Hannah McGowan

The increasing burden of cardiovascular disease calls for greater secondary prevention and management strategies to reduce further adverse health consequences. A growing body of knowledge has drawn attention to the positive effects of regular heart-healthy physical activity on the cardiovascular health of individuals with cardiovascular disease. Despite this knowledge, far too few individuals with cardiovascular disease engage in regular physical activity. Even those who complete a structured cardiac rehabilitation programme often struggle to maintain an active lifestyle in the long term. This draws attention to the need to better support individuals with cardiovascular disease in sustaining a physically active lifestyle through exploration into the determinants (i.e., influencing factors) of physical activity in this population and how interventions can be best designed and implemented for promoting physical activity behaviour.

In this dissertation, exploration into this stems from both a systematic synthesized approach and patient-reported perspectives to identify what determinants (i.e., factors) are most relevant and should be incorporated into physical activity-promoting interventions. Moreover, given the rise of digital health interventions, this dissertation also explores the potential and how digital health interventions may be best developed and implemented in healthcare based on patient-reported usage and perceptions, as well as collated findings from healthcare professional perspectives.

To explore this, this dissertation addresses the following two driving aims:

(1) To investigate and synthesize key determinants (i.e., promoting and hindering factors) of physical activity engagement among individuals with cardiovascular disease through:
a. collated quantifiable association strength measures extracted from primary studies
b. patient-reported perspectives of facilitators and barriers, as well as motivating reasons of physical activity

(2) To explore the potential of digital health interventions for promoting physical activity in cardiovascular disease secondary prevention through:
a. patient-reported perspectives on the reasons for and against digital technology usage; insights into the desired features and means of digital technology-promoting physical activity interventions
b. synthesized (quantitative and qualitative) findings of facilitating and hindering factors for the uptake of digital health interventions in clinical practice from healthcare professional perspectives, to provide strategies for increased uptake of evidence-based digital health interventions in healthcare

A summary of each chapter is presented below in alignment to the above-mentioned research aims.

Chapter one begins with a general introduction of the scope of cardiovascular disease and draws attention to its increasing prevalence and overall health burden worldwide. It highlights the global and European efforts to reduce the mortality and morbidity rates of cardiovascular disease and further addresses how healthy lifestyle behaviours are pertinent in reducing its adverse consequences. It stresses the critical role that physical activity plays as a key modifiable behavioural factor, but the concerning high levels of physical inactivity found among patients with cardiovascular disease, where physical activity is critical in preventing negative outcomes. It highlights a need to better understand the factors contributing to physical inactivity among individuals with cardiovascular disease given a gap in synthesized findings of the relevant determinants in this population. It draws upon the well-researched area of determinants found in the general public through prior systematic reviews as a basis to build upon, but underlines that individuals with cardiovascular disease may present unique challenges based on their cardiac condition, warranting further investigation specific to this population. Among determinants, motivation for physical activity is as key factor to explore among patients with cardiovascular disease, as patients may present specific motivating reasons for physical activity unique to their condition that should be reflected in physical activity-promoting interventions. Here, self-determination theory is introduced as the framework applied to this dissertation to investigate and categorize patient motivation. Lastly, the introduction discusses the emergence of digital health interventions and their potential in improving clinical outcomes and behavioural change in cardiovascular disease prevention. It further addresses the current gaps in their uptake for patients and healthcare providers underscoring a need for greater insight into reasons behind low acceptability from these two stakeholder groups.

Chapter two begins with addressing the first aim of this dissertation, namely an investigation into the most prevalent determinants of physical activity among patients with cardiovascular disease. To investigate this, a systematic review was utilized as the best approach for addressing this aim, given its ability to collate association strength measures from determinants and physical activity behaviour across primary studies. This allows for a synthesis of determinants’ importance based on the strength of association and directionality across a range of samples. Here, to categorize determinants, the OPTimAL ontology framework was utilized to allow for a systematic structurization, such that similar determinants were ordered to similar overarching themes (e.g., cognitive factors, psychological factors) allowing for improved comparison. Overall, 70 primary studies from 29 countries (2005-2025) were included resulting in 56 determinants. The determinants that are regarded as main facilitators of physical activity are self-efficacy and prior exercise behaviour followed by education level, social support, intention, exercise belief, illness perception, and psychological well-being. Negative emotion (mostly kinesiophobia) and older age were identified as the strongest indicators for negative physical activity behaviour.

Chapter three moves from an overall global view of determinants to a sample-specific analysis of determinants and motivation for physical activity in an Austrian sample of former cardiac rehabilitation participants. Here, a cross-sectional study was conducted and specifically targeted individuals who had completed a cardiac rehabilitation programme approximately three years prior to the study. This was purposely targeted to observe what determinants and motivating reasons relates to physical activity in long-term secondary prevention, i.e., self-management phase. Here, health, pain and motivation were found as main determinants of physical activity, with autonomous motivation relating to health-related goals and quality-of-life aspirations most prevalent. Furthermore, it was found that in this sample of predominately older-aged patients, there was an overall large preference for outdoor, aerobic, and individual physical activities. This study provided important considerations for creating physical activity-promoting interventions in such a population.

Chapter four turns to the second main aim of this dissertation, namely, the role of digital health technologies in cardiovascular disease prevention. It follows the same cross-sectional study design as the prior chapter, however, differs in the content of survey. Here, a different sample of former cardiac rehabilitation participants were asked about their usage of digital technologies in their daily lives, as well as for physical activity purposes and their reasons for and against technology usage, and desired features. Findings showed that digital technologies usage - especially the smartphone - was highly prevalent in patients’ daily lives and to a large extent for physical activity purposes. Digital technologies were mostly used for information and more traditional communication aspects (e.g., email and calling), or pulse measurement and monitoring purposes for physical activity. Main reasons against physical activity usage were perceived lack of need, lack of interest or poor usability. This study provided important insights into patient views and needs of digital technology for physical activity behaviour. Taken together, chapters three and four provide valuable primary data for the Austrian context, where such research has been largely unexplored.

Chapter five expands on this by exploring healthcare professional opinions on the barriers and facilitators for digital health technology uptake in cardiovascular disease healthcare. Here, a systematic review of 125 primary studies (2020-2024) with qualitative, quantitative, and mixed methods was conducted to synthesize healthcare provider perspectives on digital health technologies. These factors were coded and categorized to the World Heart Federation Roadmap domains: healthcare professionals, patients, technology and health systems. Overall, the most frequently reported barrier for healthcare providers was excessive workload (due to current workload or perceived added workload due to use of digital health interventions). Other barriers were individual factors relating to low trust and negative attitudes or concerns. On the other hand, perceived positive clinical impact, healthcare provider motivation and training were key-reported facilitators. Moreover, healthcare providers felt hindered to use digital health technologies because of perceived low patient access to technology and digital literacy levels, whereas perceived improvements in patient-centred care positively influenced use. For health systems, work structure, financing and policies were key factors. Lastly, on the technological side, usability, adaptability, technical stability, and integration with existing technical systems were important factors. Overall, this study reveals that uptake of digital health technologies for cardiovascular disease in healthcare is complex and effort needs to be focused on better assessing the local context, building trust, incorporating provider input, and transparency with digital health technologies.

Lastly, chapter six provides an in-depth discussion of the main findings from the previous studies and their overall implications within the scope of existing literature. Here, the discussion is structured by the two driving aims of this dissertation. The first part discusses the key determinants of physical activity behaviours identified among individuals of cardiovascular disease and provides recommendations based on these factors that should be targeted in the design of such interventions. It additionally draws on the motivational findings behind physical activity and how physical activity interventions could incorporate such motivating-reasons to drive patient autonomy and possibly greater behavioural outcome. The second part of this chapter focuses on the second aim of digital health interventions. Here, recommendations are provided to facilitate the design and implementation of digital interventions based on patient-reported perspectives on their needs, opinions and preferences. Recommendations are additionally provided for the implementation of evidence-based digital health interventions in healthcare by drawing on the collated perspectives of healthcare providers. Subsequently, a section of this chapter is devoted to synthesizing all the prior chapters together to provide concrete suggestions for the design and implementation of digital physical activity interventions for individuals with cardiovascular disease. Lastly, this chapter discusses how the dissertation situates itself in the concept of Intervention Mapping and provides its limitations and future directions.