A Smartphone App (TRIANGLE) to Change Cardiometabolic Risk Behaviors in Women Following Gestational Diabetes Mellitus: Intervention Mapping Approach

Abstract

Background Gestational diabetes mellitus (GDM) is the most common complication during pregnancy and is associated with an increased risk for the development of cardiometabolic diseases. Behavioral interventions can reduce this risk, but current solutions insufficiently address the requirements for such a program. The systematic development of a scalable mobile health (mHealth) promotion program for mothers during the first years post-GDM may contribute to solving this problem. Objective The aim of this project was to systematically plan and develop a theory- and evidence-based mHealth intervention to change cardiometabolic risk behaviors in women during the first 5 years post-GDM that meets women’s expected standards of commercial health apps. Methods The intervention mapping steps 1 to 4 structured the systematic planning and development of the mHealth program described in this paper. Steps 1 and 2 led to a theory- and evidence-based logic model of change for cardiometabolic health. Based on this model, the prevention program was designed (step 3) and produced (step 4) in cooperation with industrial partners to ensure a high technological standard of the resulting smartphone app for the iPhone (Apple Inc). Step 4 included a user study with women during the first 5 years post-GDM once a beta version of the app (“TRIANGLE”) was available. The user study comprised 2 test rounds of 1 week (n=5) and 4 weeks (n=6), respectively. The tests included validated questionnaires on user acceptance, user logs, and think-alouds with semistructured interviews. Results The novel TRIANGLE app is among the first self-paced smartphone apps for individual habit change in the 3 lifestyle areas of physical activity, nutrition, and psychosocial well-being. The 3 core features—a challenge system, human coaching, and a library—address 11 behavioral determinants with 39 behavior change methods to support lifestyle changes. Participants in the user study showed a high acceptance, high perceived quality, and high perceived impact of the TRIANGLE app on their health behaviors. Participants tested the app regularly, used it intuitively, and suggested improvements. We then adapted the TRIANGLE app according to the insights from the user study before the full TRIANGLE program production. Conclusions The intervention mapping approach was feasible to plan and develop an innovative and scalable smartphone solution for women during the first 5 years post-GDM. The resulting TRIANGLE intervention has the potential to support behavior change for cardiometabolic disease prevention. However, the app needs further refinement and testing in clinical trials. Intervention mapping steps 5 (implementation plan) and 6 (evaluation plan) may support the integration of the TRIANGLE intervention into routine care. Trial Registration German Clinical Trials Register DRKS00012736; https://www.drks.de/DRKS00012736

A novel smartphone app to change risk behaviors of women after gestational diabetes: A randomized controlled trial

“…A coaching platform for healthcare practitioners mirrored these features in a content management system for individualization ( S1 Fig ). Details of the intervention can be found in a separate paper describing the planning and development process as well as early user testing of the TRIANGLE intervention [ 15 ]. Software support and online coaching for intervention participants were based in Munich.…”

“…Software support and online coaching for intervention participants were based in Munich. Control participants received a flyer with a summary of the lifestyle changes for diabetes prevention as addressed in the TRIANGLE intervention [ 15 ], thus adding the psychosocial wellbeing and sleep themes to usual standard care.…”

“…At V1, intervention participants answered an initial paper and pencil questionnaire for personalization purposes of the program and received a Garmin vívosmart HR® fitness tracker, a step tread, the TRIANGLE intervention paper note pad, and an individual login code for the TRIANGLE app ( S2 Table ) [ 15 ]. The client-server system tracked their activity in the TRIANGLE app ( Fig 1 and S3 Table ).…”

“…The primary goal of our app-based TRIANGLE intervention is to support women on a daily basis to change their lifestyle habits. Intervention Mapping fostered a multi-theory approach at the habit-goal interface [ 15 ]. This approach helped us translate multiple behavior change methods into technical app features while complying with industrial standards for interactive smartphone apps and with the specific needs of women in the late postpartum phase [ 15 ].…”

Moderate dietary salt restriction improves blood pressure and mental well‐being in patients with primary aldosteronism: The salt CONNtrol trial

“…Adherence to the study protocol was monitored every 4 weeks by two consecutive determinations of 24-h urinary sodium excretion and nutrition protocols during the study. To facilitate the dietary approach to reduce salt intake, all patients received a personal structured nutritional training at the beginning of the study and were supported by a dietician (who also conceived and conducted the training) and a mobile health program [16,17] throughout the study (see also Fig. S2 for a flowchart of the study protocol).…”