Heartwired for change: Advancing the implementation of complex eHealth interventions and lifestyle change in routine cardiac care

Breaking the cycle

Cardiovascular disease remains a leading chronic condition worldwide, driven largely by unhealthy lifestyle behaviors. IJzerman’s thesis highlights that supporting sustainable lifestyle change in routine care requires attention to patients’ psychological, social, and everyday contexts. She focuses on two key strategies that may help initiate and support change: brief lifestyle advice to spark change and structured, personalized goal setting to support it. “We ask patients to change their lives, not just their numbers,” says IJzerman. “That means care should be designed to fit into patients’ daily realities, not the other way around.”

Power of brief advice

In online experiments with more than 600 patients with cardiovascular disease, IJzerman demonstrates that brief, positively framed lifestyle advice from a trusted professional can meaningfully boost intentions to change behavior. Advice from a cardiologist was particularly powerful, but advice from physiotherapists was also effective. Interestingly, gain-framed messages, highlighting the benefits of a healthy lifestyle, were far better remembered than loss-framed messages about risks. “Only 9% of patients remembered the risks, while 89% remembered the benefits,” IJzerman explains. “This shows how important it is to communicate benefits and possibilities, not just risks.”

Goals that matter

The thesis also suggests that linking health goals to broader life goals (for example, “being able to play with grandchildren”) may be particularly relevant for some patient groups, including patients with lower and medium education levels. Exercise-related goals were most common, but stress management became more prominent when life goals were explicitly connected to health. “Meaning in life turned out to be strongly linked to motivation for change,” says IJzerman. “When lifestyle goals connect to what really matters to people, they feel more personally relevant and motivating.”

Implementing complex eHealth

A central case study in the thesis is the BENEFIT programme, a complex eHealth intervention developed in a public–private partnership to support long-term healthy living in cardiac patients. IJzerman presents a stepwise method to design, test, and refine implementation strategies using established implementation science frameworks. She identifies both facilitators (such as adaptability of the programme, strong team communication, and responsive PPP leadership) and barriers (including unclear roles, staffing shortages, IT integration issues, and vague objectives across cardiac rehabilitation sites). “Even promising innovations can struggle when they collide with the realities of daily work,” IJzerman notes. “To succeed, eHealth needs to be adaptable, co-designed with stakeholders, and anchored in clear responsibilities and realistic workflows.”

Psychosocial care and iCBT

Beyond lifestyle and eHealth, the thesis addresses psychosocial challenges such as depression and anxiety in cardiac patients. IJzerman studies the uptake of internet-based cognitive behavioral therapy (iCBT) among hospital psychologists and finds that, despite strong evidence, real-world use remains limited. Factors such as expected usefulness, ease of use, and supportive conditions in the workplace drive intention to use iCBT, yet intention often does not translate into actual adoption. “We cannot talk about holistic cardiovascular care without addressing mental health,” IJzerman emphasizes. “Online therapies like iCBT are more likely to make a difference when they are accessible, embedded in workflows, and supported by training.”

Equity and inclusion

A key message throughout the thesis is the risk that digital and behavioral innovations may widen health inequalities if they are not carefully designed. IJzerman argues for equity-sensitive communication and intervention design, including plain language, teach-back techniques, motivational interviewing, and personalized goal setting for socioeconomically vulnerable groups. “If we design for the ‘average’ patient, we will continue to miss those who need support the most,” she explains. “Reaching these groups with digital and behavioural innovations means considering equity from the very beginning, not adding it at the end.”

Towards heartwired ecosystems

In her synthesis, IJzerman calls for an integrated, ecosystem approach to cardiovascular care, one that aligns behavior change techniques, eHealth implementation strategies, organizational conditions, and psychosocial support with real-world contexts and structural determinants of health. She urges future research to focus on long-term behavioral maintenance, reducing disparities, robust health economic evaluations, and implementation models tailored to diverse and low-resource settings. “Even the best individual-level interventions are constrained by the environments in which people live,” IJzerman concludes. “To support lasting change, we need to connect clinical innovation with policy and system-level reform.”