JMIR Publications

ABSTRACT

Background:

Digital health interventions (DHIs) harness technological innovation to address challenges in accessibility and scalability of healthcare. However, the effectiveness of DHIs is challenged by low user engagement and adherence, as users tend to drop out over time. The Supportive Accountability Model (SAM) is a theoretical framework designed to enhance adherence to digital health interventions (DHIs) through the incorporation of structured human support.

Objective:

Guided by SAM, this scoping review answers the following research questions: (1) What is the extent of research on human support factors and their influence on engagement with and adherence to DHIs? (2) What is the extent of research applying SAM (i.e., accountability, bond, and legitimacy) to improve engagement with and adherence to DHIs?

Methods:

Our search strategy followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). We conducted our literature search using six databases, selected based on relevance to our research topic. Handsearching was utilized to identify relevant articles that may not have been captured by our database search terms and results. The first two authors (INTIALS MASKED) reviewed the articles over several rounds of review, eliminating articles based on our inclusion and exclusion criteria, as well as relevance to the guiding research questions. The final sample consisted of 36 empirical, peer-reviewed articles published in scholarly journals. All articles examined human-supported DHIs.

Results:

Implementation of human support among the interventions varied by the source of the support (i.e., who is providing the support?), delivery of the support (i.e., how do human supports contact the participants?), and frequency and duration of support (i.e., how often and how long is each contact?). Overall, there were inconsistencies in the application of SAM to intervention designs. Some studies used human support as the mode of intervention delivery rather than as an adjunctive tool focusing on improving engagement and adherence, as proposed by SAM. Aside from accountability, there was also a lack of explicit focus on other constructs within the model (e.g., bond and legitimacy).

Conclusions:

This scoping review helps us better understand current uses of human support in DHI adherence, as well as provides insight into the processes underlying mixed findings among human-supported DHI studies. We identify future research opportunities to optimize the DHI engagement: First, in early stages of intervention design, researchers may adapt SAM more accurately by thoroughly addressing each factor theorized to contribute to adherence, rather than solely emphasizing accountability. Additionally, researchers who wish to apply SAM to intervention design must ensure that human support is incorporated as an adjunctive tool. These recommendations may allow the field to fully leverage the promise of technology to improve healthcare outcomes, access, and scalability.