Web-Based Nutrition and Physical Activity Education Intervention to Ameliorate Cardiometabolic Risks: A Single-Arm and Non-Randomized Feasibility Study

Abstract

Objective:

This study aimed to evaluate the feasibility of the D-PATH website to improve dietary and physical activity management for patients with cardiometabolic risk.

Methods:

A website called D-PATH was developed, consisting of 6 learning units for managing hypertension. A 4-week program was implemented, and a pre- and post-intervention assessment was conducted to measure acceptability and changes in knowledge, attitude and practice, dietary intake, physical activity, and anthropometric status.

Results:

The D-PATH website was acceptable in terms of understandability, actionability and cognitive load. Knowledge, attitude and practice, and physical activity levels were improved, but no changes were noted for dietary intake and blood pressure level.

Conclusion:

The D-PATH website was accepted and feasible for the intervention study. This study has shed light on using the website to promote behavioral change in patients with cardiometabolic risks.

Introduction

The risk factors for cardiometabolic disorders (CMR) are often interrelated, and treating 1 risk factor may have a positive effect on others. Hypertension (HTN) is one of the CMRs that need to be addressed to prevent complications such as stroke or premature death. Hypertension is also known as the “silent killer” and affects millions of people worldwide. According to the World Health Organisation (WHO), an estimated 1.28 billion adults aged 30 to 79 worldwide suffer from high blood pressure, with most (two-thirds) living in low- and middle-income countries. ¹ In Malaysia, hypertension is reported to affect 6.4 million people, which is 30% of the population, or 1 in 3 Malaysians suffer from HTN. ² All patients diagnosed with hypertension receive treatment through public or private healthcare. According to the National Health and Morbidity Survey Malaysia (NHMS) 2019, approximately 90% of these patients are prescribed medications. ² Nevertheless, the control of hypertension remains poor at less than 40%, which could lead to adverse health complications and ultimately affect the cost of treating the disease. ³ Therefore, it is necessary to educate patients on the importance of controlling HTN and provide them with knowledge on managing the disease. The limited healthcare facilities in Malaysia, the insufficient number of dietitians and the impact of the COVID-19 pandemic resulted in healthcare facilities giving priority to critical cases. ⁴ Patients may miss the opportunity to consult doctors or dietitians about recommended lifestyle management for hypertension, or they may have had limited time for consultation, which may result in them receiving insufficient information at the time of the visit.

Nutrition education is important to ensure that patients with hypertension have high self-efficacy to control their disease. Since the goal of nutrition education is to promote lifestyle changes, patients need to be educated about the why, what, and how so that they can put the information into practise. ⁵ This knowledge can enable patients to make healthy dietary and physical activity choices that meet their personal needs, preferences, and goals. Assessment of knowledge, attitudes, and practises (KAP) could be helpful in understanding patients’ behavior in the management of hypertension. ⁶ In today’s digital era, numerous online platforms serve as valuable tools for nutrition education, including websites, social networking sites, and messaging applications. Among these platforms, websites stand out as the most established, with a history of usage in various sectors, including business and education. The website was introduced in late 1989, consisting of a network of interconnected web pages accessible to the public under a common domain name. ⁷ In the healthcare industry, websites have emerged as a crucial avenue for healthcare practitioners to disseminate valuable health information to patients. Several websites used for nutrition interventions have shown positive results in promoting behavior change. For example, many websites have been used to improve clinical outcomes in treating hypertension, such as lowering and maintaining blood pressure to normal levels.^8,9 Websites have become alternative and supportive educational tools for health education. Therefore, this study aims to evaluate a newly developed website called D-PATH (Diet and Physical Activity Management to Control Hypertension). The feasibility study aims to determine the feasibility of the website to be used for the intervention and identify necessary revisions to design a subsequent, more extensive hypothesis-testing research. The primary outcomes assess the feasibility of the process, and the secondary outcomes measure scientific feasibility.

Methods

Study Design

The feasibility study used a single-arm, non-randomized, quantitative intervention approach. This study compared the changes that occurred before and after the intervention. This design is employed when the objective of the trial is to obtain preliminary evidence of the feasibility of the intervention and to collect additional safety data but is not generally used as confirmation of efficacy. The design may be desirable when the available patient pool is limited, and thus, it is not optimal to randomize many participants to a control arm. ¹⁰ Participants were exposed to the website for 4 weeks to determine the process and scientific feasibility of the website.

Recruitment and Procedures

Recruitment of participants started in early July until September 2022. Participants were recruited via convenience sampling and were selected based on the inclusion and exclusion criteria. The inclusion criteria outline that the participants must be more than 18 years old, were diagnosed with hypertension, have access to the Internet, and are IT literate. IT literate is defined by the ability of the participants to browse and use websites using any platforms. On the other hand, participants with specific medical problems such as mental illnesses and pregnancy were excluded. Before the data were collected, the participants signed a consent form. The study was conducted at 2 clinical sites affiliated with Universiti Teknologi MARA, namely UiTM Clinical Training Centre Sungai Buloh and Hospital Al-Sultan Abdullah, Universiti Teknologi MARA Puncak Alam campus.

The D-PATH Website

D-PATH focuses on patients with hypertension, and the patients were presented with a website that aims to educate them on dietary and physical activity management. There are 6 learning units in the module: 1) General information about hypertension, 2) Management of Sodium Intake, 3) Dietary Approaches to Stop Hypertension (DASH) Diet and recommendation for Fruits, vegetables, and whole grains, 4) Fat and Alcohol, 5) Physical Activity and Exercise, and 6) Shopping tips. The website was validated by experts, including family medicine specialists, dietitians, senior lecturer with dietetics background and clinical psychologist.

Evaluation Criteria

Process feasibility measures the primary outcomes, whereas scientific feasibility measures the secondary outcomes. Primary outcomes assess the feasibility of retaining participants’ acceptability of the intervention in terms of understandability, actionability, cognitive load, and participants’ engagement. Meanwhile, secondary outcomes measure knowledge, attitude, and practice (KAP), dietary intake, physical activity level, anthropometry, and blood pressure (Table 1).

Table 1.

Measurement of Primary and Secondary Outcomes.

Primary outcome	Measurement
Feasibility of retaining participants	The feasibility of retaining participants was defined as at least 32.7% of the recruited participants completing the study. 11
Acceptability of the intervention	Usability was defined as the intervention being understandable and actionable through a score of more than 70%. 12
	The cognitive assessment was measured based on the Likert scale score. 13
Participants’ engagement	Data on the frequency of visits to the website, duration, and component were recorded using Google Analytics.
Secondary outcome	Measurement
Knowledge, attitude, and practice (KAP)	KAP was defined as the intervention improving the KAP scores.
Dietary intake	Dietary was defined as the intervention improving the dietary intake.
Physical activity level (PAL)	The physical activity level was defined as the intervention increasing the PAL.
Blood pressure	Blood pressure was defined as the intervention improving blood pressure to the recommended level.

The website’s understandability and actionability were measured using the PEMAT-AV questionnaire, which is a validated questionnaire that measures whether participants understand the content and can apply the information. ¹² PEMAT-P comprises a total of 26 questions, divided into 2 key domains: understandability and actionability. The assessment evaluates content quality, word choice, style, use of numbers, organization, layout, design, and the inclusion of visual aids through 19 questions under the understandability category. Conversely, the actionability domain encompasses 7 questions aimed at determining the extent to which educational materials prompt actionable insights. Understandability pertains to the ability of individuals to comprehend educational resources and extract essential information. In contrast, actionability focuses on one’s capacity to identify actionable steps or recommendations from the provided educational material. ¹² For each question, respondents are required to provide 1 of 3 responses: “1” for agree, “0” for disagree, or “N/A” (not applicable to the material). Subsequently, the total scores for both understandability and actionability are calculated as percentages. The cognitive load was measured using intrinsic, extraneous, and germane loads. A Likert scale from 1 (low) to 7 (high) was used to assess the cognitive load of the participants. The intrinsic load of the module was rated 4.4 out of 7, which means that the module requires a moderately high cognitive load. The KAP was measured using the Dietary and Physical Activity Questionnaire (DPAQ), an established questionnaire and reported descriptively. ¹⁴

Data Collection

A set of questionnaires was used for data collection. The questionnaire consists of 6 sections: 1) demographic information, 2) anthropometry and clinical data, 3) physical activity assessment, 4) dietary intake assessment, 5) knowledge, attitude and practice, and 6) participant acceptance evaluation. The Malay version of the International Physical Activity Questionnaire (IPAQ) was used to assess physical activity levels. The IPAQ is a set of well-developed instruments to determine the physical activity of individuals, ¹⁵ and it classifies physical activity levels into low, moderate, and high. Three-day food intake records were used to determine participants’ dietary intake. Dietary data were recorded in household measures and later converted to grams based on the Malaysian Food Composition Table. ¹⁶ Food data were obtained from the Malaysian Food Composition Table, the Singapore Food Composition, and the U.S. Department of Agriculture FoodData Central. The menu, which was not available in the database, was calculated manually based on the standard recipes from the recipe books. The analyses of food intake were carried out using Nutritionist Pro™ software. ¹⁷ To assess participants’ KAP, the researcher developed a questionnaire to measure the KAP for hypertensive patients. The process of developing and evaluating the questionnaire has been described elsewhere. ¹⁴ The DPAQ is a validated questionnaire suitable for patients with hypertension in Malaysia. Participants’ acceptance was measured based on 1) the understandability and actionability of the website and 2) the cognitive load assessment.

In terms of website analytics, Google Analytics was used as the tool employed to monitor website performance and gather information about visitors. It accomplishes this by retrieving user data from every website visitor using page tags. A JavaScript page tag is integrated into the code of each webpage, operating within the web browsers of visitors to collect data and transmit it to one of Google’s data collection servers. ¹⁸

Interventions

For this feasibility study, the study protocol is illustrated in Figure 1. The recruitment process started with screening and was completed after the intervention. A 4-week intervention was decided for the feasibility study based on the previous literature.^11,19 Post-intervention data were collected in week 5.

Figure 1.

Study protocol.

Potential participants were selected by reviewing the patients’ medical records and discussing them with medical doctors at the clinic. Overall, 58 participants met the inclusion criteria and were invited to participate in the study; however, only a total of 38 (76%) participants agreed to participate in the study. The participants were then informed about the study protocol and signed the informed consent form before the commencement of the intervention. At baseline (week 0), participants were informed about the intervention plan. The researcher manually collected and recorded demographic and baseline data of anthropometry and clinical data, dietary intake, physical activity level, and knowledge, attitude, and practice (KAP). Next, the researcher provided the participants with the URL https://www.makanbetul.com/home for “Module Pendidikan Pesakit: Perubahan Gaya Hidup bagi Pesakit Hipertensi (Tekanan Darah Tinggi)” (Patient Education Module: Lifestyle Changes for Patients with Hypertension). The participants were shown how to use the website, and once they were on the website, they were required to fill in the registration form available on the website’s homepage. Participants’ data were then stored in the administrator’s Google Drive. After completing the registration, the participants could navigate through the website. Each unit included up to 15 videos and 10 infographics. The average completion time for each module was 2 to 4 h, and the intervention was scheduled for 4 weeks. Each participant was recommended to complete each unit of the module weekly. The website was developed in the Malay language. Users were not allowed to download the videos as they were tied to a YouTube account on the website. In contrast, users had access to download the infographics. Participants received 1 message per week to remind them to continue using the website. At week 5 (post-intervention), the primary and secondary outcomes of the intervention were assessed using validated questionnaires.

Statistical Analysis

All analyses were performed using Statistical Package for the Social Sciences (SPSS) version 21 (IBM® SPSS®). Demographic data at baseline were reported descriptively. Categorical data were reported as frequencies (percentages), whereas continuous data were reported as mean scores and standard deviation (SD).

Results

Participant Characteristics

The Table 2 shows the demographic characteristics of the participants who completed the feasibility study. Overall, 10 participants are males, and the average age is 46.8 years. Most participants are working (83%) and had a tertiary education (78%). Most patients also had hypertension for more than 1 year (89%) and are overweight or obese (83%).

Table 2.

Demographic Characteristics of Participants Who Completed the Feasibility Study (n = 18).

Characteristics	N (%)	Mean (SD)
Gender
Female	8 (44)
Male	10 (56)
Age		46.8 (7.7)
Working status
Working	15 (83)
Not working	3 (17)
Education status
Secondary level and below	4 (22)
Tertiary level	14 (78)
Marital status
Single	1 (5)
Married	16 (90)
Widower/widowed	1 (5)
Residential status
Live alone	4 (22)
Live with family	14 (78)
Household income
<RM3860	6 (33.3)
RM3860-RM8319	6 (33.3)
>RM 8319	6 (33.3)
Period of time since initial diagnosis of hypertension
Less than 1 year	2 (11)
More than 1 year	16 (89)
Co-morbidities
Diabetes	6 (33)
Cardiovascular disease	1 (5.6)
Hypercholesterolemia	11 (61)
Smoking status
Yes	17 (94)
No	1 (6)
Medication consumption
Yes	14 (78)
No	4 (22)
Weight (kg)		78.3 (97)
Height (m)		1.6 (0.1)
Body mass index (kg/m2)
Normal weight		3 (17)
Overweight/obesity		15 (83)

Participant Retention

Thirty-eight participants (100%) were recruited at the baseline of the study; however, only eighteen participants (47%) completed the study, whereas twenty participants were unable to finish the study.

Acceptability of the Intervention

The acceptability of the study was evaluated based on the understandability and actionability of the website as well as the cognitive load of the website.

Understandability and actionability

Table 3 shows the understandability and actionability of the website. The results for understandability showed that the majority of the items scored 100% except for item 7 (90%). However, in terms of actionability, only 1 item obtained a 90% score, whereas others were rated 100%. The overall results showed that the scores for both parts are almost 100%.

Table 3.

Overall Understandability and Actionability of the Website (n = 18).

No.	Items	Mean (SD)	Percentage
Part 1: Understandability
1.	The material makes its purpose completely evident.	1	100%
2.	The material uses common, everyday language.	1	100%
3.	Medical terms are used only to familiarize the audience with the terms. When used, medical terms are defined.	1	100%
4.	The material uses the active voice.	1	100%
5.	The material breaks or “chunks” information into short sections.	1	100%
6.	The material’s sections have informative headers.	1	100%
7.	The material presents information in a logical sequence.	0.9 (0.2)	90%
8.	The material provides a summary.	1	100%
9.	The material uses visual cues (e.g., arrows, boxes, bullets, bold, larger font, highlights) to draw attention to key points.	1	100%
10.	The text on the screen is easy to read.	1	100%
11.	The material allows the user to hear the words clearly (e.g., not too fast, not garbled).	1	100%
12.	The material uses illustrations and photographs that are clear and uncluttered.	1	100%
13.	The material uses simple tables with short and clear row and column headings.	1	100%
Part 2: Actionability
1.	The material clearly identifies at least one action the user can take.	1	100%
2.	The material addresses the user directly when describing actions.	1	100%
3.	The material breaks down any action into manageable, explicit steps.	1	100%
4.	The material explains how to use charts, graphs, tables, or diagrams to take action.	0.9 (0.2)	90%

Cognitive load measurement

Table 4 depicts the cognitive load of participants while using the website. Participants perceived moderate mental effort (4.4) and concentration to maintain throughout the program. The difficulty was rated as low (3), while the navigation was rated as low as 2.5. Overall, the participants obtained a high amount of knowledge at the end of the module, as evidenced by a score of 6.3.

Table 4.

Cognitive Load Assessment.

Domain	Items	Mean (SD)
Intrinsic load	How much mental effort was necessary to accomplish the module?	4.4 (1.9)
Intrinsic load	How difficult was the online course content?	3.0 (2.0)
Extraneous load	How difficult was it to navigate on our platform?	2.5 (2.1)
Germane load	How much knowledge did you acquire after participating in our online course?	6.3 (0.97)
Germane load	How much concentration did you maintain during our course activities?	4.9 (1.4)

Rating 1 is low, and Rating 7 is high.

Participants’ Engagement

Based on Google Analytics, Figure 2 depicts the participants’ engagement throughout the programme. During the week of September 4 to 11, 55 people visited the website. The level of engagement has, however, been declining over time. Only 7 people visited the website during the week of October 10 to 16.

Figure 2.

Participants’ engagement throughout the program (n = 18).

Knowledge, Attitude, and Practice (KAP)

Table 5 shows the total scores for knowledge, attitude, and practice (KAP). Participants’ knowledge and attitude scores significantly improved after the intervention program with P-values of <.001 and .024, respectively. On the other hand, although the score for practice showed an extent of improvement, the score was not significant.

Table 5.

Total Scores for Knowledge, Attitude, and Practice (KAP) (n = 18).

Domain	Baseline (Week 0)	Post-intervention (Week 5)	Percentage change (%)	P-value
	Mean (SD)	Mean (SD)
Knowledge	17.3 (3.58)	21.0 (2.38)	17.6	<.001
Attitude	50.4 (21.8)	63.2 (7.62)	20.2	.024
Practice	32.2 (11.26)	36.0 (8.67)	10.6	.099

Dietary Intake

Table 6 shows the comparison of participants’ dietary intake at baseline and post-intervention with reference to the dietary guidelines. The mean fat intake was 34% at baseline and 36.5% at post-intervention, significantly different from the maximum fat intake recommendation. Sodium intake was significantly higher than the recommendation (P = .008), while potassium intake was significantly lower than the recommendation (P < .001). Fiber intake was also far less than the minimum recommendation at baseline and post-intervention. Fat and sodium intake increased after the intervention, although not significant. Meanwhile, potassium and fiber intake were reduced by 4.8 and 8.5%, respectively.

Table 6.

Dietary Intake of Participants at Baseline and Post-Intervention With Reference to the Dietary Guidelines (n = 18).

Domain	Reference value	Baseline (Week 0)	P-value*	Post-intervention (Week 5)	P-value*	Percentage of change (%)	P-value**
		Mean (SD)		Mean (SD)
Carbohydratesa-c (%)	50-65% of the total energy intake	48.17 (9.15)	.407	48.4 (7.77)	.390	0.4	.938
Proteina,b (g)	1.0 g/kg body weight	0.93 (0.40)	.461	0.91 (0.29)	.169	−2.0	.764
Fata,b (%)	25-30% of the total energy intake	34.0 (7.15)	.031	36.5 (6.77)	.001	6.8	.242
Sodium c (mg)	<1500 mg	2427 (1101)	.002	2648 (1371)	.008	8.3	.916
Potassium d (mg)	3500-4000 mg	1300 (558.9)	<.001	1240 (514.5)	<.001	−4.8	.699
Fibrea,c (g)	20-30 g	7.6 (3.2)	<.001	7.0 (4.0)	<.001	−8.5	.538

One-sample t-test. The reference value for carbohydrates was set at 50% and fat at 30%.

^aMalaysian Dietary Guidelines.

^bRecommended Nutrient Intake 2017 for Malaysians.

^cDASH Diet.

^dAmerican Clinical Guidelines for Hypertension.

^*One sample t-test.

^**Paired t-test.

Physical Activity Level

Table 7 shows the physical activity level of the participants before and after the program. Overall, the physical activity level showed improvement after the program. The participants categorized with low physical activity reduced from 11 to 7 or a reduction of 57%.

Table 7.

Physical Activity Level (n = 18).

Physical activity level	Baseline (Week 0)	Post-intervention (Week 5)	Percentage of change (%)
	N (%)	N (%)
Low	11 (61)	7 (39)	−57
Moderate	5 (28)	7 (39)	28
High	2 (11)	4 (22)	50

Blood Pressure and Anthropometry

Table 8 shows blood pressure and anthropometric changes before and after the program. Additionally, systolic and diastolic blood pressure were compared with the recommended level. The systolic blood pressure reduced to 6.1% after the intervention; however, it was higher than the recommended value. Meanwhile, the diastolic blood pressure, weight, and BMI showed no significant difference in pre and post-intervention.

Table 8.

Blood Pressure and Anthropometric Changes Before and After the Program (n = 18).

Domain	Target value a	Baseline	P-value	Post-intervention	One sample t-test	Percentage of change (%)	Paired t-test
		Mean (SD)		Mean (SD)	P-value		P-value
Systolic blood pressure (mmHg)	130 mmHg	143.0 (14.3)	.001	136.9 (14.1)	.053	−6.1	.146
Diastolic blood pressure (mmHg)	80 mmHg	85.9 (10.5)	.028	85.9 (8.1)	.007	0	.981
Weight (kg)	—	81.3 (23.0)		81.1 (22.5)		−0.2	.658
Body mass index (BMI) (kg/m2)	—	31.2 (6.9)		31.2 (6.8)		0	.649

^aBased on the AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. ²⁰

Discussion

Participants’ Retention

Feasibility was assessed by participant retention, acceptance of the intervention, and engagement. Participants’ knowledge, attitude, and practice, as well as their dietary intake, physical activity level, blood pressure, and anthropometry, were also evaluated. Feasibility is an essential assessment before an intervention study takes place in order to reduce the risk of bias and achieve successful results. Although the study was not able to detect statistically significant differences, the researcher analyzed pre- and post-intervention differences in knowledge, attitude, and practice, as well as in dietary intake, blood pressure, and anthropometry, to determine the potential of the intervention for improving health outcomes. At the beginning of the study, a total of 38 participants agreed to participate in the study. Overall, 18 participants (47%) completed the study and were evaluated before and after the intervention. The results of the present study contradicted the findings of another study. ²¹ Gardiner and colleagues conducted an 8-week pilot study to assess the feasibility of web-based nutrition education for low-income populations with hypertension and reported a high completion rate of 88%. ²¹ Participant characteristics were comparable to the present study, in which most participants had tertiary education. ²¹ One possible explanation for the higher rate could be that the program combined web-based learning with a face-to-face cooking class every fortnight. Another feasibility study of online education also found a completion rate of 88% after 12 weeks of intervention among 26 participants. ²² This result could be attributed to the program’s weekly email monitoring system, telephone consultations, free access to a private Facebook community, and individualized food plans. Another study reported a high completion rate (87%) at the end of the 3-month intervention phase. ²² The study involved 209 employees of a US staffing company. However, in the present study, the components in the previous studies, as mentioned above, were not present, which may contribute to the lower completion rate.^21,22

Acceptability of the Intervention

In the present study, the participants were paid MYR100 (USD25) for logistics and Internet subscriptions during the intervention period as compensation, and the payment was made at the end of the study. This initiative serves as part of the strategies to support participant retention, and the same approach was used in another study. ²³ In addition, the participants also received a weekly message to remind them to continue using the website. However, since the completion rate was still low, it is suggested that participants receive at least 20% of the total reward at the beginning of the study. Another way to increase completion rates is to conduct remote assessments through an online platform. Online assessment is one of the methods that could be used to increase the retention rate of participants. However, the participants must still be provided with personal equipment such as blood pressure monitoring devices, weighing scales, and so on, which increases research expenses. This strategy has been shown to be effective in another study. ²⁴ One of the main problems identified in this study was the study duration. The biggest concern of the participants was time, as they stated that they did not have enough time to complete the module in 4 weeks. Some participants also stated they had difficulty accessing the website during office hours due to their work schedules. A systematic review showed that the web-based intervention module requires at least 3 months to achieve positive results. ²⁵ For example, a feasibility study on web-based intervention showed high satisfaction among participants. In the present study, the researcher found that participants’ backgrounds, such as education level, employment status, marital status and living arrangement, are the most important aspects to consider, besides the quality of the content or the amount of information. ²⁶

It is important to assess the understandability and actionability elements to ensure that the website meets users’ expectations. The assessment also ensures that the information on the website conveys the components of the “what to knowledge,” “why to knowledge,” and “how to knowledge,” all of which are essential for nutrition education interventions as they increase patient self-efficacy and ultimately optimize the management of hypertension. ²⁷ This study measured the website’s understandability and actionability using the PEMAT-AV questionnaire. The PEMAT instrument has been used in numerous studies to assess the understandability and actionability of patient education materials.^{28 -30} The ability of the instrument to provide direct information on the good content of the material, the accuracy of visual aids, the choice of words, the appropriate layout and design, and the delivery strategies of the materials is the reason for choosing this instrument to evaluate the website in this study. In addition, the tool also provides suggestions for improving the teaching materials, including the consistent use of the active voice and the minimal use of medical jargon. Overall, the scores for understandability and actionability were 100% in both sections, except for items 7 and 4. Item 7 outlines whether the information was arranged in sequence, while item 4 outlines whether the material explains how to use charts, graphs, tables, or diagrams to take action. Nevertheless, the total score was over 70%, the minimum cut-off point to consider the educational materials understandable and acceptable. The results are similar to another study regarding the hypertension website in Malaysia’s Internet space. ³⁰ High understandability can be explained by the educational material on the website, which provides learning outcomes in each module. The result is important because patients’ health-seeking behavior is considered an intentional and purposeful action rather than a passive intake of information.^31,32 In addition, high understandability could also be attributed to the integration of comprehension of verbal information, concepts and rules, and principles. ³³ However, some participants did not feel that the materials presented information in a logical order; therefore, item 7 received a score of 90%, and this could be due to the participants’ personal preferences. In terms of the actionability of the website, all participants agreed that the content of the website is applicable in practice. The theory of identical elements can explain the high actionability of the website. ³⁴ This concept states that thinking about how new information can be applied in a real-life setting or scenario helps users put their new knowledge into practice. ³⁵ For example, participants were told how to improve their physical activity at work and home; thus, the instructions were practical for the participants. However, 1 item scored 90% because a participant disagreed that the material explains how to use charts, graphs, tables, or diagrams to take action. These results are consistent with another study which evaluated 24 websites on hypertension in the United States and found that most websites were understandable and actionable. ³⁶ The websites also have similar characteristics to those found in the current study.

The module’s difficulty level was moderately low, indicating that the website has a low cognitive load. One way to reduce intrinsic load is by applying the organizing principle and using mnemonics, analogies, songs, and aphorisms. ³⁷ Another way to minimize intrinsic load also includes using the mental model. ³⁸ The designer can provide a conceptual model or outline for each unit in the form of a map or flowchart on the introductory side to help participants develop good mental models by understanding the learning process in each unit of the module. ³³ On the other hand, the navigation function of the website was rated low, and, as a result, the participants had less trouble using the website. In fact, the website was designed to be simple and clear. The knowledge acquired by participants after using the website was high, as shown by the rating of 6.3 out of 7. This means that the participants gained a lot of information after using the module. Besides, the development of the module was also based on the clinical guidelines for the management of hypertension and experts’ evaluation, and it includes an overview of hypertension, stress management, dietary salt DASH diet, fruits and vegetables, fat, alcohol, physical activity, and tips for groceries shopping. The participants indicated that the website requires a moderately high concentration level (score 4.9 out of 7), which is relevant because the module consists of many units and sub-units. However, since participants must go through each component, which requires them to understand, recall, and apply information, some people may experience information overload or an overabundance of facts when learning.

Participants’ Engagement

Google Analytics analysis revealed a gradual decline in participants’ engagement, and such a decreasing trend could be due to the possibility that the participants can browse all units at any time without a fixed duration. Some participants might have finished the program after 1 to 2 days or a week and were no longer visiting the website. Thus, allowing users to browse the module freely without duration limitation empowers the participants’ locus of control. Another reason for the low engagement rate is that the website did not emphasize the users’ intrinsic motivation. According to Malone, intrinsic motivation, which includes challenge, curiosity, control and imagination, could improve users’ motivation to continue using the website because they enjoy the learning process more. ³⁹ In contrast, another study showed a high engagement rate (73.3%), although the study used the same approach as the present study. ⁴⁰ Hence, engagement in using the website can be maintained throughout the intervention period by activating the selected module on a weekly or monthly basis. In other words, the developer’s checkpoint is set and not determined by the user.

Knowledge, Attitude, and Practice (KAP), Dietary Intake, Physical Activity Level, Blood Pressure, and Anthropometry

This study’s knowledge, attitude, and practice outcomes improved after the intervention. However, only the knowledge domain was found to be statistically significant. Participants’ knowledge and attitude were improved by 17.6 and 20.2%, respectively, and were significant (P <.005). Meanwhile, a positive change of 10.6% was observed in practice. Overall, the program succeeded in improving the KAP of the participants. The improvement of knowledge could be due to the participants manage to finish the module within the designated time frame. In addition, the positive outcomes of this study could be attributed to the application of the theories of behavioral change and learning, where the learning objectives and specific behavior were stated at the beginning of each session. Specific behavioral change goals should be addressed to ensure effective intervention. ²⁵ However, despite a small improvement in the attitude and practice score, the actual dietary practices did not improve at the end of the study. A similar finding was found in other study that investigated the KAP among Malaysians on COVID-19. ⁴¹ Several factors may have contributed to these outcomes in the current study, including participants’ strong daily habits, the absence of intrinsic motivation, a lack of supportive surroundings, time constraints, and stress.^42,43

The participants’ dietary intake was compared with the recommendations, and the results showed that the intake of fat, salt, potassium, and fiber significantly differed from the recommendations. The majority of the participants consumed more than the recommended amount, and the subjects’ dietary intake also did not change significantly after the intervention. The short duration of the program might have contributed to the possibility that the patients were not motivated to change their diet and that they took the need to change their dietary habits for granted. Furthermore, the module, comprising various topics and requiring participants to complete it within 4 weeks, may result in missing some topics, potentially leading to a less comprehensive understanding of hypertension management, even though the individual units are highly rated for their clarity and understandability. The researcher expected that the intervention results would improve the participants’ dietary intake; however, as the program was delivered in only 4 weeks, it was too early to expect participants to change even though behavioral change theories such as the TTM and BCT were incorporated. In addition, the use of TTM in the intervention study requires a longer time to be more effective and to maintain new behaviours.^44,45 Interventions using TTM that focus on a specific dietary component, such as increasing fruit and vegetable consumption or optimizing healthy fat intake, are also more likely to yield positive outcomes.^46,47 Another study showed improvement in dietary habits and physical activity after a 3- and 6-month follow-up with participants who completed a web-based intervention programme. ⁹ Patients’ dependence on medication to control their blood pressure might also be a reason for not adhering to the dietary component. Many patients preferred regulating their blood pressure with medication alone, while a small percentage chose to incorporate behavioral or lifestyle changes as part of blood pressure management. ⁴⁸ Besides, some patients often choose to disregard the advice of their doctors and maintain their previous misbehaviour. ⁴⁹ Another factor contributing to an unhealthy diet includes unhealthy food traditions such as fried foods or foods cooked with coconut milk, as well as taste preferences that become a barrier to healthy eating among patients. ⁵⁰ The participants’ physical activity level increased after the intervention, as evidenced by an increase in the number of participants with moderate- to high-level physical activity. The result of the current study is consistent with that reported in another study, which found that a web-based intervention statistically improved physical activity levels in 219 patients with coronary heart disease aged 45 to 69 years in Hong Kong. ⁵¹ However, the website used additional features, such as requiring users to log in and offering a personalized plan and goal for maintaining physical activity, along with a 6-month study duration. ⁵¹ In contrast, they found moderate physical activity remained constant after a 4-week web-based intervention; however, vigorous exercise increased in their feasibility study.

Blood pressure values were compared with recommendations and changes at baseline and after the intervention. Systolic blood pressure was significantly elevated at baseline but decreased after the intervention compared to the recommended values; however, the difference was insignificant. Similar finding was found in another study which investigated the effects of a technology-based intervention on blood pressure in African Americans with Hypertension. On the other hand, diastolic blood pressure remained constant between baseline and intervention. ⁵² The results are consistent with another study that found no significant changes in blood pressure after a 3-month internet-based intervention. ⁴⁰ Participants might have had constant blood pressure because they were taking antihypertensive medication. In addition, the “floor effect” phenomenon might change the outcome when blood pressure has reached the recommended level, and any intervention would not lower blood pressure further. Another feasibility study also found no significant difference in clinical outcomes, such as blood glucose levels. ²⁶

Strengths and Limitations

The main strength of this study lies in the fact that it used a comprehensive and validated website. Another strength of this study is that it is cost-effective and that the website can be used for self-directed learning. In fact, there were no problems with the software and the intervention was delivered as planned. In addition, the content of the intervention was evidence-based, and the design was ethnically specific for the Malay participants. One of the main limitations of the feasibility study is the low fidelity of participants. The number of participants dropped by more than 50% after the intervention. Several factors contribute to the poor completion rate, which needs to be addressed in the actual intervention study. In addition, due to the small sample size and a short follow-up period, the data for assessing the impact of the intervention on secondary outcomes (scientific feasibility) lacked statistical power and might be subject to interpretation bias. In addition, the feasibility study did not measure the changes in participants’ self-efficacy between the pre and post-intervention periods. The evaluation could be helpful in getting an idea of whether the website improves self-efficacy because self-efficacy helps control blood pressure.

Conclusion

In summary, this study has shed light on the use of the website to promote behavioral change in patients with hypertension. The feasibility study was able to achieve the intended objectives. First, the website is feasible, as shown by the 47% participation rate at the end of the study. The website is also highly understandable and actionable, as demonstrated by the overall rating of more than 90%. Participants were satisfied with the website, and there was a positive improvement in their knowledge, attitude, and practice. The physical activity level also improved as the participants were moderate to highly active at the end of the study. However, no changes were observed in the food intake, blood pressure, and anthropometric measurements.