Mobile Technology–Enabled Rehabilitation (MoTER) is a platform designed for home-based monitoring in cardiac rehabilitation using a smartphone app and the web [14]. The platform consists of a smartphone app (Android or iOS) with educational videos, health measures, exercise review, goal setting, motivational text messages, and a web portal. We extended the platform to create MoTER for patients with ACS (MoTER-ACS), which integrates a smartphone app (Android or iOS), Bluetooth-enabled devices (blood pressure [BP] cuff and body weight [BW] scale), and a web portal to provide health monitoring, evidenced-based education, and health care provider support for patients with ACS following discharge from the hospital. Furthermore, we aimed to optimize the app’s usability and to simplify navigation by including different levels of menu choices, creating a highly engaging appearance using quality images and adequate text, and reducing app errors through frequent testing. To achieve these aims, we studied mHealth apps by conducting literature reviews, including a systematic review on mHealth strategies and structures [15].

Based on the Australian guidelines [16], interventions to reduce modifiable risk factors for cardiovascular disease (CVD) include advice and treatment on (1) smoking cessation, (2) maintenance of normal BP, (3) lowering of the serum cholesterol concentration and maintenance of the lipid profile within guideline levels, (4) lowering of serum glucose to within guideline levels, and (5) information on lifestyle risk factors, such as physical activity, diet, obesity, and alcohol consumption. The core components of secondary prevention include health evaluation, patient education, exercise training, lifestyle risk factor management, medication, and psychosocial management [16]. In this study, we aimed to address these components in the development of an mHealth intervention for postdischarge management of patients with ACS.

Theory-based interventions have been demonstrated to be more effective than those without theoretical underpinnings. Applying behavior change theories to mHealth intervention designs significantly increases the likelihood of success [9]. The use of a theoretical framework enables researchers to address the complexity of mHealth interventions when involving a diverse set of stakeholders and their perspectives in order to create change [13].

The development of the MoTER-ACS intervention was informed by the social cognitive theory and used components of self-efficacy informational sources. The self-efficacy theory was adopted to reinforce behavior change, including problem solving, goal setting, action planning, e-diaries, self-monitoring, educational instructions, role modeling, and health care providers’ persuasion.

Self-efficacy stands at the core of the social cognitive theory and consists of all the thoughts that affect human functioning [17]. Self-efficacy is defined as an individual's belief in his or her capacity to achieve behaviors necessary to produce specific performance skills [17]. Self-efficacy reflects confidence in the ability to control one's own motivation, behavior, and social environment [17]. MoTER-ACS pedagogical principles were based on self-efficacy elements, including mastery experience, role modeling, and verbal persuasion. Previous research has recommended using a combination of 3 to 4 sources of the theory to promote a stronger sense of self-efficacy and a greater willingness to undergo behavioral change and thus produce optimal results [18]. Mastery experience was implemented by asking participants to self-monitor and record their health measures (for example, BP and BW) and lifestyle parameters, such as smoking, drinking alcohol, and consuming fruits and vegetables.

Role modeling through observing others’ actions is considered effective in increasing self-efficacy [19]. Peer role modeling was reinforced through educational materials linked to the Australian Heart Foundation website and the stories of people who had similar conditions. This aimed to resemble role models and encourage patients’ engagement with the intervention. A further source of self-efficacy, verbal persuasion, was applied to the intervention through motivational SMS text messages and feedback from health care professionals.

The purpose of the MoTER-ACS was to overcome accessibility barriers and enable patients to either receive traditional face-to-face outpatient follow-up or a smartphone-based approach. The major platform design objectives were to provide patient-centered educational materials and symptom monitoring, support, and feedback by health care professionals based on the theory-driven strategies. To achieve these objectives and extend the platform, we conducted prestudy surveys that consisted of questionnaires among a group of patients (n=30), a focus group discussion with health care professionals (n=10), and an online survey among cardiologists (n=15). The study procedure was approved by the relevant human research ethics committee.

To address the research methodology as an iterative process and to modify the MoTER-ACS intervention, the survey among patients and the focus group with health care professionals will be repeated following feasibility testing. Repeating the prestudy surveys aims to determine any modifications required.

We extended the MoTER platform (Figure 1) based on the results from the prestudy. The MoTER-ACS platform consists of smartphone apps (Android and iOS), Bluetooth-enabled medical devices, and a web portal. Apps are used for providing education and personalized feedback, collecting physiological data, recording patients’ self-observations of their health-related behaviors, and facilitating health care providers’ consultations via audio or video. All the data entered into the apps by patients are synchronized daily to a web portal on a secure server with a user-friendly front-end web portal, where clinicians can regularly (every 2 to 3 days) monitor physiological data.

MoTER-ACS provides an alternative model of care to a postdischarge clinic, and it is essential to determine how the intervention compares with traditional programs before it can be implemented as routine practice. Therefore, a pilot randomized controlled trial is planned to test the feasibility of the MoTER-ACS platform with a small group (N=54) of patients with ACS for 12 weeks. The trial will aim to test aspects of the platform and intervention content design, such as educational instructions, self-management interventions, and health care providers’ support. The pilot study will be conducted based on the adopted framework and assess several outcome measures, such as participants’ compliance and adherence to the intervention, modifiable cardiovascular risk factors, medication adherence, and health status. Based on the results of the pilot randomized controlled trial, patient survey, and focus group discussion (as a poststudy activity), the MoTER-ACS intervention will be modified and a subsequent larger randomized controlled trial with longer follow-up will be conducted to observe patients over a longer period.

This paper outlines the development and extension of an evidence- and theory-based mHealth intervention to support patients with ACS. Advanced sensor and smartphone technologies overcome common accessibility barriers that limit patient support. mHealth interventions can potentially meet the needs of patients who are unable or unwilling to attend outpatient clinics following discharge from the hospital [28]. MoTER-ACS provides educational instructions, self-management interventions, and health care providers’ support. We aimed to close the gap between hospital- and home-based postdischarge programs by proposing an alternative model of health care delivery.

The incorporation of social and behavioral theory in apps is crucial in developing complex interventions [29]. However, there is a lack of theory-based mHealth interventions, even though some theories of behavior change are validated in evidenced-based interventions for primary and secondary prevention [30,31]. To develop the MoTER-ACS intervention, the self-efficacy theory (drawn from the social cognitive theory) was adopted to reinforce behavior change, including problem solving, goal setting, action planning, e-diaries, self-monitoring, educational instructions, role modeling, and health care providers’ persuasion.

The prestudy surveys provided information on patients' perceived learning needs and health-related literacy, which was required for developing mHealth educational interventions. Prior to developing educational interventions, assessing and evaluating patients’ learning needs is essential, and it is evidenced that adopting a structured educational plan increases the likelihood of a successful recovery [32]. Furthermore, engaging patients in the development phase and identifying their needs and preferences empowers their enthusiasm for learning and therefore assists health care providers in developing patient-centered interventions.

The focus group discussion with health care professionals resulted in useful feedback regarding content and features for the development of the MoTER-ACS intervention. The educational materials and self-management interventions identified from the prestudy surveys and systematic reviews [15,28] were incorporated into the MoTER-ACS platform to engage patients with the intervention and improve their health outcomes after discharge from the hospital. The MoTER-ACS app contains multimedia educational instructions and tools to support self-management. Educational materials with diet information could influence patient knowledge and provide guidance to follow healthy diet instructions, tips, and recipes.

Previous research has demonstrated the benefits of tracking health behaviors through mHealth. Self-monitoring, goal setting, and feedback are recommended for tracking because they are likely to increase patients’ engagement in their personalized care and offer health care providers assessments of their patients’ daily activity patterns [11]. A recent systematic review and meta-analysis of remotely delivered interventions using self-monitoring and feedback demonstrated a significant effect on patient behavior change [33]. Therefore, we considered symptom monitoring, goal setting, and feedback from health care providers within the MoTER-ACS intervention.

A systematic review of mHealth pain management showed that mobile apps are beneficial for patients, particularly those in outpatient clinics, and that both patients and health care providers were satisfied with apps that provided pain management tools [34]. Furthermore, previous research has shown that a smartphone pain diary facilitates gathering more accurate and complete pain ratings [35]. Hence, a body pain map for the MoTER-ACS app was developed to identify pain and its characteristics.

Motivational messages are delivered as part of the MoTER-ACS intervention. It is evidenced that 4 SMS text messages per week are effective in improving patients’ health outcomes [36]. Additionally, personally tailored and interactive interventions seem to be more efficacious, especially when users can choose when to receive messages [36].

Although mHealth can potentially improve patients’ self-management, adoption of such technologies by adults 50 years or older is limited by age-related barriers. Higher age, physical decline, comorbidities, and low health literacy have been identified as mHealth engagement barriers [37]. Despite older adults’ interest in using mHealth, current evidence reports that their usage and adoption of such interventions are inconsistent [38]. Therefore, facilitators and barriers potentially influencing older adults’ acceptance of mHealth must be considered [37]. In addition to providing flexible tools to engage patients via written, verbal, or video interactions, there is a need to consider how individuals without advanced technical skills will interact with the app or participate in mHealth interventions [39]. Previous research has shown that most participants expect in-person training on the use of the mHealth app in addition to on-demand online help, phone support, or support from family and friends [40-42]. Therefore, in-person training on using the mHealth intervention and the involvement of family and caregivers could be solutions to improve engagement with the MoTER-ACS intervention.

Well-designed educational strategies grounded in theory and contemporary evidence are crucial in the development of complex interventions [15]. We used a theoretical framework to form the important constructs of the MoTER-ACS intervention and fully integrated it into all parts of the platform. We conducted the prestudy surveys to enhance the intervention design before embarking on feasibility testing. However, the patient survey was limited by the recruitment of a small sample of 30 patients with ACS from a metropolitan hospital. This limits the generalizability of the study results compared with sampling from other settings, including regional and remote areas. A larger sample size and nonurban hospital may provide precise information about patients' learning needs and preferences; however, the results of this study are consistent with previous research that examined cardiovascular patients’ educational needs [43].

The MoTER-ACS platform provides comprehensive educational and self-management interventions based on the secondary prevention components recommended by national guidelines. The MoTER-ACS app is designed for both Android and iOS smartphones. Moreover, the flexible platform architecture enables rapid integration of new smartphones and wearable and nonwearable sensor capabilities as they become available.

Learning to use a smartphone and health-measuring devices represents a potential barrier for older adults [37]. Although we aimed to design the MoTER-ACS app to be user-friendly, a dedicated training module is required to familiarize patients with the technology. However, some patients may not be able to overcome the technological barriers. Therefore, involving family and caregivers could be a solution to overcome these barriers [44].

The MoTER-ACS platform extends the capabilities of the previous MoTER platform and provides an alternative model of care for postdischarge follow-up of patients with ACS. If proven effective, this research would enable clinicians to overcome the accessibility barriers of traditional hospital-based programs by providing mHealth follow-up. Mobile technology provides an ideal platform for the delivery of health care services and could easily be applied to the prevention and management of other chronic diseases.