{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,2]],"date-time":"2026-11-02T20:20:15Z","timestamp":1793650815208,"version":"4.5.1"},"reference-count":50,"publisher":"JMIR Publications Inc.","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JMIR Form Res"],"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n Chronic hypertension affects 1%\u20105% of pregnancies, increasing women\u2019s risks of adverse pregnancy outcomes and life-long cardiovascular disease risk. Therefore, care management during pregnancy includes close monitoring of blood pressure and medication. Healthy dietary and physical activity behaviors have proven beneficial effects on blood pressure outside and during pregnancy. However, little is known about the best way to support women with chronic hypertension during pregnancy to adopt such behaviors, which could improve pregnancy outcomes, as well as future cardiovascular health.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n This study aims to develop and optimize a digital lifestyle intervention\u2014the DAPHNY (Diet and Activity for Pregnancy Hypertension) app\u2014with those who have experienced chronic hypertension during pregnancy.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n Guided by the person-based approach to intervention development, a review of literature and continuous expert input, including from patient and public representatives, informed the planning stage. This was followed by focus groups with maternity health professionals (n=23) and think-aloud interviews with women who had experience of chronic hypertension during pregnancy (n=11). A content analysis, underpinned by theoretical modeling using the capability opportunity motivation-behavior model, informed 3 logic models to visualize modifications for meaningful engagement with an intervention and sustained behavior change. The intervention was modified iteratively, leading to a first version of the digital intervention that was tested by women (n=10) to further optimize acceptability and engagement. App use data and user engagement patterns were captured.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n An evidence-based, theoretically informed lifestyle app, named DAPHNY, was developed. Key features included in logic models and implemented into a first version of the app comprised supportive messaging to acknowledge challenges of hypertensive pregnancy, goal setting and progress reports for feedback on behaviors, information about health consequences to shape knowledge, credible source endorsement, and a reward or recognition system to acknowledge effort had been made. Engagement with the DAPHNY app during user testing demonstrated variability across users, with a mean of 13 (SD 6.84) sessions per participant. Session duration was variable, with a median of 36 seconds (range: 5 seconds to 5 minutes, 20 seconds). Action-based pages, including recording blood pressure (40 sessions) and step count (39 sessions), were accessed more frequently than informational pages, which required a deeper level of app engagement.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Development of the DAPHNY app, underpinned by an established behavioral framework for developing digital interventions, provided new data insights about how to support women with chronic hypertension to engage in healthy behaviors, a currently overlooked aspect of blood pressure management. Future iterations should focus on increasing engagement and supporting implementation through streamlined content and integration with existing health systems and self-monitoring data. Rigorous, larger-scale studies including comprehensive process evaluation would determine potential clinical effectiveness, implementation strategies, and impact for women and health care professionals.<\/jats:p>\n <\/jats:sec>","DOI":"10.2196\/68927","type":"journal-article","created":{"date-parts":[[2025,7,24]],"date-time":"2025-07-24T11:49:42Z","timestamp":1753357782000},"page":"e68927-e68927","source":"Crossref","is-referenced-by-count":4,"title":["A Digital Lifestyle App for Hypertension During Pregnancy: Mixed Methods Intervention Development Study Using the Person-Based Approach"],"prefix":"10.2196","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3505-2399","authenticated-orcid":false,"given":"Lucy","family":"Goddard","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6544-8066","authenticated-orcid":false,"given":"Katherine","family":"Tucker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9301-7458","authenticated-orcid":false,"given":"Nerys M","family":"Astbury","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9164-8659","authenticated-orcid":false,"given":"Cristian","family":"Roman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8677-1476","authenticated-orcid":false,"given":"Yuan","family":"Chi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-6782-1493","authenticated-orcid":false,"given":"Katherine","family":"Morgan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-5925-8616","authenticated-orcid":false,"given":"Patricia","family":"Devitt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3638-028X","authenticated-orcid":false,"given":"Richard J","family":"McManus","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1010","published-online":{"date-parts":[[2025,7,18]]},"reference":[{"issue":"4","key":"R1","doi-asserted-by":"publisher","first-page":"251","DOI":"10.1038\/s41569-020-00437-9","article-title":"Lifestyle interventions for the prevention and treatment of hypertension","volume":"18","author":"Valenzuela","journal-title":"Nat Rev Cardiol"},{"issue":"S1","key":"R2","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1002\/ijgo.14540","article-title":"Hypertensive disorders of pregnancy and long\u2010term cardiovascular health: FIGO best practice advice","volume":"160","author":"Poon","journal-title":"Intl J Gynecology Obste"},{"key":"R3","doi-asserted-by":"publisher","DOI":"10.1016\/j.preghy.2022.12.004","article-title":"Evidence of lifestyle interventions in a pregnant population with chronic hypertension and\/or pre-existing diabetes: a systematic review and narrative synthesis","volume":"31","author":"Goddard","journal-title":"Pregnancy Hypertens"},{"issue":"10","key":"R4","doi-asserted-by":"publisher","first-page":"890","DOI":"10.1016\/j.amjmed.2009.03.036","article-title":"Hypertension in pregnancy and women of childbearing age","volume":"122","author":"Yoder","journal-title":"Am J Med"},{"key":"R5","unstructured":"Hypertension in pregnancy: diagnosis and management. National Institute for Health and Care Excellence (NICE). 2019. URL: https:\/\/www.nice.org.uk\/guidance\/NG133 [Accessed 09-07-2025]"},{"issue":"1","key":"R6","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2393-12-47","article-title":"Preeclampsia complicated by advanced maternal age: a registry-based study on primiparous women in Finland 1997-2008","volume":"12","author":"Lamminp\u00e4\u00e4","journal-title":"BMC Pregnancy Childbirth"},{"issue":"7","key":"R7","doi-asserted-by":"publisher","first-page":"475","DOI":"10.1016\/j.annepidem.2004.12.008","article-title":"The risk of preeclampsia rises with increasing prepregnancy body mass index","volume":"15","author":"Bodnar","journal-title":"Ann Epidemiol"},{"issue":"2","key":"R8","doi-asserted-by":"publisher","first-page":"2401","DOI":"10.23889\/ijpds.v9i2.2401","article-title":"Global trends in prevalence of maternal overweight and obesity: a systematic review and meta-analysis of routinely collected data retrospective cohorts","volume":"9","author":"Kent","journal-title":"Int J Popul Data Sci"},{"key":"R9","unstructured":"Health survey for England 2021: part 4\u2014trends. NHS Digital. 2023. URL: https:\/\/digital.nhs.uk\/data-and-information\/publications\/statistical\/health-survey-for-england\/2021\/part-4-trends [Accessed 09-07-2025]"},{"key":"R10","unstructured":"Global report on hypertension: the race against a silent killer. World Health Organization. 2023. URL: https:\/\/www.who.int\/teams\/noncommunicable-diseases\/hypertension-report [Accessed 09-07-2025]"},{"key":"R11","unstructured":"Maternal and child nutrition: nutrition and weight management in pregnancy, and nutrition in children up to 5 years. National Institute for Health and Care Excellence (NICE). 2025. URL: https:\/\/www.nice.org.uk\/guidance\/ng247 [Accessed 09-07-2025]"},{"key":"R12","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.j3119","article-title":"Effect of diet and physical activity based interventions in pregnancy on gestational weight gain and pregnancy outcomes: meta-analysis of individual participant data from randomised trials","volume":"358","author":"International Weight Management in Pregnancy (i-WIP) Collaborative Group","journal-title":"BMJ"},{"issue":"5","key":"R13","doi-asserted-by":"publisher","DOI":"10.1111\/obr.13199","article-title":"A meta-review of systematic reviews of lifestyle interventions for reducing gestational weight gain in women with overweight or obesity","volume":"22","author":"Fair","journal-title":"Obes Rev"},{"key":"R14","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.e2088","article-title":"Effects of interventions in pregnancy on maternal weight and obstetric outcomes: meta-analysis of randomised evidence","volume":"344","author":"Thangaratinam","journal-title":"BMJ"},{"issue":"6","key":"R15","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD007145.pub3","article-title":"Diet or exercise, or both, for preventing excessive weight gain in pregnancy","volume":"2015","author":"Muktabhant","journal-title":"Cochrane Database Syst Rev"},{"key":"R16","unstructured":"2025\/26 priorities and operational planning guidance. NHS England. 2025. URL: https:\/\/www.england.nhs.uk\/long-read\/2025-26-priorities-and-operational-planning-guidance\/#our-national-priorities-for-2025-26 [Accessed 09-07-2025]"},{"key":"R17","unstructured":"Maternity transformation programme. NHS England. 2024. URL: https:\/\/www.england.nhs.uk\/mat-transformation\/ [Accessed 09-07-2025]"},{"issue":"11","key":"R18","doi-asserted-by":"publisher","DOI":"10.2196\/37552","article-title":"Assessing the content and quality of digital tools for managing gestational weight gain: systematic search and evaluation","volume":"24","author":"Brammall","journal-title":"J Med Internet Res"},{"key":"R19","doi-asserted-by":"publisher","DOI":"10.1177\/20552076231198683","article-title":"Safety considerations for assessing the quality of apps used during pregnancy: a scoping review","volume":"9","author":"Carrandi","journal-title":"Digital Health"},{"issue":"6","key":"R20","doi-asserted-by":"publisher","DOI":"10.2196\/jmir.9262","article-title":"eHealth as the next-generation perinatal care: an overview of the literature","volume":"20","author":"van den Heuvel","journal-title":"J Med Internet Res"},{"issue":"1","key":"R21","doi-asserted-by":"publisher","DOI":"10.1186\/s12884-022-04422-7","article-title":"Sources of information used by women during pregnancy and the perceived quality","volume":"22","author":"Vogels-Broeke","journal-title":"BMC Pregnancy Childbirth"},{"issue":"1","key":"R22","doi-asserted-by":"publisher","DOI":"10.1186\/s40814-019-0537-z","article-title":"Intervention planning and modification of the BUMP intervention: a digital intervention for the early detection of raised blood pressure in pregnancy","volume":"5","author":"Band","journal-title":"Pilot Feasibility Stud"},{"issue":"17","key":"R23","doi-asserted-by":"publisher","first-page":"1666","DOI":"10.1001\/jama.2022.4726","article-title":"Effect of self-monitoring of blood pressure on blood pressure control in pregnant individuals with chronic or gestational hypertension: The BUMP 2 randomized clinical trial","volume":"327","author":"Chappell","journal-title":"JAMA"},{"issue":"1","key":"R24","doi-asserted-by":"publisher","DOI":"10.1186\/s12884-017-1592-1","article-title":"Blood pressure self-monitoring in pregnancy (BuMP) feasibility study; a qualitative analysis of women\u2019s experiences of self-monitoring","volume":"17","author":"Hinton","journal-title":"BMC Pregnancy Childbirth"},{"issue":"17","key":"R25","doi-asserted-by":"publisher","first-page":"1656","DOI":"10.1001\/jama.2022.4712","article-title":"Effect of self-monitoring of blood pressure on diagnosis of hypertension during higher-risk pregnancy: the BUMP 1 randomized clinical trial","volume":"327","author":"Tucker","journal-title":"JAMA"},{"issue":"4","key":"R26","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2019-033516","article-title":"Guidance for reporting intervention development studies in health research (GUIDED): an evidence-based consensus study","volume":"10","author":"Duncan","journal-title":"BMJ Open"},{"issue":"5","key":"R27","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0196868","article-title":"Using the person-based approach to optimise a digital intervention for the management of hypertension","volume":"13","author":"Bradbury","journal-title":"PLoS One"},{"issue":"1","key":"R28","doi-asserted-by":"publisher","DOI":"10.1186\/s40814-015-0033-z","article-title":"The person-based approach to enhancing the acceptability and feasibility of interventions","volume":"1","author":"Yardley","journal-title":"Pilot Feasibility Stud"},{"issue":"4","key":"R29","doi-asserted-by":"publisher","first-page":"1232","DOI":"10.1111\/hex.13506","article-title":"Meaningful patient and public involvement in digital health innovation, implementation and evaluation: a systematic review","volume":"25","author":"Baines","journal-title":"Health Expect"},{"key":"R30","unstructured":"Public involvement. Health Research Authorty. 2024. URL: https:\/\/www.hra.nhs.uk\/planning-and-improving-research\/best-practice\/public-involvement\/ [Accessed 09-07-2025]"},{"issue":"1","key":"R31","doi-asserted-by":"publisher","first-page":"28","DOI":"10.1093\/intqhc\/mzr066","article-title":"The impact of patient and public involvement on UK NHS health care: a systematic review","volume":"24","author":"Mockford","journal-title":"Int J Qual Health Care"},{"issue":"42","key":"R32","doi-asserted-by":"publisher","first-page":"42","DOI":"10.1186\/1748-5908-6-42","article-title":"The behaviour change wheel: a new method for characterising and designing behaviour change interventions","volume":"6","author":"Michie","journal-title":"Implement Sci"},{"key":"R33","unstructured":"Michie S Atkins L West R . The behaviour change wheel. In: A Guide to Designing Interventions. 1st ed. Silverback Publishing; 2014:1003-1010."},{"issue":"1","key":"R34","doi-asserted-by":"publisher","first-page":"81","DOI":"10.1007\/s12160-013-9486-6","article-title":"The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions","volume":"46","author":"Michie","journal-title":"Ann Behav Med"},{"issue":"1","key":"R35","doi-asserted-by":"publisher","DOI":"10.1186\/1472-6947-10-52","article-title":"Understanding reactions to an internet-delivered health-care intervention: accommodating user preferences for information provision","volume":"10","author":"Yardley","journal-title":"BMC Med Inform Decis Mak"},{"issue":"1","key":"R36","first-page":"58","volume":"54","author":"van den Haak","journal-title":"Tech Commun"},{"key":"R37","doi-asserted-by":"publisher","DOI":"10.1155\/2014\/561320","article-title":"Developing digital interventions: a methodological guide","volume":"2014","author":"Bradbury","journal-title":"Evid Based Complement Alternat Med"},{"issue":"1","key":"R38","doi-asserted-by":"publisher","DOI":"10.1038\/s41598-022-17554-9","article-title":"User engagement in relation to effectiveness of a digital lifestyle intervention (the HealthyMoms app) in pregnancy","volume":"12","author":"Henriksson","journal-title":"Sci Rep"},{"issue":"1","key":"R39","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0084238","article-title":"Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: a systematic review and meta-analysis of qualitative and quantitative studies","volume":"9","author":"Khatib","journal-title":"PLOS One"},{"issue":"4","key":"R40","doi-asserted-by":"publisher","first-page":"448","DOI":"10.1111\/jmwh.13375","article-title":"Pregnant and postpartum women\u2019s perceptions of barriers to and enablers of physical activity during pregnancy: a qualitative systematic review","volume":"67","author":"McKeough","journal-title":"J Midwife Womens Health"},{"issue":"1","key":"R41","doi-asserted-by":"publisher","DOI":"10.1111\/mcn.13068","article-title":"Be healthy in pregnancy: exploring factors that impact pregnant women\u2019s nutrition and exercise behaviours","volume":"17","author":"Grenier","journal-title":"Matern Child Nutr"},{"issue":"11","key":"R42","doi-asserted-by":"publisher","first-page":"565","DOI":"10.4066\/AMJ.2013.1881","article-title":"Enablers of and barriers to making healthy change during pregnancy in overweight and obese women","volume":"6","author":"Sui","journal-title":"Australas Med J"},{"issue":"6 Suppl","key":"R43","doi-asserted-by":"publisher","first-page":"S1","DOI":"10.1016\/j.cvdhj.2022.10.001","article-title":"Identifying barriers, facilitators, and interventions to support healthy eating in pregnant women with or at risk for hypertensive disorders of pregnancy","volume":"3","author":"Kovell","journal-title":"Cardiovasc Digital Health J"},{"issue":"1","key":"R44","doi-asserted-by":"publisher","DOI":"10.1186\/s12884-022-04539-9","article-title":"Applying the behaviour change wheel to develop a smartphone application \u201cstay-active\u201d to increase physical activity in women with gestational diabetes","volume":"22","author":"Smith","journal-title":"BMC Pregnancy Childbirth"},{"issue":"1","key":"R45","doi-asserted-by":"publisher","DOI":"10.1186\/s40814-024-01562-9","article-title":"Intervention development and optimisation of a multi-component digital intervention for the monitoring and management of hypertensive pregnancy: the My Pregnancy Care Intervention","volume":"10","author":"Tucker","journal-title":"Pilot Feasibility Stud"},{"key":"R46","unstructured":"The NHS long term plan. NHS England. 2019. URL: https:\/\/www.longtermplan.nhs.uk\/publication\/nhs-long-term-plan\/ [Accessed 09-07-2025]"},{"issue":"1","key":"R47","doi-asserted-by":"publisher","DOI":"10.1038\/s41746-022-00557-1","article-title":"Deploying digital health tools within large, complex health systems: key considerations for adoption and implementation","volume":"5","author":"Marwaha","journal-title":"NPJ Digital Med"},{"issue":"3","key":"R48","doi-asserted-by":"publisher","first-page":"714","DOI":"10.1038\/s41440-023-01474-w","article-title":"Using self-monitoring to detect and manage raised blood pressure and pre-eclampsia during pregnancy: the BUMP research programme and its impact","volume":"47","author":"Tucker","journal-title":"Hypertens Res"},{"key":"R49","doi-asserted-by":"publisher","DOI":"10.1016\/j.preghy.2022.09.006","article-title":"Perceptions and experiences of blood pressure self-monitoring during hypertensive pregnancy: a qualitative analysis of women\u2019s and clinicians\u2019 experiences in the OPTIMUM-BP trial","volume":"30","author":"Pealing","journal-title":"Pregnancy Hypertens"},{"issue":"1","key":"R50","doi-asserted-by":"publisher","DOI":"10.1186\/s13063-020-04613-7","article-title":"Developing a roadmap to improve trial delivery for under-served groups: results from a UK multi-stakeholder process","volume":"21","author":"Witham","journal-title":"Trials"}],"container-title":["JMIR Formative Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/formative.jmir.org\/2025\/1\/e68927","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T17:56:04Z","timestamp":1782842164000},"score":1,"resource":{"primary":{"URL":"https:\/\/formative.jmir.org\/2025\/1\/e68927"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7,18]]},"references-count":50,"URL":"https:\/\/doi.org\/10.2196\/68927","relation":{},"ISSN":["2561-326X"],"issn-type":[{"value":"2561-326X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,7,18]]},"article-number":"v9i4e68927"}}