The Effectiveness of a Personalised Digital Health Intervention (Naluri) on Self-Care Behaviours and Quality of Life Outcomes among Cardiac Patients at the Malaysian National Heart Institute: A Randomized Controlled Trial

Each participant will be approached individually and face-to-face by the researcher for consent and to complete a baseline assessment which includes the Adherence to Healthy Lifestyle Questionnaire, Brief Illness Perception Questionnaire (BIPQ), International Physical Activity Questionnaire (IPAQ), Hospital Anxiety and Depression Scale (HADS) and Heart Quality of Life (HeartQOL). Information on basic demographic information will be obtained and height, weight, blood pressure, HbA1c and cholesterol levels will also be measured. Participants in the intervention group will be requested to download a digital health intervention called Naluri on their smartphone. Participants will be approached individually. Participants are required to engage with the app for 16 weeks. The Naluri app consists of real-time chat with a dedicated health coach and expert coaches such as dietitian, fitness coach, medical advisor, pharmacist and executive coach. There are over 70 daily modules which participants can complete one daily. This series of proprietary daily modules cover topics like mental readiness, diet, exercise, stress management and self-care. There is a food journal feature that allows patients to log their daily food intake and the coaches will comment and suggest healthier alternatives. The thought journal feature encourages participants to log any helpful or unhelpful thoughts and behaviors related to those thoughts. The participants are then guided by the health coach to understand what were the underlying beliefs and emotions behind those unhelpful actions and to learn skills to eventually prevent recurrence of those behaviours. Participants are encouraged to engage the app at least 5-10 minutes, once a day by using any of the available features of the app - modules, food journal, thought journal, chat channels, progress planner. Participants are expected to complete at least the first 14 modules which looks into the baseline of participant's current diet and exercise behaviours. Subsequent modules will be recommended by the coaches. Each module takes about 5 to 10 minutes to complete. The modules can be divided into three categories - informational (provides information for the participants), self-help/functional (participants learn a practical skill/technique from the module), and assessment (gather useful information for coaches). Exercises prescribed in the modules include stretching exercises, bodyweight exercises and also identifying daily activities that can be considered as exercise, for example taking the stairs instead of the lift, parking the car further so that participants can walk further to reach the office. The stretching exercises module allows the participant to choose between warm-up or cool down stretching, select the intensity of the stretching and there are short videos on the different types of stretching such as high knees, calf stretch and butt kicks. The bodyweight exercises module consists of a 7-minute simple workout which includes planks, sit-ups, burpees, abs crunches and squats. There are video tutorials to illustrate these different exercises. Participants may choose the level of intensity for these workouts. Nutritional information includes educating participants on smart choices for carbohydrates, fats, salt, beverages and snacks. The diet modules also teaches participants about eating mindfully and slowly; planning for flexibility (allowing for cheat meals), calculating and meeting daily water intake, healthy food portions and also differentiating between hunger, desire and cravings. To monitor user’s progress, the Naluri app is linked to a weighing scale which allows the user to track their weight and body fat percentage trends. Naluri’s approach to lasting healthy habit changes is based on one small change or task a day, with regular feedback and coaching. Examples of small changes or tasks can be encouraging participants to limit sugary drinks to only 1 glass per day for a week, or suggesting participants to take at least two flights of stairs everyday for a week. For the following week, participants can be encouraged to improve those behaviour goals. The first 12-weeks cover daily exercises, improvements to food intake and regular feedback, and the final 4 weeks switches to self-management to get user’s ready to independently take charge of their lifestyle. To assess and monitor adherence to the app, app analytics allows the researcher to monitor which feature of the app the participants have used everyday. If user is not active, the health coach can send a message which will pop-up as a notification on the participant's smartphone. The app also has a Challenges feature, whereby the participants can set daily/weekly behaviour tasks to do. The app will send reminders of these tasks at the set time and when the participants complete these tasks, they can acknowledge them in the app. The health coach can work together with the participants in setting these tasks.