mHealth-delivered education interventions in heart failure, using smartphone, tablet and internet-based programmes and apps

Review question

What is the randomised controlled trial evidence for mHealth-delivered education interventions in heart failure (HF) knowledge, self-care and self-efficacy for people with HF when compared to traditional methods of patient education?

Background

Education is vital for self-care (activities individuals undertake with the intention of improving health, preventing disease, limiting illness and restoring health) in HF. Traditionally, education has been provided to people with heart failure in a face-to-face manner, using paper-based materials or video/DVD presentations. In an age of rapidly-evolving technology and uptake of smartphones and tablet devices, mHealth-based technology is a new way to provide health education, with the benefit of being able to reach people who are unable or unwilling to access traditional HF education programmes and services.

Search date

We found studies by searches conducted in October 2019.

Study characteristics

We include in this review five randomised controlled trials (971 participants) of mHealth-delivered education interventions for people with HF. The average age of participants ranged from 60 years to 75 years and 63% of participants were men. Studies came from Australia, China, Iran, Sweden and The Netherlands.

Key results

Five studies addressed HF knowledge; we found that the use of mHealth-delivered education programmes showed no evidence of a difference in HF knowledge compared to usual care. One study assessing self-efficacy reported uncertainty in the evidence for mHealth-delivered education compared with usual care. Three studies evaluated HF self-care using different scales. We did not combine the studies, because of the differences between the outcome measures, and the evidence is uncertain. The studies did not report any side effects of the interventions. Four studies examined health-related quality of life and showed uncertainty in the evidence between mHealth-delivered education and usual care. Three studies reported on HF-related hospitalisation rates. The use of mHealth-delivered education may result in little to no difference in HF-related hospitalisations.

Quality of the evidence

We rated the quality of the evidence as very low to low, due to limitations in study design and execution and fewer than 500 participants in the analysis.

Conclusion

There is no evidence for a difference in the use of mHealth-delivered educational intervention for people with HF on HF knowledge. There is uncertainty in the evidence for self-efficacy, self-care and health-related quality of life. There may be little to no difference in HF-related hospitalisations, compared to usual care. 'Usual care' in this case means enrolment in a heart failure-management programme (clinic- or home-based). This is an area of HF research from which further evidence will emerge in the short and longer term.

Authors' conclusions: 

We found that the use of mHealth-delivered educational interventions for people with HF shows no evidence of a difference in HF knowledge; uncertainty in the evidence for self-efficacy, self-care and health-related quality of life; and may result in little to no difference in HF-related hospitalisations. The identification of studies currently underway and those awaiting classification indicate that this is an area of research from which further evidence will emerge in the short and longer term.

Read the full abstract...
Background: 

Heart failure (HF) is a chronic disease with significant impact on quality of life and presents many challenges to those diagnosed with the condition, due to a seemingly complex daily regimen of self-care which includes medications, monitoring of weight and symptoms, identification of signs of deterioration and follow-up and interaction with multiple healthcare services. Education is vital for understanding the importance of this regimen, and adhering to it. Traditionally, education has been provided to people with heart failure in a face-to-face manner, either in a community or a hospital setting, using paper-based materials or video/DVD presentations. In an age of rapidly-evolving technology and uptake of smartphones and tablet devices, mHealth-based technology (defined by the World Health Organization as mobile and wireless technologies to achieve health objectives) is an innovative way to provide health education which has the benefit of being able to reach people who are unable or unwilling to access traditional heart failure education programmes and services.

Objectives: 

To systematically review and quantify the potential benefits and harms of mHealth-delivered education for people with heart failure.

Search strategy: 

We performed an extensive search of bibliographic databases and registries (CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, IEEE Xplore, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) Search Portal), using terms to identify HF, education and mHealth. We searched all databases from their inception to October 2019 and imposed no restriction on language of publication.

Selection criteria: 

We included studies if they were conducted as a randomised controlled trial (RCT), involving adults (≥ 18 years) with a diagnosis of HF. We included trials comparing mHealth-delivered education such as internet and web-based education programmes for use on smartphones and tablets (including apps) and other mobile devices, SMS messages and social media-delivered education programmes, versus usual HF care.

Data collection and analysis: 

Two review authors independently selected studies, assessed risks of bias, and extracted data from all included studies. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the odds ratio (OR) for dichotomous data with a 95% confidence interval (CI). We assessed heterogeneity using the I2 statistic and assessed the quality of evidence using GRADE criteria.

Main results: 

We include five RCTs (971 participants) of mHealth-delivered education interventions for people with HF in this review. The number of trial participants ranged from 28 to 512 participants. Mean age of participants ranged from 60 years to 75 years, and 63% of participants across the studies were men. Studies originated from Australia, China, Iran, Sweden, and The Netherlands. Most studies included participants with symptomatic HF, NYHA Class II - III.

Three studies addressed HF knowledge, revealing that the use of mHealth-delivered education programmes showed no evidence of a difference in HF knowledge compared to usual care (MD 0.10, 95% CI −0.2 to 0.40, P = 0.51, I2 = 0%; 3 studies, 411 participants; low-quality evidence). One study assessing self-efficacy reported that both study groups had high levels of self-efficacy at baseline and uncertainty in the evidence for the intervention (MD 0.60, 95% CI −0.57 to 1.77; P = 0.31; 1 study, 29 participants; very low-quality evidence).Three studies evaluated HF self-care using different scales. We did not pool the studies due to the heterogenous nature of the outcome measures, and the evidence is uncertain. None of the studies reported adverse events. Four studies examined health-related quality of life (HRQoL). There was uncertainty in the evidence for the use of mHealth-delivered education on HRQoL (MD −0.10, 95% CI −2.35 to 2.15; P = 0.93, I2 = 61%; 4 studies, 942 participants; very low-quality evidence). Three studies reported on HF-related hospitalisation. The use of mHealth-delivered education may result in little to no difference in HF-related hospitalisation (OR 0.74, 95% CI 0.52 to 1.06; P = 0.10, I2 = 0%; 3 studies, 894 participants; low-quality evidence). We downgraded the quality of the studies due to limitations in study design and execution, heterogeneity, wide confidence intervals and fewer than 500 participants in the analysis.

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