Supporting Self-Management of Cardiovascular Diseases Through Remote Monitoring Technologies: Metaethnography Review of Frameworks, Models, and Theories Used in Research and Development

Background Electronic health (eHealth) is a rapidly evolving field informed by multiple scientific disciplines. Because of this, the use of different terms and concepts to explain the same phenomena and lack of standardization in reporting interventions often leaves a gap that hinders knowledge accumulation. Interventions focused on self-management support of cardiovascular diseases through the use of remote monitoring technologies are a cross-disciplinary area potentially affected by this gap. A review of the underlying frameworks, models, and theories that have informed projects at this crossroad could advance future research and development efforts. Objective This research aimed to identify and compare underlying approaches that have informed interventions focused on self-management support of cardiovascular diseases through the use of remote monitoring technologies. The objective was to achieve an understanding of the distinct approaches by highlighting common or conflicting principles, guidelines, and methods. Methods The metaethnography approach was used to review and synthesize researchers’ reports on how they applied frameworks, models, and theories in their projects. Literature was systematically searched in 7 databases: Scopus, Web of Science, EMBASE, CINAHL, PsycINFO, Association for Computing Machinery Digital Library, and Cochrane Library. Included studies were thoroughly read and coded to extract data for the synthesis. Studies were mainly related by the key ingredients of the underlying approaches they applied. The key ingredients were finally translated across studies and synthesized into thematic clusters. Results Of 1224 initial results, 17 articles were included. The articles described research and development of 10 different projects. Frameworks, models, and theories (n=43) applied by the projects were identified. Key ingredients (n=293) of the included articles were mapped to the following themes of eHealth development: (1) it is a participatory process; (2) it creates new infrastructures for improving health care, health, and well-being; (3) it is intertwined with implementation; (4) it integrates theory, evidence, and participatory approaches for persuasive design; (5) it requires continuous evaluation cycles; (6) it targets behavior change; (7) it targets technology adoption; and (8) it targets health-related outcomes. Conclusions The findings of this review support and exemplify the numerous possibilities in the use of frameworks, models, and theories to guide research and development of eHealth. Participatory, user-centered design, and integration with empirical evidence and theoretical modeling were widely identified principles in the literature. On the contrary, less attention has been given to the integration of implementation in the development process and supporting novel eHealth-based health care infrastructures. To better integrate theory and evidence, holistic approaches can combine patient-centered studies with consolidated knowledge from expert-based approaches. Trial Registration PROSPERO CRD42018104397; https://tinyurl.com/y8ajyajt International Registered Report Identifier (IRRID) RR2-10.2196/13334


Focus group interview with HCP
The focus group interviews method can be used to obtain detailed information on the thoughts, emotions, attitudes, or experiences of participants.It is a suitable model for sharing patient care experiences [User-centred design (Ad hoc;Baek et al. 2018)]

Surveys and interviews with patients
User research can be conducted through face-to-face interviews and a survey targeting patients with CVD [User-centred design (Ad hoc;Baek et al. 2018)]

SOCIOECOLOGICAL PERSPECTIVE
Integrating theory-, evidence-and person based approaches Approach to eHealth; A combination of theory-, evidence-and person based approaches are important to increase the acceptability, engagement with, and effectiveness of an intervention [Band et al.Common processes in user centred design; Testing design using paper prototypes or simulations [Usercentred design] Understanding the work context Common processes in user centred design; Understanding the work context involves identifying all the stakeholders and their concerns.eHealth changes the way people work, otherwise there would be no point in introducing them [Usercentred design] Testing a top level design against your understanding of the work

Common processes in user centred design; Testing the design using story boards, scenario or cognitive walkthrough [User-centred design]
Understanding the work Common processes in user centred design; Understanding the particular work to be supported by the eHealth system.As with the work context, the data used to do this will come from interviews and observation in the work place.Common types of representations for work are Hierarchical Task Analysis and scenarios [User-centred design] Planning Identification of key behavioral issues, needs, and challenges the intervention must address.This stage can be operationalized, for example, through collating and analyzing evidence via a quantitative or qualitative literature synthesis, as well as through primary qualitative research [Person-Based Approach]

Implementation
The model is reviewed according to the previous phase and the eHealth solution is assessed in a real environment with real users.The system is validated with stakeholders to update the system requirements and through system design and implementation [Iterative Software Design process] Development and evaluation of acceptability and feasibility All intervention components evaluated in detail and optimized from user perspective, as proposed by the Person Based Approach.This stage can be operationalized, for example, by collating and analyzing evidence derived from primary mixed-methods research such as a feasibility study [Person-Based Approach] Conceptualization (ISD)

Evaluation
The system's evaluation corresponds to the systematic exploration of usability.In our work, we also consider user engagement with the system as an additional important factor for usability.This can be quantified by recording how often specific system features are used, indicating the extent to which the system is being adopted [31,32] [Iterative Refinement and Patient Participatory Approach]

Community level
The SEM incorporates a wide range of individuals involved at various points of the CVD illness journey through its various levels (eg, individual, interpersonal, organizational, community, and policy) [Social Ecological Model]

Organizational level
The SEM incorporates a wide range of individuals involved at various points of the CVD illness journey through its various levels (eg, individual, interpersonal, organizational, community, and policy) [Social Ecological Model]

Individual level
The SEM incorporates a wide range of individuals involved at various points of the CVD illness journey through its various levels (eg, individual, interpersonal, organizational, community, and policy) [Social Ecological Model]

Policy level
The SEM incorporates a wide range of individuals involved at various points of the CVD illness journey through its various levels (eg, individual, interpersonal, organizational, community, and policy) [Social Ecological Model]

Interpersonal level
The SEM incorporates a wide range of individuals involved at various points of the CVD illness journey through its various levels (eg, individual, interpersonal, organizational, community, and policy) [Social Ecological Model] Target population involvement (Cross-cutting theme) The target audience must be involved in order to ensure the intervention is engaging and useful.Input should be appreciated and should be able to be acted upon by altering the intervention accordingly [

Diversity of user experiences
Development assumption; Heterogeneity (Heart failure); Technology acceptance; Accounting for the diversity of user experiences in the development and maintenance of eHealth systems is likely to increase the extent of successful uptake and impacts on outcomes for patients and providers.In practice, this highlights the importance of investing time into understanding how different types of users adopt and incorporate digital-health technology into their daily lives [Chantler et al. 2016]

User involvement
End-users should be involved in assessing the acceptability and usability of a behavioral intervention before scaling it up for further clinical evaluation.This can be done in practice through a multi-phased parallel approach of theoretical, modelling, and exploratory or piloting phases [MRC Guidance for Developing and Evaluating Complex Interventions] eHealth is a participatory development process Line-of-argument (Conceptual network)

Program plan
Stage of intervention mapping that includes a description of the scope and sequence of the components of the intervention, the completion of program materials, and protocols for implementation [Intervention Mapping] Tailored, personalized, and timely support eHealth added value; eHealth stateof-the-art; Increasingly widespread access to the internet and mobile phones means that eHealth can be accessible to the majority of patients and can be used to provide information and support at any time the patient needs it.eHealth can empower patients by providing better access to personalized information and support for active involvement in treatment and self-management [Band et al. 2016]

Community level
The SEM incorporates a wide range of individuals involved at various points of the CVD illness journey through its various levels (eg, individual, interpersonal, organizational, community, and policy)

Individual level
The SEM incorporates a wide range of individuals involved at various points of the CVD illness journey through its various levels (eg, individual, interpersonal, organizational, community, and policy) [Social Ecological Model]

Interpersonal level
The SEM incorporates a wide range of individuals involved at various points of the CVD illness journey through its various levels (eg, individual, interpersonal, organizational, community, and policy) [Social Ecological Model] Interdisciplinary methods

Development state-of-the-art;
Limitations of study/project; There is a growing need to consider adopting methods from other disciplines rather than using deployment-evaluation cycles [54].Theories, models, and methods to support this approach can be found in engineering and related sectors (e.g., use of factorial or fractionated evaluation designs that have been utilized well within the HCI sphere) [Walsh et al. 2018a]

Organizational level
The SEM incorporates a wide range of individuals involved at various points of the CVD illness journey through its various levels (eg, individual, interpersonal, organizational, community, and policy) [Social Ecological Model]

Policy level
The SEM incorporates a wide range of individuals involved at various points of the CVD illness journey through its various levels (eg, individual, interpersonal, organizational, community, and policy)  Integrating theory-, evidence-and person based approaches Approach to eHealth; A combination of theory-, evidence-and person based approaches are important to increase the acceptability, engagement with, and effectiveness of an intervention [Band et al. 2017] Tailoring and personalization Heterogeneity (CVD); An individual assessment (e.g., on psychological readiness for change) and tailored and personalized features can be useful to achieve health behavior change, to empower patients to make choices and direct them to the most appropriate content for them at a specific time [Walsh et al. 2018a]

Determinants of technology acceptance; The degree to which using a technology will provide benefits to consumers in performing certain activities [Unified Theory of Acceptance and Use of Technology model]
AIMS OPERATIONALIZATION eHealth development integrates theory, evidence, and participatory approaches for persuasive design

Patient activation
Self-management state-of-the-art; The term 'patient activation' is employed to represent patients who are 'more effective managers of their health and healthcare' (Lupton, 2013).However, even these digitally engaged, tech savvy patients may find the obligation of self-care surveillance overwhelming, forcing them to confront their illness, engage in routine actions they would rather avoid, or deal with digital interactions that are tiresome (Oudshoorn, 2012)

Bidirectional service model
Development assumption; Considering the patients' perspective, advice from doctors or communication with them is proposed as an important factor in a successful eHealth support model [Baek et al. 2018] Tailored, personalized, and timely support eHealth added value; eHealth stateof-the-art; Increasingly widespread access to the internet and mobile phones means that eHealth can be accessible to the majority of patients and can be used to provide information and support at any time the patient needs it.eHealth can empower patients by providing better access to personalized information and support for active involvement in treatment and self-management [Band et al. 2016] CA: Relational integration Target constructs (Logic model); Developing relationships with HCPs; Building confidence in the system and in relationships with HCPs [Normalization Process Theory] Acceptability and fit of hardware in everyday life

Mechanisms (CMO hypotheses) [CHF PSMS]
Adaptation to personal routines Mode of delivery and implementation; Development assumption; Heterogeneity (Heart Failure); The technology must fit intuitively, naturally and in a userfriendly way the user's health and mental status, preferences, and recommended medical protocol [Villalba et al. 2009] Adaptive and user friendly eHealth An adaptive and user-friendly monitoring system can enable a wide range of patients to monitor their health status regularly.This can be achieved through automated collection of user interactions with the system (log data) and through remote automatic updates without required input from the patients [Rahimi et al. 2015

Diversity of user experiences
Development assumption; Heterogeneity (Heart failure); Technology acceptance; Accounting for the diversity of user experiences in the development and maintenance of eHealth systems is likely to increase the extent of successful uptake and impacts on outcomes for patients and providers.In practice, this highlights the importance of investing time into understanding how different types of users adopt and incorporate digital-health technology into their daily lives [Chantler et al. 2016]

Domestication of technology
The processes of acceptance, rejection and use of technology by its users.Users are seen as social entities and this conceptual model aims to provide a framework for understanding how technology innovations change, and are changed, by their social contexts.For instance, according to the Domestication of Technology Theory this process can be divided in four dimensions : appropriation, objectification, incorporation, and conversion [Domestication of  BEHAVIORAL OUTCOMES

Global health
Health outcomes [HeartMapp] HEALTH OUTCOMES

Health outcomes [HeartMapp]
Patient medication adherence and titration

Patient intervention components [HOME BP]
Patient lifestyle change

Patient intervention components [HOME BP]
Ability Seek to understand the users, their tasks, goals, different aspects of the surrounding environment, and broader contexts [User-centred design of Consumer-facing Health IT] METHODS Evaluate Evaluate the designs against initial understandings of users and goals [User-centred design of Consumerfacing Health IT] PHASES Design (UCD-CHIT) Design abstract representations or more traditional artifacts such as wireframes or user interface prototypes [User-centred design of Consumer-facing Health IT] OPERATIONALIZATION User testing of more detailed prototypes

development requires continuous evaluation cycles
<>Usability testMethod to evaluate how easily the end user understands, learns, and uses software or an app under specific conditions[Usercentred design (Ad hoc; Baek et al.  2018)] ] Technology Theory]