The Implementation and Effectiveness of Mobile Health Interventions for Cardiometabolic Disease Management in China and Australia

Abstract

© 2021 Enying GongIntroduction Cardiometabolic diseases are the leading causes of deaths globally. Although effective strategies for managing these chronic conditions have been proposed as clinical guidelines and action plans, the translation of evidence into practice is challenging. With the advancement of information and communication technologies (ICTs), digital health and mobile health (mHealth) technologies are increasingly applied to healthcare purposes and hold promise for the promotion of disease management and the strengthening of the healthcare system. Although there is a rapidly growing volume of studies in this field, the benefits of mHealth interventions and strategies for implementing mHealth innovations for disease management are still not evident. This thesis includes three studies that aim to provide evidence of the effectiveness of mHealth interventions for cardiometabolic disease management and illustrate how mHealth interventions could be better implemented in real-world settings. Methods The present thesis utilizes two cardiometabolic conditions, diabetes and stroke, as index conditions to anchor mHealth interventions for cardiometabolic diseases management. The thesis incorporates three studies: (1) a systematic review and evaluation of publicly available mobile applications for diabetes self-management in China; (2) a randomized controlled trial which evaluated a mobile app-based embodied conversational agent (My Diabetes Coach- MDC intervention) for improving diabetes self-management; (3) a cluster randomized controlled trial which evaluated a technology-enabled community-based intervention (SINEMA) for stroke management in rural China. The thesis utilizes the chronic care model to emphasize the important role of mHealth interventions in supporting patients’ self-management and improving coordinated care within the community for cardiometabolic diseases management. Multiple research methodologies, including quantitative and qualitative data analysis, are adopted, and evaluation and implementation research frameworks, such as the RE-AIM framework and the Medical Research Council (MRC) complex intervention framework, are applied. Thesis summary Chapter 1 presents an overview of cardiometabolic disease burden, challenges in cardiometabolic diseases management, and related concepts of digital health and chronic disease management. Chapter 2 provides a narrative review about the general effectiveness and implementation of mHealth interventions for cardiometabolic diseases. The review has a particular focus on mHealth interventions for diabetes self-management coaching and mHealth-enabled community-based interventions for cardiometabolic disease management. Chapter 3 reviews the methodologies used in evaluating mHealth programs and describes the overall study design. Chapter 4 reports the findings of a systematic evaluation of 67 Chinese publicly available Chinese mobile apps for diabetes self-management. The chapter provides additional evidence to the research literature by showing the key limitations of existing tools for helping people manage their diabetes conditions in China. Chapter 5 reports the findings on the effectiveness and implementation of the MDC intervention based on a randomized controlled trial, which involved 187 adults with type 2 diabetes in Australia. The chapter illustrates a large but declined program use over 12 months and demonstrates a significant benefit for health-related quality of life but insignificant impact on HbA1c reduction of the MDC intervention compared with usual care. Chapter 6 reports the findings on the effectiveness and implementation from the SINEMA cluster-randomized controlled trial, which recruited 1299 adults with stroke from 50 villages in rural China. The chapter shows that the SINEMA intervention reached a representative group of stroke survivors, delivered interventions with high program implementation fidelity, and resulted in a significant improvement in blood pressure control, medication adherence and other secondary or exploratory outcomes. Factors that influence the program implementation and the impact pathway on effectiveness are identified. Chapter 7 discusses some key aspects in the development of digital health interventions for improving cardiometabolic diseases management, including the design of tailored content, reaching vulnerable populations, building patient-doctor alliance and integrating with the healthcare system. Recommendations for future research, industry and public health practice are also proposed. Conclusion The research contained in the thesis contributes to the evidence base by investigating the quality, implementation, and effectiveness of mHealth solutions for cardiometabolic disease management. The findings indicated that digital health interventions could bring positive health benefits to patients with existing cardiometabolic conditions, even in the resource-limited setting, by empowering disease self-management, increasing patients’ access to and adherence to treatment, and strengthening the interaction between patients and providers. However, in “real-world” settings, the impact of digital health solutions is influenced by individual and contextual factors that determined the adoption, implementation, and engagement of digital health solutions. Rigorous evaluation of the quality and effectiveness of the health apps are essential before its access to the general population. Future studies could adapt the effective interventions into other contexts and explore strategies that may increase long-term program engagement and more in-depth system integration