JMIR Publications

ABSTRACT

Background:

Lifestyle behaviors are major predictors of cardiovascular morbidity and mortality, emphasizing the need for strategies that support sustained lifestyle changes in cardiac patients. Digital health solutions, including wearables, mobile apps, and chatbot systems, enable self-monitoring of lifestyle behaviors but often face challenges with engagement and usability. While self-monitoring systems can increase awareness and accountability—promoting behavior change and long-term improvements—maintaining user engagement remains crucial for their effectiveness.

Objective:

This study evaluated patient experiences with a lifestyle monitoring system combining a web application, health watch, and chatbot. To inform future self-monitoring strategies, we explored facilitators and barriers to long-term adherence and assessed the impact of self-monitoring on lifestyle awareness and behavior change in cardiac patients.

Methods:

We conducted a mixed-methods study with patients who used an eHealth platform for self-monitoring lifestyle behaviors during one year following an invasive cardiac procedure. The study included 100 participants (mean age: 61.6 ± 10.4 years; 88% male), comprising both completers (n = 57) and dropouts (n = 43). Participants engaged in quarterly phone interviews and questionnaires, and completed an end-of-study questionnaire. Completers participated in a structured evaluation interview, while dropouts provided a reason for discontinuation. Quantitative and qualitative data analysis focused on usability, long-term adherence facilitators and barriers, lifestyle awareness, and behavior change.

Results:

Participants completed 157 quarterly questionnaires (145 by completers and 12 by dropouts) and 217 phone interviews (171 with completers and 46 with dropouts). 77 participants (of whom 54 were completers and 23 dropouts) completed end-of-study questionnaires, and 56 of 57 completers participated in the evaluation interviews. Completers reported higher perceptions of the platform’s usefulness, ease of use, and satisfaction (all, p < 0.001) than dropouts. Dropout reasons included high self-report burden and dissatisfaction with the chatbot (29%), poor overall usability experience (15%), health watch technical challenges causing frustration (9%), limited perceived usefulness (9%), mental stress from self-monitoring (18%), and low motivation (15%). Key facilitators of long-term engagement included routine formation, structured reminders, and minimal effort associated with the wearable. Barriers involved repetitive chatbot questions (causing cognitive burden) and technical issues with the health watch. Self-monitoring increased lifestyle awareness among completers, particularly for physical activity (45%) and nutrition (52%), with smaller effects for sleep quality (13%) and mental stress (1%). It facilitated behavior change in physical activity and nutrition (29% each), sleep quality (7%), but not in mental stress. Participants indicated that adherence could be enhanced by improving adaptive personalization, mobile accessibility, and real-time feedback.

Conclusions:

Fostering routine formation while minimizing patient burden through personalized, flexible, and adaptive features is important for sustained patient engagement in eHealth monitoring systems. Enhancing relevance, usability, and personalization while reducing complexity and technical barriers can optimize digital health tools, promoting lasting behavior change in cardiac rehabilitation and beyond. Clinical Trial: Dutch Trial Register (Landelijk Trial Register); NL9861.