Unveiling the pros and cons of digital health interventions for people with one or more chronic conditions

This blog summarises a recent systematic review published in the Journal of Medical Internet Research titled Benefits and Harms of Digital Health Interventions Promoting Physical Activity in People With Chronic Conditions.

The problem

We face a pressing challenge with chronic conditions imposing a significant global health burden. This burden is linked with a substantial negative impact on the individual and escalating healthcare costs (1,2). Engaging in regular physical activity can greatly benefit physical and mental health without additional risks (3). However, many people living with chronic conditions fail to meet recommended activity levels due to various barriers such as lack of time, social support, safety concerns, and cost (4).

The possible solution

To address this, personalised and accessible health care is crucial. Digital health interventions offer promising solutions through various platforms like websites, mobile apps, or wearables (5). The convenience and potential for personalised care have driven the growth of digital health interventions in recent years, especially during the COVID-19 pandemic (6). However, the effectiveness of these interventions to improve health remains unclear. Thus, this blog provides a comprehensive overview of our latest paper on the benefits and harms of digital health interventions promoting physical activity in people with one or more chronic conditions (multimorbidity) (7). This can help guide clinicians and decision-makers in implementing effective digital health interventions.

What did we do?

We performed a systematic review on digital health interventions promoting physical activity in people (≥ 18 years old) with one or more of the following conditions: depression or anxiety (mental health condition), heart disease, chronic obstructive pulmonary disease, osteoarthritis of the hip or knee, hypertension, or type 2 diabetes (7). These conditions were selected due to their high prevalence globally and association with physical inactivity and systemic low-grade inflammation (2, 8, 9). This review included randomized controlled trials that compared interventions with a digital health component versus standard care. Digital health interventions were defined as interventions that used technology (e.g., websites, apps, wearables) to promote physical activity with or without healthcare-provided support (10).

What did we find?

Our findings revealed several favourable, but small, effects of digital health interventions on various health outcomes, particularly at the end of the interventions, while only a few were sustained over time (see Infographic). Notably:

• Digital health interventions improved objectively measured physical activity levels compared to usual care or minimal intervention, translating to an average increase of 971 daily steps.
• Similarly, physical function improved, with an average increase of nearly 20 meters on the 6-minute walking test.
• Digital health interventions reduced depression and anxiety symptoms and improved health-related quality of life.
• While the intervention groups experienced a higher risk of nonserious adverse events, there was no significant difference in the risk of serious adverse events compared to the control groups.

Can we trust these findings?

Overall, we are confident that the findings on objectively measured physical activity, depression symptoms, and adverse events are robust, that is moderate certainty of evidence, according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach (11). Suggesting that future studies will most likely confirm these results. However, for the other outcomes investigated, our confidence is low.

What is next?

To improve the confidence in these results and possibly health outcomes, there is the need to co-develop (with people living with chronic conditions and other relevant stakeholders), evaluate, and implement high-quality digital health interventions as the currently available options for people living with one or more chronic conditions have limited quality and potential for behaviour change (12). Furthermore, while doing so, it is imperative to understand the impact of digital health literacy and its association with physical activity. To diminish equality and avoid marginalising those who may be in greater need of physical activity or those who may be challenged in using digital health interventions, digital health literacy levels may need to be considered.

Conclusion – what can the reader take away from this blog?

• Digital health interventions hold promise in promoting physical activity among people living with one or more chronic conditions.
• These interventions, which may have small effects, can lead to improvements in physical activity levels, physical function, and quality of life. Additionally, they can help reduce symptoms of depression and anxiety while being relatively safe.
• There is a need to co-develop higher-quality digital health interventions to improve treatment outcomes and confidence in these results and understand the impact of digital health literacy on physical activity.

Author names & affiliations 

Alessio Bricca [1,2], Søren T. Skou [1, 2], Graziella Zangger [1, 2].

[1] Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark

[2] The Research and Implementation Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospital, Slagelse, Denmark

References 

1. Booth FW, Roberts CK, Laye MJ. Lack of exercise is a major cause of chronic diseases. Compr Physiol 2012;2(2):1143-211. doi: 10.1002/cphy.c110025 [published Online First: 2012/04/01]
2. Diseases GBD IC. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020;396(10258):1204-22. doi: 10.1016/S0140-6736(20)30925-9 [published Online First: 2020/10/19]
3. Reid H, Ridout AJ, Tomaz SA, et al. Benefits outweigh the risks: a consensus statement on the risks of physical activity for people living with long-term conditions. Br J Sports Med 2022;56(8):427-38. doi: 10.1136/bjsports-2021-104281 [published Online First: 2021/10/16]
4. Vancampfort D, Koyanagi A, Ward PB, et al. Chronic physical conditions, multimorbidity and physical activity across 46 low- and middle-income countries. Int J Behav Nutr Phys Act 2017;14(1):6. doi: 10.1186/s12966-017-0463-5 [published Online First: 2017/01/20]
5. Murray E, Hekler EB, Andersson G, et al. Evaluating Digital Health Interventions: Key Questions and Approaches. Am J Prev Med 2016;51(5):843-51. doi: 10.1016/j.amepre.2016.06.008
6. Whitelaw S, Mamas MA, Topol E, et al. Applications of digital technology in COVID-19 pandemic planning and response. Lancet Digit Health 2020;2(8):e435-e40. doi: 10.1016/S2589-7500(20)30142-4 [published Online First: 2020/08/25]
7. Zangger G, Bricca A, Liaghat B, et al. Benefits and Harms of Digital Health Interventions Promoting Physical Activity in People With Chronic Conditions: Systematic Review and Meta-Analysis. J Med Internet Res 2023;25:e46439. doi: 10.2196/46439 [published Online First: 2023/07/06]
8. Gleeson M, Bishop NC, Stensel DJ, et al. The anti-inflammatory effects of exercise: mechanisms and implications for the prevention and treatment of disease. Nat Rev Immunol 2011;11(9):607-15. doi: 10.1038/nri3041 [published Online First: 2011/08/06]
9. Pedersen BK, Saltin B. Exercise as medicine – Evidence for prescribing exercise as therapy in 26 different chronic diseases. Scandinavian Journal of Medicine and Science in Sports 2015;25:1-72. doi: 10.1111/sms.12581
10. Fatehi F, Samadbeik M, Kazemi A. What is Digital Health? Review of Definitions. Stud Health Technol Inform 2020;275:67-71. doi: 10.3233/shti200696 [published Online First: 2020/11/24]
11. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924-6. doi: 10.1136/bmj.39489.470347.AD [published Online First: 2008/04/26]
12. Bricca A, Pellegrini A, Zangger G, et al. The Quality of Health Apps and Their Potential to Promote Behavior Change in Patients With a Chronic Condition or Multimorbidity: Systematic Search in App Store and Google Play. JMIR Mhealth Uhealth 2022;10(2):e33168. doi: 10.2196/33168 [published Online First: 2022/02/05]