Qualitative study identifies specific barriers that impact patient and public uptake of digital health interventions and provide recommendations to break them down.
The miniaturization, diversification, and interconnectedness of everyday technologies have triggered the development and use of digital health interventions (DHIs) for the management of health behaviours and illness. DHIs include technologies like electronic medical records (EHRs), mobile health apps, wearable fitness trackers, patient portals, and social health networks. These interventions have improved access to healthcare and information, partially relieved rising healthcare costs by reducing health service usage long-term through prevention, and imparted self-control to users. However, a general understanding of which barriers and facilitators affect DHI uptake are not clear as studies tend to focus on a specific patient population or a single DHI. To address gaps in research evidence related to DHI enrollment and engagement, a group of researchers sought to review relevant qualitative literature to develop a concept of what needs to be addressed to improve DHI uptake.
Researchers systematically identified and synthesized literature on the barriers and facilitators impacting DHI engagement and recruitment. Common biomedical databases were searched for studies published between 2005-2015 using search keywords like ‘telemedicine’, ‘mobile applications’, ‘social media’ and ‘personal health record’. Two independent reviewers screened 290 articles for inclusion. Data from 19 articles covering DHIs such as patient-accessible EHRs, telehealth services, wearable devices, and smoking cessation/weight loss programs were then extracted and analyzed for the current study.
Four main issues were discovered to affect patient and public engagement in DHI: 1) personal agency and motivation, 2) personal life and values, 3) engagement and recruitment approach, and 4) the quality of the DHI.
1) Personal Agency and Motivation
Most people decided to engage or enroll in DHIs so that they could have more choice and control over behaviours related to health. The technology motivated them to eat healthier and exercise more, allowed them access to health information at any time, and attentively monitor chronic conditions. In contrast, barriers to DHIs included the inability to see the potential or benefit of the technology, as well as the lack of motivation to understand how electronic data could help improve health. Other barriers included the dislike of reminders on failed health goals, the disruptive nature of the technology, and the preference to use non-electronic strategies to monitor health and illness like paper-based systems.
2) Personal Life and Values
A busy personal life or competing priorities often affected the ability of people to engage with or enroll in DHIs. It was discovered that individuals who recognized the value of the DHI, were digitally-savvy, or those who could easily fit it into their lifestyle were the most eager to take it up. Common barriers for deciding not to engage with DHIs were a demanding family life, career, or caregiving pressures, as well as concerns for privacy and security of personal data. Another barrier was digital literacy, where engagement was impeded by a lack of experience in using a computer or mobile device.
3) Engagement and Recruitment Approach
Patients were more likely to take up a DHI if they received personal recommendations from trusted people like family members, friends, or health care professionals. These trusted individuals provided social support and were sources of assistance with enrollment and engagement. Personalization of promotional materials or recruitment strategies also facilitated increased enrollment. Alternatively, not knowing that the technology existed or how it could be used to benefit their health were crucial barriers to enrollment. Unclear promotional materials about the DHI, its benefits, how to sign up, or how to use the technology impeded both its uptake and use. The absence of a clinical endorsement by a physician, health care professional or accredited agency also greatly impacted recruitment.
4) Quality of the Digital Health Intervention
The quality of information and interaction provided via technology was critical to those who signed up and used a DHI. Many believed that the technology facilitated a more open communication channel with their health care provider, and others were linked to supportive social groups that helped them better manage their illness or health goals. On the flip side, the impersonal nature of technology was seen to reduce the quality of care provided by physicians and nurses, where human interaction plays a critical role. The information given through a DHI was also viewed as unreliable as it did not come directly from a ‘real’ heath care professional. In some cases, poor user functionality also reduced engagement and continued use.
This study examined the literature as to how people and patients enrolled and engaged in DHIs. From the results, it is evident that digital health engagement and recruitment is a complex process that requires refinement. The categorization and analysis of barriers and facilitators in this report, however, highlight important areas for improvement. As such, the authors recommend that greater investment is needed to raise the profile of DHIs, as well as increased digital education and accessibility so that the public are more knowledgeable in these matters. They recommend that recruitment and engagement strategies would benefit from improved design and personalization, that appropriate clinical accreditation and endorsement by trusted individuals would enhance DHI uptake, and that DHI quality should be examined to ensure greater usability and access.
Written By: Fiona Wong, PhD