A smartphone application for sedentary behaviour change in cardiac rehabilitation and the effect on hospitalisations

  • Kacie Patterson

    Student thesis: Doctoral Thesis


    Background: High sedentary time is associated with increased risk of mortality. People with coronary heart disease tend to be more sedentary compared to healthy adults which contributes to disease morbidity and higher hospitalisation risk. Traditional phase-II hospital-based cardiac rehabilitation reduces risk of morbidity and mortality in those with coronary heart disease. Nonetheless, it appears to have minimal effectiveness on reducing sedentary behaviour. Cardiac rehabilitation participants are interested in support through technology-based interventions, which offer many behaviour change techniques. Conversely, little is known about the effectiveness of smartphone applications (apps) as an adjunct to cardiac rehabilitation to influence sedentary behaviour and reduce hospitalisations. Objective: Explores the effectiveness of smartphone apps and use of behaviour change techniques for sedentary behaviour and physical activity change in people with cardiovascular disease. Additionally, explore whether a novel, theory-based sedentary behaviour change smartphone app (Vire app and online ToDo-CR program), is effective at reducing non-elective hospital admissions and emergency department (ED) presentations over 12-months, and assess its feasibility and acceptability for future healthcare. Methods: A systematic review and meta-analyses of smartphone apps for sedentary behaviour and physical activity change in people with cardiovascular disease was conducted. Smartphone app content was further analysed according to the Behaviour Change Technique Taxonomy (v1). To explore the effect of a sedentary behaviour change smartphone app, a mixed methods design was used. Cardiac rehabilitation participants from phase-II hospital-based programs were recruited to a multi-centre, randomised controlled trial. Participants were randomised 1:1 to cardiac rehabilitation plus the fully automated 6-month Vire app and online ToDo-CR program (intervention) or usual care cardiac rehabilitation (control). The primary outcome was non-elective hospital admissions and ED presentations over 12-months. Secondary outcomes including accelerometer-measured sedentary behaviour were recorded at baseline, 6- and 12- months. Intervention and hospital admission costs were collected, and the incremental cost effectiveness ratios (ICER) were calculated for secondary outcomes. Qualitative data were collected using semi-structured interviews with participants who had used the Vire app. The researchers used inductive thematic analysis and deductive mapping of themes to the Theoretical Domains Framework and the Capability, Opportunity, Motivation – Behaviour Model. Results: In the systematic review, only two studies explored the use of smartphones apps for sedentary behaviour change in people with diagnosed cardiovascular disease. Smartphone apps targeting physical activity in this group are effective at increasing physical activity (40.35- minutes of moderate-to-vigorous physical activity, 95%CI 1.03 to 79.67, p = 0.04), particularly when using the behaviour change techniques of action planning (β = 0.42, 90%CI 0.07 to 0.78), graded tasks (β = 0.33, 90%CI -0.04 to 0.67), and self-monitoring of behaviour. In the ToDo-CR multi-centre randomised controlled trial, 120 cardiac rehabilitation participants were recruited. Participants were aged 62±10 years, majority were male (78%), tertiary educated (79%) and employed (56%). Approximately 50% had prior experience using smartphone apps and activity trackers. Intervention group participants were more likely to experience all-cause (OR 1.54, 95%CI 0.58 to 4.10, p = 0.39) and cardiac-related (OR 3.26, 95%CI 0.84 to 12.55, p = 0.09) hospital admissions and ED presentations (OR 2.07, 95%CI 0.89 to 4.77, p = 0.09) compared to the control group. Despite this, cardiac-related hospital admission costs appeared lower in the intervention group over 12-months ($252.40 vs $859.38, p = 0.24). Cardiac rehabilitation participants were sitting on average for 10 hours-per-day at baseline. There were no significant between-group differences in sedentary behaviour minutes-per-day over 12-months, though the intervention group indicated to complete 22-minutes less sedentary behaviour than the control, with a small effect size (95%CI -22.80 to 66.69, p = 0.33, Cohen d = 0.21). When considering the cost-effectiveness plane, there was an indication of effect for the intervention being more effective but also more costly in reducing sedentary behaviour (ICER $351.77) at 12-months. Retention rates were high in this study (88%) however, engagement with the Vire app and online ToDo-CR program were low with 40% not engaging at all and 33% engaging with the app less than once per month over 6-months. Fifteen participants were interviewed, and five core themes were identified. The themes were linked to engagement and implementation strategies for future smartphone apps for sedentary behaviour change in cardiac rehabilitation participants: 1) being tech savvy can be both an enabler and a barrier; 2) app messaging needs to be clear – set expectations from the beginning; 3) get to know me – personalisation is important; 4) curious to know more instant feedback; and 5) first impression is key. Conclusion: Few studies have explored the use of smartphone apps for changing sedentary behaviour in people with cardiovascular disease. This thesis contributes to the small but growing body of evidence informing the use of sedentary behaviour change smartphones apps in people with coronary heart disease attending cardiac rehabilitation. The Vire app and online ToDo-CR program did not reduce rate or incidence of non-elective hospital admissions and ED presentations. Despite being more costly to implement, the Vire app and online ToDo-CR program in addition to cardiac rehabilitation indicated potential to slow the increase in sedentary behaviour over 12-months compared to usual care. However, as the intervention stands, it may not provide value for money and an adequate investment given the size of effect. Prior experience and familiarity with smartphone apps may be an indicator for engagement with this type of intervention in cardiac rehabilitation participants. Further research is needed to improve implementation and engagement with smartphone apps for sedentary behaviour change in cardiac rehabilitation participants before they become a feasible and acceptable recommendation for future healthcare.
    Date of Award2023
    Original languageEnglish
    SupervisorNicole Freene (Supervisor), Rachel Davey (Supervisor) & Richard Keegan (Supervisor)

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