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

Andreas Lechner,Anne Lotte Potzel,Jochen Seissler,Christina Gar

doi:10.2196/26163

Abstract

BackgroundGestational 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.ObjectiveThe 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.MethodsThe 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.ResultsThe 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.ConclusionsThe 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 RegistrationGerman Clinical Trials Register DRKS00012736; https://www.drks.de/DRKS00012736

Highlights

Recent research highlighted the importance of starting interventions earlier, in the first year postpartum [6], as the years following Gestational diabetes mellitus (GDM) offer a window of opportunity for preventive lifestyle interventions to prevent the progression of cardiometabolic disturbances early on [7]
Based on expertise and the literature [6,26,27], we defined the target group as women of reproductive age, with ≥1 child in the household, ≥1 recent pregnancy complicated by GDM, in the extended postpartum period, and at high risk for or with cardiometabolic disturbances
We chose the threshold of BMI ≥23 kg/m2 previously applied to Asian populations [28] instead of the traditional threshold of BMI ≥25 kg/m2 [29] to define overweight since the women in the target group were younger [30] than traditional at-risk cohorts [29,31]

Summary

Introduction

Qualitative research showed that lifestyle interventions within the 10 years following GDM face specific challenges such as prioritization of the family and a mother’s perceived lack of resources [8] These challenges are reflected in the modest effects of previous behavior interventions in the first few years post-GDM [6,7]. Experts call for innovative, flexible, and personalized interventions specific to the needs of women during the first few years post-GDM and the socio-ecological contexts of health behaviors [9] These needs include a practical and accessible tool for behavior change support that is compatible with daily family life [9,10,11]. The ideal mHealth platform for women post-GDM appears to be smartphone apps since they are frequently used for health purposes by women during the first few years post-GDM [14]

Methods

Results

Discussion

Conclusion