Figure 1
PRISMA diagram of identifying studies of eHealth interventions [17].
Table 1
Characteristics of reviewed studies (n = 10).
| AUTHOR, YEAR | COUNTRY | PARTICIPANTS MEAN AGE (SD) | SAMPLE SIZE | STUDY DURATION (FOLLOW UP) | INTERVENTION GROUP | CONTROL GROUP | HEALTH OUTCOMES | |||
|---|---|---|---|---|---|---|---|---|---|---|
| PHYSICAL | NON-PHYSICAL | |||||||||
| BEHAVIOURAL | PSYCHOLOGICAL | OTHERS | ||||||||
| Dale 2015 [19] | New Zealand | 59.5 (11.1) | 123 | 10 months | Guidelines delivered by SMS and a supporting website over 24 weeks to educate patients about cardiovascular risk factors and support to make relevant lifestyle changes. Recommended lifestyle changes included stopping smoking, limiting alcohol consumption, eating right and maintaining regular physical activity | Usual care | BMI, BP, lipid profile | Medication adherence, physical activity, health behaviour | Anxiety, Depression | – |
| Frederix 2015 [20] | Belgium | 61 (9) | 140 | 1 year 7 months | 24-week telerehabilitation programme in combination with conventional cardiac rehabilitation | Conventional cardiac rehabilitation | BMI, BP | Physical activity | – | QoL |
| Martin 2015 [21] | United States of America | 58 (8) | 48 | 4 months | Receiving SMS | Usual care | – | – | – | – |
| Skobel 2017 [22] | Spain, United Kingdom and Germany | *IG: 60 (50/65)*CG: 58 (52/67) | 118 | 1 year 10 months | GEX, sensor monitor breathing rate, ECG | Conventional care | BMI, BP, lipid profile | - | Anxiety, depression | QoL |
| Kamal 2018 [23] | Pakistan | IG: 59.1 (11.6)CG: 57.7 (11.1) | 197 | 9 months | Access to helpline number to address queries in addition to standard of care as per institutional guidelines, IVR technology tailored to their respective prescriptions and have the ability to hear information about medication dosage, correct use, side effects, mechanism of action and how and why use the medication. Also receive scheduled SMS message reminders to take their medications. | Regular follow-up visits with stroke neurologist or cardiologist | – | Medication adherence | – | – |
| Choi 2019 [24] | American | IG: 57.2 (1.8)CG: 56.6 (1.7) | 100 | 6 months | Custom smartphone application that reinforced the Mediterranean diet | In-person dietary counselling sessions with registered dietitian at 1 month and 3 months | BMI, BP, lipid profile | Diet | – | – |
| Dorje 2019 [25] | China | IG: 59.1 (9.4)CG: 61.9 (8.7) | 312 | 4 months (FU-1 year) | Standard care and 2-month intensive SMART-CR/SP programme, followed by a 4-month step-down stage. During the intensive phase, participants received four educational modules per week via WeChat. In the step-down phase, participants received only 2 cartoon pictures with key motivational message per week. | Standard care provided by community doctors and cardiologists (brief inpatient health education by ward nurse, medication management, and ad-hoc follow-up visits to a cardiologist or other health-care providers according to the patient’s self-assessment of their cardiovascular health). WeChat for sending follow-up visit reminders | BMI, BP, lipid profile | Medication adherence, physical activity, dietary behaviour, smoking cessation | – | QoL |
| Broers 2020 [26] | Netherlands and Spain | 61.97 (11.61) | 150 | 5 months (FU-6 months) | Ambulatory health-behaviour assessment technologies for 6 months combined with a 3-month behavioural intervention programme | Usual care | – | Health Promotion Lifestyle Profile | – | QoL |
| Lunde 2020 [27] | Norway | 59 (8.7) | 113 | 9 months (FU-1 year) | Individualised follow-up enabled with an application for one year | Usual care | BP, lipid profile | – | – | QoL |
| Song 2020 [28] | China | IG: 54.17 (8.76)CG: 54.83 (9.13) | 106 | 6 months | Using telemonitoring software (MEMRS-CRS, developed by Medicus) on smartphones, heart rate monitors (Suunto, provided by Medicus) for monitoring patients’ HR | Usual care | – | Physical activity | – | – |
[i] SD: standard deviation, IG: intervention group, CG: control group, FU: follow up post-intervention, HR: heart rate, BP: blood pressure, BMI: Body Mass Index, SMS: Short Message Service, QoL: Quality of Life, IVR: Interactive Voice Response, GEX: Guided exercise system, ECG: Electrocardiogram, SMART-CR/SP: smartphone-based and WeChat-based cardiac rehabilitation and secondary prevention.
* Median (25th/75th centile).
Table 2
Overview of the overall modality of the eHealth interventions (n = 10).
| AUTHOR, YEAR | EHEALTH INTERVENTIONS MODALITY | ||||||
|---|---|---|---|---|---|---|---|
| SMARTPHONE MOBILE APPLICATION | SMS | WEBSITE | TELEMONITORING | PHONE CALL | OTHER DEVICES | ||
| Dale 2015 [19] | / | / | Pedometer | ||||
| Frederix 2015 [20] | / | / | / | Accelerometer | |||
| Martin 2015 [21] | / | / | / | Accelerometer | |||
| Skobel 2017 [22] | / | / | |||||
| Kamal 2018 [23] | / | / | / | ||||
| Choi 2019 [24] | / | ||||||
| Dorje 2019 [25] | / | / | |||||
| Broers 2020 [26] | / | / | / | Smartwatch, sleep tracker | |||
| Lunde 2020 [27] | / | ||||||
| Song 2020 [28] | / | / | / | / | Heart rate monitors | ||
[i] SMS: Short Message Service.
Figure 2
(a) The risk-of-bias graph: proportions of studies with low, high, and unclear risks of bias in each domain. (b) The risk-of-bias summary: the risk-of-bias judgement of each included study in each domain.
Figure 3
The effect of eHealth intervention on physical health outcomes. (a) The effect of eHealth intervention on BMI at 6 months (n = 5). (b) The effect of eHealth intervention on Systolic BP at 6 months (n = 5). (c) The effect of eHealth intervention on Diastolic BP at 6 months (n = 4). (d) The effect of eHealth intervention on LDL at 6 and 12 months (n = 6). (e) The effect of eHealth intervention on HDL at 6 and 12 months (n = 6). (f) The effect of eHealth intervention on Total Cholesterol at 6 and 12 months (n = 6).
Figure 4
Funnel plot comparison of eHealth intervention for physical health outcomes. (a) Funnel plot comparison of eHealth intervention for BMI (n = 5). (b) Funnel plot comparison of eHealth intervention for resting systolic BP at 6 months (n = 5). (c) Funnel plot comparison of eHealth intervention for resting diastolic BP at 6 months (n = 4). (d) Funnel plot comparison of eHealth intervention for LDL at 6 and 12 months (n = 6). (e) Funnel plot comparison of eHealth intervention for HDL at 6 and 12 months (n = 6). (f) Funnel plot comparison of eHealth intervention for Total Cholesterol at 6 and 12 months (n = 6).
Figure 5
Sensitivity analysis on the effect of eHealth intervention on BP at 6 months. (a) Sensitivity analysis on the effect of eHealth intervention on Systolic BP at 6 months (n = 3). (b) Sensitivity analysis on the effect of eHealth intervention on Diastolic BP at 6 months (n = 3).
Table 3
Outcome summary for non-physical health outcomes utilising eHealth interventions (n = 10).
| AUTHOR, YEAR, STUDY DURATION OUTCOME | NON-PHYSICAL HEALTH OUTCOME (EHEALTH INTERVENTION VERSUS CONTROL) | |||||
|---|---|---|---|---|---|---|
| BEHAVIOURAL | PSYCHOLOGICAL | QUALITY OF LIFE | ||||
| MEDICATION ADHERENCE | PHYSICAL ACTIVITY | DIETARY BEHAVIOUR | OTHERS | |||
| Dale 2015 [19], at 6 months | MMAS-8 Mean difference: 0.58, 95% CI 0.19–0.97; ** p = 0.004 | Godin Leisure Time Physical Activity Questionnaire IG: 28% to 31% CG: 11% to 24% | – | Self-reported composite health behaviour AOR: 1.93, 95% CI 0.83–4.53; p = 0.13 IG: 33% to 53%CG: 27% to 39% | HADS (anxiety) Mean difference: 1.18, 95% CI 0.28, 2.08; * p = 0.01 | – |
| Frederix 2015 [20], at 6 months | – | IPAQ in MET-min/week of VMW IG: χ2 (2): 13.7; * p = 0.01CG: χ2 (2): 0.6; p = 0.72 | – | – | – | HRQL IG: χ2 (2): 14.0; ** p < 0.001 CG: χ2 (2): 3.1; p = 0.21 |
| Martin 2015 [21] | – | Daily steps Mean difference: 3376, 95% CI 1951–4801; ** p < 0.001 | – | – | – | – |
| Skobel 2017 [22], at 6 months | – | – | – | – | HADS (Anxiety) Mean (SD); p = 0.1 IG: 1.6 (3.1) CG: –0.63 (3.8) HADS (Depression) Mean (SD) p = 0.27 IG: 1.36 (3.7) CG: 0 (1.6) | EQ–5D Mean (SD); p = 0.98 IG: 0.64 (13.9) CG: 0.54 (10.7) |
| Kamal 2018 [23], at 3 months | MMAS–8 Mean difference (SD): –0.06 (0.13), 95% CI –0.39–0.19; p = 0.69 | – | – | – | – | – |
| Choi 2019 [24], at 6 months | – | – | MDS compliance (** p < 0.001) IG: 27.5% to 64.7% CG: 18.4% to 57.1% | – | – | – |
| Dorje 2019 [25], at 6 months | Adherence to cardioprotective medications Mean difference: 1.79, 95% CI 1.76–1.87; * p = 0.019 | SF-12 Physical Health score Mean difference: 1.26, 95% CI –0.74 – 3.26; p = 0.22 | – | Smoking status Mean difference: 2.42, 95% CI 0.42–14.00; p = 0.32 | GAD–7 Mean difference: 0.60, 95% CI –0.25 – 1.46; p = 0.17 | – |
| Broers 2020 [26], at 6 months | – | – | – | Health Promotion Lifestyle Profile F unadjusted (2,271.90) = 8.28; ** p < 0.001 | – | WHOQOL-BREF F(2,135.42) = 9.63; ** p < 0.001 |
| Lunde 2020 [27], at 1 year | – | Exercise habits Mean change (SD) IG: 1.4 (1.5); (** p < 0.001) CG: 0.6 (1.1); (** p < 0.001) | – | – | – | Heart QoL Mean change (SD) IG: 0.21 (0.47); (* p < 0.05) CG: 0.09 (0.45) |
| Song 2020 [28], at 6 months | – | Exercise habits based on ACSM χ2 9.826; * p = 0.02 | – | – | - | – |
| Outcome summary | Significant | Significant | Significant | Not significant | Not significant | Not significant |
[i] IG: Intervention group, CG: Control group, MMAS-8: Morisky 8-item Medication Adherence Questionnaire, HADS: Hospital Anxiety and Depression Scale, VMW: vigorous and/or moderate and/or walking, IPAQ: International Physical Activity Questionnaire, HRQL: Health-Related Quality of Life, χ2 (2): Friedman’s test, EQ-5D: European Quality of Life Five Dimension, MDS: Mediterranean diet scores, SF-12: 12-Item Short Form Survey, GAD-7: GAD-7: Generalised Anxiety Disorder 7-item scale, WHOQOL-BREF: World Health Organization Quality of Life–BREF, F: Analysis of Variance (ANOVA), HeartQol: Heart Quality of Life, ACSM: 10th Edition American College of Sports Medicine Guidelines for Exercise Testing and Prescription.
* Statistical significance: p < 0.05, ** p < 0.005.