smartphone app on adherence, self-efficacy, knowledge, and medication social support in a medically underserved adult population with various chronic illnesses. Participants were randomized to a group who used the app for one month or a control group provided with a printed medication list. Compared to the control group, participants receiving the intervention had significantly greater medication adherence (Cohen's d = -0.52, p = .014) and medication self-efficacy (Cohen's d = 0.43, p = .035). No significant effects were observed related to knowledge or social support. The findings suggest use of the app could positively impact chronic disease management in a medically underserved population in the United States.

Development of a Health Behavioral Digital Intervention for Patients With Hypertension Based on an Intelligent Health Promotion System and WeChat: Randomized Controlled Trial

BACKGROUND

The effectiveness of timely medication, physical activity (PA), a healthy diet, and blood pressure (BP) monitoring for promoting health outcomes and behavioral changes among patients with hypertension is supported by a substantial amount of literature, with "adherence" playing a pivotal role. Nevertheless, there is a lack of consistent evidence regarding whether digital interventions can improve adherence to healthy behaviors among individuals with hypertension.

OBJECTIVE

The aim was to develop a health behavioral digital intervention for hypertensive patients (HBDIHP) based on an intelligent health promotion system and WeChat following the behavior change wheel (BCW) theory and digital micro-intervention care (DMIC) model and assess its efficacy in controlling BP and improving healthy behavior adherence.

METHODS

A 2-arm, randomized trial design was used. We randomly assigned 68 individuals aged >60 years with hypertension in a 1:1 ratio to either the control or experimental group. The digital intervention was established through the following steps: (1) developing digital health education materials focused on adherence to exercise prescriptions, Dietary Approaches to Stop Hypertension (DASH), prescribed medication, and monitoring of BP; (2) using the BCW theory to select behavior change techniques; (3) constructing the intervention's logic following the guidelines of the DMIC model; (4) creating an intervention manual including the aforementioned elements. Prior to the experiment, participants underwent physical examinations at the community health service center's intelligent health cabin and received intelligent personalized health recommendations. The experimental group underwent a 12-week behavior intervention via WeChat, while the control group received routine health education and a self-management manual. The primary outcomes included BP and adherence indicators. Data analysis was performed using SPSS, with independent sample t tests, chi-square tests, paired t tests, and McNemar tests. A P value <.05 was considered statistically significant.

RESULTS

The final analysis included 54 participants with a mean age of 67.24 (SD 4.19) years (n=23 experimental group, n=31 control group). The experimental group had improvements in systolic BP (-7.36 mm Hg, P=.002), exercise time (856.35 metabolic equivalent [MET]-min/week, P<.001), medication adherence (0.56, P=.001), BP monitoring frequency (P=.02), and learning performance (3.23, P<.001). Both groups experienced weight reduction (experimental: 1.2 kg, P=.002; control: 1.11 kg, P=.009) after the intervention. The diet types and quantities for both groups (P<.001) as well as the subendocardial viability ratio (0.16, P=.01) showed significant improvement. However, there were no statistically significant changes in other health outcomes.

CONCLUSIONS

The observations suggest our program may have enhanced specific health outcomes and adherence to health behaviors in older adults with hypertension. However, a longer-term, larger-scale trial is necessary to validate the effectiveness.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200062643; https://www.chictr.org.cn/showprojEN.html?proj=172782.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/46883.

Applications of Clinical Decision Support Systems in Diabetes Care: Scoping Review

BACKGROUND

Providing comprehensive and individualized diabetes care remains a significant challenge in the face of the increasing complexity of diabetes management and a lack of specialized endocrinologists to support diabetes care. Clinical decision support systems (CDSSs) are progressively being used to improve diabetes care, while many health care providers lack awareness and knowledge about CDSSs in diabetes care. A comprehensive analysis of the applications of CDSSs in diabetes care is still lacking.

OBJECTIVE

This review aimed to summarize the research landscape, clinical applications, and impact on both patients and physicians of CDSSs in diabetes care.

METHODS

We conducted a scoping review following the Arksey and O'Malley framework. A search was conducted in 7 electronic databases to identify the clinical applications of CDSSs in diabetes care up to June 30, 2022. Additional searches were conducted for conference abstracts from the period of 2021-2022. Two researchers independently performed the screening and data charting processes.

RESULTS

Of 11,569 retrieved studies, 85 (0.7%) were included for analysis. Research interest is growing in this field, with 45 (53%) of the 85 studies published in the past 5 years. Among the 58 (68%) out of 85 studies disclosing the underlying decision-making mechanism, most CDSSs (44/58, 76%) were knowledge based, while the number of non-knowledge-based systems has been increasing in recent years. Among the 81 (95%) out of 85 studies disclosing application scenarios, the majority of CDSSs were used for treatment recommendation (63/81, 78%). Among the 39 (46%) out of 85 studies disclosing physician user types, primary care physicians (20/39, 51%) were the most common, followed by endocrinologists (15/39, 39%) and nonendocrinology specialists (8/39, 21%). CDSSs significantly improved patients' blood glucose, blood pressure, and lipid profiles in 71% (45/63), 67% (12/18), and 38% (8/21) of the studies, respectively, with no increase in the risk of hypoglycemia.

CONCLUSIONS

CDSSs are both effective and safe in improving diabetes care, implying that they could be a potentially reliable assistant in diabetes care, especially for physicians with limited experience and patients with limited access to medical resources.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.37766/inplasy2022.9.0061.

Evaluating a WeChat-Based Health Behavioral Digital Intervention for Patients With Hypertension: Protocol for a Randomized Controlled Trial

BACKGROUND

Hypertension is the most prevalent chronic condition and a significant risk factor for cardiovascular and kidney diseases. The efficacy of health behavioral interventions in blood pressure (BP) control has been demonstrated by a large and expanding body of literature, with "adherence" playing a crucial role. WeChat is the most common social communication mobile app in China, and it has been shown to be an acceptable delivery platform for delivering health interventions. The WeChat-based health behavioral digital intervention program (WHBDIP) showed high feasibility and efficacy. However, the results regarding BP improvement between the WHBDIP and control groups were inconsistent.

OBJECTIVE

The objective of this study is to develop a WHBDIP and assess its efficacy in controlling BP and improving adherence among patients with hypertension.

METHODS

A 2-arm, parallel-group, and randomized trial design was used. Patients older than 60 years and with hypertension were randomly assigned to either the control group or the experimental group, which received a 12-week intervention. The program, primarily developed based on the Behavior Change Wheel (BCW) theory, offers health education on exercise, diet, BP monitoring, and medicine adherence (MA). It also includes other behavior interventions guided by an intervention manual, incorporating behavior change techniques (BCTs). The primary outcomes encompass BP and adherence indicators, while the secondary outcomes encompass cardiovascular function indicators, body composition indicators, learning performance, satisfaction, and acceptability. The exercise and blood pressure monitoring adherence (BPMA) indicators for the WHBDIP group were assessed weekly via WeChat during the initial 3 months, while other outcome data for both groups will be collected at the baseline assessment phase, 3 months after the intervention, and 1 year after the program.

RESULTS

The trial will assess the efficacy of WHBDIP for patients with hypertension (N=68). The WHBDIP seeks to enhance participants' knowledge of healthy behaviors and assist patients in developing positive health behaviors to improve their health outcomes. Patient recruitment for individuals with hypertension commenced on September 5, 2022, and concluded on September 19, 2022. The 3-month intervention and phased data collection were finalized in January 2023. Data analysis will commence in August 2023, and the final 1-year health outcome results will be collected in September 2023.

CONCLUSIONS

A successful WHBDIP will establish the management mode as a feasible approach for hypertension management in the community. Additionally, it will pave the way for the development of related mobile health programs.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200062643; https://tinyurl.com/mwyv67wk.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46883.

Inconsistent Control Status of Office, Home, and Ambulatory Blood Pressure All Taken Using the Same Device: The HI-JAMP Study Baseline Data

BACKGROUND

Inconsistencies between the office and out-of-office blood pressure (BP) values (described as white-coat hypertension or masked hypertension) may be attributable in part to differences in the BP monitoring devices used.

METHODS

We studied consistency in the classification of BP control (well-controlled BP vs. uncontrolled BP) among office, home, and ambulatory BPs by using a validated "all-in-one" BP monitoring device. In the nationwide, general practitioner-based multicenter HI-JAMP study, 2,322 hypertensive patients treated with antihypertensive drugs underwent office BP measurements and 24-hour ambulatory BP monitoring (ABPM), consecutively followed by 5-day home BP monitoring (HBPM), for a total of seven BP measurement days.

RESULTS

Using the thresholds of the JSH2019 and ESC2018 guidelines, the patients with consistent classification of well-controlled status in the office (<140 mmHg) and home systolic BP (SBP) (<135 mmHg) (n = 970) also tended to have well-controlled 24-hour SBP (<130 mmHg) (n = 808, 83.3%). The patients with the consistent classification of uncontrolled status in office and home SBP (n = 579) also tended to have uncontrolled 24-hour SBP (n = 444, 80.9%). Among the patients with inconsistent classifications of office and home BP control (n = 803), 46.1% had inconsistent ABPM-vs.-HBPM out-of-office BP control status. When the 2017 ACC/AHA thresholds were applied as an alternative, the results were essentially the same.

CONCLUSIONS

The combined assessment of the office and home BP is useful in clinical practice. Especially for patients whose office BP classification and home BP classification conflict, the complementary clinical use of both HBPM and ABPM might be recommended.

Web-Based Nutrition and Physical Activity Education Intervention to Ameliorate Cardiometabolic Risks: A Single-Arm and Non-Randomized Feasibility Study

OBJECTIVE

This study aimed to evaluate the feasibility of the D-PATH website to improve dietary and physical activity management for patients with cardiometabolic risk.

METHODS

A website called D-PATH was developed, consisting of 6 learning units for managing hypertension. A 4-week program was implemented, and a pre- and post-intervention assessment was conducted to measure acceptability and changes in knowledge, attitude and practice, dietary intake, physical activity, and anthropometric status.

RESULTS

The D-PATH website was acceptable in terms of understandability, actionability and cognitive load. Knowledge, attitude and practice, and physical activity levels were improved, but no changes were noted for dietary intake and blood pressure level.

CONCLUSION

The D-PATH website was accepted and feasible for the intervention study. This study has shed light on using the website to promote behavioral change in patients with cardiometabolic risks.

Facilitators and barriers to blood pressure telemonitoring: A mixed-methods study

Background

Telemonitoring of blood pressure (BP) may improve BP control. However, many patients are not using BP telemonitoring due to personal, technological, and health system barriers. Individuals are required to have electronic health literacy (e-HL), defined as knowledge and skills to use technology services effectively, such as BP telemonitoring.

Objective

The objective was to determine the facilitators and barriers experienced by patients with hypertension in telemonitoring of BP using the e-HL framework (e-HLF).

Methods

This study was a prospective mixed-methods study using a convergent design. We recruited a convenience sample of 21 patients with hypertension. The qualitative section was online or phone individual in-depth interviews based on the e-HLF, which has seven domains. The quantitative section was an online survey consisting of demographics, an e-HL questionnaire, and patient-provider communication preferences. A joint display was used in the mixed-methods analysis.

Results

Five themes including knowledge, motivation, skills, systems, and behaviors along with 28 subthemes comprising facilitators or barriers of BP telemonitoring were identified. The mixed-methods results showed concordance between the participants' e-HL status and their experiences in the ability to actively engage with BP monitoring and managing digital services (domain 3) of the e-HLF. Other e-HL domains showed discordance.

Conclusion

Patients may engage with BP telemonitoring when they feel the usefulness of concurrent access to telemonitoring services that suit their needs.

Persons' experiences of having hypertension: An interview study

Background

among the 1-1.5 billion persons with hypertension globally only, 20-30% have controlled blood pressure (BP). The most important problem identified is non-adherence to treatment, i.e., failure to change lifestyle and to take prescribed medication. Knowledge about the reasons for this is limited.

Objectives

The aim of the study was to explore people's experiences of having hypertension.

Design

Inductive design based on qualitative interviews.

Settings

The south of Sweden.

Participants

Twelve adults diagnosed with hypertension and treated in primary care were interviewed.

Methods

The transcribed interviews were analysed using content analysis, which rendered three categories.

Results

The individuals adapted to their diagnosis in different ways. Collaboration with the staff gave security, but the persons still perceived anxiety and uncertainty.

Conclusions

To meet the needs of people with hypertension, strategies such as person-centred counselling and care, using digital interventions, following national guidelines and starting nurse-led clinics, may be of help. These strategies can give a foundation for increased self-efficacy, which is crucial for persons to be able to change lifestyle and adhere to prescribed medication in order to achieve BP control.

Relationships Between Blood Pressure Reduction, Weight Loss, and Engagement in a Digital App–Based Hypertension Care Program: Observational Study

Background

Home blood pressure (BP) monitoring is recommended for people with hypertension; however, meta-analyses have demonstrated that BP improvements are related to additional coaching support in combination with self-monitoring, with little or no effect of self-monitoring alone. High-contact coaching requires substantial resources and may be difficult to deliver via human coaching models.

Objective

This observational study assessed changes in BP and body weight following participation in a fully digital program called Lark Hypertension Care with coaching powered by artificial intelligence (AI).

Methods

Participants (N=864) had a baseline systolic BP (SBP) ≥120 mm Hg, provided their baseline body weight, and had reached at least their third month in the program. The primary outcome was the change in SBP at 3 and 6 months, with secondary outcomes of change in body weight and associations of changes in SBP and body weight with participant demographics, characteristics, and program engagement.

Results

By month 3, there was a significant drop of –5.4 mm Hg (95% CI –6.5 to –4.3; P<.001) in mean SBP from baseline. BP did not change significantly (ie, the SBP drop maintained) from 3 to 6 months for participants who provided readings at both time points (P=.49). Half of the participants achieved a clinically meaningful drop of ≥5 mm Hg by month 3 (178/349, 51.0%) and month 6 (98/199, 49.2%). The magnitude of the drop depended on starting SBP. Participants classified as hypertension stage 2 had the largest mean drop in SBP of –12.4 mm Hg (SE 1.2 mm Hg) by month 3 and –13.0 mm Hg (SE 1.6 mm Hg) by month 6; participants classified as hypertension stage 1 lowered by –5.2 mm Hg (SE 0.8) mm Hg by month 3 and –7.3 mm Hg (SE 1.3 mm Hg) by month 6; participants classified as elevated lowered by –1.1 mm Hg (SE 0.7 mm Hg) by month 3 but did not drop by month 6. Starting SBP (β=.11; P<.001), percent weight change (β=–.36; P=.02), and initial BMI (β=–.56; P<.001) were significantly associated with the likelihood of lowering SBP ≥5 mm Hg by month 3. Percent weight change acted as a mediator of the relationship between program engagement and drop in SBP. The bootstrapped unstandardized indirect effect was –0.0024 (95% CI –0.0052 to 0; P=.002).

Conclusions

A hypertension care program with coaching powered by AI was associated with a clinically meaningful reduction in SBP following 3 and 6 months of program participation. Percent weight change was significantly associated with the likelihood of achieving a ≥5 mm Hg drop in SBP. An AI-powered solution may offer a scalable approach to helping individuals with hypertension achieve clinically meaningful reductions in their BP and associated risk of cardiovascular disease and other serious adverse outcomes via healthy lifestyle changes such as weight loss.

Patient and Health Professional Perceptions of Telemonitoring for Hypertension Management: Qualitative Study

Background

Hypertension is the most prevalent and important risk factor for cardiovascular disease, affecting nearly 50% of the US adult population; however, only 30% of these patients achieve controlled blood pressure (BP). Incorporating strategies into primary care that take into consideration individual patient needs, such as remote BP monitoring, may improve hypertension management.

Objective

From March 2018 to December 2018, Stanford implemented a precision health pilot called Humanwide, which aimed to leverage high-technology and high-touch medicine to tailor individualized care for conditions such as hypertension. We examined multi-stakeholder perceptions of hypertension management in Humanwide to evaluate the program’s acceptability, appropriateness, feasibility, and sustainability.

Methods

We conducted semistructured interviews with 16 patients and 15 health professionals to assess their experiences with hypertension management in Humanwide. We transcribed and analyzed the interviews using a hybrid approach of inductive and deductive analysis to identify common themes around hypertension management and consensus methods to ensure reliability and validity.

Results

A total of 63% (10/16) of the patients and 40% (6/15) of the health professionals mentioned hypertension in the context of Humanwide. These participants reported that remote BP monitoring improved motivation, BP control, and overall clinic efficiency. The health professionals discussed feasibility challenges, including the time needed to analyze BP data and provide individualized feedback, integration of BP data, technological difficulties with the BP cuff, and decreased patient use of remote BP monitoring over time.

Conclusions

Remote BP monitoring for hypertension management in Humanwide was acceptable to patients and health professionals and appropriate for care. Important challenges need to be addressed to improve the feasibility and sustainability of this approach by leveraging team-based care, engaging patients to sustain remote BP monitoring, standardizing electronic medical record integration of BP measurements, and finding more user-friendly BP cuffs.

Virtual management of hypertension: lessons from the COVID-19 pandemic-International Society of Hypertension position paper endorsed by World Hypertension League and European Society of Hypertension

The coronavirus disease 2019 pandemic caused an unprecedented shift from in person care to delivering healthcare remotely. To limit infectious spread, patients and providers rapidly adopted distant evaluation with online or telephone-based diagnosis and management of hypertension. It is likely that virtual care of chronic diseases including hypertension will continue in some form into the future. The purpose of the International Society of Hypertension's (ISH) position paper is to provide practical guidance on the virtual management of hypertension to improve its diagnosis and blood pressure control based on the currently available evidence and international experts' opinion for nonpregnant adults. Virtual care represents the provision of healthcare services at a distance with communication conducted between healthcare providers, healthcare users and their circle of care. This statement provides consensus guidance on: selecting blood pressure monitoring devices, accurate home blood pressure assessments, delivering patient education virtually, health behavior modification, medication adjustment and long-term virtual monitoring. We further provide recommendations on modalities for the virtual assessment and management of hypertension across the spectrum of resource availability and patient ability.

Associations Between Behavior Change Techniques and Engagement With Mobile Health Apps: Protocol for a Systematic Review

Background

Digitally enabled care along with an emphasis on self-management of health is steadily growing. Mobile health apps provide a promising means of supporting health behavior change; however, engagement with them is often poor and evidence of their impact on health outcomes is lacking. As engagement is a key prerequisite to health behavior change, it is essential to understand how engagement with mobile health apps and their target health behaviors can be better supported. Although the importance of engagement is emphasized strongly in the literature, the understanding of how different components of engagement are associated with specific techniques that aim to change behaviors is lacking.

Objective

The purpose of this systematic review protocol is to provide a synthesis of the associations between various behavior change techniques (BCTs) and the different components and measures of engagement with mobile health apps.

Methods

The review protocol was structured using the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) and the PICOS (Population, Intervention, Comparator, Outcome, and Study type) frameworks. The following seven databases will be systematically searched: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, APA PsycInfo, ScienceDirect, Cochrane Library, and Web of Science. Title and abstract screening, full-text review, and data extraction will be conducted by 2 independent reviewers. Data will be extracted into a predetermined form, any disagreements in screening or data extraction will be discussed, and a third reviewer will be consulted if consensus cannot be reached. Risk of bias will be assessed using the Cochrane Collaboration Risk of Bias 2 and the Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) tools; descriptive and thematic analyses will be conducted to summarize the relationships between BCTs and the different components of engagement.

Results

The systematic review has not yet started. It is expected to be completed and submitted for publication by May 2022.

Conclusions

This systematic review will summarize the associations between different BCTs and various components and measures of engagement with mobile health apps. This will help identify areas where further research is needed to examine BCTs that could potentially support effective engagement and help inform the design and evaluation of future mobile health apps.

Trial Registration

PROSPERO CRD42022312596; https://tinyurl.com/nhzp8223

International Registered Report Identifier (IRRID)

PRR1-10.2196/35172

Efficacy of a centralized, blended electronic, and human intervention to improve direct oral anticoagulant adherence: Smartphones to improve rivaroxaban ADHEREnce in atrial fibrillation (SmartADHERE) a randomized clinical trial

BACKGROUND

Improving adherence to direct oral anticoagulants (DOAC) is challenging, and simple text messaging reminders have not been effective.

METHODS

SmartADHERE was a randomized trial that tested a personalized digital and human direct oral anticoagulant adherence intervention compared to usual care. Eligibility required age ≥ 18, newly-prescribed (≤90 days) rivaroxaban for atrial fibrillation (AF), 1 of 4 at-risk criteria for nonadherence, and a smartphone. The intervention consisted of combination of a medication management smartphone app, daily app-based reminders, adaptive text messaging, and phone-based counseling for severe nonadherence. The primary outcome was the proportion of days covered by rivaroxaban (PDC) at 6 months. There were 25 U.S. sites, all cardiology and electrophysiology outpatient practices, activated for a target sample size of 378, but the study was terminated by the sponsor prior to reaching target enrollment.

RESULTS

There were 139 participants (age 65±9.6 years, 30% female, median CHA₂DS₂-VASc score 3 with IQR 2 to 4, mean total medication burden 7.7±4.4). DOAC adherence was high in both arms with no difference in the primary outcome (PDC 0.86±0.25 intervention vs 0.88±0.25 control, p=0.62) or in secondary outcomes including PDC ≥ 0.80 and medication persistence. Per protocol analyses had similar results. Because of the high overall PDC, the likelihood to answer the primary hypothesis was only 51% even if target enrollment were achieved. There were no study-related adverse events.

CONCLUSIONS

The use of a centralized digital and human adherence intervention was feasible across multiple sites. Overall adherence was much higher than expected despite prescreening for at-risk individuals. SmartADHERE illustrates the challenges of trials of behavioral and technology interventions, where enrollment itself may lead to selection bias or treatment effects. Pragmatic study designs, such as cluster randomization or stepped-wedge implementation, should be considered to improve enrollment and generalizability.

Feasibility and Acceptability of an Asthma App to Monitor Medication Adherence: Mixed Methods Study

BACKGROUND

Poor medication adherence is a major challenge in asthma, and objective assessment of inhaler adherence is needed. The InspirerMundi app aims to monitor adherence while providing a positive experience through gamification and social support.

OBJECTIVE

This study aimed to evaluate the feasibility and acceptability of the InspirerMundi app to monitor medication adherence in adolescents and adults with persistent asthma (treated with daily inhaled medication).

METHODS

A 1-month mixed method multicenter observational study was conducted in 26 secondary care centers from Portugal and Spain. During an initial face-to-face visit, physicians reported patients' asthma therapeutic plan in a structured questionnaire. During the visits, patients were invited to use the app daily to register their asthma medication intakes. A scheduled intake was considered taken when patients registered the intake (inhaler, blister, or other drug formulation) by using the image-based medication detection tool. At 1 month, patients were interviewed by phone, and app satisfaction was assessed on a 1 (low) to 5 (high) scale. Patients were also asked to point out the most and least preferred app features and make suggestions for future app improvements.

RESULTS

A total of 107 patients (median 27 [P25-P75 14-40] years) were invited, 92.5% (99/107) installed the app, and 73.8% (79/107) completed the 1-month interview. Patients interacted with the app a median of 9 (P25-P75 1-24) days. At least one medication was registered in the app by 78% (77/99) of patients. A total of 53% (52/99) of participants registered all prescribed inhalers, and 34% (34/99) registered the complete asthma therapeutic plan. Median medication adherence was 75% (P25-P75 25%-90%) for inhalers and 82% (P25-P75 50%-94%) for other drug formulations. Patients were globally satisfied with the app, with 75% (59/79) scoring ≥4,; adherence monitoring, symptom monitoring, and gamification features being the most highly scored components; and the medication detection tool among the lowest scored. A total of 53% (42/79) of the patients stated that the app had motivated them to improve adherence to inhaled medication and 77% (61/79) would recommend the app to other patients. Patient feedback was reflected in 4 major themes: medication-related features (67/79, 85%), gamification and social network (33/79, 42%), symptom monitoring and physician communication (21/79, 27%), and other aspects (16/79, 20%).

CONCLUSIONS

The InspirerMundi app was feasible and acceptable to monitor medication adherence in patients with asthma. Based on patient feedback and to increase the registering of medications, the therapeutic plan registration and medication detection tool were redesigned. Our results highlight the importance of patient participation to produce a patient-centered and engaging mHealth asthma app.

Improving Medication Adherence Through Adaptive Digital Interventions (iMedA) in Patients With Hypertension: Protocol for an Interrupted Time Series Study

BACKGROUND

There is a strong need to improve medication adherence (MA) for individuals with hypertension in order to reduce long-term hospitalization costs. We believe this can be achieved through an artificial intelligence agent that helps the patient in understanding key individual adherence risk factors and designing an appropriate intervention plan. The incidence of hypertension in Sweden is estimated at approximately 27%. Although blood pressure control has increased in Sweden, barely half of the treated patients achieved adequate blood pressure levels. It is a major risk factor for coronary heart disease and stroke as well as heart failure. MA is a key factor for good clinical outcomes in persons with hypertension.

OBJECTIVE

The overall aim of this study is to design, develop, test, and evaluate an adaptive digital intervention called iMedA, delivered via a mobile app to improve MA, self-care management, and blood pressure control for persons with hypertension.

METHODS

The study design is an interrupted time series. We will collect data on a daily basis, 14 days before, during 6 months of delivering digital interventions through the mobile app, and 14 days after. The effect will be analyzed using segmented regression analysis. The participants will be recruited in Region Halland, Sweden. The design of the digital interventions follows the just-in-time adaptive intervention framework. The primary (distal) outcome is MA, and the secondary outcome is blood pressure. The design of the digital intervention is developed based on a needs assessment process including a systematic review, focus group interviews, and a pilot study, before conducting the longitudinal interrupted time series study.

RESULTS

The focus groups of persons with hypertension have been conducted to perform the needs assessment in a Swedish context. The design and development of digital interventions are in progress, and the interventions are planned to be ready in November 2020. Then, the 2-week pilot study for usability evaluation will start, and the interrupted time series study, which we plan to start in February 2021, will follow it.

CONCLUSIONS

We hypothesize that iMedA will improve medication adherence and self-care management. This study could illustrate how self-care management tools can be an additional (digital) treatment support to a clinical one without increasing burden on health care staff.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04413500; https://clinicaltrials.gov/ct2/show/NCT04413500.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24494.

Effectiveness of motivational interviewing on medication adherence among Palestinian hypertensive patients: a clustered randomized controlled trial

BACKGROUND 

This trial aimed to evaluate the effectiveness of motivational interviewing (MINT) among medication non-adherent hypertensive patients attending primary healthcare centres in Gaza Strip.

METHODS AND RESULTS 

A clustered randomized controlled trial was run among 355 hypertensive participants; who were identified as non-adherent by a self-reported adherent scale and were recruited from 10 centres by two stages cluster random sampling approach (five centres were randomly allocated to each group). Standard of hypertension care was provided to 173 participants, parallel to 182 one who received their standard of care including non-blinded MINT sessions for 3 months. The change in medication adherence status was the primary outcome and within-patient changes of systolic blood pressure (SBP), diastolic blood pressure (DBP), self-efficacy and intrinsic motivation were the secondary outcomes. Data were collected via an interview-based structured questionnaire and were analysed by generalizing equation estimation model adjusting for covariates. The results showed a significant improvement in medication adherence status among participants in the intervention group (n = 159) [OR= 6.28; 95% confidence interval (CI): 3.20, 12.33; P < 0.001] compared with those in the control group (n = 151). Moreover, there were significant drops in both SBP (OR = 0.18; 95% CI: 0.06, 0.55; P = 0.002) and DBP (OR = 0.26; 95% CI: 0.09, 0.76; P = 0.013) and significant positive changes in both within-patient's self-efficacy (OR = 15.4; 95% CI: 3.9, 60.6; P < 0.001) and intrinsic motivation (OR = 31.7; 95% CI: 13.9, 71.9; P < 0.001).

CONCLUSION 

Standard of care including MINT is an effective client-centred approach which promoted medication adherence, decreased mean blood pressure, and improved self-efficacy and intrinsic motivations among hypertensive patients.

Our Whole Lives for Hypertension and Cardiac Risk Factors (OWL-H)—Combining a Teaching Kitchen Group Visit with an Online Platform: A Feasibility Trial (Preprint)

Background

Hypertension (HTN) affects millions of Americans. Our Whole Lives: an eHealth toolkit for Hypertension and Cardiac Risk Factors (OWL-H) is an eHealth platform that teaches evidence-based lifestyle strategies, such mindfulness and cooking skills, to improve self-management of HTN.

Objective

The primary goal of this pilot study was to evaluate the feasibility of OWL-H combined with teaching kitchen medical group visits (TKMGVs) in a low-income population of participants with HTN.

Methods

We conducted a pre-post 8-week study to assess the feasibility of a hybrid program (a web-based 9-module self-management program, which includes mindfulness and Mediterranean and Dietary Approaches to Stop Hypertension diet) accompanied by 3 in-person TKMGVs among patients with HTN. Data including demographics, platform use, and satisfaction after using OWL-H were examined. Outcome data collected at baseline and 8 weeks included the Mediterranean Diet Questionnaire, Hypertension Self-Care Profile Self-Efficacy Instrument, Blood Pressure Knowledge Questionnaire, and the number of self-reported blood pressure readings. For the statistical analysis, we used descriptive statistics, paired sample t tests (1-tailed), and qualitative methods.

Results

Of the 25 enrolled participants, 22 (88%) participants completed the study. Participants’ average age was 57 (SD 12.1) years, and 46% (11/24) of them reported a household income <US $30,000 per year. Among the 22 participants who logged in to OWL-H, the average number of mindfulness practices completed was 7 and the average number of module sessions accessed was 4. In all, 73% (16/22) of participants reported that they were “very satisfied” with using OWL-H to help manage their HTN. Participants’ blood pressure knowledge significantly increased from baseline (mean 5.58, SD 1.44) to follow-up (mean 6.13, SD 1.23; P=.03). Participants significantly increased their adherence to a Mediterranean diet from baseline (mean 7.65, SD 2.19) to follow-up (mean 9, SD 1.68; P=.004). Participants’ self-efficacy in applying heart-healthy habits, as measured by the Hypertension Self-Care Profile Self-Efficacy Instrument, increased from baseline (mean 63.67, SD 9.06) to follow-up (mean 65.54, SD 7.56; P=.14). At the 8-week follow-up, 82% (18/22) of the participants had self-reported their blood pressure on the OWL-H platform at least once during the 8 weeks.

Conclusions

The eHealth platform for HTN self-management, OWL-H, and accompanying in-person TKMGVs have the potential to effectively improve lifestyle management of HTN.

Trial Registration

ClinicalTrials.gov NCT03974334; https://clinicaltrials.gov/ct2/show/NCT03974334

Using a Commercially Available App for the Self-Management of Hypertension: Acceptance and Usability Study in Saudi Arabia

BACKGROUND

The use of smartphone apps to assist in the self-management of hypertension is becoming increasingly common, but few commercially available apps have the potential to be effective along with adequate security and privacy measures in place. In a previous study, we identified 5 apps that are potentially effective and safe, and based on the preferences of doctors and patients, one (Cora Health) was selected as the most suitable app for use in a Saudi context. However, there is currently no evidence of its usability and acceptance among potential users. Indeed, there has been little research into the usability and acceptance of hypertension apps in general, and less research considers this in the Gulf Region.

OBJECTIVE

This study aims to evaluate the acceptance and usability of the selected app in the Saudi context.

METHODS

This study used a mixed methods approach with 2 studies: a usability test involving patients in a controlled setting performing predefined tasks and a real-world usability study where patients used the app for 4 weeks. In the usability test, participants were asked to think aloud while performing the tasks, and an observer recorded the number of tasks they completed. At the end of the real-world pilot study, participants were interviewed, and the mHealth App Usability Questionnaire was completed. Descriptive statistics were used to analyze quantitative data, and thematic analysis was used to analyze qualitative data.

RESULTS

In total, 10 patients completed study 1. The study found that app usability was moderate and that participants needed some familiarization time before they could use the app proficiently. Some usability issues were revealed, related to app accessibility and navigation, and a few tasks remained uncompleted by most people. A total of 20 patients completed study 2, with a mean age of 51.6 (SD 11.7) years. Study 2 found that the app was generally acceptable and easy to use, with some similar usability issues identified. Participants stressed the importance of practice and training to use it more easily and proficiently. Participants had a good engagement level with 48% retention at the end of study 2, with most participants' engagement being classed as meaningful. The most recorded data were blood pressure, followed by stress and medication, and the most accessed feature was viewing graphs of data trends.

CONCLUSIONS

This study shows that a commercially available app can be usable and acceptable in the self-management of hypertension but also found a considerable number of possibilities for improvement, which needs to be considered in future app development. The results show that there is potential for a commercially available app to be used in large-scale studies of hypertension self-management if suggestions for improvements are addressed.