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Cardiovascular disease, a behaviour change technology-based intervention and treatment fidelity, what are the challenges?

By Artur Direito, on 5 July 2018

By Dr. Orlagh O’Shea (1) & Prof. Catherine Woods (2)

(1) Dublin City University, Ireland; (2) University of Limerick, Ireland

Cardiovascular disease (CVD) is a major cause of death worldwide. Importantly for behaviour change research, 80% of cases are precipitated by modifiable behavioural risk factors including physical activity, smoking, alcohol consumption, diet, stress management and medication adherence. The current standard of care targets these risk factors through cardiac rehabilitation: a supervised exercise class, including, education and psychological support. Despite the proven benefits of cardiac rehab in terms of reducing mortality and morbidity, uptake and adherence to cardiac rehabilitation are suboptimal. Reasons for this include lack of time, travel and perceived body image. Home-based cardiac rehab programmes can overcome these barriers and have also been shown to be effective. However, few centres offer remote rehabilitation.

With advancements in technology, there is increasing interest in eHealth interventions. This provides a unique opportunity to develop remote interventions to allow for increased access to cardiac rehab programmes for patients who encounter barriers to participation. We set to design an eHealth cardiac rehab programme which would incorporate the components of traditional cardiac rehab; therefore, behaviour modification was integral to the intervention components: The PATHway (Physical Activity Towards Health) programme.

The PATHway programme was designed and developed to answer many important gaps in the current literature and to provide a solution to problems regarding the management of CVD. PATHway aims to empower participants to self-manage their CVD risk factors which is achieved through a patient centred behaviour change approach that involves an internet-enabled home exercise platform as the core component of a lifestyle intervention programme. Through a detailed and iterative design process, twenty-two behaviour change techniques (BCTs) were mapped to PATHway. A key area for future research identified by our team was whether the included BCTs are effective.

Whether the BCTs included in PATHway are effective will depend on whether they are delivered as intended, this is known as treatment fidelity. Despite the well acknowledged importance of monitoring treatment fidelity to enhance the reliability and validity of an intervention, it is a concept that is often neglected in the literature. The reasons of the lack of attention to treatment fidelity in the literature are unknown; previous authors have postulated that this could relate to the increase in resources required to assess treatment fidelity. However, with the advancements in technology PATHway provides an automated fidelity assessment system, which can reduce staff time required for monitoring fidelity. For example, PATHway automatically records data on participant login to different intervention components, including frequency of use, duration of time in each component, number of classes undertaken and furthermore within this, technology allows us to assess the completeness of the class.

While technology provides us with opportunities to more readily assess fidelity, it is not without its challenges. The computer literacy of the target population, the absence of face-to-face and unforeseen difficulties with technology such as systems updating can impact on the assessment of fidelity.  With all of this in mind we pose the following questions:


  • Do you think technology alone can accurately assess treatment fidelity?
  • With advancements in technology and increased eHealth behaviour change interventions do you think there is a need for a framework to assess fidelity specifically in eHealth interventions?
  • Do you think defining the effectiveness of BCTs is important for the development of behaviour change research? Have you attempted to define this in your own research?


Dr. Orlagh O’Shea

Dr. Orlagh O’Shea (@orlaghoshea88) is a postdoctoral researcher on the PATHway project. Orlagh’s research interests are physical activity and exercise in clinical populations, including cardiovascular and chronic lung diseases as well as the evaluation of treatment fidelity in behaviour change interventions.


Prof. Catherine Woods

Prof. Catherine Woods (@CatherineBWoods) joined the Department of Physical Education and Sport Sciences (PESS), Faculty of Education and Health Sciences at the University of Limerick (UL) in 2016.  She is a member of UL’s Health Research Institute and her research cuts across its themes of technology, lifestyle and health. Catherine enjoys developing and testing theoretically sound interventions to change population levels of physical activity.  She seeks better, more systematic methods of bringing research, practice and policy closer together to achieve real and sustainable impact

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