| Background:The high recurrence and mortality rates of coronary heart disease place a heavy burden on global health systems.Treatment of coronary artery disease currently includes drug therapy,percutaneous coronary intervention or coronary artery bypass grafting.However,drug therapy has limitations,with the latter two modalities targeting localised areas and temporarily addressing myocardial ischaemia and hypoxia,but not stopping the progression of the disease.As various cardiovascular risk factors remain,patients are at high risk of adverse cardiovascular events such as in-stent stenosis and plaque rupture,which can endanger their lives.In addition,many unstable patients have multiple vulnerable plaques,making systemic therapies that treat all lesions simultaneously more advantageous than a limited strategy that treats only one target lesion.Cardiac rehabilitation and secondary prevention is a multidisciplinary team(cardiologists,nurses,physiotherapists,dieticians,counsellors)working together to improve the patient’s level of function,alter the natural course of the disease,reduce readmission rates and mortality and improve the patient’s quality of life through medical evaluation,exercise prescription,correction of cardiac risk factors,education,counselling and behavioural interventions.Cardiac rehabilitation and secondary prevention have a key role in preventing recurrence of coronary heart disease and reducing mortality and readmission rates.Nurses play an important role in cardiac rehabilitation and secondary prevention.Cardiac rehabilitation care includes five areas of physical activity promotion,improving medication adherence,healthy eating,stress management and smoking cessation,which play an important role in reducing readmission and mortality rates in patients with coronary heart disease.Of these,physical activity is an emerging intervention in recent years and has been classified as Class A evidence,Level I recommendation for the treatment of coronary heart disease by the American Heart Association,Cardiology,the European Society of Cardiology and the Chinese guidelines for cardiac rehabilitation and secondary prevention of coronary heart disease.The beneficial effects of physical activity on coronary risk factors,endothelial dysfunction,inflammation,propensity to thrombosis,autonomic tone and myocardial ischaemia may all play a role in reducing the risk of death and new coronary events.However,physical activity,an emerging intervention in recent years,has not yet resulted in a systematic rehabilitation care programme.Most patients with coronary artery disease suffer from physical inactivity.The main reason for this is a lack of physical activity follow-up and motivation for behavioural change.Therefore,new behavioural interventions are needed to increase patients’ motivation to participate and promote physical activity.With the rapid development of mobile health and the popularity of smart electronic devices,smartphone and tablet-based mobile health interventions are gradually being used in the management of coronary heart disease.Mobile health can overcome spatial and temporal barriers to clinical monitoring and improve access to healthcare by providing remote out-of-hospital follow-up of physical activity through the web and mobile apps.Mobile health is widely used in cardiac rehabilitation care to provide health education and improve cardiac rehabilitation awareness;facilitate interaction,increase social support and improve cardiac rehabilitation participation;assist with self-management and improve cardiac rehabilitation compliance;and improve out-of-hospital cardiac rehabilitation safety with real-time exercise monitoring;gamification is the integration of game design elements(e.g.points,levels,leaderboards,etc.)into non-gamified environments(e.g.healthcare)to enhance patient motivation and motivate behaviour change.Mobile health-based gamified behavioural interventions have greater potential to improve physical activity behaviours in patients with coronary heart disease.Purpose:This study aims to integrate gamification into m Health,develop a m Health-based gamified behavioural intervention programme and explore the acceptability of the m Health-based gamified physical activity behavioural intervention programme among patients with coronary heart disease through a randomised controlled trial;explore the impact of the gamified m Health intervention programme on physical activity participation of patients with coronary heart disease;and explore the effects of the gamified m Health intervention in terms of physical function,psychological status and social support in a multi-dimensional manner.Methods:This study consists of five sections:(1)A cross-sectional survey of the current status of physical activity in post-PCI patients with coronary heart diseaseA cross-sectional study method was used to conduct a questionnaire survey on 290post-PCI patients with coronary heart disease to understand the type,intensity,level and influencing factors of physical activity after coronary heart disease PCI in Changchun,Jilin Province.To provide a basis for the development of the later protocol.(2)A Systematic review of mhealth-based gamified physical activity behavioural interventionsA systematic review of 50 m Health-based gamified physical activity behavioural interventions based on PRISMA guidelines and Cochrane systematic review guidelines:(i)identify the most common types of m Health that provide gamified physical activity behavioural interventions(e.g.wearable devices or mobile apps);(ii)describe the most common and effective gamification elements of m Health-based physical activity behavioural interventions;(iii)identify behaviour change theories that guide gamified physical activity interventions;and(iv)summarise the effects of gamification interventions on physical activity(including daily steps and physical activity time)and sedentary behaviour for this study.(3)identify the behaviour change theories that guide gamified physical activity interventions;(4)summarise the effects of gamification interventions on physical activity(including daily steps and physical activity time)and sedentary behaviour,providing a theoretical basis and practical reference for the design of gamified behavioural interventions for physical activity in this study.(3)Developing and refining a mhealth-based gamified physical activity behavioural interventionBased on the effective game design elements identified in the previous study and guided by self-determination theory and behavioural economics,the researcher drafted the mhealth-based physical activity gamification intervention,revised the details of the gamification mechanism in the intervention using the expert working group method and patient feedback,and then drafted the final version of the gamification intervention.(4)Developing and testing the mhealth-based physical activity gamified Wechat applet1)The researcher established the functional points,structure,and content of the Wechat applet implementation and creates the necessary text,images,and videos.After multiple changes,the applet was established in collaboration with software engineers.2)After the applet was completed,15 coronary heart patients were invited to conduct usability tests to explore the usability and acceptability of the applet,identify unfriendly parts of the user interface and suggest ways to improve it.(5)A randomized controlled trial exploring the effectiveness of the mhealth-based gamified physical activity behavioural intervention1)To provide measurement tools for the intervention study’s outcome indicators,the Psychological Needs Satisfaction in Exercise Scale,the Behavioural Regulation in Exercise Questionnaire-3,and the Physical Activity Enjoyment Scale were evaluated for their reliability and validity,and scales for physical activity appropriate for post-PCI patients with coronary heart disease were revised.2)A total of 108 patients were randomised into three groups(control,individual and team groups),patients in the control group received only daily step target setting,the individual and group groups received a gamified behavioural intervention and the team group received social motivation on top of the individual group.The aim is to explore the acceptability of the mhealth-based gamified physical activity behavioural intervention among patients with coronary heart disease;to explore the impact of the gamified mhealth intervention programme on the physical activity participation of patients with coronary heart disease;to explore the effects of the gamified mhealth intervention in terms of physical function,psychological status and social support,and other multi-dimensions.The study also explored the internal psychological mechanisms of the gamified mobile health behavioural intervention through semi-structured interviews.Results:(1)A cross-sectional survey of the current status of physical activity in post-PCI patients with coronary heart diseaseIn this study,72.1%(209/290)of post-PCI patients with coronary artery disease did not meet the recommended guidelines for physical activity,and more than half(53.1%,154/290)of the participants demonstrated low levels of physical activity.Factors affecting patients’ physical activity included income(p=0.022),type of health insurance(p=0.005),body mass index(p=0.018)and waist circumference(p=0.010).(2)A Systematic review of mhealth-based gamified physical activity behavioural interventionsThe results of the systematic review of physical activity gamification interventions found that the recommended gamification elements for a gamification intervention were1-10,with frequently used gamification elements including “achievement and progress oriented” such as goal setting,progress,rewards,points,leaderboards,feedback,and “social interaction oriented” such as competition and cooperation.Gamification interventions using theoretical guidance may be more effective than those without,and the more widely used theories are self-determination theory and the principles of behavioural economics.Of these,there is an intrinsic link between self-determination theory and the concept of gamification,and the fact that gamification can make interventions more enjoyable is consistent with self-determination theory,which assumes that enjoyment is a key aspect of intrinsic motivation.The principles of behavioural economics are the more effective theories to guide gamification interventions.(3)Developing and refining a mhealth-based gamified physical activity behavioural interventionThe protocol was drafted by the researcher herself,taking into account the findings of the literature review and the insights from the theoretical study.Based on the feedback from the expert working group and the patients,the “step goal setting”,“gamification elements and mechanism”,“patient-side applet function”,“patient-side applet interface”,“follow-up intervention Research proposals” and other aspects were revised to form the final draft of the plan.(4)Developing and testing the mhealth-based physical activity gamified Wechat applet1)The researcher identified the expected functionalities and back-end management solutions for the We Chat app;collected and collated the educational materials needed for the app,including text,video and images,to form a text requirement.A total of 12 meetings were held with software engineers to discuss solutions and implementation paths,as well as interface design and colour selection,resulting in the “Tahnee Weh” app.2)The researchers recruited 15 post-PCI patients with coronary heart disease and conducted usability tests using a one-to-one approach.They found that the points and levels icons were not eye-catching enough and the rules were not clear enough.Based on this,the points,levels and rules features were revised again,resulting in a user-friendly interface.(5)A randomized controlled trial exploring the effectiveness of the mhealth-based gamified physical activity behavioural interventionThe study found that the m Health-based gamified physical activity behavior intervention was a higher usability score,indicating that the intervention was acceptable,with significantly higher daily steps(difference 988;95% CI,259 to 1717;P < 0.01)and physical activity adherence(difference 0.08;95% CI,0.04 to 0.13;P < 0.001)in the individual group of patients,and in daily steps(difference 819;95% CI,24 to 1613;P < 0.01)and physical activity adherence(difference 0.07;95% CI,0.06 to 0.09;P < 0.05),but patients in the group group had a maintenance effect during the intervention for daily steps(difference 472;95% CI,-325 to 1268;P = 0.115)and physical activity adherence(difference 0.04;95% CI,-0.01 to 0.08;P=0.074)were not significantly different between the group and the control group.During the intervention period,patients in the individual group showed significant decreases in body weight(difference-0.5;95% CI,-1.0 to 0.1;P < 0.001),BMI(difference-0.4;95% CI,-0.6 to-0.2;P < 0.001),waist circumference(difference-1.2;95% CI,-1.7 to-0.6;P < 0.001),while systolic blood pressure,diastolic blood pressure and resting heart rate were not significantly different compared with controls;whereas there were no significant differences between the team group and controls in weight,BMI,waist circumference,systolic blood pressure,diastolic blood pressure,and resting heart rate.Neither type of intervention improved patients’ anxiety,depression and social support status.During the intervention period,patients in the individual group had an increased competence need(difference 0.6;95% CI,0.3 to 0.8;P < 0.001)and significantly higher autonomous motivation(difference 3.3,2.2 to 2.4;P < 0.001),but no increase in autonomy need and relatedness need;the team group had no improvement in competence need(difference 0.3;95% CI 0.1 to 0.6;P < 0.001),and relatedness need(difference 0.9;95% CI0.7 to 1.2;P < 0.001)and autonomous motivation(difference 3.0;95% CI 2.1 to 4.0;P <0.001),but not autonomy need.Conclusion:Post-PCI patients with coronary artery disease do suffer from a lack of physical activity and failure to meet guideline standards.Patients lack out-of-hospital physical activity follow-up and motivation for behaviour change,and new behavioural interventions are needed to promote physical activity in post-PCI patients with coronary artery disease.A mhealth-based gamified behavioural intervention has more potential to improve patients’ physical activity behaviour with maintenance effects.For the individual group,the mobile health-based gamification intervention significantly increased physical activity in patients with coronary artery disease over 12 weeks and had a good maintenance effect during follow-up;for the team group,the team-based gamification intervention did not lead to a significant increase in physical activity.Gamification may offer a promising approach to changing health behaviours in cardiac rehabilitation care,however the effectiveness of combining gamification with collaboration remains to be further explored. |
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