Exploring eHealth Implementation: Understanding Factors Affecting Engagement and Enrolment in Consumer Digital Health

Student thesis: Doctoral ThesisDoctor of Philosophy


At the dawn of the 21st century, ageing populations combined with rising numbers of people with chronic conditions are placing burdens on patients, carers, professionals, and health systems worldwide. Digital health interventions (DHIs) such as mobile, online, wearable and sensor technologies are being used to promote healthy lifestyles and encourage self-management of disease in an effort to address some of these global health challenges. However, these kinds of electronic tools can be difficult to implement. Engaging patients, the public and health professionals in digital health and getting them signed up to these technologies can be challenging in real-world settings.

The primary aim of this thesis is to examine the barriers and facilitators affecting engagement and enrolment in consumer digital health interventions. It examines these complex processes from the perspective of three key stakeholder groups: 1) patients and the public; 2) health professionals; and 3) those implementing the technologies. The secondary aim is to identify the strategies used to engage and enrol individuals in consumer DHIs.

An exploratory, multi-method qualitative study design was adopted. This included a qualitative systematic review and collection and analysis of primary and secondary qualitative data, gathered as part of a large (£37 million) digital health innovation programme called Delivering Assisted Living Lifestyles at Scale (dallas). The dallas programme deployed a wide range of digital health products and services in the United Kingdom ranging from telehealth and telecare systems through to mobile health applications, personal electronic medical records, and online health and wellbeing portals. These were deployed among patients with chronic illness and healthy people providing an ideal opportunity to study engagement and enrolment in DHIs. The systematic review explored the experiences of patients and the public when engaging with or signing up to DHIs. Primary data collection during the dallas programme consisted of fourteen interviews and five focus groups with patients, carers, clinicians, and those implementing the various technologies. Secondary analysis was undertaken of forty-seven baseline, midpoint, and endpoint interviews with stakeholders implementing the DHIs during the dallas programme. All analyses followed the framework approach to identify key themes and subthemes. This was underpinned by Normalization Process Theory (NPT) to synthesise the findings and develop a conceptual model of digital health engagement and enrolment.

A wide range of factors affected engagement and enrolment in DHIs for the three stakeholder groups. Where patients or the public were concerned, four themes emerged from the systematic review. These were; 1) personal agency and motivation, 2) personal lifestyle and values, 3) engagement and enrolment approach, and 4) quality of the DHI. A preliminary Digital Health Engagement Model (DIEGO) was developed along with an initial catalogue of engagement and enrolment strategies. The results of the dallas programme expanded on the barriers and facilitators influencing patient and public engagement and enrolment in digital health. The main themes that arose were; 1) personal perceptions and agency, 2) personal lifestyle and values, 3) digital accessibility, 4) implementation strategy, and 5) quality of the DHI. For health professionals, three overarching themes came to light; health professional role, health service organisation and culture, and digital infrastructure. Those implementing digital health products and services were slightly different as two main themes, each of which has several subthemes, appeared to affect engagement and enrolment in DHIs. These were organisation of engagement and enrolment, and implementation strategy. Hence, the conceptual model highlighting key issues affecting patient and public engagement and enrolling in DHIs was refined and developed further based on the findings from the dallas programme. In addition, the initial catalogue of engagement and enrolment strategies was extended.

This thesis provides new insights into the digital health implementation process, in particular the early phases of engagement and enrolment. A preliminary conceptual framework of digital health engagement and enrolment, the DIEGO model, was developed which summarises key issues that need to be considered during the earliest stages of implementing digital health products and services. This new framework could help researchers, clinicians, businesses, and policy makers appreciate the dynamics of deploying digital interventions in healthcare. This work suggests that educating patients, the public, and health professionals about the benefits, risks, and limitations of health technology is needed, while supporting research that describes engagement and enrolment strategies for consumer digital health and examines their effectiveness. Implementation teams could benefit from building strategic partnerships with marketing specialists and third sector agencies, and having clear business plans and budgets to enhance the reach and impact of engagement and enrolment in digital health. A positive digital health culture also needs to be cultivated in the health service, with leaders that champion the appropriate use of technology. National policies and funding that supports health informatics education, digital literacy for citizens, and digital infrastructure may also be necessary to enable people to sign up for DHIs. These recommendations may help support implementation and improve uptake to digital health products and services in the future.
Date of Award2020
Original languageEnglish
Awarding Institution
  • University of Glasgow

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