JMIR Publications

ABSTRACT

Background:

In recent years, the (cost-)effectiveness of digital health services for people with musculoskeletal complaints has increasingly been studied and shows potential. Despite the potential of digital health services, its usage in primary care is lagging. Therefore, a thorough implementation is needed, including the development of implementation strategies that potentially improve the usage of digital health services in primary care. The first step in designing implementation strategies which fit the local context, is to gain insight into determinants that influence implementation for patients and healthcare professionals. Up until now, no systematic overview exists of barriers and facilitators influencing the implementation of digital health services for people with musculoskeletal complaints in the primary healthcare setting.

Objective:

The aim of this systematic literature review was to identify barriers and facilitators to the implementation of digital health services for people with musculoskeletal complaints in the primary healthcare setting.

Methods:

PUBMED, EMBASE, and CINAHL were searched for eligible qualitative and mixed-methods studies up to March 2024. Methodological quality of the qualitative component of the included studies was assessed with the Mixed Methods Appraisal Tool. Then, a framework synthesis of barriers and facilitators to implementation was conducted using the Consolidated Framework for Implementation Research (CFIR). Finally, all identified CFIR constructs were given a reliability rating (high, medium or low) to assess the consistency of reporting across each construct.

Results:

Thirty-five studies were included in the qualitative synthesis. Methodological quality was high in thirty-four studies and medium in one study. Barriers (-) and facilitators (+) to implementation were identified in all five CFIR domains: ‘digital health characteristics’ (i.e. commercial neutral (+), privacy and safety (-), Specificity (+) and good usability (+)), ‘outer setting’ (i.e. acceptance by stakeholders (+), lack of healthcare guidelines (-) and external financial incentives (-)), ‘inner setting’ (i.e. change of treatment routines (+/-), information incongruence (-) and support from colleagues (+)), ‘characteristics of the healthcare professionals’ (i.e. healthcare professionals’ acceptance (+/-) and job satisfaction (+/-)), and the ‘implementation process’ (i.e. involvement (+) and justification and delegation (-)). Almost all identified (sub-)constructs of the CFIR had a high reliability rating. Some identified determinants that influence implementation may be a facilitator in certain cases, while in others it may be a barrier.

Conclusions:

Barriers and facilitators were identified across all five CFIR domains. This suggests that the implementation process can be complex and requires implementation strategies across all CFIR domains. Stakeholders, such as digital health intervention developers, healthcare professionals, healthcare organizations, health policy makers, healthcare funders, and researchers, can consider the identified barriers and facilitators to design tailored implementation strategies, after a prioritization has been carried out in their local context.