Designing for meaningful engagement with Digital Health Interventions
By Artur Direito, on 20 April 2018
By Kathleen Ryan, PhD student, University College Cork, Ireland
Digital health interventions (DHIs), are health promotion attempts, delivered primarily through the internet (‘eHealth’) and through mobile devices (‘mHealth’). They hold promise in preventing and treating a host of lifestyle diseases, as they can be delivered in a scalable, cost-effective, timely and convenient manner. But they also suffer from the ‘Law of Attrition;’ the observation that, in any digital health trial, a substantial proportion of users drop out before completion or stop using the application.
This is a serious issue, as DHIs cannot live up to their promise and improve health if they are not used. No matter how well-crafted and evidence-based the intervention, active ingredients proven to effect health behaviour change simply cannot work if the technological components that house them are not accessed by participants. As such, lack of adequate engagement with DHIs poses a barrier to evaluating the effectiveness of these interventions.
But why don’t participants engage with these interventions? There can be many reasons. One qualitative study found that those who dropped out of an eHealth intervention reported their low motivation came from frustrating technology, irrelevant and incomprehensible content, prioritisation of other activities and the lack of face-to-face encounters. This speaks to two factors influencing disengagement: 1. Technology-related issues and 2. Person-related (e.g. their beliefs, cognitions and values).
Participants give up their precious time to take part in research. Researchers therefore owe it to participants to design effective interventions that are in line with their values, user-friendly and even enjoyable – placing the least possible burden on participants to achieve a ‘win’ in terms of health behaviour change (cue the concept of ‘effective engagement’– previously thoughtfully discussed on this blog – here and here).
But how can we do this? The first step is to adequately define what engagement is within the domain of each unique study. The second to apply a person-based, reflective design approach and the third is to implement helpful strategies in facilitating engagement.
“Engagement” is broadly defined in the scientific literature and refers to two separate but related phenomena. The first is DHI usagemetrics– the process of quantifying participants’ use of digital components (where more use = more engagement). The second is subjective experience of engagement – something akin to attention, interest and how the person feels and thinks about the intervention (where more attention/ affect / enjoyment = more engagement).
Both aspects of engagement should be explicitly defined, in relation to the specific target behaviour to be changed, the participant’s context, and the DHI technology used.
The design process needs to be reflective, asking- at what point do usage metrics constitute meaningful engagement? What type of experience will the participant have in using the DHI? How might they think or feel? We should aim to make every interaction meaningful. This is in the spirit of person-based approaches that systematically integrate the user in the design process and aim to make DHIs more effective by placing them at the heart of the intervention.
Another step in designing for meaningful engagement is to identify factors and strategies that may apply within the context of the study to help overcome barriers to engagement, e.g. this rapid review of factors that influence engagement in weight management. DHI technology needs to be easy to use with content that is easy to understand. Personalisation strategies can be used to provide content that is personally relevant and meets the specific needs of the user. The use of human contacts can allow for “supportive accountability” via remotely delivered prompts, social support and encouragement. These strategies may help in promoting meaningful and effective engagement.
Ultimately, we can see that fostering participants’ engagement with DHIs- to a meaningful level- can be a challenging but necessary task as we seek to establish the effectiveness and usefulness of DHIs. Considering the promise these interventions hold in terms of promoting health, it is worth investing in and designing them with the concept of meaningful engagement to the fore.
- How might we measure “meaningful engagement”?
- How might we tell if a lack of usage of a DHI technology is a sign of someone disengaging with a DHI or a lesson learned?
- What other strategies can be used to promote “meaningful engagement”?
Kathleen Ryan is a third year PhD student in the School of Applied Psychology, at University College Cork, Ireland. Her PhD work takes a person-based approach to refining eHealth weight loss interventions to make them more personally relevant, engaging and effective. She is supervised by Dr Samantha Dockray and Dr Conor Linehan. Her research is supported by the Irish Research Council.