Result of our Focus Groups

Focus groups were used to identify patient preferences and barriers regarding health behaviour change. We hosted 9 focus group interviews with 2-6 participants each, at the Tilburg Elisabeth-TweeSteden Hospital in collaboration with Tilburg University (TiU) in the Netherlands, at Klinik Königsfeld in Germany and at Hospital Clínico Universitario de Santiago de Compostela (SERGAS) in Spain. To analyse information from the focus groups, we used a combination of inductive and deductive coding.

The most common barriers that were discussed in the focus groups and that should be taken into account when developing an eHealth intervention for patients with CAD are: negative emotional state for dietary behaviour, stress reduction and smoking cessation, lack of time/priority for physical activity and stress-reduction, side-effects of medication and lack of habits for medication adherence, physical dysfunction (i.e., complications due to physical injury) for physical activity, and (lack of) knowledge for dietary behaviour. The most common facilitators of health behaviour change that were identified during the focus groups and that should be taken into account when developing new interventions are: physical wellbeing (maintain a healthy quality of life) for physical activity and dietary behaviour, life events for dietary behaviour and smoking cessation, social support for physical activity, established habit for medication adherence, intrinsic motivation (willpower) for smoking cessation, and enhancing positive emotional states for stress reduction.

The focus groups also determined what behavioural change techniques (BCTs) patients would respond most positively to. Patients mostly discussed BCTs for physical activity, with self-monitoring of behaviour, prompts/cues, and instructions on how to perform the behaviour receiving the most positive response. For medication adherence, only four BCTs were identified (self-monitoring of behaviour, prompts/cues, social support and conserving mental resources), to which patients responded relatively positive. Five BCTs were identified for diet, with self-monitoring of behaviour, instructions on how to perform the behaviour, and conserving mental resources receiving the most positive response. For smoking, five BCTs were identified, with prompts/cues being the only one that people responded negatively to and goal setting, self-monitoring of outcomes behaviour, social reward and behaviour substitution receiving a relatively positive response. Only two BCTs were identified for stress reduction, one of which patients responded positively to (self-monitoring of behaviour) and one of which patients responded negatively to (prompts/cues).

Triangulating the results of the focus groups and the literature review resulted in a set of recommendations for BCTs that should be incorporated into eHealth interventions for patients with CAD. First of all, it was evident that self-monitoring of behaviour, prompts/cues, instructions on how to perform the behaviour, goal setting and social support were most likely to result in change in physical activity. This was concluded based on the literature review, that demonstrated that these BCTs were more frequently used in interventions that succeeded in changing behaviour, and the focus groups, in which patients responded favourably to these BCTs. Furthermore, it was evident that prompts/cues were unlikely to stimulate smoking cessation in patients with CAD. This was concluded based on the literature review, demonstrating that this BCT was more common in interventions that did not succeed in more smoking cessation, and the focus groups, in which patients responded negatively towards prompts/cues in smoking interventions. For the other behaviours, no overlap between the literature review and the focus groups was found, though the findings of each method separately should still inform intervention development.

In general, because of the high variety of preferences between patients, it is important that patients have the option to personalize any app they may use. Additionally, it is important that their data are protected and only shared with their health care providers. Patients should also be given the option to receive help with and after installing the app.