The residency period constitutes a critical phase of medical training, during which increasing clinical and professional responsibilities influence residents’ well-being. Grounded in the Job Demands-Resources model, this study investigates how burnout and engagement evolve during this period and examines their associations with specific demands, resources, and personality traits. Between 2021 and 2025, data were collected annually via an online survey administered to medical residents from five Belgian universities (n = 1068). Burnout dimensions (i.e., emotional exhaustion, cynicism and reduced professional efficacy) and engagement were assessed alongside their associations with demands, resources, and personality traits. Linear mixed-effects models estimated the relationships between independent and dependent variables. The findings show that emotional exhaustion and cynicism modestly but gradually increased over time, while engagement slightly declined and professional efficacy remained stable. Work–home conflict showed the strongest association with the outcomes, while meaningfulness was identified as the most prominent resource and neuroticism as the strongest personal factor consistently linked to all outcome variables. These findings highlight the urgent need for structural interventions within residency programs to address key demands and strengthen meaningful work, while recognizing neuroticism as a vulnerability factor in protecting residents' well-being. Not applicable.

The use of respectful communication is essential to establishing a good therapeutic relationship between the healthcare professional (HCP) and the patient. Negative language can adversely affect interactions between the public and HCPs. Person-centred care is advocated in cardiovascular care, but there is lack of information regarding on how communication and respectful language can be applied. The aim of this statement is to explore the concept of respectful language in the delivery of person-centred cardiovascular care and present a working definition of respectful language in the context of healthcare and HCPs. This paper outlines of the role of communication in the delivery of cardiovascular care with critical analysis of the relevant literature. Factors influencing respectful language including ethnicity and culture and the move from the term 'patient' to 'person' are explored. Digital technologies (such as remote monitoring) now play a key role in delivering healthcare and HCPs need to be mindful on how it affects communication. Another important consideration is artificial intelligence and its potential impact on respectful language. Many healthcare providers and organizations have developed plain language documents, and non-technical lay summaries are available for evidence-based guidelines and research. This paper offers suggestions for ensuring best practice in the use of respectful language. Undoubtedly, respectful language is central to delivering person centred care. Every individual HCP involved in providing cardiovascular care can make some changes to their communication. Further education and training in the use of respectful language is needed along with evidence highlighting patient-reported outcomes and experience.

The high prevalence of burnout in medical education indicates an urgent need to develop and implement effective interventions at both the individual and organisational levels. Currently, there is a shortage of studies that include perspectives from multiple stakeholders, such as medical students, trainees and university staff. Our objective is to identify and discuss interventions from various stakeholders using a bottom-up approach to guide future implementation. A co-creation methodology was adopted, including workshops and a Delphi session, engaging 96 participants. The study included 12 workshops with medical students and trainees in Flanders (Belgium): first-year bachelor students (n = 12), first-year master students (n = 13), first-year General Practice (GP) trainees (n = 14) and first-year specialist trainees (n = 39). Additionally, one Delphi session was held with 18 other relevant stakeholders, including university staff. All workshops were transcribed verbatim and thematically analysed using NVivo. Our results identified interventions to prevent and mitigate burnout among medical students and trainees. On the individual level, participants discussed personalized coaching, annual health assessments and training sessions. On the organisational level, a distinction was made between interventions intended for universities, and those for hospitals and GPs involved in medical training. Six interventions focused on preventing burnout in all contexts (i.e., onboarding programs); three were meant for universities only (i.e., pass-fail system), and six were tailored for hospitals and GPs (i.e., flexibility in scheduling). Through an iterative multistakeholder co-creation process, this study identified interventions to prevent and mitigate burnout within medical education. These interventions span individual and organisational levels, targeting universities, hospitals and GPs. While organisational interventions are increasingly recognized as crucial to address burnout, individual-focused interventions remain predominant in current research. There is a pressing need to further investigate organisational interventions and their combination with individual-focused strategies.

Introduction Digital health has the potential to support health care in rural areas by overcoming the problems of distance and poor infrastructure, however, rural areas have extremely low use of digital health because of the lack of interaction with technology. There is no existing tool to measure digital health literacy in rural China. This study aims to test and validate the digital health readiness questionnaire for assessing digital readiness among patients in rural China. Methods Due to the different Internet environments in China compared to Belgium, a cultural adaptation is needed to optimize the use of Digital Health Readiness Questionnaire in China. Then, a prospective single-center survey study was conducted in rural China among patients with hypertension. Confirmatory factor analysis was computed to test the measurement models. Results A total of 330 full questionnaires were selected and included in the analysis. The model-fit measures were used to assess the model's overall goodness of fit (Chi-square/degrees of freedom = 5.060, comparative fit index = 0.889, Tucker–Lewis index (TLI) = 0.869, root mean square error of approximation (RMSEA) = 0.111, standardized root mean square residual (SRMR) = 0.0880). TLI is a little bit lower than the borderline (more than 0.9) and RMSEA is higher than it (less than 0.08 means good model fit). We deleted two items 2 and 4 and the result shows a better goodness of fit (Chi-square/degrees of freedom = 4.897, comparative fit index = 0.914, TLI = 0.895, RMSEA = 0.109, SRMR = 0.0765) Conclusion To increase applicability and generalizability in rural areas, it should be considered to use the calculation of only the parts Digital skills, Digital literacy and Digital health literacy which are equally applicable in a Belgian population as in a rural Chinese population.

Aims ICD codes are used for classification of hospitalizations. The codes are used for administrative, financial, and research purposes. It is known, however, that errors occur. Natural language processing (NLP) offers promising solutions for optimizing the process. To investigate methods for automatic classification of disease in unstructured medical records using NLP and to compare these to conventional ICD coding.Methods and results Two datasets were used: the open-source Medical Information Mart for Intensive Care (MIMIC)-III dataset (n = 55.177) and a dataset from a hospital in Belgium (n = 12.706). Automated searches using NLP algorithms were performed for the diagnoses 'atrial fibrillation (AF)' and 'heart failure (HF)'. Four methods were used: rule-based search, logistic regression, term frequency-inverse document frequency (TF-IDF), Extreme Gradient Boosting (XGBoost), and Bio-Bidirectional Encoder Representations from Transformers (BioBERT). All algorithms were developed on the MIMIC-III dataset. The best performing algorithm was then deployed on the Belgian dataset. After preprocessing a total of 1438 reports was retained in the Belgian dataset. XGBoost on TF-IDF matrix resulted in an accuracy of 0.94 and 0.92 for AF and HF, respectively. There were 211 mismatches between algorithm and ICD codes. One hundred and three were due to a difference in data availability or differing definitions. In the remaining 108 mismatches, 70% were due to incorrect labelling by the algorithm and 30% were due to erroneous ICD coding (2% of total hospitalizations).Conclusion A newly developed NLP algorithm attained a high accuracy for classifying disease in medical records. XGBoost outperformed the deep learning technique BioBERT. NLP algorithms could be used to identify ICD-coding errors and optimize and support the ICD-coding process. Graphical Abstract

Cardiac telerehabilitation is proven to be equally safe and effective as center-based cardiac rehabilitation. Nevertheless, some real-world barriers significantly impact the adoption and successful implementation of cardiac rehabilitation as well as cardiac telerehabilitation. This study assesses willingness and actual participation in cardiac (tele)rehabilitation, examining key influencing factors (i.e. digital health readiness, health literacy, patients’ awareness). It explores the relation between digital health readiness and patients’ awareness concerning their intention to participate in cardiac telerehabilitation. Additionally, it investigates the relation between intention and actual participation in cardiac rehabilitation, considering the impact of health literacy and patients’ awareness. In this prospective single-center survey study, patients with cardiovascular disease were asked to fill in questionnaires. Digital health readiness was measured by Digital health readiness questionnaire (DHRQ), and health literacy was assessed with the Health Literacy Scale (HLS-EU). Patients' awareness of their cardiovascular disease was determined by the accuracy of their understanding of their specific cardiovascular condition. A total of 72 patients (mean age 62.7 ± 13.3; 33.3% is women) were included in this survey. 81.7% and 50% patients have respectively the intention to participate in cardiac rehabilitation and telerehabilitation. Additionally, 50,7% patients actually participated cardiac rehabilitation. There is a negative correlation between age and digital health readiness (r = -0.05, p < 0.001)/learnability ( r= -0.26, P = 0.025). There is no correlation between digital health readiness (r= 0.011, P= 0.931) and patients’ awareness with the intention to participate in cardiac telerehabilitation (r = -0.045, P = 0.733). Furthermore, there is also no correlation between health literacy (r = 0.196, P= 0.123) and patients’ awareness (r = 0.002, P = 0.086) with the intention to participate in cardiac rehabilitation. Lastly, no correlation between health literacy and actual participation in cardiac rehabilitation is detected (r = -0.115, P = 0.375), but it has been established that there is a relationship between patients’ awareness and actual participation in cardiac rehabilitation (r = -0.266, P = 0.033). Cardiovascular patients express a moderate intention to participate in cardiac terehabilitation, and there is no relation between digital health readiness and this intention, suggesting that digital health readiness is not a barrier to the willingness to participate cardiac telerehabilitation. Additionally, higher levels of patients’ awareness of their cardiovascular disease appears to result in increased engagement in cardiac rehabilitation program. However, further research is necessary to explore the barriers in participation to cardiac (tele)rehabilitation.

BACKGROUND:Changes in NR3C1 and IGF2/H19 methylation patterns have been associated with behavioural and psychiatric outcomes. Maternal mental state has been associated with offspring NR3C1 promotor and IGF2/H19 imprinting control region (ICR) methylation patterns. However, there is a lack of prospective studies with long-term follow-up. METHODS:52 mother-offspring pairs were studied from 12 to 22 weeks of pregnancy and offspring was followed-up until 28-29 years-of-age. During pregnancy, mothers filled in a Life Event Scale and a Daily Hassles Scale measuring perceived stress; i.e., appraisal or subjectively experienced severity of impact of important life events and of daily hassles in several life domains during pregnancy, respectively. Green space was quantified around the residence, using high-resolution (1 m2) map data. Saliva and blood samples were obtained from the adult offspring. Absolute DNA methylation levels were determined in blood and saliva on four NR3C1 amplicons, and one IGF2/H19 ICR amplicon using a bisulfite PCR and sequencing method. Linear mixed effect models were used to test the associations between perceived stress and green spaces during pregnancy, and adult offspring methylation patterns. RESULTS:We found associations between maternal perceived stress during pregnancy and methylation patterns on two out of the four NR3C1 amplicons, measured in blood, from offspring in adulthood, but not with IGF2/H19 methylation. For an interquartile-range (IQR) increase in maternal perceived life event or daily hassles stress scores, absolute methylation levels on several NR3C1 CpG sites were significantly changed (-1.62 % to +5.89 %, p<0.05). Maternal perceived stress scores were not associated with IGF2/H19 methylation, neither in blood nor in saliva. Maternal exposure to green spaces surrounding the residence during the pregnancy was associated with IGF2/H19 ICR methylation (-0.80 % to -1.04 %, p<0.05) in saliva, but not with NR3C1 promotor methylation. CONCLUSION:We observed significant long-term effects of maternal perceived stress during pregnancy on the methylation patterns of the NR3C1 promotor in offspring well into adulthood. This may imply that maternal psychological distress during pregnancy may influence the regulation of the HPA-axis well into adulthood. Additionally, maternal proximity to green spaces was associated with IGF2/H19 ICR methylation patterns, which is a novel finding.

Aims: Cardiac rehabilitation (CR) is a class Ia recommendation by international guidelines. However, the participation remains disappointingly low. Multiple barriers were already identified. Nevertheless, the rela-tionship with psychosocial factors remains unsettled. The aim of this study is to analyse the role of psychosocial factors in CR participation.Methods and results: A prospective study on 165 patients with a percutaneous coronary intervention. The main outcome was participation in a centre-based CR programme. The independent relationship between participation and optimism, type D personality or distressed personality, health literacy, depression, social support and self-efficacy.A total number of 165 patients were included in the study of which 81 (49.1%) participated in a centre-based CR programme. Participants were predominantly male. Solely, patients participating in CR were significantly younger (P = 0.005). Participants of CR had significantly higher levels of social support especially from their significant other (P = 0.020) and family (P = 0.050). Furthermore, the health literacy score was significantly higher in the participants group (P = 0.030). A multiple logistic regression demonstrated that higher age, higher social support, not working, being obese and being able to drive a car were significant statistical predictors for CR participation. Conclusions: This study is one of the first to demonstrate the role of social support and health literacy in the participation of CR. Other well-known barriers for CR participation such as age, transport and scheduling issues were identified as barriers in this study.

Lifestyle optimization is one of the most essential components of cardiovascular disease prevention. Motivational counseling provided by health care professionals could promote lifestyle modification. The purpose of the review is to identify possible evidence-based psychological principles that may be applicable to motivational counseling in the prevention of cardiovascular disease. These motivational communication skills promote behavioral change, improved motivation and adherence to cardiovascular disease prevention. A personal collection of the relevant publications. The review identified and summarized the previous evidence of implementation intentions, mental contrasting, placebo effect and nocebo effects and identity-based regulations in behavior change interventions and proposed their potential application in cardiovascular disease prevention. However, it is challenging to provide real support in sustainable CVD-risk reduction and encourage patients to implement lifestyle changes, while avoiding being unnecessarily judgmental, disrespectful of autonomy, or engaging patients in burdensome efforts that have little or no effect on the long run. Motivational communication skills have a great potential for effectuating sustainable lifestyle changes that reduce CVD-related risks, but it is also surrounded by ethical issues that should be appropriately addressed in practice. It is key to realize that motivational communication is nothing like an algorithm that is likely to bring about sustainable lifestyle change, but a battery of interventions that requires specific expertise and long term joint efforts of patients and their team of caregivers.

Introduction: Co-creation is becoming increasingly popular to develop interventions that can achieve results beyond scientific findings. Workshops are one of the main ways to collect data and generate ideas in co-creation, which traditionally have been conducted at a fixed, physical location. However, organising face-to-face workshops is considered challenging, due to the transportation time, low flexibility and high costs. This study aims to investigate the online format of co-creation workshops and to discuss methodological considerations. Methods: Co-creation workshops were organised with 78 medical students, general practitioner (GP) trainees and specialist trainees from five Belgian universities. The study included four different cohorts, namely first-year bachelors ( n = 12), first-year masters ( n = 13), first-year GP trainees ( n = 14) and first-year specialist trainees ( n = 39). Three consequential online workshops were organised for each cohort, resulting in 12 workshops in total. The collected data included qualitative data (video-and audio recordings, notes from interdisciplinary team discussions, Miro boards) and quantitative data (registrations and actual attendance rates). All workshops were transcribed verbatim and thematically analysed using NVivo. Results: The participants reported increased flexibility and reduced costs as main benefits of the online format. In addition, the online platforms Miro and Microsoft Teams were considered dynamic and inspiring, facilitating high levels of engagement and interactivity. However, the online format also showed some challenges, such as the need for a digitally educated population and a stable internet connection. Conclusion: This study has shown that online workshops, also in the highly interactive method of co-creation, provide a viable alternative to collect data and generate ideas. This is particularly the case, when the target population is geographically dispersed, has a high workload and is digitally educated. Online workshops, however, also face limitations and challenges that need to be considered when choosing this format.

Background While questionnaires for assessing digital literacy exist, there is still a need for an easy-to-use and implementable questionnaire for assessing digital readiness in a broader sense. Additionally, learnability should be assessed to identify those patients who need additional training to use digital tools in a health care setting. Objective The aim of the development of the Digital Health Readiness Questionnaire (DHRQ) was to create a short, usable, and freely accessible questionnaire that was designed from a clinical practice perspective. Methods It was a prospective single-center survey study conducted in Jessa Hospital Hasselt in Belgium. The questionnaire was developed with a panel of field experts with questions in following 5 categories: digital usage, digital skills, digital literacy, digital health literacy, and digital learnability. All participants who were visiting the cardiology department as patients between February 1, 2022, and June 1, 2022, were eligible for participation. Cronbach α and confirmatory factor analysis were performed. Results A total number of 315 participants were included in this survey study, of which 118 (37.5%) were female. The mean age of the participants was 62.6 (SD 15.1) years. Cronbach α analysis yielded a score of >.7 in all domains of the DHRQ, which indicates acceptable internal consistency. The fit indices of the confirmatory factor analysis showed a reasonably good fit: standardized root-mean-square residual=0.065, root-mean-square error of approximation=0.098 (95% CI 0.09-0.106), Tucker-Lewis fit index=0.895, and comparative fit index=0.912. Conclusions The DHRQ was developed as an easy-to-use, short questionnaire to assess the digital readiness of patients in a routine clinical setting. Initial validation demonstrates good internal consistency, and future research will be needed to externally validate the questionnaire. The DHRQ has the potential to be implemented as a useful tool to gain insight into the patients who are treated in a care pathway, tailor digital care pathways to different patient populations, and offer those with low digital readiness but high learnability appropriate education programs in order to let them take part in the digital pathways.

Journal Article Smartphone-based 6-minute walking test while walking in the park: bringing physical fitness monitoring to the patient's hands Get access Scherrenberg Martijn, Scherrenberg Martijn Heart Centre Hasselt, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, BelgiumFaculty of Medicine and Life Sciences, UHasselt, 3590 Diepenbeek, BelgiumFaculty of Medicine and Health Sciences, Antwerp University, 2000 Antwerp, Belgium Corresponding author. Email: martijn.scherrenberg@telenet.be https://orcid.org/0000-0001-9483-3828 Search for other works by this author on: Oxford Academic Google Scholar Bonneux Cindel, Bonneux Cindel UHasselt, Faculty of Sciences, HCI and eHealth, 3590 Diepenbeek, Belgium Search for other works by this author on: Oxford Academic Google Scholar Falter Maarten, Falter Maarten Heart Centre Hasselt, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, BelgiumFaculty of Medicine and Life Sciences, UHasselt, 3590 Diepenbeek, BelgiumFaculty of Medicine, Department of Cardiology, KULeuven, Herestraat 49, 3000 Leuven, Belgium Search for other works by this author on: Oxford Academic Google Scholar Hansen Dominique, Hansen Dominique Heart Centre Hasselt, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, BelgiumREVAL/BIOMED, Faculty of Rehabilitation Sciences, Hasselt University, 3500 Hasselt, Belgium https://orcid.org/0000-0003-3074-2737 Search for other works by this author on: Oxford Academic Google Scholar Mahmood Deeman, Mahmood Deeman UHasselt, Faculty of Sciences, HCI and eHealth, 3590 Diepenbeek, Belgium Search for other works by this author on: Oxford Academic Google Scholar Kaihara Toshiki, Kaihara Toshiki Heart Centre Hasselt, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, BelgiumFaculty of Medicine and Life Sciences, UHasselt, 3590 Diepenbeek, BelgiumDivision of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 210 Kawasaki, Japan Search for other works by this author on: Oxford Academic Google Scholar Xu Linqi, Xu Linqi Heart Centre Hasselt, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, BelgiumFaculty of Medicine and Life Sciences, UHasselt, 3590 Diepenbeek, Belgium Search for other works by this author on: Oxford Academic Google Scholar Jaeken Elaine, Jaeken Elaine Faculty of Medicine and Life Sciences, UHasselt, 3590 Diepenbeek, Belgium Search for other works by this author on: Oxford Academic Google Scholar Schols Lotte, Schols Lotte Heart Centre Hasselt, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, Belgium Search for other works by this author on: Oxford Academic Google Scholar Kindermans Hanne, Kindermans Hanne Faculty of Medicine and Life Sciences, UHasselt, 3590 Diepenbeek, Belgium https://orcid.org/0000-0003-2723-1645 Search for other works by this author on: Oxford Academic Google Scholar ... Show more Coninx Karin, Coninx Karin UHasselt, Faculty of Sciences, HCI and eHealth, 3590 Diepenbeek, Belgium Search for other works by this author on: Oxford Academic Google Scholar Dendale Paul Dendale Paul Heart Centre Hasselt, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, BelgiumFaculty of Medicine and Life Sciences, UHasselt, 3590 Diepenbeek, Belgium Search for other works by this author on: Oxford Academic Google Scholar European Journal of Preventive Cardiology, Volume 29, Issue 15, October 2022, Pages e350–e352, https://doi.org/10.1093/eurjpc/zwac157 Published: 28 July 2022 Article history Received: 28 June 2022 Revision received: 21 July 2022 Accepted: 23 July 2022 Published: 28 July 2022 Corrected and typeset: 09 August 2022

Depression and anxiety have a detrimental effect on the health outcomes of patients with heart disease. Digital health interventions (DHIs) could offer a solution to remotely diagnose, monitor and treat depression and anxiety in patients with heart disease, but evidence of its efficacy remains scarce. This review summarizes the latest data about the impact of DHIs on depression/anxiety in patients with cardiac disease. This review summarizes the latest data about the impact of DHIs on depression/anxiety in patients with cardiac disease. Articles from 2000 to 2021 in English were searched through electronic databases (PubMed, Cochrane Library, Embase). Articles were included if they incorporated a randomized controlled trial design for patients with cardiac disease and used DHIs in which depression or anxiety was set as outcomes. A narrative systematic review was performed. After removing duplicates, 1675 articles were included and the screening identified a total of 17 articles. Results indicated that telemonitoring systems for heart failure (HF) patients, both with or without involving a psychological intervention, have a beneficial effect on depression/anxiety. Virtual reality (VR) technologies including relaxation exercises for patients with cardiac disease have a beneficial influence on anxiety. Results on internet- or cell phone-based intervention for patients with a coronary heart disease or internet-based intervention for patients with implantable cardioverter defibrillator were inconclusive. Telemonitoring systems for HF and VR relaxation have a beneficial effect on depression and/or anxiety. Regarding telemonitoring for HF, this effect was reached even without incorporating a specific psychological intervention. These results illustrate the future potential for cardiac telemonitoring systems and DHIs for mental health.

After a cardiac event, secondary prevention is recommended to foster recovery and reduce the risk of recurrent events.European guidelines and EAPC position statements on prevention of cardiovascular diseases recommend a holistic approach that actively engages patients by using shared decision making (SDM).It has been demonstrated that telerehabilitation can be a feasible and effective add-on or alternative compared to conventional in-hospital secondary prevention.However, till date, there is no eHealth solution that offers a holistic approach for secondary prevention that includes SDM.In this paper, we present the CoroPrevention-SDM approach, a technology-supported shared decision making approach for a comprehensive secondary prevention program for cardiac patients.The CoroPrevention Tool Suite consists of three applications that support patients and caregivers in following this approach: 1) a caregiver dashboard that includes decision support systems and supports SDM, 2) a patient mobile application that supports patients in making behaviour changes in their daily life, and 3) an extended ePRO application that collects patient reported outcomes and patient preferences.In a formative usability study, we assessed patients' and caregivers' opinion about our approach.The study indicated that both are willing to use our proposed approach to collaboratively set behavioural goals during SDM encounters.

Background and Aim Maternal mental state has been associated with offspring NR3C1 promotor and IGF2/H19 imprinting control region (ICR) methylation patterns. However, more prospective studies with long-term follow-up are needed, and protective factors such as proximity to green spaces during pregnancy remain understudied. In this study, we investigated the associations between these maternal exposures, and the methylation patterns in adult offspring (28-29 y/o). Methods 51 mother-newborn pairs were followed up from 12-22 weeks of pregnancy until 28-29 years after birth. During pregnancy, participants filled out questionnaires measuring the impact of important life events and of daily stressors. Using addresses, quantities of green space around the residence were determined using high-resolution map data (1 m2). 28-29 years later, blood and saliva samples were collected from the offspring. DNA methylation levels were determined on the NR3C1 promotor, and on the IGF2/H19 ICR using a bisulfite PCR and sequencing method. Mixed effect models were used to test the associations between maternal exposure to stressors and green spaces, and methylation patterns. Results We found significant associations between the life events and daily stressor scores, and methylation patterns on two out of the four NR3C1 promotor region amplicons in offspring blood 28 years later. The same maternal stress measures were not associated with IGF2/H19 methylation levels. Maternal exposure to green spaces 1000m around the residence was associated with IGF2/H19 ICR methylation, but not with NR3C1 promotor methylation. Conclusion We observed significant effects of maternal stress exposure during the pregnancy on the methylation patterns on the NR3C1 promotor into adulthood, which implies that maternal mental states during the pregnancy can induce HPA-axis regulation changes that can be persistent into adulthood. The observation that prenatal exposure to green spaces is associated with IGF2/H19 ICR methylation generates new hypotheses around the environmental determinants of DNA methylation patterns.

Abstract Background Despite the benefits of cardiac rehabilitation and secondary prevention, patients with coronary heart disease frequently fail to meet their daily physical activity goals. When one is stuck in a cycle of bad habits, changing one's behavior can be very challenging. One of the difficulties to maintaining a healthy lifestyle may be a lack of motivation. The use of game design elements (such as points, leaderboards, progress bars, and badges) in non-game contexts to promote motivation and engagement is known as gamification. It could be a powerful tool for encouraging patients to engage in physical activity. However, solid ideas that utilize the fundamental experience and psychological impacts of gaming mechanics must be built upon. Purpose The aim of this study is to look into the impact of a smartphone-based gamification intervention on physical activity engagement and other related psychological outcomes in patients with coronary heart disease, as well as the 24-week maintenance of effects beyond the 12-week intervention. Methods Participants with coronary heart disease were randomly assigned to three groups (control group, individual group and team group). The individual and team groups received gamified behavior intervention based on behavioral economic principles. Based on the Individual group, the team earned social incentives (collaboration). The intervention lasted 12 weeks, with another 12 weeks of follow-up. The primary outcomes included the change in daily steps and the proportion of patient-days that step goals achieved. The secondary outcomes included competence, autonomous, relatedness and autonomous motivation. Results The follow-up period has now been completed by 65 participants (mean age 52.8+10.3, 18.2% female) completed the follow-up period. Compared with the control group (n=17), participants in the individual group (n=25) had a significantly greater increase in mean daily steps from baseline during the intervention group (difference 956; 95% CI, 243–1623; P<0.01), and had a significantly greater proportion of patient-days that step goals achieved (difference 0.35; 95% CI, 0.03–0.12; P<0.001), competence (difference 0.5, 95% CI, 0.3–0.7; P<0.001), autonomous motivation (difference 3.2; 95% CI, 2.0–4.0; P<0.001). However, no significant difference of change in step counts was found between team group (n=23) and control group. During the follow-up period, mean daily steps and autonomous motivation in the individual declined but remained significantly greater than that in the control arm compared with baseline (steps: difference 452; 95% CI, 138–818; P<0.05) (motivation: difference 1.2; 95% CI, 0.3–1.8; P<0.05). Conclusions A smartphone-based gamification intervention was found to be an effective strategy to enhance motivation and physical activity engagement, as well as having a great maintenance effect. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work is financially supported by a Construction Programme of Independent Innovation Ability of Community Health Nursing Engineering Laboratory in Jilin Province (Study code: 2020C038-8) awarded to FL.