Table 2 Summary of included studies evaluating perioperative digital lifestyle interventions

Mundi et al., 2015 (United States of America) Feasibility Smartphone app (diet and physical activity) Bariatric (laparoscopic sleeve gastrectomy)

Bariatric surgery patients (n = 30) 27 women and 3 men 41.3 (11.4)

12 weeks (66.7%)

1. Bariatric surgery knowledge questionnaire (knowledge in areas of nutrition, physical activity and bariatric surgery)

2. International Physical Activity Questionnaire short form (IPAQ-SF)

3. Electronic survey (app user experience)

1. Small increase in nutrition knowledge. (26.0 ± 2.5 to 27.3 ± 2.0, p = 0.07)

2. Increase in self-reported minutes of vigorous activity. (25.5 ± 43.9 to 49.4 ± 51.1, p = 0.04)

3. Overall satisfaction with the app saying it helped them understand behaviours that may increase the likelihood of long-term weight loss (n = 19/20)

Strength: Approximately 70% of all modules were completed by users

Limitation:

Pre-post measures. Small sample size

Not disclosed

McCrabb et al., 2017 (Australia) Feasibility (pilot) Web-based smoking cessation program "Smoke-Free Recovery" (SFR) Orthopaedic (trauma)

Orthopaedic trauma patients (n = 31) Among those responding to follow-up (20): 6 women and 14 men 47.9 (14.3)

1–8 weeks post-discharge (64.5%)

1. Engagement data from the online platform

2. Semi-structured telephone interviews examining themes related to feasibility of the program (engagement, acceptability, and retention) and the smoking cessation process

1. A majority of participants (28/31) used the program during hospitalisation. Many responders (15/20) did not rate the program due to not remembering or technical issues during hospitalisation. One of the reasons for not remembering the program was medication related. Few responders (2/20) accessed the program after hospital discharge

2. Themes on program use included: Lack of time or need for additional support, computer illiteracy or technology issues, feeling unready or too stressed to quit, or feeling they had reached the boundary of what could be learnt from the program were all issues that affected program use

Strength:

Detailed intervention description

Limitation: Intervention delivery timing during hospitalisation

The National Health and Medical Research Council

Lemanu et al., 2018 (New Zealand) RCT Text messages (physical activity) Bariatric (laparoscopic sleeve gastrectomy)

Bariatric surgery patients (n = 102) 61 women and 27 men 43.8 (7.9)

Post-intervention (approx. 4–6 weeks) (86.3%) Post-operative (6 weeks) (73.5%)

Adherence to preoperative exercise advice (number of participants partaking in ≥ 450 metabolic equivalent minutes (METmin−1) exercise activity per week preoperatively) International Physical Activity Questionnaire (IPAQ)

Post-intervention: Adherence to exercise advice was significantly higher in exposure group (EG) than control group (CG) (p = 0.041). Median number of days responders partook in exercise activity was also significantly higher in EG than CG (p = 0.046). There was no difference in median weekly metabolic equivalent minutes (METmin−1) 6 week post-operative follow-up: There was no difference between the two groups for any outcome

Strength:

RCT, standardised outcome measures and hypotheses

Limitation: Underpowered, short intervention time to achieve improved physiological fitness in morbidly obese patients

Clinical Research Training Fellowship awarded by the Health Research Council of New Zealand

DeMartini et al., 2018 (United States of America) Pilot-RCT Text messages (alcohol) Transplantation (liver)

Transplant patients with alcoholic liver disease (ALD) (n = 15) 4 women and 11 men 50.80 (7.9)

8 weeks (93.3%)

1. Feasibility outcomes (participants’ intervention satisfaction ratings, 6/8 participants responded)

2. Efficacy outcomes (urine ethyl glucuronide (EtG) and self-reported alcohol measures)

1. Responders were satisfied with the intervention and found messages helpful for abstinence, coping with cravings and stress

2. In the intervention group, none of the individuals tested positive for biologically confirmed, objective alcohol consumption (e.g. ethyl glucuronide [EtG]) results at 8 weeks, however 2 out of 6 participants (33%) in the standard care group did test positive

Strength:

Detailed intervention description, intervention results and participant satisfaction

Limitation:

Small sample size, convenience sample

Internal grant from the Psychological Medicine Service of Yale-New Haven Hospital

Bendtsen et al., 2019 (Sweden)

RCT-protocol

Text messages (smoking cessation) Elective

434*

* Expected number of participants, recruitment not completed

3 months

6 months

12 months (N/A)

The following outcome measures will be used:

Smoking cessation outcomes, prolonged abstinence, point prevalence of smoking abstinence, mediating factors

Kamprad Family Foundation for Entrepreneurship, Research & Charity

Nolan et al., 2019 (United States of America)

Feasibility

Text messages (smoking cessation) Elective

Elective surgery patients (n = 100)

47 women and 53 men 52.1 (9.7)

30 days postsurgery (95%)

1. Telephone survey (smoking behaviour, use of nicotine replacement therapy, feedback about content and frequency of messages, interest in using the text message service in the future)

2. Engagement data were recorded (average number of messages sent, and received per participant)

3. The program collected data on smoking status via text messages

1. High overall satisfaction (78/95) being somewhat or very satisfied on a 5 point Likert scale. (65/95) expressed that they would be somewhat or very interested in utilizing the text messaging service again for future surgeries. 25 participants (31%) reported 7-day point prevalence abstinence at 30-day telephone follow-up

2. Median number of text messages sent was 81, and median number of responses to prompts was 10

3. Selfreported 24-h abstinence rates ranged from 37% on day 2 to 71% on day 14

Strength: Intervention description, example messages, participant satisfaction

Limitation:

Brief reporting, pre-post measures

Internally by the Mayo Clinic

Krebs et al., 2019 (United States of America) Pilot-RCT Coping skills game for smoking cessation (Quit-IT) Cancer surgery (lung or gastrointestinal)

Cancer patients scheduled for surgical treatment (n = 39)

27 women and 11 men 57.4 (10.2)

1 month (61.5%)

1. Follow-up survey (phone or e-mail)

2. Satisfaction survey (captured in game)

3. Gameplay parameters (captured in-game)

4. Confirmed abstinence (biochemically verified)

1. A nonsignificant trend for increased confidence to quit smoking (situational self-efficacy) and higher intention to stay smoke free was found in the intervention group (d = 0.25, 95% CI −0.56 to 1.06)

2. 5/8 participants thought playing the game helped them cope with urges to smoke

3. Totally 8/20 in the intervention group played the game. Users completed an average of 2.5 episodes (range 1–10)

Confirmed abstinence was higher in the intervention group (4/13) in relation to control group (2/11)

Strength:

Theoretical and BCT underpinning intervention, detailed intervention description

Limitation:

Small number of users (n = 8/20) , underpowered sample size

National Institute of Health

Low et al., 2020 (United States of America) Feasibility (pilot) Smartphone app (physical activity/sedentary behaviour) Elective

Daily assessed until 30 days postdischarge Weekly interviews (N/A)

Usability: (1) weekly ratings on a scale of 0 to 100 on easy of use; appearance, design, usability and intervention satisfaction and (2) via the System Usability Scale (ten-item questionnaire) at the end of intervention

Feasibility: (1) accrual and retention rates, compliance with reporting symptoms. (2) Objective activity and heart rate data indicated compliance with wearing the smartwatch as well as walking in response to activity prompts. (3) Weekly semistructured interviews on usability, acceptability, and experience using the app

1. Usability. Participants rated the apps as very easy and pleasant to use. Overall satisfaction with the whole system was 89.9, and the mean System Usability Scale score was 83.8 out of 100

2. Feasibility. Compliance with the intervention declined significantly after surgery (and did not improve after discharge) for both symptom reporting and Fitbit. Fitbit compliance declined from before surgery (91%) to inpatient (36%) and postdischarge (65%)

Participants generally reported that they liked the simplicity of the intervention and found the prompts to be motivating. Participants also reported that it was especially difficult to walk in the hospital immediately after surgery when they were too weak to walk unassisted, were in the middle of tests or other care procedures, or were on medications that made it difficult to get up and walk

Strength: Standardised outcome measures, objectively measured, detailed intervention description

Limitation:

Poor reporting on qualitative data, no behaviour change supportive content except "registration"

The UPMC Aging Institute and the National Cancer Institute

Kulinski and Smith, 2020 (Australia) Feasibility (pilot) Text messages (diet, physical activity, psychology and medical management) Elective

Patients with obesity undergoing (elective) surgery (n = 22) 9 women and 9 men Mean and sd not available, age range 24–77 years

6 months (81.8%)

Questionnaires (self-report, via telephone):

1. Lifestyle behaviour (weight, smoking, diet, exercise) (questionnaire not disclosed)

2. The generic health quality of life measure EuroQol-5 dimension 3-level questionnaire) (EQ-5D-3L)

3. Health engagement (Readiness to change scale, Rollnick, 1992)

4. User experience (enjoyment, recommendation to other people) and feasibility (recruitment and retention rates)

1. Self-reported improvements in lifestyle behaviour (weight, smoking, exercise). Self-reported dietary composition did not change

2. Eleven participants (61%) reported that their overall ‘health score’ improved after completing the programme

3. Seven participants (39%) rated their motivation to change their health as improved following involvement in the study

4. 15 of 18 participants (83%) found the programme useful or extremely useful. All stated that they would recommend the programme to others in the lead-up to elective surgery

Strength:

Multiple lifestyle (physical activity and diet)

Limitation:

Pre-post measures, no standardised behavioural outcome measures, poor reporting of qualitative data

Department of Anaesthesia Research Fund, Wollongong Hospital, Wollongong, New South Wales, Australia

Thomas et al., 2018 (Sweden)

Qualitative study

Text messages (smoking cessation) Elective

Individual interviews with patients (n = 10) 4 women and 6 men Mean and sd not available, age range 45-70 years

3 months after the intervention (N/A)

Individual interviews: Semistructured format, included questions that aimed to capture patients’ experiences and use of the intervention

Patients showed strong motivation to quit smoking and an openness to incorporate the intervention into their behaviour change journey; however, the timing of the intervention and messages were important to optimize support. A text messaging, smoking cessation intervention can be a valuable and feasible way to reach smoking patients having elective surgery

Strength:

Participants recruited among patients who visited a health care unit rather than out of convenience

Limitation:

No measures to ensure heterogeneity among participants

Kamprad Family Foundation for Entrepreneurship, Research & Charity

van der Velde et al., 2021 (Netherlands) Pilot-RCT Smartphone app (smoking, alcohol, physical activity, unintentional weight-loss) Major elective surgery

Patients with major elective surgery (n = 86) 39 women and 40 men 60.0 (5.2)

Pre-surgery (3 days prior to surgery) (58.1%) Post-surgery (30 days post-discharge) (73.2%)

Online questionnaires:

1. Usability (System Usability Scale) (3 days prior to surgery)

2. Change in risk behaviours (3 days prior to surgery) (questionnaire not disclosed)

3. Functional recovery (30 days post-discharge) (PROMIS-PF, Patient-Reported Outcomes Measurement Information System physical functioning 8-item short form)

4. Semi-structured telephone interviews (usability of the app) with 12 participants in the intervention group (pre- and postoperatively)

1. Patients considered the app to have acceptable usability (mean 68.2) [SD 18.4])

2. Compared with the control group, the intervention group showed an increase in self-reported physical activity and muscle strengthening activities prior to surgery. Also, 2 of 2 frequent alcohol users in the intervention group versus 1 of 9 in the control group drank less alcohol prior to surgery. No difference was found in change of smoking cessation.

3. Between-group analysis showed no meaningful differences in functional recovery after correction for baseline values (β = – 2.4 [95% CI – 5.9 to 1.1])

4. Interviews supported the usability of the app. The major point of improvement identified was further personalization of the app

Strength:

Multiple lifestyle (physical activity, smoking, alcohol), detailed intervention description

Limitation: Underpowered, lack of description of behaviour change outcomes

Foundation Innovative Alliance—Regional Attention and Action for Knowledge circulation