Implementation tells us more beyond pooled estimates: Secondary analysis of a multicountry mhealth trial to reduce blood pressure

Background: The uptake of an intervention aimed at improving health-related lifestyles may be influenced by the participant’s stage of readiness to change behaviors. Objective: We conducted secondary analysis of the Grupo de Investigación en Salud Móvil en América Latina (GISMAL) trial according to levels of uptake of intervention (dose-response) to explore outcomes by country, in order to verify the consistency of the trial’s pooled results, and by each participant’s stage of readiness to change a given lifestyle at baseline. The rationale for this secondary analysis is motivated by the original design of the GISMAL study that was independently powered for the primary outcome—blood pressure—for each country. Methods: We conducted a secondary analysis of a mobile health (mHealth) multicountry trial conducted in Argentina, Guatemala, and Peru. The intervention consisted of monthly motivational phone calls by a trained nutritionist and weekly tailored text messages (short message service), over a 12-month period, aimed to enact change on 4 health-related behaviors: salt added to foods when cooking, consumption of high-fat and high-sugar foods, consumption of fruits or vegetables, and practice of physical activity. Results were stratified by country and by participants’ stage of readiness to change (precontemplation or contemplation; preparation or action; or maintenance) at baseline. Exposure (intervention uptake) was the level of intervention (<50%, 50%-74%, and ≥75%) received by the participant in terms of phone calls. Linear regressions were performed to model the outcomes of interest, presented as standardized mean values of the following: blood pressure, body weight, body mass index, waist circumference, physical activity, and the 4 health-related behaviors. Results: For each outcome of interest, considering the intervention uptake, the magnitude and direction of the intervention effect differed by country and by participants’ stage of readiness to change at baseline. Among those in the high intervention uptake category, reductions in systolic blood pressure were only achieved in Peru, whereas fruit and vegetable consumption also showed reductions among those who were at the maintenance stage at baseline in Argentina and Guatemala. Conclusions: Designing interventions oriented toward improving health-related lifestyle behaviors may benefit from recognizing baseline readiness to change and issues in implementation uptake.Fil: Carrillo-Larco, Rodrigo M.. Universidad Peruana Cayetano Heredia; Perú. Imperial College London; Reino UnidoFil: Jiwani, Safia S.. Universidad Peruana Cayetano Heredia; PerúFil: Diez Canseco, Francisco. Universidad Peruana Cayetano Heredia; PerúFil: Kanter, Rebecca. Institute of Nutrition of Central America and Panama; Guatemala. Universidad de Chile; ChileFil: Beratarrechea, Andrea Gabriela. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Institute for Clinical Effectiveness and Health Policy; ArgentinaFil: Irazola, Vilma. Institute for Clinical Effectiveness and Health Policy; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Ramirez Zea, Manuel. Institute of Nutrition of Central America and Panama; GuatemalaFil: Rubinstein, Adolfo Luis. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Martinez, Homero. Nutrition International; Canadá. Hospital Infantil de Mexico Federico Gomez; MéxicoFil: Miranda, J. Jaime. Cronicas Centro de Excelencia En Enfermedades Crónicas; Perú. Universidad Peruana Cayetano Heredia; PerúFil: Alasino, Adrían. Funprecal; ArgentinaFil: Budiel Moscoso, Berneth Nuris. Universidad Peruana Cayetano Heredia; PerúFil: Carrara, Carolina. Instituto Universitario del Hospital Italiano de Buenos Aires; ArgentinaFil: Espinoza Surichaqui, Jackelyn. Universidad Peruana Cayetano Heredia; PerúFil: Giardini, Gimena. Instituto Universitario del Hospital Italiano de Buenos Aires; ArgentinaFil: Guevara, Jesica. Institute of Nutrition of Central America And Panama Guatemala; GuatemalaFil: Morales Juárez, Analí. Institute of Nutrition of Central America And Panama Guatemala; GuatemalaFil: Lázaro Cuesta, Lorena. Funprecal; ArgentinaFil: Lewitan, Dalia. Institute For Clinical Effectiveness And Health Policy; ArgentinaFil: Palomares Estrada, Lita. Universidad Peruana Cayetano Heredia; PerúFil: Martínez Ramírez, Carla. Universidad Peruana Cayetano Heredia; PerúFil: de la Cruz, Gloria Robles. Universidad Peruana Cayetano Heredia; PerúFil: Salguero, Julissa. Institute Of Nutrition Of Central America And Panama Guatemala; GuatemalaFil: Saravia Drago, Juan Carlos. Universidad Peruana Cayetano Heredia; PerúFil: Urtasún, María. Institute For Clinical Effectiveness And Health Policy; ArgentinaFil: Zavala Loayza, José Alfredo. Universidad Peruana Cayetano Heredia; Per