Research team

The study investigators included a doctoral student (BS), two faculty members with experience in heart failure, behavioural intervention, and qualitative research methods (JA, ML), two HF cardiologists (SM, AA), and one social scientist with qualitative expertise (MS). There was no prior relationship between the interviewer (BS) and the participants.

Study participants and recruitment

A purposive sampling strategy was used to recruit patients from two outpatient HF clinics in Toronto, Canada. Patients who were smartphone/tablet users aged ≥18 years with a diagnosis of HF were included. Eligible patients also had preserved ejection faction (>50%), mildly reduced ejection fraction (40–50%) or reduced ejection fraction (<40%) with the presence of HF symptoms (i.e., shortness of breath, fatigue or edema). Patients included were on stable medical therapy without hospital admission for > 6 months. Patients were excluded if they were unable to self-select food intake, unable to independently administer medications (i.e., living in a long-term care facility) and/or had difficulty communicating in the English language. Patients were identified and screened for eligibility by their treating physicians (SM and AA). Eligible patients were sent a recruitment letter inviting them to participate in the study. Interested participants met with the doctoral student during a clinic appointment. Informed consent was obtained either in person or via online consent form from patients prior to participation in the study. Participants were compensated $25 in the form of cash or gift card for their time.

Data collection

Patients participated in focus group interviews (n = 4, 3–5 participants per focus group), led by a doctoral student (BS, female), with a research assistant recording observations about nonverbal cues. One-on-one interviews were conducted with patients who required accommodations. Qualitative studies usually require a minimum sample size of at least 12 participants; and three to six focus groups [36, 37]. Focus groups were chosen as the main method of data collection as they provide an opportunity to explore topics in-depth, allowing participants to build on each other’s ideas and insights [38]. Interviews were conducted in English and completed between June 2019 and March 2021. Interviews were conducted either on-site at the recruiting HF clinic or online via the Zoom platform (during the COVID-19 pandemic). Interviews were audio-recorded and lasted 45–60 minutes. Reflective notes were taken by the doctoral student after each focus group/one-on-one interview on the interview experience and unique perspectives shared by participants; and informed changes to wording and order of interview guide questions between subsequent focus groups. The decision to complete data collection was made by the research team when the intended number of focus groups (n = 3 to 6) was reached, and no new information emerged from the interviews.

A semi-structured interview guide (S1 File), consisting of ten open-ended questions and probes, was used to lead the focus groups/one-on-one interviews. The interview guide was developed by the research team and questions were informed by the five main constructs influencing the adoption of an innovation, described by the Diffusion of Innovation theory [39]. The five constructs include relative advantage, compatibility, complexity, trialability, and observability. All questions and probes were reviewed by the research team to ensure clarity and appropriateness. Participant sociodemographic and relevant medical information was collected from patient charts.

Data analysis

The interviews were transcribed verbatim and anonymized, removing all identifiable information. The accuracy of verbatim transcripts was verified by a Research Assistant by comparing the transcripts to the audio-recordings. The computer software NVivo (version 12) was used for coding of transcripts and content analysis. Data analysis involved independent inductive coding of transcripts by two researchers (BS, MS), comparison of codes and sub-codes, establishment of intercoder agreement through collaborative discussion, followed by categorization of codes into themes. A theme reflected accounts of patient needs, motivations, or challenges on the use of mobile apps to support HF management. Themes were finalized through consensus from research team.

Patient usage of technology

Participants described using a variety of technologies, including laptops/desktop computers, mobile phones, and devices such as tablets for communication and social media, daily activities and for monitoring their health. Most participants stated that they used technology to communicate with their friends and families (e.g., phone, text, Zoom, email) and for social media. Several mentioned using apps for daily activities such as checking news, navigation, and weather, electronic banking, and shopping, and for entertainment and leisure purposes (e.g., movies, music, reading). Technology was also used by some participants to monitor their health, including tracking parameters such as daily step count and heartbeat.

Patient views on adopting new technology

Many participants stated that they waited to get new technology and did not “feel a need to get new technology as it comes out”, some replacing their technology only when it was no longer working. They felt that if their current technology (e.g., phone, apps) “meets their needs” and is functioning well, they do not feel the need to “jump on the latest technology”. Prior to buying new technologies or downloading apps, they would read reviews, research its’ benefits, and rely on the recommendations of others. Certain participants identified themselves as “early adopters”, getting the latest technology as it comes out.

Four key themes were identified from the interviews: 1) Factors impacting technology use by patients, 2) Providing support through access to information and self-monitoring, 3) Facilitating connection and communication, and 4) Patient preferences of app features.

Factors impacting technology use by patients

Providing support through access to education and self-monitoring

Participants felt that an app for HF management could be supportive by providing access to information about HF symptoms, prognosis, warning signs, diet, exercise, and medications, as well as the ability to monitor and track self-care activities.

The majority of participants agreed that they could use an app as a source of reference for HF-related information. For example, several participants said that they “don’t understand what heart failure is”, or that “technical” terms such as ejection fraction is “not well explained”, therefore, such information could be provided on an app. Moreover, education on cardinal HF symptoms (e.g., tiredness, shortness of breath) and guidance on what to do in case of cardiac events (e.g., defibrillator shocks, arrhythmias, HF-related hospitalizations) were also stated to be useful. One participant said:

“Well just as I said before, maybe some sort of you know reminder about a particular symptom that might occur that would require attention. I mean I’ve got a pacemaker; you know, I don’t know what might go wrong with a pacemaker, but you know if it started going down below a certain point for example, which never has, but I don’t even know if it could, you know, that kind of thing. And you know, I’ve got a couple of stents and I guess they do collapse from time to time. I don’t know what the symptoms would be if that happened, so maybe something along those lines”.

[Focus group #4]

Several participants stated that access to diet-related information would be helpful in an app. This included having access to recipes and menus that are “heart healthy”, as well as information on healthier alternatives for foods and ingredients. One participant also saw value in having “customized meal plans through an app”. Moreover, guidance on what foods to consume versus what to avoid was also seen as helpful. This could be in the form of curated shopping lists, or information from a registered dietitian. Interestingly, some participants commented on the delivery of nutrition information, stating that most websites providing such information focus exclusively on cutting out foods that are “bad for you” (e.g., “cut out all the sugars”). These participants felt that this type of information was not useful, rather “realistic” advice and an explanation on why certain foods should be avoided or limited should be provided.

“I mean I know salt’s a big one, I’m not going to look at every darn thing I’m eating here, you know what I mean I try to keep the salt low and […] doctors may have other suggestions about it, about doing it, that would be great in an app to know or to have a dietitian put some information into that app”.

[Focus group #3]

“[…] practical part of finding you know like cereal, you know I’ve experienced this but you like buying cereal in the store and trying to find low sodium and also low sugar content cereal is very, very difficult and…and so if…if when the dietitian or whoever said […] here are you know the top five in term of being low sodium and low sugar, and you know low fat or whatever and, and that would be a small thing but maybe quite helpful”.

[Focus group #3]

Participants additionally emphasized that information on exercise in an app would also be helpful. This included information on exercises that are recommended for HF patients such as the amount of weight one should lift or types of exercises, as well as indicators to look for that signify that one should slow down or stop exercising. One participant stated:

“I’ve had incidences in the past where I was doing what I thought was okay and then when I mentioned it to a doctor, they had said that is not the kind of exercise you should do and it’s too intense, but I had no idea. So, I think just that information, that have some limitations on what exercise we can and cannot do, it would be helpful to know that”.

[Focus group #4]

Participants agreed that access to medication-related information on the app would be useful. Participants identified that they are on multiple medications for HF and other comorbidities; thus, it would be helpful to have information regarding medication interaction and potential side effects. For example, one participant shared an experience of taking a cold medication that interacted with their HF medications. Another participant expressed that they had “multiple health issues” and would like to know how the medications are “affecting one another”. Participants felt an app could be beneficial in providing an explanation of why medications are prescribed, guidance on what to do in case of missed doses, as well being able to store personalized medication information such as medication name, frequency, and dosage.

“Again, for me the knowledge […] what are these pills doing? What are the side effects? You know, am I having this side effect because of this pill or because of something else I’m taking given the fact that I take so many things, right? Is it the heart issue?”

[Individual Interview #2]

“I always have to call in ‘hey [name of their doctor] I’m going to get a deviated septum surgery and the doctor prescribed me with steroid […], can I take this with my heart medicine?’. So, to be able to do that on an app and say, ‘will this interact?’ would be fantastic”.

[Focus group #1]

Participants felt that an app can support monitoring and tracking of self-care activities. A few participants stated that a medication tracker may be useful as they sometimes miss doses due to forgetfulness and being on multiple pills. One participant shared that they currently used a spreadsheet and “tick off” medications as they take them, but would rather use an app, which would provide them “assurance” that they are taking their medication. Being able to record indicators such as blood pressure and weight was also viewed to be a helpful function in an app. One participant shared their experience using an app for tracking:

“I use an app called [app name], which is through one of my cardiologists that is again just sort of tracking day-to-day where you’re at and then they will call me if there is any changes or if they have questions.”

[Focus group #4]

Facilitating connection and communication

It was viewed that apps can potentially help patients connect and share information with their healthcare providers, connect and talk with other patients, and provide a medium for caregivers to connect and communicate.

Most participants saw an opportunity for apps to make information sharing easily accessible for both them and their healthcare provider. Many also expressed that they often feel a “sense of isolation” and “alone” in managing their HF; and if data such as their blood pressure readings, symptoms, medications, test results can be shared with their healthcare provider through an app it would provide them with a “sense of encouragement that you’re connected in some way”. They felt that this information can help healthcare providers keep track of their health and help flag problems. Some participants also said that they occasionally feel unwell in between clinic appointments, however they forget to recount these episodes with their healthcare provider. If they were able to capture these periods of time on an app as it happened, they could easily share this information with their healthcare provider.

“…you can take everything with you when you go, your information, your medication list you know, you can log all your symptoms…you know the names are so difficult, so you just put it there and you don’t have to talk just show it to the doctor”.

[Focus group #2]

“It would be especially good if it’s information that the cardiologist would be interested in. I don’t mean that the cardiologist should check in on you every day, but you know when I next come for an appointment, he can look at the app and see what my blood pressure’s been over the last six months and whether or not I’ve been exercising or whatever the information that would be useful to the doctor in monitoring my progress or lack of would be good”.

[Focus group #4]

Several participants saw value in connecting with other patients through an app. They felt that an app has the potential to facilitate social support, a sense of community, and support their mental health.

“…helps to talk to people who are going through the same stuff because family they don’t always understand”.

[Focus group #1]

“I would have a community. And maybe if I start to get symptoms and I want to talk to somebody about them. It might be interesting to just say ‘have you had this? And what happened?’”.

[Individual Interview #1]

Multiple participants expressed that this type of support system through an app may be especially beneficial to newly diagnosed patients. In contrast, a few participants expressed that they do not a feel a need to connect with other HF patients. Interestingly, one participant felt that it would be of value to offer a medium for caregivers to connect with each other:

“The person that really needs to come together with other people is the caregiver…they are the ones that have to really understand what we are going through […] they don’t know what you are experiencing and how that experience translates into something else or what they can do to be able to improve your circumstance…my wife is my caregiver…she is the one that reads all the labels…nothing gets past her in terms of sodium…she knows exactly how much sodium is in everything that I put in my mouth […] but these are the people that really need to communicate with other people”.

[Focus group #2]

Patient preferences of app features

Participants shared their views on potential app features to be integrated into an app for HF management including alarms or reminders for medication, exercise and appointments, goal setting features, connectivity between other apps and devices, graphs, and other visuals to show progress and changes in symptom indicators, and gamification.

Several participants felt that it would be useful for an app to include alarms or reminders for HF self-care activities such as taking medications, tracking blood pressure and weight, as well as exercise. A few participants also suggested that being able to set goals on an app such as step counts can be “motivating” and “encouraging”. Moreover, visual representations such as graphs could be used to show progress on goals and track symptoms over time.

“It’s sort of that visual representation that I actually accomplished my goal of ten thousand steps for the week and I just say that because you know it’s something that they use on the Peloton app, the Apple app, and things that have been very successful so I think for some people that can be a motivating factor”.

[Focus group #4]

“My background is research, I like graphs, I think graphs and you know spreadsheets are very informative and I will create a graph for my doctor and show him my blood pressure changes over last ten years, and that would have made an enormous difference in terms of her decision making”.

[Focus group #3]

The ability to have health information connected across apps and devices was also viewed as a helpful app feature, as highlighted by one participant:

“[…] you know I use the Apple health app for example, and I love the ability to connect different things. So, if there’s like an exercise app where it’s tracking your heart rate and all of this be linked together, so we would have like an accurate portrayal of our health at any given time, so it’s related to weight, your medications, etc.”

[Focus group #4]

There were mixed views on a gamified app for HF. Some participants expressed that they “have never taken to games”, they would find it “annoying”, that it would be a “good idea for younger people”. A participant also questioned the longevity of a game, stating that it would be “interesting for the first little while” but that people might not return to it. One participant mentioned that gamification with the intent of being educational could be acceptable, but with a caveat, stating:

“don’t treat us as if we are in kindergarten, you know there’s that thing about older people, you know you here it especially when they get into cognitive impairments, you know they are just like kids, no they are not just like kids”.

[Focus group #3]

Conversely, few participants stated that games, such as those focused on cognitive skills could keep the “mind young and active” and that gamification elements such as badges for reaching achievements could be “motivation for some people”.