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Dealing with cardiovascular disease is challenging, and people often struggle to follow rehabilitation and self-management programs. Several systematic reviews have explored quantitative evidence on the potential of digital interventions to support cardiac rehabilitation (CR) and self-management. However, although promising, evidence regarding the effectiveness and uptake of existing interventions is mixed. This paper takes a different but complementary approach, focusing on qualitative data related to people’s experiences of technology in this space.
Through a qualitative approach, this review aims to engage more directly with people’s experiences of technology that supports CR and self-management. The primary objective of this paper is to provide answers to the following research question: What are the primary barriers to and facilitators and trends of digital interventions to support CR and self-management? This question is addressed by synthesizing evidence from both medical and computer science literature. Given the strong evidence from the field of human-computer interaction that user-centered and iterative design methods increase the success of digital health interventions, we also assess the degree to which user-centered and iterative methods have been applied in previous work.
A grounded theory literature review of articles from the following major electronic databases was conducted: ACM Digital Library, PsycINFO, Scopus, and PubMed. Papers published in the last 10 years, 2009 to 2019, were considered, and a systematic search with predefined keywords was conducted. Papers were screened against predefined inclusion and exclusion criteria. Comparative and in-depth analysis of the extracted qualitative data was carried out through 3 levels of iterative coding and concept development.
A total of 4282 articles were identified in the initial search. After screening, 61 articles remained, which were both qualitative and quantitative studies and met our inclusion criteria for technology use and health condition. Of the 61 articles, 16 qualitative articles were included in the final analysis. Key factors that acted as barriers and facilitators were background knowledge and in-the-moment understanding, personal responsibility and social connectedness, and the need to support engagement while avoiding overburdening people. Although some studies applied user-centered methods, only 6 involved users throughout the design process. There was limited evidence of studies applying iterative approaches.
The use of technology is acceptable to many people undergoing CR and self-management. Although background knowledge is an important facilitator, technology should also support greater ongoing and in-the-moment understanding. Connectedness is valuable, but to avoid becoming a barrier, technology must also respect and enable individual responsibility. Personalization and gamification can also act as facilitators of engagement, but care must be taken to avoid overburdening people. Further application of user-centered and iterative methods represents a significant opportunity in this space.
Cardiovascular diseases (CVDs) are the leading cause of death worldwide. An estimated 17.9 million people died from CVD in 2016, representing 31% of all global deaths [
After a person is hospitalized and following a discharge and recuperation period, they are typically recommended to attend a cardiac rehabilitation (CR) program offered by hospitals. Following this, they need to continue to self-manage their cardiac health. CR is considered a vital part of long-term recovery by targeting risk factor modification, supervised exercise, psychological support, and medication review [
Although there is a significant literature and a growing number of reviews on digital interventions for CVD rehabilitation and management, most previous studies base their conclusions on quantitative data. To better understand what drives the effectiveness and usage of technologies, there is also a need to analyze the collective perspectives of patients, focusing on their experiences, needs, and the barriers they face in using digital interventions. The literature outlined earlier has provided evidence that personalization [
The analysis in this paper draws strongly on research in the field of human-computer interaction (HCI). Our findings are analyzed from an HCI perspective, which emphasizes the benefits of iterative development of technology and user involvement throughout the design and evaluation process [
The primary objective of this paper is to provide answers to the following research question: What are the primary barriers to and facilitators and trends of digital interventions to support CR and self-management? This question is answered by synthesizing evidence from both medical and computer science literature. Using a qualitative approach, we aim to engage more directly with people’s needs from and experiences of technology that supports CR and self-management. Given the strong evidence from the field of HCI that user-centered and iterative design methods increase the success of digital health interventions, we also assess the degree to which user-centered and iterative methods have been applied in the studies included in this review.
This review follows the grounded theory literature review (GTLR) method [
What kind of technological support is provided for CR and self-management?
What design approaches were applied in designing the technologies identified?
What experiences and attitudes do patients have of technology?
What are the barriers to using technology for rehabilitation and self-management after a cardiac incident?
What are the facilitators for using technology for rehabilitation and self-management after a cardiac incident?
This review follows the 5 stages recommended in the GTLR method [
In this section, we describe the inclusion and exclusion criteria of our review, database sources and search keywords used, the screening and selection process, data extraction process, and, finally, the analysis process.
To include a wide range of perspectives on designing technologies for rehabilitation and self-management of cardiac conditions, we selected papers from PsycINFO, Scopus, PubMed, and ACM (Association for Computing Machinery) Digital Library. HCI literature about designing technology for cardiac conditions was gathered from the ACM Digital Library. Similarly, psychology and medical literature on these types of technologies were gathered from PsycINFO and PubMed. Other major journals and conferences, such as Biomed Central, IEEE (Institute of Electrical and Electronics Engineers), BMJ (British medical journal), International Journal of Telemedicine and Applications, SAGE (Scientific Advisory Group for Emergencies), and Global Telehealth, are included in Scopus.
Title, abstract, and keyword searches were carried out on the above mentioned databases to obtain the results for this review (
We limited our search to papers published in the last 10 years and focused on papers in the English language and including adult patients.
Domain
Cardiovascular disease
Cardiology
Cardiac
Heart disease
Coronary heart disease
Coronary artery disease
Heart failure
Technology
Mobile
Wearable
Wearable sensors
mHealth interventions
Smartphone
Tele-monitoring
Sensing system
Telehealth
Telemedicine
Intervention
Persuasive or persuasion
Quantified self
Tracking
Behavior change or behavior
Personal informatics
Habit
Prevention
Detection
Rehabilitation
Management
The review was concerned with the use of technology for self-management and rehabilitation practices in the context of CVDs. This excluded several papers that would otherwise be featured in the review, such as those suggesting design concepts without evaluating them [
Furthermore, this review focuses on studies of patients with cardiac conditions. This excluded self-management and rehabilitation technologies focusing on other chronic conditions [
Domain
Cardiac condition
Technology
Use of technology with evaluation
Technologies having active patient role (eg, mobile, wearable, mobile health, and telemedicine)
Intervention
Secondary prevention involving self-management and rehabilitation
Domain
Other chronic conditions and general well-being and lifestyle
Technology
Design concepts, technology description, algorithms, and software architecture without evaluation
Technologies having passive patient role: biomarkers
Technology used in clinical settings
Photoplethysmogram
Implantable devices
Defibrillators
Intervention
Detection and monitoring for primary prevention
The search keywords retrieved 4282 articles, of which 3973 remained after removing duplicates. We first performed a prescreening of these papers by reading the title and abstract and removed papers concerning research abstracts, systematic reviews, protocols, workshops, studies dealing with patients aged <18 years, studies involving chemical and biological sciences, and studies involving clinical procedures. At this stage, the first author (ST) reviewed all papers, and the second author was consulted in any situation where the first author was uncertain. Where any disagreement occurred, the paper was not excluded at this stage. In the second phase of screening, the first author reviewed the title and abstract of all remaining papers using the full eligibility checklist to decide if they should be included in preselection. This was done to exclude papers that involved studies inclined toward medical and clinical techniques, for example, studies related to biomarkers, photoplethysmogram, implantable devices, and defibrillators and studies related to algorithms, methods, and techniques. The second author reviewed 10% (170/1700) of the papers at this stage, and agreement was verified across both authors. Where any disagreement was found, the paper in question was reviewed again by both authors and discussed to reach an agreement. Both researchers then met and cross-checked 50% of the final preselection list, discussed inconsistencies, and agreed upon a final list that included 61 papers for potential inclusion.
Each of these papers was further assessed in the final stage of the screening process to check if they applied qualitative methods and included qualitative data. Any paper that contained both quantitative and qualitative data was included in the final review, but only qualitative data in these papers were analyzed. A total of 25 papers were found to include no data, and 20 papers included only quantitative data. These papers were excluded. This left 16 papers that included qualitative data in our final analysis.
Flow diagram illustrating the screening and selection process of papers.
The critical appraisal skills program (CASP) checklist [
Data from the included papers were initially extracted based on the keywords used in the search terms and eligibility criteria (
The analysis step of the GTLR method involves a comparative analysis process with 3 levels of coding: open coding, axial coding, and selective coding. From the set of papers in the final review, ST selected a random paper and carefully read it again, highlighting principal findings, which the GTLR method calls excerpts. Similarly, excerpts from each paper were then listed. At the axial coding stage, these excerpts were articulated to form groups or insights. Both authors carried out an affinity mapping exercise on these excerpts. This led to the formation of groups and subgroups of the excerpts. At the selective coding stage, these groups were then compared and moved around, followed by discussions among the authors to form themes. This process involved iterative back and forth analysis between the excerpts and groups identified, in which stages were repeated and papers reread until a final consensus was reached. The coding process was supported by Boardthing [
As noted earlier, the keyword search retrieved 4282 articles, of which 16 were included in the final analysis. An overview of the included studies is provided in
All studies in the final list focus on patients who had gone through or were going through a cardiac condition. Some of the studies specifically targeted patients diagnosed with heart failure, myocardial infarction, and coronary heart disease. Furthermore, some studies particularly involved participants’ postcardiac condition awareness and those who were in their CR phase. Some studies also involved physicians, informal caregivers, nurses, and cardiologists as participants. The papers included studies on both CR [
In general, the papers in this review investigated mobile or web apps, with some integrating sensors, to manage cardiac conditions. Papers featuring a web-based digital intervention were included [
In general, support for self-management was provided through apps that aim to increase adherence, motivation, and engagement. These could be achieved through gamification [
Overview of the theories and design approaches used in the final review.
Study | Design method or guiding theory | Users involvement |
Dithmer et al [ |
Gamification and gameful design principles (PERMAa) are used to design the app. Gamification principles such as badges, levels, and leader boards were used to increase engagement and motivation. | Requirements gathering, design or prototyping, and evaluation or validation |
Yehle et al [ |
No particular design principles or theory and design methodology mentioned. | Requirements gathering and evaluation or validation |
Villalba et al [ |
Goal-directed design methodology is applied. A three-phase design process is used: conceptualization, implementation, and validation. | Requirements gathering and evaluation or validation |
Jarvis-selinger et al [ |
Diffusion of innovation theory was used as the theoretical lens along with the current telehealth literature for sensitizing concepts. The study used a qualitative methodology, employing a constructivist approach. | Requirements gathering |
Fischer et al [ |
Used common sense model of illness representation and showed visualization of body structure and behavior based on different symptoms through a web-based app. | Evaluation or validation |
Pfaeffli et al [ |
A library of text and video messages were developed using self-efficacy theory framework and published exercise guidelines. | Requirements gathering, design or prototyping, and evaluation or validation |
Katalinic et al [ |
No particular design principles or theory and design methodology mentioned. | Evaluation or validation |
Antypas and Wangberg [ |
Different models of health behavior change are combined to form the tailoring algorithm. Tailoring is used as the theoretical framework. A methodological approach that is used to combine the user input and health behavior theory to develop a physical activity digital intervention for cardiac rehabilitation. | Requirements gathering and evaluation or validation |
Geurts et al [ |
The prototype design was guided by 3 pillars: simplicity and ease of use, reduce fear and anxiety, and direct and indirect motivation. A human-computer interaction perspective is given by categorizing design decisions according to 3 pillars and show how these pillars resulted in concrete app features. | Requirements gathering, design or prototyping, and evaluation or validation |
Buys et al [ |
No particular design principles or theory and design methodology mentioned. | Requirements gathering |
Cornet et al [ |
Three frameworks guided the design process: Systems Engineering Initiative for Patient Safety (Version 2.0), Patient Work Framework, and user-centered design. | Requirements gathering, design or prototyping, and evaluation or validation |
Banner et al [ |
No particular design principles or theory and design methodology mentioned. | Evaluation or validation |
Baek et al [ |
No particular design principles or theory and design methodology mentioned. | Requirements gathering, design or prototyping, and evaluation or validation |
Salvi et al [ |
Fogg’s Persuasive Systems Design principles were used when designing the GEx system, and health belief models were used to classify patients on the basis of the perceived benefits and barriers to self-efficacy in healthy behavior. The system design and development were guided by a combination of methodologies: Goal-Directed Design, Persuasive Systems Design, and agile software development. The desired behaviors were mapped into specific system’s specifications, borrowing concepts from Fogg’s Persuasive Systems Design principles. | Requirements gathering and evaluation or validation |
Beatty et al [ |
No particular design principles or theory and design methodology mentioned. | Requirements gathering, design or prototyping, and evaluation or validation |
Smith et al [ |
No particular design principles or theory and design methodology mentioned. | Requirements gathering |
aPERMA: Positive emotion, Relationships, Meaning, and Accomplishment.
The 3 main stages of the HCI design process included in the ISO 9241 HCI development lifecycle are requirements gathering, producing design solutions, and evaluating the design against the requirements [
This section presents the final themes identified in our grounded theory analysis.
Evidence from the review suggests that knowledge plays an important role in rehabilitation and self-management. Education and knowledge influence self-management and increase confidence. To explain this further, we have categorized knowledge into 2 types: background knowledge and personal and in-the-moment understanding.
General knowledge or background knowledge about CVD is the fundamental information or awareness that is required to be known by all patients with CVD. This can be information about one’s health condition, symptoms, body, medication, preventive measures, and advised lifestyle changes. Background knowledge also includes awareness about different support systems that help people to care for themselves, such as rehabilitation support and digital interventions.
There is a growing trend to use digital interventions to provide the required educational support. A study conducted to validate a self-care digital system to manage cardiovascular condition at home emphasized that education on symptoms and medication was highly valued by patients and health professionals; however, younger patients had reservations about lifestyle education, as they considered it to be intrusive and annoying. Similarly, patients who were initially scared of new technologies, later, after introductory explanations, found it easier to interact with the system [
Now I understand why my legs always swelled up.
We truly know how to, what is happening inside his heart, and why he’s getting all these symptoms. In the 2 years that we’ve been dealing with this illness, it’s so good to have it summarised up so that we know how to care for ourselves better.
Participants also repeatedly referred to the need to find the right answers either through an online forum or some kind of knowledge bank [
It should be a forum where you have the opportunity to get the right answers, access to a resource, this is what I believe it becomes. It has an effect.
CR classes are also popularly known to provide essential knowledge, guidance, and support for patients:
...Your class (cardiac rehabilitation) because they stressed what is really bad for you and what is good for you so that makes you stop and think when you are even buying your groceries to make sure you are getting the right stuff.
Personal and in-the-moment understanding is the supplementary information that patients seek to enhance their self-care process. This type of information is acquired through personal tracking and monitoring and refers to the ongoing knowledge people develop about their individual condition. Knowing one’s body plays a key role is achieving control of the cardiac condition; however, it may be difficult to notice some changes and trends in everyday life. Technology has been used to make health and contextual information more easily available to patients and caregivers on an ongoing basis [
The application is not only beneficial for people who are afraid to exercise, but also supports people that have a higher risk to train too much.
A study conducted to understand the current technology usage of patients with CVD and to understand their needs and interests found that ongoing advice on exercise ideas, exercise prompts, information on local exercise opportunities, healthy meal ideas and recipes, and practical ideas to manage stress received the highest ratings for inclusion in a technology-based CR platform [
I am unsure if I am doing the right thing, like food, so I like advice on that.
Although most patients often manage their care autonomously, clinicians, other people living with the same condition, and caregivers play an equally important role.
Responsibility for change in behavior is personal [
If you could get a message every day, there and then?
I believe that someone gets used to it, if we make a system, habits. That it doesn’t get too much, that we know that...we go online...and we get our own responsibility of our own training.
Technology can support small personal achievements such as getting out of the house to get fit. The use of digital systems as a tool for self-management is valued, especially among the younger ones:
It gave me the opportunity to get out of the home and try and get myself fit after the operation. I believe it has achieved that and more. I feel better in myself and I can achieve most jobs without taking about it.
Patients often seek to connect with others living with the same condition, and they use these interactions to understand how to live with their condition, validate their assumptions about their body and self-care, and obtain emotional support [
You know I had stents four years ago, and you start off with the best of intentions, but nobody looks over your shoulder and you peter out. At this time, I felt this is a nifty program...somebody’s watching it and I better do it. Keeps you honest, keeps you focused.
Keeping in touch with the group helps to lift people’s mood, is comforting, and provides support; therefore, many patients liked to use forums and web-based groups. Groups and forums on the internet are seen to help individuals be more committed to fitness by sharing goal completions and bragging about it for healthy competition. Forums brought more focus and motivation, as it makes individuals feel obliged to do activities. A study that used gamification for telerehabilitation program of patients with CVD also demonstrates the importance of social and family support, with patients stating that the most important aspect of the game was being able to play with a partner, thus enabling them to deal with rehabilitation as a team:
Training diary on the Internet...And also have a group where someone can subscribe to a forum, or have a...to brag...yesterday I walked for an hour and today I have been to the training...and tomorrow I have thought, yes...So, it is like this that someone gets to, a bit, a bit like a competition, internally between each of us. We will train, as much as possible we will commit to ourselves a bit more also.
I am saying that if we have it fixed, one time per week, that we send a message to each other and then, then you feel committed to say yes, for as long as you like...Yes, then you must have something else that really, you have something else that you have to do, or else...you just do it.
The systems in the listed papers took a number of approaches to provide engagement and motivation toward self-management. Some of the key features of technology and patients’ attitudes toward them are described below.
Digital health interventions such as text messages and mobile- and web-based app reminders push patients to maintain the desired changes [
I went cycling without the application today, but it was less fun!
Two teams explicitly stated that on a day with bad weather, they would not have gone for a walk had they not been motivated by the application.
Reminders in any form were positively accepted by the patients. Text messages, although intrusive, pushed them to perform exercises, and many stated that reminders such as an alarm are needed for medication management [
Digital health interventions that had the ability to track patients’ activities, heart rate, and current health status and showed their progress over time were considered valuable and engaging [
I like the fact that I can put all of that and track it, and that my doctors can as well. I can show my doctor what I’ve been working on.
I think that the idea of an app that records all of the information that this app is doing will be very valuable. Actually somewhat of a motivation for me to do this thing.
Some studies in this review suggested that digital interventions that gave the user the ability to personalize the app based on personal interests contributed toward motivation [
Some studies in this review demonstrated patients’ concerns regarding using technology. For instance, some patients suggested that adding a device on top of what they already have led to them getting side tracked and thus not using it every day [
I’m retired and I gave all the computerization that I wanted up, that is it I do not even look at it and I will not even turn it on.
Furthermore, lack of time and other priorities is a barrier to self-management and use of technology. Most patients already have measuring devices at home, such as weight scales and blood pressure cuffs, and preferred to continue using devices they already know [
There are people who like this (application) kind of stuff...and got the time. So for these people it might be great.
In contrast, studies in this review also demonstrated patients’ willingness to use technology. For example, one study reported that patients’ interest or intent to use an app for CVD management was high, despite the fact that most were older people who were unfamiliar with the information technology environment [
Nevertheless, to reach the entire target population of patients with CVD, a variety of technology solutions should be designed to reach both men and women [
Finally, usability and ease of use are crucial for the acceptance of any type of digital intervention and thereby influence engagement. Many studies in this review emphasize that simple interaction methods are preferable. For example, one study stated that 38% of the patients preferred an interaction of no more than a few mouse clicks [
It was pretty easy...I like that it’s simple.
I’m not used to this. Once I get used to it, I’ll know where everything is.
This review aims to understand users’ perspectives of technology in CR and self-management and identify barriers and facilitators of the use of technology. The results suggest that many patients have a positive attitude toward the use of technology. The grounded theory approach enabled us to identify common themes across the included papers, resulting in 3 principal findings:
Designers of new technologies and clinicians recommending existing systems to patients should consider seeking the support of both background knowledge and greater in-the-moment understanding. Background knowledge and awareness about the condition and its symptoms, medication, and posthospital care measures are important factors for effective self-management. However, effective self-management also requires patients to be aware of their current body condition and changes in their body, providing reassurance and enabling them to take appropriate measures in self-management.
Self-care is a personal responsibility, and people like to try different ways to keep themselves motivated to continue performing self-management activities. For some, but not all, opportunities to stay connected with family, caregivers, and others with a similar health condition are considered as one of the most effective ways to stay motivated and driven toward rehabilitation activities. Again, technology that supports both approaches is likely to be most beneficial.
Technologies can use different approaches to support engagement and motivation toward rehabilitation and self-management, including personalization, tracking and monitoring, reminders, and feedback. However, they should take into account the potential to demotivate because of issues including overburdening caused by different devices and apps, privacy concerns, lack of trust, lack of interest, and system usability. If not properly accounted for, these issues can impact the acceptability of systems and become major hindrances to effective rehabilitation and self-management.
These principal findings are discussed in greater detail below and also considered via the lens of relevant HCI literature.
Our first principal finding emphasizes the importance of different types of knowledge. Awareness of available resources, such as awareness of rehabilitation classes, existing online support groups, existing self-care digital apps, and remote rehabilitation videos and programs, is important so that patients can leverage these resources for better and sustained recovery and smoother transition to long-term self-management. In addition, ensuring that patients have knowledge of available emotional and physical support helps to foster self-efficacy if they feel overwhelmed by their CVD condition, leading to the inability to effectivity self-manage [
Effective self-management requires patients to change certain behaviors. An individual’s inclination to change behavior depends on the extent to which they are motivated to change [
Digital health interventions draw on 2 central domains of study, those originating in health (eg, medicine, biomedical sciences, and psychology) and in technology disciplines (eg, computer science, HCI, and software engineering). This trend is seen in the papers listed in this review. Blandford et al [
As the aim of this review is to investigate and obtain subjective evidence of the barriers and facilitators of using technology for CR and self-management, only qualitative papers were considered, and review was limited by the analysis of the included studies. The possibility of subjectivity in analyzing the findings is acknowledged, although strategies to limit bias were undertaken through the process of grounded theory analysis and consultation with a second reviewer. In addition, the included studies had varied sample sizes, and the technology was used for different amounts of time in different studies. We acknowledge that this variation could have had an impact on the themes emerging in this review.
This research was conducted in the Republic of Ireland. It is part of the Eastern Corridor Medical Engineering (ECME) collaborative research project, which seeks to improve cardiovascular health with a broad focus on enhancing user-ready sensor technology; improving smart wearables; reducing the complexity of point-of-care diagnostics; and improving smart, clinically relevant monitoring in the assisted living and rehabilitation environments. ECME is a partnership between 5 academic research centers in Northern Ireland, the Republic of Ireland and Scotland, and the Southern Health & Social Care Trust. It involves collaboration between researchers in the medical and technology fields. Both the authors of this paper are based at the Insight Centre for Data Analytics at Dublin when this study was conducted. ST was raised in India and had lived in Dublin for 2 years at the time of the study. She has experience in User Experience design in mobile and assistive technologies. DC has multigenerational roots in Ireland and is an expert in the field of HCI with a focus on the design of digital health technologies. None of the authors have direct lived experience of CVD. This study did not seek to directly address issues such as ethnicity, social and cultural background, and gender, and standard checklists, including the CASP tool, were used to assess the quality of included studies. However, we recognize the potential for bias, both in its own analysis and in the original research papers.
The primary objective of this review was to apply qualitative methods to answer the following research question: What are the primary barriers to and facilitators and trends of digital interventions to support CR and self-management? Our findings show that the use of technology is acceptable to many people undergoing CR and self-management. Although background knowledge is an important facilitator, technology should also support greater ongoing and in-the-moment understanding. Connectedness is valuable, but to avoid becoming a barrier, technology must also respect and enable individual responsibility. Personalization and gamification can also act as facilitators of engagement, but care must be taken to avoid overburdening people. The findings also highlighted the limited use of iterative, user-centered approaches to guide design in this space. Going forward, further application of user-centered and iterative methods represents a significant opportunity.
Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist.
Search strategy.
Qualitative assessment table.
Table with overview of included studies.
critical appraisal skills program
cardiac rehabilitation
cardiovascular diseases
Eastern Corridor Medical Engineering
European Union
grounded theory literature review
human-computer interaction
Medial Subject Headings
mobile health
Preferred Reporting Items for Systematic Reviews and Meta-Analysis
virtual cardiac rehabilitation program
This project was supported by the European Union’s (EU) INTERREG VA program, which is managed by the Special EU Programmes Body.
None declared.