title: The Space From Heart Disease Intervention for People With Cardiovascular Disease and Distress: A Mixed-Methods Study.
abstract: BACKGROUND
  Poor self-management of symptoms and psychological distress leads to worse outcomes and excess health service use in cardiovascular disease (CVD). Online-delivered therapy is effective, but generic interventions lack relevance for people with specific long-term conditions, such as cardiovascular disease.
  
  
  OBJECTIVE
  To develop a comprehensive online CVD-specific intervention to improve both self-management and well-being, and to test acceptability and feasibility.
  
  
  METHODS
  Informed by the Medical Research Council (MRC) guidance for the development of complex interventions, we adapted an existing evidence-based generic intervention for depression and anxiety for people with CVD. Content was informed by a literature review of existing resources and trial evidence, and the findings of a focus group study. Think-aloud usability testing was conducted to identify improvements to design and content. Acceptability and feasibility were tested in a cross-sectional study.
  
  
  RESULTS
  Focus group participants (n=10) agreed that no existing resource met all their needs. Improvements such as "collapse and expand" features were added based on findings that participants' information needs varied, and specific information, such as detecting heart attacks and when to seek help, was added. Think-aloud testing (n=2) led to changes in font size and design changes around navigation. All participants of the cross-sectional study (10/10, 100%) were able to access and use the intervention. Reported satisfaction was good, although the intervention was perceived to lack relevance for people without comorbid psychological distress.
  
  
  CONCLUSIONS
  We have developed an evidence-based, theory-informed, user-led online intervention for improving self-management and well-being in CVD. The use of multiple evaluation tests informed improvements to content and usability. Preliminary acceptability and feasibility has been demonstrated. The Space from Heart Disease intervention is now ready to be tested for effectiveness. This work has also identified that people with CVD symptoms and comorbid distress would be the most appropriate sample for a future randomized controlled trial to evaluate its effectiveness.
authors.affiliation: Post Graduate Research Department, Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, United Kingdom. elizabeth.barley@kcl.ac.uk.
authors.forename: Elizabeth Alexandra
authors.identifier: http://orcid.org/0000-0001-9955-0384
authors.initials: EA
authors.lastname: Barley
authors.forename: Abigail
authors.identifier: http://orcid.org/0000-0003-0739-456X
authors.initials: A
authors.lastname: Clifton
authors.forename: Geraldine
authors.identifier: http://orcid.org/0000-0001-6385-8600
authors.initials: G
authors.lastname: Lee
authors.forename: Ian J
authors.identifier: http://orcid.org/0000-0001-7567-2977
authors.initials: IJ
authors.lastname: Norman
authors.forename: David
authors.identifier: http://orcid.org/0000-0001-9866-1381
authors.initials: D
authors.lastname: O'Callaghan
authors.forename: Karen
authors.identifier: http://orcid.org/0000-0003-3191-5652
authors.initials: K
authors.lastname: Tierney
authors.forename: Derek
authors.identifier: http://orcid.org/0000-0003-0871-4078
authors.initials: D
authors.lastname: Richards
keywords: Internet; anxiety; behavioral therapy; cardiovascular disease; cognitive behavioral therapy; depression; online interventions; self-management; well-being