Understanding factors affecting patient and public engagement and recruitment to digital health interventions: a systematic review of qualitative studies
© The Author(s). 2016
Received: 20 August 2016
Accepted: 3 September 2016
Published: 15 September 2016
Numerous types of digital health interventions (DHIs) are available to patients and the public but many factors affect their ability to engage and enrol in them. This systematic review aims to identify and synthesise the qualitative literature on barriers and facilitators to engagement and recruitment to DHIs to inform future implementation efforts.
PubMed, MEDLINE, CINAHL, Embase, Scopus and the ACM Digital Library were searched for English language qualitative studies from 2000 – 2015 that discussed factors affecting engagement and enrolment in a range of DHIs (e.g. ‘telemedicine’, ‘mobile applications’, ‘personal health record’, ‘social networking’). Text mining and additional search strategies were used to identify 1,448 records. Two reviewers independently carried out paper screening, quality assessment, data extraction and analysis. Data was analysed using framework synthesis, informed by Normalization Process Theory, and Burden of Treatment Theory helped conceptualise the interpretation of results.
Nineteen publications were included in the review. Four overarching themes that affect patient and public engagement and enrolment in DHIs emerged; 1) personal agency and motivation; 2) personal life and values; 3) the engagement and recruitment approach; and 4) the quality of the DHI. The review also summarises engagement and recruitment strategies used. A preliminary DIgital Health EnGagement MOdel (DIEGO) was developed to highlight the key processes involved. Existing knowledge gaps are identified and a number of recommendations made for future research. Study limitations include English language publications and exclusion of grey literature.
This review summarises and highlights the complexity of digital health engagement and recruitment processes and outlines issues that need to be addressed before patients and the public commit to digital health and it can be implemented effectively. More work is needed to create successful engagement strategies and better quality digital solutions that are personalised where possible and to gain clinical accreditation and endorsement when appropriate. More investment is also needed to improve computer literacy and ensure technologies are accessible and affordable for those who wish to sign up to them.
Systematic review registration
International Prospective Register of Systematic Reviews CRD42015029846
KeywordsDigital health eHealth Electronic health records Telemedicine Mobile applications mHealth Engagement Recruitment Barrier Facilitator
Patients are beginning to use a range of digital health interventions (DHIs) to manage chronic illness at home and support independent living and self-care, while remaining connected to health and care providers . DHIs may address many of the problems patients experience with today’s health systems, such as poor access, uncoordinated care and increasingly costly healthcare . Furthermore, DHIs aimed at the public are seen as one way to promote preventative health, potentially reducing health service utilisation and cost long-term . DHIs range from telehealth and telecare systems , to patient portals and personal health records (PHRs) [5, 6], mobile health applications , and other online platforms and devices . As the technology diversifies, miniaturises and becomes more interconnected, the shift towards using such DHIs will continue to grow.
However, numerous barriers prevent people from participating in evaluations of DHIs such as being too busy, feeling incapable of using the technology or disliking its’ impersonal nature [9, 10]. There are also factors that help patients and the public to engage with these electronic platforms such as personal motivation to improve health and learn new ways to manage illness . Much of this evidence has been generated through quantitative methods, in particular Randomized Controlled Trials (RCTs), which provide little detail or context of the real-world difficulties individuals’ face [12, 13] such as the cost of the technology and issues around privacy and security . Understanding these problems is particularly important as we move from recruiting to RCTs, to engaging and enrolling patients and the public in large-scale deployments of digital health in real world settings. This gap in knowledge is often referred to as the second translation gap, moving from initial concept testing and RCTs to full-scale implementation [15, 16].
Although an increasing number of qualitative studies have examined some of these issues, quite often they have focused on a particular patient population and a single piece of technology [17, 18]. Therefore, the literature is fragmented and does not present a clear picture of the barriers and facilitators people face when engaging and enrolling in all types of DHIs. Qualitative syntheses can aid our understanding of how complex interventions are embedded into daily routine, which can help to inform health policy and clinical practice [19, 20]. A qualitative review of public engagement with eHealth has been conducted  but the majority of included studies looked at people who searched for health information online only, so it is limited in terms of its technological scope and it was undertaken in 2009, six years ago, which is a long time in a fast moving area. The review also lacked any assessment of the quality of included studies and had no theoretical basis, thereby diminishing the lessons that can be drawn from it.
This paper aims to address the fragmentation of research evidence by systematically reviewing and synthesising the qualitative literature on barriers and facilitators patients’ and the public experience during engagement and recruitment to DHIs. It will also outline the strategies described to get people engaged and signed up to DHIs in the published literature. To address the lack of theoretical insights in this area, two empirically grounded theories will be utilised to aid in the conceptualisation of the complexities involved and develop a model of these processes. A series of recommendations about how patients and the public can be better supported to take up digital health products and services will also be outlined to improve the initial phases of the digital health implementation journey. Any outstanding research gaps will also be highlighted.
A protocol was created and the review registered on PROSPERO, the International Register of Systematic Reviews (CRD42015029846, http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015029846).
A scoping search was conducted to identify key papers and search terms to inform the design of the search protocol. This included three groups of concepts: (1) engagement and recruitment, (2) DHIs, and (3) barriers and facilitators. As it was thought important to capture the views of multiple stakeholders who would be aware of the experiences of patients and the public the population was not specified. A combination of MeSH headings, free text search terms and a novel text mining approach were used to narrow the considerable digital health literature and overcome the challenges of identifying relevant papers, which is described in detail elsewhere . Six online bibliographic databases; CINAHL (EBSCHOHost), PubMed, Medline, Embase, Scopus and the ACM Digital Library, were searched for English language publications between January 1, 2000 and August 19, 2015 (see Additional file 1). Reference and citation tracking, the ‘Similar articles’ function in PubMed, personal knowledge, and contacting experts in the field were also utilised to identify relevant papers. Endnote was used to remove duplicate citations before screening.
Inclusion and exclusion criteria used for the screening process
Publication date from 2000 present.
Studies from any geographical location.
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.
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).
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.
Published pre 2000.
Non English language.
Grey literature/not published in a peer reviewed journal.
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 .
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
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
The titles, abstracts and full papers were screened independently by two reviewers using DistillerSR software. Any discrepancies were discussed and disagreements adjudicated by a third party. A standardised data extraction template was then used which addressed a number of study characteristics (see Additional file 2). Text pertaining to barriers, facilitators, engagement and recruitment strategies, which included findings and interpretations written by the authors or participant quotes, were regarded as data and extracted for coding. Two reviewers independently performed a quality assessment using the 32-item Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [23, 24]. Although some would argue against such critical appraisal due to the unique philosophical and methodological underpinnings of qualitative work and the sometimes prescriptive use of such checklists [25, 26], others believe applying quality standards enables a more thorough exploration of the contribution of each study thereby improving the credibility of qualitative synthesis . All articles meeting the inclusion criteria were retained, regardless of their quality, as even methodologically weak studies can sometimes offer valuable insights [28, 29].
NPT Coding Framework
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
Skillset Workability (CA-sw)
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)
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)
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
Relational Integration (CA-ri)
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
Characteristics of included studies
A summary of the characteristics of included studies and participants can be found in Additional file 3. The included studies were published between 2005 and 2015, with the majority being published in the last four years. The studies were published in a number of countries with eight taking place in the United Kingdom [41–48], five in the United States [49–53], four in Canada [54–57] and one each in Norway  and Spain . They spanned numerous types of DHIs including patient accessible electronic health records and PHRs [47, 48, 57], a telehealth system for diabetics , web-based sexual health and cognitive behavioural therapy services [42–45, 55, 56], an online appointment booking and patient provider communication system [46, 58], an Internet support group ; a social networking application ; and email, SMS or mobile phone based health promotion, smoking cessation or weight loss programmes [41, 51, 52, 59]. Only one study was a mixed intervention combining a pedometer with nutritional education and meal preparation training . Fifteen studies were purely qualitative using a combination of interviews, focus groups, participant observation and documentary evidence [41–45, 47, 49, 52–59] with only four studies adopting mixed method approaches [46, 48, 50, 51]. The participants in the studies were patients, carers and healthy individuals from a variety of ages, genders, socioeconomic groups and ethnicities [42, 44, 45, 47, 48, 50–59] or were health professionals such as nurses or family doctors [43, 44, 46, 48, 49, 59]. Three studies had a mixture of other participants such as employees of large public and private companies, general practice staff and a range of individuals from local and national organisations affiliated with the implementation of a DHI [41, 46, 48]. However, several studies did not describe participant characteristics in detail: with three not depicting gender [44, 48, 49], four not portraying age [43, 44, 48, 49], nine not describing socio-economic status [43–46, 48, 49, 56, 57, 59], and eleven not highlighting ethnicity in detail [41, 43–46, 48, 49, 55, 57–59]. In general there was a trend towards younger and more middle aged people, rather than older adults, and those of “white” ethnicity.
Engagement and recruitment strategies
List of digital health engagement and recruitment strategies
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
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
Consent is assumed and a digital profile or account is created
Register online via a website
Complete a paper based registration form
Healthcare professional helps to create a digital profile or account
Telephone or mobile phone
Telephone registration line
Send a SMS text message
The quality of reporting in the included studies varied with between 10 and 24 of the 32 items from the COREQ checklist (see Additional file 4) . All 19 studies included the sample size, presented the main themes clearly and demonstrated consistency between the data collected and the findings. Seventeen provided some type of interview guide and described how participants were approached. Only one study reported repeating interviews and one returning transcripts to respondents. Overall the studies were of reasonable quality.
Issues affecting digital health engagement and recruitment
Factors affecting digital health engagement and recruitment
Themes 1: Personal Agency and Motivation
Lack of Motivation
Lack of motivation to understand or improve health
Motivation to understand and improve health
Awareness and understanding
Unaware of or lacks understanding of how a DHI could be helpful
Awareness and understanding
Ability to understand a DHI and personal health data
Personal Agency (choice and control)
Alternative ways of documenting health information and managing illness
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
Busy lifestyle with competing priorities
DHI fits with personal lifestyle
Barrier Subtheme 2.2:
Skills and equipment
Poor digital literacy
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
Privacy and security
Values the privacy and anonymity of DHI information or interaction
Theme 3: Engagement and Recruitment Approach
Difficulty understanding the recruitment message
Active promotion and engagement strategies
Health professional acts as a gatekeeper
Lack of support from family members, friends or peers
Support from family members, friends or peers offline
Lack of advice and recommendations from trusted sources
Recommended by family members, friends or peers
Lack of clinical endorsement and support for a DHI
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)
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
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) 
“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) 
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) 
“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) 
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) 
“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) 
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) 
“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) 
In some cases the quality of health information accessed online was thought to be unreliable, without input from a qualified doctor or nurse, and the potential for identity fraud made it difficult for some people to trust advice from virtual health professionals [45, 55–57]. In one paper, abusive or threatening behaviour that could develop in virtual relationships was a barrier that prevented others from engaging and enrolling . Finally, the usability of the DHI also featured under quality as some individuals felt they would not sign up if it was too slow and cumbersome to register or use it [41, 47, 48, 56].
Developing a conceptual understanding of digital health engagement and recruitment processes
This review provides a summary of reported engagement and recruitment strategies, a catalogue of barriers and facilitators patients and the public experience when engaging and enrolling in DHIs as well as a preliminary conceptual model of key elements in this process. While none of the included papers comprehensively covered the entire process of engaging with and signing up to a DHI each study examined one or more aspects of people’s positive and negative experiences.
Existing knowledge and future research
This systematic review explores how patients and the public engage with and enrol in a broad range of DHIs. Its findings support and expand those of an earlier review, which primarily looked at people accessing health information online . One theme from that paper which affected engagement was the “characteristics of users”, such as their age, ethnicity, economic status and educational attainment; this did not emerge strongly from our review given the diversity of participants involved. However, the educational level people attain was one factor in our review that did affect engagement with digital health, as those with poor computer skills found it challenging to enrol which is in keeping with previous literature. In addition, as very few of the included studies in our review involved people over sixty years of age and other literature on usability points to older adults having more difficulties with digital health [60, 61], it would be wise to explore in more depth why this population do or do not engage with and enrol in DHIs. Similarly, ethnicity and socioeconomic status were not well described in the papers in this review so definitive conclusions about how culture and social position affects engagement with DHIs cannot be made. Literacy skills [62–64] and being able to pay for the technology  do impact on people’s ability to interact with and use DHIs, which is consistent with the findings of our review.
This review incorporated several different DHIs but newer platforms such as wearable devices are also emerging in this space  and more will undoubtedly follow as nanotechnology and biotechnology take off. It will therefore be important to update this review in due course to incorporate these new trends, expand on the taxonomy of engagement and enrolment strategies used to encourage people to sign up to them and the barriers and facilitators experienced in the process. However, it is likely that many of the same issues will emerge as the generative mechanisms of digital health engagement and enrolment have been teased out through our conceptual work when developing the new DIgital Health EnGagement MOdel (DIEGO).
This review followed the ENTREQ guidelines for the reporting of systematic reviews of qualitative studies but it does have some limitations. The search strategy used introduced a number of constraints. Publications included were in the English language only; while this may have excluded potentially useful studies, there is evidence that limiting studies in this way does not introduce significant bias . The search dates were limited to studies after the year 2000 but as this is a rapidly evolving sphere we believe this is justifiable. The selection criteria specifically excluded studies discussing recruitment to RCTs, as the focus here was on engagement and enrolment to “real-world” DHIs. Furthermore, many DHIs are developed in the commercial space and marketed to consumers but these have not been formally evaluated through rigorous research and so the literature is limited to only those applications that have undergone academic evaluation . This does mean that some pertinent evidence could have been missed. The analysis and synthesis of the qualitative studies was based on our review of published data and not the original data, which may result in the loss of some important explanatory context. In addition, cultural differences in how people perceive and engage with DHIs, is not well understood, and the existing literature presents a predominantly Western viewpoint, which is a limitation. Furthermore, issues of socioeconomic disadvantage are not systematically addressed in the literature, which is another limitation. However, although more research will be required, based on the literature published to date, a number of recommendations are made about how to address the difficulties patients and the public face when engaging or enrolling in DHIs and what health professionals, health service managers, policy makers, industry and others need to consider to overcome these challenges.
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.
Work is needed to increase public awareness of different technologies and understanding of how they work, what benefits they can bring and potential risks inherent in using them. Further research is needed on novel ways to engage and educate the public about digital health as well as more investment in traditional forms of public health education . Identifying which engagement and recruitment strategies are most effective for different groups of patients, consumers and technologies would also be beneficial [14, 70], as detailed descriptions of these were largely missing from the included studies. While communicating via mass media such as newspapers, television and radio advertising is becoming less popular as these services move online, the virtual space offers numerous opportunities to provide interactive educational content and promote collaborative sharing and learning, especially through social media . However, this is dependent on patients and the public having access to digital platforms in the first instance, which as outlined in the review is not always feasible for some so more digital inclusion initiatives are necessary to address the digital divide . Identifying and measuring which engagement and enrolment strategies are most effective for different groups of patients, consumers and technologies would also be beneficial to improve awareness and understanding of DHIs [14, 70], as detailed descriptions of these were largely missing from the included studies. A range of metrics could be developed, such as the cost of engaging an individual through a particular strategy or the time taken to recruit a critical mass of users via a certain method, to help determine which approaches are most successful and some such as web analytics are already in use . It will be important that future studies describe engagement or recruitment strategies in greater detail to improve the fidelity and impact of these approaches . Development of a template for engagement and enrolment strategies analogous to the one developed for intervention description and replication called the Template for Intervention Description and Replication (TIDieR)  would be helpful.
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.
Gamification , social networking applications  and wearable technologies  are currently being explored to improve the usability and social connectedness of digital health products and services and further work should explore how these can contribute to engagement and enrolment. There is growing evidence that additional support, such as peer support, can be an effective strategy for reaching individuals that healthcare has traditionally described as “hard to reach” [77, 78]. More research examining whether or how these new platforms can help address the different barriers to engagement and recruitment would be useful.
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.
More research on whether DHIs should be accredited and approved by healthcare organisations and clinicians and how this should be done, given legal and ethical implications, would also be useful to provide guidance to individual healthcare professionals as well as local and national health services on how to promote engagement in digital health . Health professionals have been known to act as gatekeepers to DHIs and block patient recruitment . More research on how to address this issue would be beneficial as it is an important avenue by which patients and the public can learn about DHIs and enrol in them.
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.
As disease trends change over time DHIs must be designed in a flexible manner to accommodate the changing demographic and health landscape. For example, as multimorbidity becomes more commonplace it will impact on the future design requirements of many DHIs, which typically have a single disease focus and are not yet capable of providing holistic self-management solutions for patients and the public . In the future, DHIs may also need to combine the health and social care needs of individuals, as these are often closely intertwined, and some health systems are now moving towards integrating health and social care services [80, 81]. Research in this space is exploring personalising technology through co-design and other participatory methods to improve usability as patients and the public are often excluded from this process and their input will be vital if DHIs are to be successful [82, 83]. Furthermore, digital health readiness assessments are under development to see if an individual has the capacity for a DHI, what form this should take, and what engagement and enrolment strategies suit them . More work in this area would be beneficial and DIEGO could be a starting point for the development of future digital health readiness toolkits that focus on the patient and consumer perspective.
The review has reinforced the fact that usability is a significant factor in a person’s decision to sign up to a DHI. Therefore, digital platforms should have simple and short enrolment processes and it is essential that the systems themselves are easy to use so they are not burdensome, as this is a key factor that will affect uptake. In addition, people expect more integrated and automated systems that are continuously available. Interoperability issues between technologies and electronic systems are currently being tackled  and the development of application programming interfaces  are helping to close this gap further but more work on how to provide seamless digital health services would be helpful to encourage patients and the public to sign up to them.
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.
Better funding models need to be put in place to help ensure equity of access to digital health products and services.
Research in this space is emerging [63–65] but further work is necessary to illuminate the best means of achieving this for different groups of patients and the public. There is an assumption that these issues will become less of a factor over time, as the younger generation who are more digitally literate get older, and 4G and 5G telecommunication networks are rolled out. However, there is evidence that the penetration of technology in society does not guarantee that adolescents have more chance to learn and use IT, as numerous factors such as home IT access, gender and socio-economic status can affect children’s digital skills  and recent statistics show older adults still continue to struggle to use digital health . While many countries are investing in upgrading their network capacity, the ability to pay for technology whether it is the hardware, software, network connectivity or data consumption necessary to utilise DHIs will not always be feasible for some people , especially those in low and middle-income nations. Therefore, to prevent further inequalities in health developing more work on these issues is necessary.
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.
Given that some technology sectors such as the mobile app industry are completely unregulated [90–92] and cybercrime is prevalent , it would also be pertinent to inform the public about the potential risks involved in using digital health products and services and what is being done to protect the privacy and security of their data.
It is clear from our framework of barriers and facilitators that digital health engagement and recruitment processes are complex, with many interconnecting factors that affect patients’ and the public’s ability to engage and enrol in a technology and there remains outstanding gaps in knowledge. Our preliminary Digital Health Engagement Model (DIEGO) provides a useful checklist for health professionals, health service managers, policy makers, academia, industry and others to consider when implementing digital health in the real world and will be particularly helpful for newcomers to the field. Future research must aim to describe engagement or enrolment strategies in greater detail, including theoretical underpinnings if we are to more effectively study, classify, and learn which approaches are more likely to succeed.
Burden of treatment theory
Consolidated criteria for reporting qualitative research
Digital health engagement model
Enhancing transparency in reporting the synthesis of qualitative research
Interactive voice recognition
Normalization process theory
Personal health records
Randomized controlled trials
Short message service
Template for intervention description and replication
We would to thank Stephen Brewster from Text Mining Solutions Ltd who assisted the research team with the implementation of the search strategy for this systematic review.
We would like to acknowledge Innovate UK (formerly known as the UK Technology Strategy Board) who part funded this work through a research grant. The funder had no part in the design of this review and the views expressed in this paper are those of the authors and not necessarily those of Innovate UK.
Availability of data and materials
The data that supports the findings of this systematic review can be found in main paper and the additional supporting files.
SOC, FM and COD conceptualised the study and designed the review. JG and SG designed the search strategies with input from SOC and FM. SOC and PH conducted the screening, quality assessment, data extraction and analysis with support from FM and COD where necessary. SOC wrote the first draft of the review paper. All authors contributed to the writing of the manuscript and approved the final version of the manuscript.
The authors declare that they have no competing interests
Consent for publication
Ethics approval and consent to participate
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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