3.2. Pilot Testing: Healthy Eating Pilot Study
Twenty people completed the first pilot study survey and were sent the healthy eating program. Ten participants had CVD and were participating in traditional CR and 10 self-identified as being at risk for developing CVD due to having high blood cholesterol. The majority of participants were New Zealand European (14/20) and the mean age was 52 (SD = 15.5) years (see
Table 2). Most participants completed the grocery shopping (18/20) and planned/prepared meals (19/20) at least some of the time for their household.
Nearly all participants (19/20) thought using mobile technology was a good way to deliver a healthy eating CR program. All participants reported receiving the text messages and self-reported reading most (10/20) or all (10/20) of the messages. Thirteen participants reported sharing the text messages with family and friends. Participants accessed the website from 0–9 times over the course of the 4 week program (median = 1). Viewing sessions ranged from 1–40 min with a median view time of 4 min. The program was well received.
Table 5 displays a descriptive summary of program aspects that participants liked or disliked.
Table 5.
Nutrition program survey response data (N = 20).
Table 5.
Nutrition program survey response data (N = 20).
Please rate the following according to whether you liked or disliked them | Liked | Disliked | No comment | Didn’t use |
---|
Ideas on how to eat healthier | 19 | 0 | 1 | 0 |
Information on the benefits of healthy eating | 18 | 0 | 2 | 0 |
Information on cooking healthy meals | 16 | 0 | 3 | 0 |
Receiving motivational messages | 15 | 2 | 1 | 2 |
Being supported to feel like I could make these changes | 13 | 1 | 4 | 2 |
Feeling like I belonged/like there were others going through the same thing as me | 11 | 1 | 6 | 2 |
Receiving lots of text messages | 10 | 6 | 4 | 0 |
The website | 10 | 1 | 3 | 6 |
The time of day messages were sent | 9 | 2 | 9 | 0 |
Seeing videos from health professionals | 9 | 0 | 2 | 9 |
Being able to see ‘my goals’ on the website | 8 | 1 | 3 | 8 |
Seeing videos from people like me | 4 | 0 | 6 | 10 |
Themes emerging from open-ended responses are summarized below and are supported with direct written quotes from participants.
- 1
Text messaging was a convenient way to deliver healthy eating information. Participants felt that receiving texts was “quick and easy” and “non-invasive”. The content of the messages was “relevant”, “concise and interesting”.
- 2
Texts were encouraging and an effective reminder to make informed healthy food choices. Participants felt the texts “encouraged and reminded me to make healthy choices”. The texts helped to serve “as alerts of what type of foods are good and are healthy substitutes”.
- 3
I’d prefer a more personalized program. Seven participants commented on how to personalize the program, such as receiving feedback on their progress. Another suggestion was to tailor the time of day the messages were sent out, in order to send a relevant message at a time of day when people often struggled to make the healthy choice, such as “after dinner”. A few participants also mentioned they wanted some personal contact.
- 4
Technical and time barriers prevented me from using the website. Three participants reported problems accessing the website; they forgot their password and revealed it wasn’t a priority to contact the research team for a new password. Some participants also commented that it was too time consuming to view the website, as they were “really busy at work” or “too tired to open the website again at home”.
HHESES
Descriptive data for self-efficacy scores are presented in
Table 6. Environmental self-efficacy and total self-efficacy scores increased from baseline to follow-up. Scores were higher post-intervention for heart healthy eating self-efficacy and outcome expectancy, but these differences were not statistically significant.
Table 6.
Descriptive summary of Heart Healthy Eating Self-efficacy scale and subscales.
Table 6.
Descriptive summary of Heart Healthy Eating Self-efficacy scale and subscales.
Scale (Mean ± SD) | Pre-intervention | Post-intervention | Difference (Post–Pre) |
---|
Heart healthy eating | 4.59 ± 53 | 4.76 ± 66 | 0.20 ± 55 |
Environmental | 4.22 ± 71 | 4.83 ± 70 | 0.62 b ± 74 |
Total self-efficacy a | 4.41 ± 59 | 4.79 ± 66 | 0.39 b ± 64 |
Outcome expectancy | 5.22 ± 77 | 5.37 ± 82 | 0.15 ± 65 |
3.3. Discussion
This paper described the results of two studies assessing the usability and acceptability of an mHealth healthy eating program in a CVD population. A key finding from the formative research was that adults diagnosed with CVD used mobile technologies regularly and were interested in receiving CR by mobile phone. These findings speak to the utility of using mobile phones to deliver lifestyle content to this population. While text messaging and the Internet tend to be more popular with younger age groups, media literacy is increasing among adults [
31]. Participants preferred a text message format over the Internet, perhaps because text messaging pushes content to passive recipients, whereas accessing a website requires users to actively seek out information. A rate limiting factor for the web-based component in the pilot study was the time it took to log in with passwords, particularly if they were infrequent computer users. For the future trial, step 4 in the framework, the intervention will be delivered primarily by text message with additional information delivered via a more user-friendly website, which will include additional interactive features to promote engagement [
32,
33].
The pilot study was one of the first to examine the acceptability of an mHealth healthy eating program in a CVD population. Participants found the program useful and acceptable. Participants felt the messages were encouraging and felt supported to make changes to a healthier diet, which reflected the social persuasion source of self-efficacy [
25]. Text messages reminded participants to observe what they were eating, which indicated self-regulation concepts were being internalized [
33]. Self-efficacy did not appear to be influenced by vicarious learning [
25], which was targeted through the video messages on the supporting website, as the majority of participants chose not to comment or did not use the website. Quantitative findings showed an increase in environmental self-efficacy, or confidence to make healthy eating choices when influenced by external factors [
28].
Framing the program in SCT was a strength of the pilot study, as theory-based interventions are more likely to be effective [
18,
19]. Based on the present work and the HEART intervention [
20,
21], manipulating self-efficacy in an mHealth format may lead to greater behavior change in a CVD population, however other theories and specific behavior change techniques need to be considered [
34]. While the changes in self-efficacy were promising, it is important to note that the results should be interpreted with caution as there was no comparison group. The next step is to determine whether changes in self-efficacy translate to healthy eating behavior change.
The pilot study provided important feedback on how to personalize mHealth programs. A review found tailored mHealth interventions were more effective at changing behavior, however few studies had implemented tailored components [
19]. Iterations to the healthy eating CR program will include greater tailoring, such as using the participant’s name and delivering messages at the time participants have selected. Bi-directional messaging will be included that allows for personal contact and tailored responses from the study team. This dynamic feedback loop holds promise to improve health behavior as rapid two-way communication provides just-in-time information or strategies to participants [
34]. Designing effective automated yet personalized interventions in a cost-effective way is challenging [
35], however a personal and multi-faceted approach may enhance motivation to use future programs and lead to improved disease self-management.
A limitation of both studies was the small samples, which were not necessarily representative of the entire CVD population. The technology in the pilot study was also a limitation as participants were required to have access to a mobile phone and the Internet, indicating that enrolled participants were familiar with this technology. Participants were recruited from CR services and non-attenders may have different mobile phone and Internet usage. Future development research should target CR non-attenders as they may benefit most from an mHealth program. Despite the above limitations, the results warrant further investigation into alternative methods for CR delivery.
Suggestions for Future Research
Formative research and pilot testing of intervention content have been completed and the next step in the mHealth development and evaluation framework is to conduct a randomized controlled trial. The results from the two development studies in steps 2 and 3, including the iterations described above, will be used to create a comprehensive CR program, aiming to change multiple health behaviors including physical activity, smoking cessation, medication adherence, and healthy eating. Physical activity and smoking cessation components for the comprehensive CR program have already been developed and pre-tested [
20,
23] and will be refined according to the findings of the healthy eating pilot study. A randomized controlled trial is planned to determine the effectiveness of a comprehensive CR mHealth program to change behavior compared to standard care (control).