Text Message and Internet Support for Coronary Heart Disease Self-Management: Results From the Text4Heart Randomized Controlled Trial.
BACKGROUND
Mobile technology has the potential to deliver behavior change interventions (mHealth) to reduce coronary heart disease (CHD) at modest cost. Previous studies have focused on single behaviors; however, cardiac rehabilitation (CR), a component of CHD self-management, needs to address multiple risk factors.


OBJECTIVE
The aim was to investigate the effectiveness of a mHealth-delivered comprehensive CR program (Text4Heart) to improve adherence to recommended lifestyle behaviors (smoking cessation, physical activity, healthy diet, and nonharmful alcohol use) in addition to usual care (traditional CR).


METHODS
A 2-arm, parallel, randomized controlled trial was conducted in New Zealand adults diagnosed with CHD. Participants were recruited in-hospital and were encouraged to attend center-based CR (usual care control). In addition, the intervention group received a personalized 24-week mHealth program, framed in social cognitive theory, sent by fully automated daily short message service (SMS) text messages and a supporting website. The primary outcome was adherence to healthy lifestyle behaviors measured using a self-reported composite health behavior score (≥3) at 3 and 6 months. Secondary outcomes included clinical outcomes, medication adherence score, self-efficacy, illness perceptions, and anxiety and/or depression at 6 months. Baseline and 6-month follow-up assessments (unblinded) were conducted in person.


RESULTS
Eligible patients (N=123) recruited from 2 large metropolitan hospitals were randomized to the intervention (n=61) or the control (n=62) group. Participants were predominantly male (100/123, 81.3%), New Zealand European (73/123, 59.3%), with a mean age of 59.5 (SD 11.1) years. A significant treatment effect in favor of the intervention was observed for the primary outcome at 3 months (AOR 2.55, 95% CI 1.12-5.84; P=.03), but not at 6 months (AOR 1.93, 95% CI 0.83-4.53; P=.13). The intervention group reported significantly greater medication adherence score (mean difference: 0.58, 95% CI 0.19-0.97; P=.004). The majority of intervention participants reported reading all their text messages (52/61, 85%). The number of visits to the website per person ranged from zero to 100 (median 3) over the 6-month intervention period.


CONCLUSIONS
A mHealth CR intervention plus usual care showed a positive effect on adherence to multiple lifestyle behavior changes at 3 months in New Zealand adults with CHD compared to usual care alone. The effect was not sustained to the end of the 6-month intervention. A larger study is needed to determine the size of the effect in the longer term and whether the change in behavior reduces adverse cardiovascular events.


BACKGROUND
ACTRN 12613000901707; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364758&isReview=true (Archived by WebCite at http://www.webcitation.org/6c4qhcHKt).
National Institute for Health Innovation, University of Auckland, Auckland, New Zealand. l.pfaeffli@auckland.ac.nz.
Leila
http://orcid.org/0000-0002-7473-6243
L
Pfaeffli Dale
Robyn
http://orcid.org/0000-0003-0901-9149
R
Whittaker
Yannan
http://orcid.org/0000-0002-7663-9164
Y
Jiang
Ralph
http://orcid.org/0000-0002-6167-1225
R
Stewart
Anna
http://orcid.org/0000-0002-4804-8869
A
Rolleston
Ralph
http://orcid.org/0000-0001-8564-5518
R
Maddison
D003324:Coronary Artery Disease / Q000534:rehabilitation*; D005260:Female; D015438:Health Behavior; D006801:Humans; D020407:Internet / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D017216:Telemedicine / Q000706:statistics & numerical data*; D060145:Text Messaging / Q000706:statistics & numerical data*; D016896:Treatment Outcome
behavior; cardiovascular diseases; cellular phone; intervention; lifestyle change; mHealth; text messaging