JMIR Publications

ABSTRACT

Background:

Lifestyle modification via digital self-management is crucial for MASLD treatment but faces the challenge of high attrition. Understanding attrition requires examining both retention (dropout) and adherence (usage quality), which are often evaluated in isolation. This study employs a mixed methods approach to integrate quantitative retention data with qualitative adherence patterns, aiming to uncover the multifaceted determinants of engagement and inform more effective, patient-centered digital interventions.

Objective:

To integrate quantitative retention metrics with qualitative adherence insights to evaluate the attrition of digital MASLD self-management interventions.

Methods:

Following PRISMA guidelines, we searched five databases (PubMed, Web of Science, Embase, Cochrane and CINHAL) from June 2015 to June 2025. The Mixed Methods Appraisal Tool (MMAT) was used for quality assessment. Adopting a convergent segregated design, we analyzed data streams independently. Quantitative retention data were synthesized using a random-effects meta-analysis to estimate pooled rates, with mixed-effects meta-regression employed to explore moderators. Qualitative adherence data underwent inductive thematic synthesis to identify engagement determinants. Finally, findings were integrated narratively to interpret the distinct facets of attrition.

Results:

The quantitative analysis revealed a moderate mean retention rate of 79% across included studies. Subgroup analysis indicated that interventions with high interactivity significantly improved retention, whereas low-interactivity methods showed no significant effect. Due to substantial data heterogeneity, adherence was evaluated through narrative synthesis. Thematic analysis identified four key determinants influencing adherence: factors related to digital forms, detailed intervention measures, end-user characteristics, and the maintenance of motivation.

Conclusions:

Digital self-management interventions hold promise for improving retention in MASLD care, though effectiveness relies heavily on delivery modality. Interactive formats appear superior to text messaging. Findings emphasize that interventions must go beyond technological solutions to address patient needs and behavioral support. Future research should prioritize developing standardized attrition measures and evaluating strategies to sustain long-term engagement. Clinical Trial: PROSPERO registration: (CRD420251068217).