Patients’ and providers’ perspectives on e-health applications designed for self-care in association with surgery – a scoping review

The length of a hospital stay after major surgery has in recent years been shortened by several days [1, 2], leaving patients to take responsibility for their own recovery once discharged. User-friendly access to information is a prerequisite for patients to feel confident in taking on the responsibility for their recovery. For this reason, several e-health applications have been developed over the last two decades to support patients [3‐5]. A research group mapping the concept of e-health defined it as follows:

“E-health is an emerging field of medical informatics, referring to the organization and delivery of health services and information using the internet and related technologies. In a broader sense, the term characterizes not only a technical development, but also a new way of working, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology” [6].

Van der Meij et al. found that the purpose of most developed e-health applications is to complement or replace standard care [7]. In addition to information, there are some applications that also give patients opportunities to report symptom experiences and vital parameters, such as pulse or blood pressure. Some e-health applications have added alerts for the purpose of making healthcare professionals aware if their patients have been severely impacted by symptom experiences [8].

The rapid development of e-health applications has led to a need for mapping different areas of use in the context of perioperative care. Six reviews were found that focused on different aspects of exchanging information between healthcare professionals and patients [7, 9‐13]. Of these reviews, two have a scoping approach and four have a systematic approach. The intention of scoping reviews is to capture knowledge in novel areas according to comprehensive wide-ranging aims, while systematic reviews are to get answers to specified questions [14]. The scoping review performed by Koutras et al. explored the socioeconomic impact of e-health in perioperative care [9], while Maramba et al. examined methods to test the functionality of e-health applications [11]. Three systematic reviews examined the use of smartphone and tablet devices from an organisational perspective in the context of surgery [7, 10, 12], while one offered a patient perspective [13]. None of these reviews covered motivating and supporting effects from e-health applications in pre- and postoperative self-care.

The concept of self-care is described as taking responsibility for one’s well-being during the phase of acute illness, in contrast to the concept of self-management, which is explained as being used for chronic illness [15]. The World Health Organisation has not defined a time aspect for when the concept of self-care can be used [16]. Its definition of self-care is more comprehensive: “The ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a health-care provider.” The same applies for the definition from the National Board of Health and Welfare in Sweden, which defines self-care as “when a patient performs health care activities at home, either by himself/herself or with the help of, for example, a relative or a personal assistant” [17]. In this review, self-care is defined as taking responsibility for one’s own preparation before surgery and for recovery after surgery to achieve well-being and health during the perioperative period.

Preoperatively, patients are expected to prepare themselves for surgery, whereas the postoperative process aims at regaining the activities of daily life and psychological well-being that existed before surgery [18]. The rapid development of fast-track surgeries has put more emphasis on detailed information from the healthcare system, such as mapping risks for complications, readmissions, and economic consequences. Furthermore, suggestions for the collection of patient-reported outcome measures are growing [19]. If e-health applications should not only be a further place for information retrieval but also support patients to take on the responsibility for their postoperative care, knowledge about how to promote self-care in this context is of importance motivation this review. The population selected for this review includes both patients and providers of perioperative care since the use of e-health applications affects both perspectives. The aim of this review is therefore to give an overview of e-health applications designed for self-care associated with surgery by collecting perspectives from both providers and patients. As our research question is broad and has the purpose of capturing the breadth of previously acquired knowledge, the methodology of a scoping review was chosen. This in line with Peters et al., (2020), who describe the methodology used in a scoping review appropriate when the research question is broad as well as key factors within a specific area are sought. We posed the following questions to the research literature:

This review follow the framework outlined by Arksey and O’Malley in 2005, and further developed by Peters et al., (2020) members of Joanna Briggs Institute. The original framework consisted of five stages, that is; identify the research question; identifying relevant studies; study selection; charting the data; collating, summarising and reporting the results [20]. The authors also gave an optional sixth stage; consultation exercise, which is not employed in this study. A protocol for the review was registered with the Open Science Framework on 13 August 2020 (https://​doi.​org/​10.​17605/​OSF.​IO/​R3QND). The protocol was informed by the Joanna Briggs Institute manual for scoping reviews [21], and the results are reported according to the PRISMA guidelines [22]. The search terms (Table 1) were chosen in collaboration with a research librarian (E.N.), who also conducted the searches.

The following inclusion criteria were used: a) e-health (smartphone, tablet device, computer) applications designed for self-care for any type of surgery involving a skin incision, b) providers of perioperative care incorporating described e-health applications, c) adult in- and out-patients (≥ 18 years) who have undergone any type of surgery with a skin incision and had access to a surgical e-health application, d) interventions comparing e-health applications with standard care, e) qualitatively analysed experiences of providers and/or patients, f) phenomenon of interest was the impact of the use of the e-health application on patients’ self-care and their recovery, and g) outcomes describe what stimulates and motivates patient self-care. In this review, e-health applications are defined as smartphone/computer tablet applications designed for providing information and communication regarding acute care, that is, perioperative information and self-assessed progression of recovery to support self-care. Surgery is defined as a procedure in which an incision is made in the skin. The following exclusion criteria were used: a) e-health applications only focusing on healthcare providers’ interaction, b) sources older than 5 years, c) adolescents and children, and d) reviews. The reasons for limitation was that the rapid digital development may have influenced the design of e-health applications and the last reason was that patients' use of applications may have increased, influencing their willingness and motivation [23]. Publications were limited to peer-reviewed articles in English, Danish, Norwegian, and Swedish from 1 January 2015 to the date of the final search on 2 June 2020.

Literature searches were developed by a research librarian (E.N.) to reflect the concepts outlined above, using controlled vocabulary whenever possible and supplemented with keyword searches in the title and abstract fields. Searches were run in the following subject databases known for indexing publications that would probably be most relevant to the research question: CINAHL with Full Text (EBSCOhost), MEDLINE (EBSCOhost), and PsycInfo (ProQuest). The search strategy was further expanded to include citation platforms that could identify additional articles of interest: Scopus (Elsevier) and Web of Science Core Collection (SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, ESCI). In addition, the internet was searched through Google Scholar (Publish or Perish Software). See Additional file 1 for full documentation of the search strategies.

Records found during the search phase were exported to reference management software (EndNote) to enable the identification and removal of duplicates [24]. Prior to the formal screening process, a calibration exercise was undertaken to pilot and refine the screening questions. Records were then screened using Rayyan QCRI, a web-based application for systematic reviews [25]. Selection was based on the previously described exclusion/inclusion criteria. The sample was divided into three parts, and each part was reviewed by two members who independently performed the screening process on the title/abstract level as well as conducted the full-text assessment of included records. Any disagreements during the screening process were resolved by discussion and consensus between the three reviewers (LW, KS, KE).

Data charting was undertaken in accordance with our predefined research questions. The data from the results sections were searched by the three reviewers (LW, KS, KE) and discussed until consensus was achieved, as recommended in the Joanna Briggs manual [21]. Studies that did not present data in accordance with our research questions were excluded at this stage (Fig. 1).

In addition to the results, the following data from the included studies were collected and tabulated as outlined by Evans [26]: author, publication year, country, characteristics of the study population, objectives of the study, study design and methods, and intervention content and characteristics (Tables 2 and 3).

In the synthesis of results, all results corresponding to the research questions in the included studies were compiled by the main author (LW). Identified data were categorized for each research question by the main author and discussed by the three reviewers (LW, KS, KE) to ensure consensus. The quantitative measures were presented with descriptive statistics, and the presentation of the qualitative synthesis followed the steps of Braun and Clarke for theoretical (deductive) thematic descriptive analysis [42].

A total of 15 studies were identified for inclusion in the review. The searches provided a total of 960 citations. After adjusting for duplicates, 638 remained. Of these, 566 studies were discarded because, after reviewing the abstracts, these papers clearly did not meet the criteria. The full text of each of the remaining 72 citations was examined in more detail, and 57 studies did not meet the inclusion criteria as described. No unpublished relevant studies were obtained. See flow diagram Fig. 1.

E-health applications have become increasingly common in many countries over the last several years [43]. Sweden belongs to the countries that have the highest level of e-health adoption [44]. Our study aimed to give an overview of e-health applications designed for self-care associated with surgery from the perspectives of providers and patients.

The main findings revealed that the most common self-care actions included preoperative preparations [28, 31, 32, 35, 36, 38, 39] and self-assessments of postoperative recovery [28, 32, 33, 37, 38, 40, 41], while the most commonly identified motivational factors for self-care in pre- and postoperative e-health applications included supportive reminders and messages [31‐34, 36‐38, 40] and chat features [30‐34, 38]. There was a great variance in research design and technical solutions. In spite of this, patients’ willingness to engage with and adherence to the different e-health applications seemed to increase self-care activities [33, 36, 40] and thereby accelerated return to work and normal activities [28, 35], resulting in an apparent decrease in the patients’ need for physical healthcare visits [38, 40]. Despite the fact that age groups were not primarily explored, the included studies showed that adult patients of any age engaged in surgical self-care supported by e-health. No studies were found that explored providers’ perspectives.

Despite the wide variety of surgeries and the varying level of support that e-health applications offer in surgical self-care, e-health in this context seems to have a positive impact on recovery. This means that e-health solutions supporting self-care can be a good alternative for those patients who are willing to engage in self-care and can manage the technology. However, to increase the effects of e-health, motivating technical measures to maintain patient’s adherence over time needs to be further evaluated by both providers and patients. Furthermore, e-health applications were found to include a wide variety of self-care activities, which presupposed patients’ ability to take responsibility for their care, meaning that surgical self-care activities in the home are under development. Providers and patients and their experiences of surgical self-care are valuable contributions to the development of available sustainable technological solutions at reasonable costs. Therefore, according to our findings and with a view to future care, there is a need for studies focusing on providers’ attitudes to surgical self-care at home and patients’ capabilities, needs, and wishes for accessibility and user-friendliness concerning e-health solutions.