Description of the condition

Heart failure is defined by the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: guidelines for the prevention, detection, and management of heart failure in Australia 2018 as "a complex clinical syndrome with typical symptoms and signs which generally occur on exertion, but can also occur at rest. It is secondary to an abnormality of cardiac structure or function that impairs the ability of the heart to fill with blood at normal pressure or eject blood sufficient to fulfil the needs of the metabolising organs" p. 1136 (Atherton 2018). It is characterised by typical symptoms such as breathlessness, ankle swelling and fatigue which may be accompanied by signs, e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema (Ponikowski 2016). Heart‐failure patients often experience many of these symptoms at the same time, which eventually lead to decreased functional status, frequent hospitalisation and a diminished quality of life (Hoekstra 2013). A 2016 update from the American Heart Association estimated that 5.7 million people in America have heart failure and more than 915,000 new diagnoses occur every year (Mozaffarian 2016). Globally, the prevalence of HF is estimated to be 2% to 3% (Ambrosy 2014; Bui 2011; Dunlay 2017), and increases with age. At least 20% of hospital admissions among people older than 65 years are due to HF (Dunlay 2017).

The goal of HF management is to relieve symptom burden, prevent hospitalisation, and improve survival (Ponikowski 2016). Over the last few decades, the use of effective treatment, including pharmacological agents, non‐surgical devices, as well as disease‐management programmes, have reduced the risk of hospitalisation and sudden cardiac death, and improved overall mortality among people with HF (Al‐Khatib 2018; Kristensen 2018; Nochioka 2018; Velazquez 2018). However, the prognosis of HF still remains poor (Al‐Khatib 2018; Schmidt 2016). Approximately 30% of people hospitalised with HF are readmitted within 30 to 90 days (Ambrosy 2014; Pandolfi 2017), and non‐adherence is a common cause of admission. Among 54,322 admissions from 236 hospitals in the USA, non‐adherence to medication or dietary requirements accounted for 10.3% of HF admissions (Ambardekar 2009). There is high‐quality evidence to support HF disease‐management programmes (case management‐type interventions led by a specialist HF nurse), with benefits seen in HF‐related and all‐cause readmissions and all‐cause mortality (Takeda 2019). Patient education is central to all disease‐management programmes (Ambardekar 2009; Angermann 2012; Bekelman 2015; Clark 2015; Jonkman 2016), but effective methods for delivering patient education are yet to be identified.

Description of the intervention

Traditionally, patient education has been conducted in a face‐to‐face manner using printed or written materials, with perhaps the use of a video to support key messages. Information communication technology is now commonplace in both the developed and developing worlds (WHO 2011) and as healthcare rationalisation reforms reduce or restrict face‐to‐face services, using information communication technology to assess, educate, support and interact with patients is becoming more common. Using technologies such as smartphone and tablet apps, SMS messages and social media‐delivered education programmes will become more commonplace in the future. To date, many patients already expect these innovations to support modern healthcare delivery by facilitating a more personalised person‐centred care (Cowie 2016).

The interventions included in this review fall under the description of mHealth. mHealth is defined by the WHO as " the use of mobile and wireless technologies to support the achievement of health objectives" (WHO 2011).

mHealth‐delivered education interventions provide patients with disease‐specific information through a mobile platform. This mobile platform could be a tablet, a mobile phone or a laptop. Technology‐based mobile patient‐education interventions have been used for people living with many different conditions, such as depression (Pinto 2013), diabetes (Heinrich 2012; Pal 2014), and breast cancer (Jibaja‐Weise 2011). An example of such an intervention in heart failure is the 'Heart Failure Matters' (heartfailurematters.org) by the European Society of Cardiology. The interventions we examine in this review provide education to people with heart failure, with the purpose of increasing their knowledge and understanding of what heart failure is, symptoms of heart failure, and how these can be managed and prevented from exacerbation, and the importance of adhering to any prescribed therapies such as medications, diet or exercise. The intervention are aimed at the patient, but caregivers may also access the information provided to the patient.

Technological innovations are very heterogeneous and lack shared definitions, which limits the possibility of comparing and evaluating different programmes. This review addresses a critical gap by examining the effectiveness of technology‐based HF patient‐education tools and platforms. We examine mHealth education for people with HF, focusing on interventions which are delivered using technologies such as smartphone and tablet apps, SMS messages and social media‐delivered education programmes. We exclude TV programmes, videos (other than those incorporated into the included technologies), telephone calls, interactive voice response systems and paper‐based education materials, where these are used in isolation from one of the listed technologies. We provide a description of the mode, method, and frequency of the intervention, as well as conceptual underpinnings of the intervention, methods of instructional design and processes of promoting intervention fidelity. We identify both the structural and functional mechanisms of effective interventions to facilitate broad translation.

How the intervention might work

Self‐management is “the engagement of a person in activities which protect or promote their own health, manage their symptoms and the impact which their condition has on their life and also adhere to any prescribed therapies” (Gruman 1996). Self‐management can be learned through health‐education interventions, and targets improving knowledge about the disease, treatment, and outcomes (health literacy), so that the person is better informed and capable of engaging in activities which protect or promote their own health (e.g. fluid restriction), manage their symptoms (e.g. breathlessness and fatigue), the impact which heart failure has on their life, and also adherence to any prescribed medications. A range of patient, provider and healthcare system factors influence HF management. As a consequence, self‐care and patient outcomes and technological innovation are promising in promoting access to health education and self‐management strategies (Omura 2017).

Engaging clinicians and patients as partners in care is increasingly recognised as critical, and has led to an increased emphasis on shared decision‐making (Ting 2014). Implicit in this process is engaging the patient as an active partner, and this can challenge traditional paradigms of health education, where the patient is a passive recipient of care. In promoting effective self‐management, the capacity to tailor and target the approaches to an individual's needs is important. Innovative health education using eHealth and mHealth technologies may provide greater opportunities for patient and clinician engagement, as well as being better tailored to patient preferences and needs, be these cognitive, language, or sensory disabilities. These individual factors include understanding how factors such as health literacy, numeracy, cognitive capacity, cultural needs and health‐seeking behaviours contribute to both the learning experience and the capacity to adopt health information and education, and progress to self‐management (Davidson 2013; Dennison 2011; McNaughton 2013). Due to the comorbidity burden in heart failure, and the fact that it is a condition of the elderly (Dunlay 2017), factors such as cognition and psychomotor skills influence the capacity to both engage in and benefit from technological innovation in information delivery and promotion of behaviour change (Holden 2013). Recent research in neuroscience, cognitive and developmental psychology has also increased our understanding of how to actively engage learners in achieving a desired outcome. Cognitive impairment is an important consideration in understanding both the design and the feasibility and acceptability of educational interventions (Cameron 2017; Uchmanowicz 2017). Appreciating the diverse range of physical, social, psychological, economic and cultural factors that contribute to heart failure outcomes is important to promote both the efficacy and effectiveness of education interventions. As drivers of health outcomes are strongly mediated by social determinants of health, it is important to appraise health‐education interventions within this context (Marmot 2017).

In addition, mHealth‐delivered interventions can provide timely access to health information and communication with healthcare professionals to support self‐management and decision‐making (WHO 2011). In this review, we examine whether mHealth‐delivered education interventions work, which is important not only in implementing evidence‐based recommendations, but also in advancing the science of self‐care and self‐management. This is a novel and important focus for this review and is guided by a standardised taxonomy using criteria such as theoretical underpinning, mode of instructional design, and mode of delivery and capacity for interaction. Appreciating how eHealth‐ and mHealth‐based assisted learning incorporate concepts such as grounded cognition, spaced learning, and simulation in educational media is important, and both underscore the complexity and capability of intervention development (Koong 2014). Focusing solely on the medium of technology (such as SMS or social media support) in evaluating the efficacy of interventions is simplistic and less likely to be effective in translating research into practice.

Why it is important to do this review

Disease management has been shown to significantly improve patient outcomes and reduce costs of care for HF (Angermann 2012; Bekelman 2015). Although improvements in care and outcomes have been achieved through disease management, the range of patient, provider and healthcare‐system factors that influence HF management often remain unaddressed (Omura 2017), and disparities in HF outcomes are growing. As a consequence, the overall prognosis of HF remains poor (Schmidt 2016).

Health care is rapidly evolving, and information technology, which is evolving ever more rapidly, offers great promise as a tool to promote effective communication and learning that is highly individualised to patients' circumstances and needs in the developing and developed worlds (WHO 2011). Patient education is central to all disease‐management programmes (Ambardekar 2009; Angermann 2012; Bekelman 2015; Clark 2015; Jonkman 2016; Takeda 2019). It is not clear which of the various methods for delivering patient education are effective. A text messaging intervention to improve HF self‐management in a largely African‐American population has shown a positive impact on outcomes (Nundy 2013). Similarly, an education and coaching programme integrated with telehealth has also shown improved outcomes (Stut 2015). The ever‐increasing role of technology and access to health apps, social media and web pages, not all of which may have been underpinned by evidence or evaluated in any way, warrants the need to conduct this systematic review. The survey of global mHealth use undertaken by the WHO in 2011 identified effectiveness and cost effectiveness as key barriers to mHealth implementation (Cowie 2016).

Implementation of effective, tailored, technology‐driven patient‐education interventions that promote self‐management in heart failure may promote access to heart‐failure care across the trajectory and reduce growing health disparities.

In the current setting of increasing use of information communication technology worldwide, mHealth‐delivered interventions for patient education are becoming more available (Cowie 2016; Schwamm 2017). We do not believe that age is a barrier to the application of these interventions, as smartphones and tablet computers are becoming more common (Cowie 2016; Schwamm 2017). Although limited research exists to fully understand the use of information‐communication technology amongst typically older people with cardiovascular illness, a survey of 123 patients (mean age 51 years) at an outpatient cardiopulmonary clinic in a large tertiary hospital in Australia indicates that for this sampled population, information‐communication devices are becoming a part of everyday life, with most survey respondents engaging regularly with a computer (83%), mobile telephone (97%) and the internet (86%) (Disler 2015). Accessing health information online was also a common activity, with 74% regularly consulting online health information sites (Disler 2015). Although this study was undertaken at a single site, it does provide some insight into the patterns of use amongst people for whom the technologies examined in this review are being designed.

The National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand guidelines strongly recommend educating patients and carers about HF and self‐management to decrease hospitalisation and mortality (Atherton 2018). This should begin soon after diagnosis, must be patient‐centred, appropriate to their level of health literacy, culturally appropriate and revised throughout the person's life (Atherton 2018). Similarly, the European Society of Cardiology guidelines have also emphasised the importance of education for self‐care (Ponikowski 2016). It has recommended that patients must be provided with sufficient up‐to‐date information to make decisions on lifestyle adjustment and self‐care (Ponikowski 2016). The American Heart Association guidelines also highlight that education must be tailored individually and must consider relevant comorbidities that may influence retention of information (Mozaffarian 2016).