Background
Methods
Search strategy
Selection criteria
Inclusion criteria | |
Study type | Publication date from 2000 present. |
Studies from any geographical location. | |
English language. | |
Original qualitative studies, studies involving secondary analysis of qualitative data or qualitative studies that are part of a mixed methods study (e.g. the study also has a quantitative component but the major component is qualitative and a qualitative methodology is described). The study must have direct contact with individuals or direct observation using any form of qualitative method. | |
Participant Type | Any individual (adult or child). This includes patients, the public and health professionals who would be aware of the experiences of these groups. |
Type of digital health intervention | Any health intervention delivered by a digital technology (hypothetical or in development, simulated or real-world) which takes information from patients or the public or provides some form of advice or feedback about their health. This includes, but is not limited to: • Web-based interventions on personal computers (PCs) or mobile platforms, • Mobile health applications or apps, • Patient portals or personal health records, • Interventions delivered by short message service (SMS) or interactive voice recognition (IVR). |
Setting | Any ‘usual’ setting (hypothetical or in development, simulated or real-world) such as primary, secondary or tertiary care, the home or workplace. |
Phase of implementation | Engagement and recruitment phase of a digital health intervention, which can span from gauging an individual’s readiness for a digital health intervention, to the initial marketing or reach of the initiative, to actively signing individuals up to use the technology so they are registered on the digital application or system. |
Exclusion criteria | |
Study Type | Published pre 2000. |
Non English language. | |
Grey literature/not published in a peer reviewed journal. | |
Dissertation/thesis. | |
Published abstracts or conference proceedings. | |
Studies using the following methodologies: descriptive case studies, lexical studies that analyse natural language data presented as qualitative results; qualitative studies using questionnaires or other methods that do not involve direct contact or observation of participants. | |
Any type of literature review, systematic review and meta-analyses, or a qualitative study that did not involve direct contact or observation of participants. | |
Randomized Controlled Trials due to the large volume of literature on the difficulties recruiting to clinical trials that already exists [94]. | |
Commentary articles, written to convey opinion or stimulate research/discussion, with no research component. | |
Type of digital health intervention | Primary digital intervention is; telephone based with no additional technological function (e.g. telephone counselling or triaging service); Internet based with no additional interactive function (e.g. searching for health information online); or an implantable device that is remotely monitored |
Setting | Any non-usual setting e.g. prison, armed forces in active duty. |
Stage of implementation | Pre-implementation work based solely around designing the interface and functionality of the digital health intervention. |
The post engagement/recruitment phase will not be explored. For example: • why patients or the public use or do not use digital health interventions, • why they drop out (attrition) or fail to continue using them (retention), • their attitudes or beliefs towards digital health interventions, or their satisfaction with them outside of that pertaining directly to engagement and recruitment. |
Screening, data extraction and quality appraisal
Data analysis
Coherence (CO) | Cognitive Participation (CP) | Collective Action (CA) | Reflexive Monitoring (RM) |
The
sense-making
work that people do individually and collectively when faced with engaging and enrolling in a digital health intervention
|
The
relational work
that people do individually and collectively to build and sustain engagement and enrolment in a digital health intervention
|
The
operational work
that people do by investing effort and resources to engage with and sign up to a digital health intervention
|
The
appraisal work
that people do to evaluate engagement and recruitment to a digital health intervention that affects them and others around them
|
Differentiation (CO-d) | Enrolment (CP-e) | Skillset Workability (CA-sw) | Reconfiguration (RM-r) |
Defining, dividing up and categorizing tasks | Recruiting the self and others to tasks | Allocating tasks and performances | Modifying or changing tasks |
Communal Specification CO-cs) | Activation (CP-a) | Contextual Integration (CA-ci) | Communal Appraisal (RM-ca) |
Making sense of shared versions of tasks | Organising a shared contribution to tasks | Supporting, resources and integrating tasks in their social contexts | Shared evaluation of contributions to tasks |
Individual Specification (CO-is) | Initiation (CP-i) | Interactional Workability (CA-iw) | Individual Appraisal (RM-ia) |
Making sense of personal versions of tasks | Organizing an individual contribution to tasks | Doing tasks, and achieving outcomes in practice | Individual evaluation of contributions to tasks |
Internalization (CO-i) | Legitimation (CP-l) | Relational Integration (CA-ri) | Systematization (RM-s) |
Learning how to do tasks in context | Making tasks the right thing to do | Developing confidence and communicating reliable knowledge about tasks | Organizing a reliable stock of knowledge about tasks |
Results
Characteristics of included studies
Engagement and recruitment strategies
Engagement Strategy | |
Advertising (Indirect) | Electronic media - television screens and digital notice boards Online media – email; social media; websites; Internet communities or forums Print media - newspaper advertising; personal letters; posters on notice boards; printed flyers and leaflets Radio |
Personal Contact (Direct) | During a consultation with a health professional Research or management staff within a healthcare facility During a consultation with an employer Family, friends or peers Co-design activities |
Recruitment Strategy | |
Automatic | Consent is assumed and a digital profile or account is created |
Electronic | Register online via a website |
Paper based | Complete a paper based registration form |
Personal Assistance | Healthcare professional helps to create a digital profile or account |
Telephone or mobile phone | Telephone registration line Send a SMS text message |
Quality appraisal
Issues affecting digital health engagement and recruitment
Barriers | Facilitators | ||
Themes 1: Personal Agency and Motivation | |||
Barrier Subtheme 1.1: Lack of Motivation | Lack of motivation to understand or improve health | Facilitator Subtheme 1.1: Personal Motivation | Motivation to understand and improve health |
Barrier Subtheme 1.2: Awareness and understanding | Unaware of or lacks understanding of how a DHI could be helpful | Facilitator Subtheme 1.2: Awareness and understanding | Ability to understand a DHI and personal health data |
Barrier Subtheme 1.3: Personal Agency (choice and control) | Alternative ways of documenting health information and managing illness | Facilitator Subtheme 1.3: Personal Agency (choice and control) | Ability to choose time and location of interaction with a DHI Ability to control electronic personal health data |
Themes 2: Personal Life and Values | |||
Barrier Subtheme 2.1: Personal lifestyle | Busy lifestyle with competing priorities | Facilitator Subtheme 2.1: Personal lifestyle | DHI fits with personal lifestyle |
Barrier Subtheme 2.2: Skills and equipment | Poor digital literacy | Facilitator Subtheme 2.2: Skills and equipment | Good digital literacy |
Lack of access to equipment and the Internet | Has or can afford computer equipment or mobile device, network connectivity and a data plan | ||
Cost of a DHI | |||
Barrier Subtheme 2.3: Privacy and security | Concern over the security and privacy of DHI information or interaction | Facilitator Subtheme 2.3: Privacy and security | Values the privacy and anonymity of DHI information or interaction |
Theme 3: Engagement and Recruitment Approach | |||
Barrier Subtheme 3.1: Recruitment strategy | Difficulty understanding the recruitment message | Facilitator Subtheme 3.1: Recruitment strategy | Active promotion and engagement strategies |
Health professional acts as a gatekeeper | |||
Barrier Subtheme 3.2: Direct support | Lack of support from family members, friends or peers | Facilitator Subtheme 3.2: Direct support | Support from family members, friends or peers offline |
Barrier Subtheme 3.3: Personal advice | Lack of advice and recommendations from trusted sources | Facilitator Subtheme 3.3: Personal advice | Recommended by family members, friends or peers |
Barrier Subtheme 3.4: Clinical endorsement | Lack of clinical endorsement and support for a DHI | Facilitator Subtheme 3.4: Clinical endorsement | Clinical accreditation and support for a DHI |
Theme 4: Quality of the Digital Health Intervention | |||
Barrier Subtheme 4.1 and 4.2: Negative digital health experience (quality of information or interaction) | Impersonal DHI (poor quality information or interaction) | Facilitator Subtheme 4.1 and 4.2: Positive digital health experience (quality of information or interaction) | Open, honest digital interaction with healthcare provider |
Lack of trust in DHI information or interaction | Previous negative experience of health services without a DHI | ||
Digital health interaction could be abusive | Social support from peers online | ||
Barrier Subtheme 4.3: Usability of the DHI | DHI is difficult to use | Facilitator Subtheme 4.3: Usability of the DHI | DHI is easy to enrol in and use (automated and integrated) |
Complex registration process |
Personal agency and motivation
“[I subscribed] to get the reminders, because if you’re sat, if you are in a lunch break and you’re sat at your desk just on the Internet and you’re not moving and you’re eating something that’s not good and then you get a reminder and it’s just: ‘have a walk!’, or something. Straight away there is a trigger in your mind and you think: ‘yeah, that’s right, I can do that!” – Facilitator (CO-i) [41]
“For me, it does not change anything because I am always in a car. I walk very little so I will feel even guilty for not having walked. I will look down at the low numbers and I’ll feel anxious.” – Barrier (CO-is) [54]
Personal life and values
“This is definitely a service I would use, not only for the convenience factor but I mean, no matter how old we are, it’s still an embarrassing issue for a lot of people.” – Facilitator (CA-iw) [55]
“I’m very wary of the internet, we leave digital footprints wherever we go and you never know what’s going to come back and haunt you and I think the more that you are in a professional working environment the more you need to be careful about what you put online. You’ve got to keep it within certain parameters.” – Barrier (CA-ri) [44]
Engagement and recruitment approach
“I make that decision by the patient’s need. If their diabetes is poorly controlled, then you need to use more tools to get them under control… you don’t really need it with all your patients with diabetes. You need it on the ones that need extra help.” – Facilitator (CP-e) [49]
“I would probably if I knew that the physician would access that prior to an appointment. If the physician didn’t read it, if it was more of a personal thing [just for me to do], I don’t know if I would kind of follow through with that.” – Barrier (CP-i) [57]
Quality of the Digital Health Intervention (DHI)
“I was so down and my peers/family couldn’t handle it and I needed someone who could tell me that it would be OK and that it was normal but also that I needed to stop feeling sorry for myself in a nice way…. I just went online and look for my support group [sic].” – Facilitator (RM-s) [53]
“I don’t think you would get the same feeling as if you were one-to-one in a room. You get more, you get to know the other person, so in a way you would. To me it would be like talking to a machine.” – Barrier (RM-ia) [45]
Developing a conceptual understanding of digital health engagement and recruitment processes
Discussion
Existing knowledge and future research
Limitations
Recommendation 1
There is a need to invest in raising the profile of digital health products and services so patients and the public are knowledgeable about them.
Recommendation 2
Technology that incorporates and enhances communication, social interaction and relationships with formal and informal care providers and peers with similar health issues, both online and offline, may help ensure engagement and enrolment, as people can quickly and easily access the social support they need to manage their wellbeing.
Recommendations 3 and 4
Accreditation and endorsement by respected clinical organisations or clinicians will be an important factor promoting engagement with digital health.
Marketing and engagement activities should consider targeting not just the individuals with a given condition or health issue but their wider relational and support networks, whose input may be a crucial factor in deciding uptake of new digital health initiatives.
Recommendation 5
Digital health engagement and enrolment strategies along with the products and services should be better designed and tailored where possible to lessen rather than increase the self-care burden of treatment people endure. This could enable them to integrate digital health with their current lifestyle, as a one-size fits all approach is unlikely to be effective.
Recommendation 6 and 7
More investment in digital upskilling mechanisms and technical infrastructure is needed alongside engagement and recruitment strategies if digital health uptake is to be enhanced.AndBetter funding models need to be put in place to help ensure equity of access to digital health products and services.
Recommendation 8
The public should be made more aware of the potential security risks with digital health products and services and better regulations need to be put in place to protect them to encourage engagement.