Negotiating Tensions Between Theory and Design in the Development of Mailings for People Recovering From Acute Coronary Syndrome

Abstract

BackgroundTaking all recommended secondary prevention cardiac medications and fully participating in a formal cardiac rehabilitation program significantly reduces mortality and morbidity in the year following a heart attack. However, many people who have had a heart attack stop taking some or all of their recommended medications prematurely and many do not complete a formal cardiac rehabilitation program.ObjectiveThe objective of our study was to develop a user-centered, theory-based, scalable intervention of printed educational materials to encourage and support people who have had a heart attack to use recommended secondary prevention cardiac treatments.MethodsPrior to the design process, we conducted theory-based interviews and surveys with patients who had had a heart attack to identify key determinants of secondary prevention behaviors. Our interdisciplinary research team then partnered with a patient advisor and design firm to undertake an iterative, theory-informed, user-centered design process to operationalize techniques to address these determinants. User-centered design requires considering users’ needs, goals, strengths, limitations, context, and intuitive processes; designing prototypes adapted to users accordingly; observing how potential users respond to the prototype; and using those data to refine the design. To accomplish these tasks, we conducted user research to develop personas (archetypes of potential users), developed a preliminary prototype using behavior change theory to map behavior change techniques to identified determinants of medication adherence, and conducted 2 design cycles, testing materials via think-aloud and semistructured interviews with a total of 11 users (10 patients who had experienced a heart attack and 1 caregiver). We recruited participants at a single cardiac clinic using purposive sampling informed by our personas. We recorded sessions with users and extracted key themes from transcripts. We held interdisciplinary team discussions to interpret findings in the context of relevant theory-based evidence and iteratively adapted the intervention accordingly.ResultsThrough our iterative development and testing, we identified 3 key tensions: (1) evidence from theory-based studies versus users’ feelings, (2) informative versus persuasive communication, and (3) logistical constraints for the intervention versus users’ desires or preferences. We addressed these by (1) identifying root causes for users’ feelings and addressing those to better incorporate theory- and evidence-based features, (2) accepting that our intervention was ethically justified in being persuasive, and (3) making changes to the intervention where possible, such as attempting to match imagery in the materials to patients’ self-images.ConclusionsTheory-informed interventions must be operationalized in ways that fit with user needs. Tensions between users’ desires or preferences and health care system goals and constraints must be identified and addressed to the greatest extent possible. A cluster randomized ...

Interventions supporting long term adherence and decreasing cardiovascular events after myocardial infarction (ISLAND): pragmatic randomised controlled trial

“…Interventions were developed to be scalable and sustainable for implementation across health systems, and were systematically developed and informed by behavioural science, patient input,17 a user centred design process,18 and results of a pilot trial 9. Interventions were coordinated and performed centrally but delivered on behalf of the cardiology team at the hospital where the patient had their index coronary angiogram.…”

“…This letter provided evidence in support of rehabilitation and persistence with cardiac drugs, suggestions for improving adherence, and a prefilled referral form with details of local cardiac rehabilitation programmes (to deal with the barrier of non-referral to rehabilitation at discharge). A description of the design process along with samples of the mail-outs has been previously published 18…”

“…The lead patient partner helped to gather input from additional patients and worked with the design team to iteratively develop the intervention materials, following user centred design methodology. This process was described in detail in a previous manuscript 18. Briefly, the process involved meeting a series of patients who experienced a heart attack to develop the content of the materials and was facilitated by a professional, user experience, design group.…”

Designing Emails Aimed at Increasing Family Physicians� Use of a Web-Based Audit and Feedback Tool to Improve Cancer Screening Rates: Cocreation Process (Preprint)

“…Behaviour change techniques previously shown to be effective may not always elicit positive responses during co-creation or user testing. This tension is not unique to physician users as it also occurred in previous work with patient users relating to the development of mailings for people recovering from acute coronary syndrome [28]. While users may be "experts of their experience" [27], they are not always experts in how to promote behaviour change in themselves or in others [28].…”

“…This tension is not unique to physician users as it also occurred in previous work with patient users relating to the development of mailings for people recovering from acute coronary syndrome [28]. While users may be "experts of their experience" [27], they are not always experts in how to promote behaviour change in themselves or in others [28]. It is important to consider user feedback alongside evidence for the effectiveness of the underlying BCT and explore potential outcomes to BCT-informed content in discussions with users.…”