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Digital interventions are effective for health behavior change, as they enable the self-management of chronic, noncommunicable diseases (NCDs). However, they often fail to facilitate the specific or current needs and preferences of the individual. A proposed alternative is a digital platform that hosts a suite of discrete, already existing digital health interventions. A platform architecture would allow users to explore a range of evidence-based solutions over time to optimize their self-management and health behavior change.
This review aims to identify digital platform-like interventions and examine their potential for supporting self-management of NCDs and health behavior change.
A literature search was conducted in January 2020 using EBSCOhost, PubMed, Scopus, and EMBASE. No digital platforms were identified, so criteria were broadened to include digital platform-like interventions. Eligible platform-like interventions offered a suite of discrete, evidence-based health behavior change features to optimize self-management of NCDs in an adult population and provided digitally supported guidance for the user toward the features best suited to their needs and preferences. Data collected on interventions were guided by the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile Health Applications and Online Telehealth) checklist, including evaluation data on effectiveness and process outcomes. The quality of the included literature was assessed using the Mixed Methods Appraisal Tool.
A total of 7 studies were included for review. Targeted NCDs included cardiovascular diseases (CVD; n=3), diabetes (n=3), and chronic obstructive pulmonary disease (n=1). The mean adherence (based on the number of follow-up responders) was 69% (SD 20%). Of the 7 studies, 4 with the highest adherence rates (80%) were also guided by behavior change theories and took an iterative, user-centered approach to development, optimizing intervention relevance. All 7 interventions presented algorithm-supported user guidance tools, including electronic decision support, smart features that interact with patterns of use, and behavior change stage-matching tools. Of the 7 studies, 6 assessed changes in behavior. Significant effects in moderate-to-vigorous physical activity were reported, but for no other specific health behaviors. However, positive behavior change was observed in studies that focused on comprehensive behavior change measures, such as self-care and self-management, each of which addresses several key lifestyle risk factors (eg, medication adherence). No significant difference was found for psychosocial outcomes (eg, quality of life). Significant changes in clinical outcomes were predominately related to disease-specific, multifaceted measures such as clinical disease control and cardiovascular risk score.
Iterative, user-centered development of digital platform structures could optimize user engagement with self-management support through existing, evidence-based digital interventions. Offering a palette of interventions with an appropriate degree of guidance has the potential to facilitate disease-specific health behavior change and effective self-management among a myriad of users, conditions, or stages of care.
Noncommunicable diseases (NCDs) are the leading cause of death and disability worldwide [
Secondary prevention in an NCD context usually involves referral to a structured hospital or community-based programs, such as cardiac rehabilitation [
Despite the proven effectiveness of secondary prevention [
Digital health is a contemporary advancement in home-based self-management of NCDs. Widespread internet connectivity to at least 55% of the global population [
A systematic review and meta-analysis of internet-based interventions targeting health behavior change in NCD groups (n=43,236) showed significant improvements in risk-related behavior, such as physical activity (effect size 0.24; 95% CI 0.09-0.38), dietary behavior (effect size 0.20; 95% CI 0.02-0.37), and alcohol consumption (effect size 0.14; 95% CI 0.00-0.27) [
Reviews of communication technologies used to deliver health services and facilitate patient and health care professional interaction [
Collectively, the literature indicates that evidence-based digital health interventions have the potential to discretely impact the self-management of NCDs while also complementing one another. Despite the advantages of these discrete interventions, no single program meets the needs of all users, as self-management of NCDs and user preferences are complex and multifaceted in nature. Discrete digital health solutions could be complimentary when combined for use. The REMOTE-CR program [
The constraints of disparate digital health interventions mean that an undue amount of time is required to seek out interventions offering the content, features, or delivery mode best suited to the current preferences of the individual user. Moreover, when a person’s health status or general lifestyle habits change, seeking practices would have to be repeated, which may reduce the sustainability of a discrete digital program intervention and long-term user adherence [
Therefore, we need flexible and versatile solutions in the digital health space. This requires a shift
We propose a digital platform that would capitalize on existing digital self-management interventions that have been evaluated for effectiveness in a specific context (eg, NCDs) through a comprehensive experimental design [
Existing disparate digital health interventions may offer modest positive effects, but engagement can be varied. Thus, a digital platform could potentially optimize engagement while also lessening the burden of care associated with irrelevant content, user ambivalence, and time-consuming seeking processes. Such an approach not only facilitates personalization but also encourages user autonomy through the self-selection of a combination of program components, which is associated with long-lasting positive effects on disease management and patient empowerment [
A preliminary pilot of this review was conducted in August 2018, but no digital platforms that matched our criteria were identified. Therefore, the focus of this review was extended to include digital
For this review, a digital platform-like intervention was defined as
The aims of this study were to identify digital platform-like interventions for the self-management of NCDs and to examine the potential for digital platform-like interventions to support self-management of NCDs through effectiveness and process outcome measures.
The eligibility criteria are outlined in
Framing the review aims according to an adapted Population, Intervention, Context, Outcome approach.
Factor | Description | ||
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Adults | Aged ≥18 years | |
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Noncommunicable chronic disease | Intervention supported participants in self-management of at least one lifestyle-related, noncommunicable, chronic disease (eg, cardiovascular disease, chronic obstructive pulmonary disease, and type 2 diabetes) | |
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Health behavior | Intervention targeted at least one health behavior (eg, physical activity or diet) | |
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Discrete behavior change components | Offered at least two evidence-based BCa components or features (eg, self-monitoring, goal setting, or feedback) | |
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Digital delivery | Compatible with any modern computing devices (eg, web based or mobile based) | |
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Guidance | Offered a choice between BC components. Provided users with a digitally assisted guidance tool to assist with feature selection. | |
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Secondary prevention and self-management | Primarily facilitating outpatient, home-based stages of NCDb care. Focus on participants’ own self-management of NCD. | |
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Intervention description | Mode of delivery, participant information, comparators, intervention features and components, theoretical frameworks or tools, development processes. | |
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Effectiveness | Significant improvements in health behavior, clinical outcomes, or evidence-based psychosocial outcomes. | |
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Process | Intervention use (log-in data), adherence (completion of follow-up data collection), and user satisfaction (quantitative or qualitative follow-up). |
aBC: behavior change.
bNCD: noncommunicable disease.
A systematic literature search of 9 electronic databases was conducted in January 2020: EBSCOhost (Academic Search Complete, Applied Science & Technology Source, Cumulative Index to Nursing and Allied Health Literature Complete, Global Health, Health Business Elite, and PsycINFO), PubMed (MEDLINE), Scopus, and EMBASE. Reference lists of included study publications and related conference proceedings were hand searched to identify additional publications that may not have appeared in database searches. Peer-reviewed systematic reviews and meta-analyses, in which the included studies were cited, were explored to identify any similar studies that did not appear in database searches.
Individual search strategies were developed for each database (example shown in
All results were exported to a reference manager (EndNote X9, Clarivate Analytics), where duplicates were removed before screening for eligibility. Search results have been reported using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement [
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart.
Methodological quality of the included literature was assessed using the Mixed Methods Appraisal Tool (MMAT; version 18) [
Data were extracted from the publications using a specifically designed MMAT tool. Publications were not excluded based on quality assessment because of little empirical evidence to support this practice [
The quality of each eligible study was rated according to 7 quality criteria. To determine the overall quality score for each study, the number of criteria met was divided by the total number of criteria (7) and expressed as a percentage. It is discouraged to simply calculate an overall score [
The extraction of intervention data was guided by the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile Health Applications and Online TeleHealth) checklist [
According to highly regarded reports on monitoring and evaluation frameworks for digital health interventions [
For this review, impact measures for effectiveness were classified as significant improvements in health behavior, clinical outcomes, or evidence-based psychosocial outcomes. Outcome measures for process evaluations were intervention use [
The combined search strategy identified 1582 records, of which 1568 were identified through electronic database searching and 14 through other sources. Duplicates were removed, and the remaining 507 records were screened for eligibility through titles and abstracts. Full-text was obtained for the 85 remaining records, of which 29 publications outlining 7 digital platform-like interventions met the inclusion criteria (
Overview of included publications (n=29).
Study name | Proposal or protocol (n=7) | Formative evaluation | Summative evaluation | Formative evaluation | |||||||||
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Year | Reference | Needs assess | Iterative development | Trial | Process evaluation | |||||||
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Qualitative (n=4) | Usability or feasibility (n=5) | Pilot or efficacy (n=5) | Effect (n=4) | Mixed methods (n=4) | ||||||
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Year | Reference | Year | Reference | Year | Reference | Year | Reference | Year | Reference | |
Antypas and Wangberg [ |
2012 | [ |
2014a | [ |
—a | — | — | — | 2014b | [ |
— | — | |
Murray et al [ |
2015 | [ |
2018 (Pal) | [ |
2019 (Dack) | [ |
2016 (Hofmann) | [ |
2017 | [ |
2017 (Alkaldi) | [ |
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— | — | — | — | — | — | — | — | — | — | 2018 (Li) | [ |
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— | — | — | — | — | — | — | — | — | — | 2018 (Poduval) | [ |
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Poppe et al [ |
2019a | [ |
2017 | [ |
2018 | [ |
2019b | [ |
— | — | — | — | |
Sakakibara et al [ |
2019 | [ |
— | — | — | — | 2017 | [ |
— | — | — | — | |
Voncken-Brewster et al [ |
2013a | [ |
— | — | 2013b | [ |
2014 | [ |
2015 | [ |
2017 | [ |
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Walsh et al [ |
2017 (Claes) | [ |
2018 | [ |
2019 | [ |
2020 (Claes) | [ |
— | — | — | — | |
Yu et al [ |
2012 | [ |
— | — | 2014a | [ |
— | — | 2014b | [ |
— | — |
aPublication type not applicable to this study
bParent publication for the study.
This review identified 7 diverse digital platform-like interventions [
Of the 7 studies, 4 evaluated the effectiveness of their interventions [
Of the 7 studies, 3 had not evaluated effectiveness at the time of this review [
Parent publications for each study [
The details of the assessment criteria can be found in
The key characteristics of the included interventions are outlined in
All 7 interventions presented algorithm-supported interventions that facilitated user guidance [
Support from a health care professional was described in all 7 interventions: typically, cardiac rehabilitation nurse practitioners, exercise specialists, or a member of the research team. The primary role of health care professionals was to facilitate trial and data collection [
Overview of digital platform-like interventions.
Intervention name | Country | Mode of delivery | Target NCDa | Targeted health behaviors | Intended use | |
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Drupal | Norway | Web based and mobile based | CVDb | Physical activity, medication adherence, diet/nutrition, and smoking cessation | Ad libitum |
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HeLP-Diabetes | England | Web based and mobile based | T2Dc | Physical activity, medication adherence, diet/nutrition, and smoking cessation | Ad libitum |
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My Plan 2.0 | The Netherlands | Web based and mobile based | T2D | Physical activity and sedentary behavior | 1 session per week |
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Healing Circles | Canada | Web based and mobile based | CVD | Multiple, unspecified: related to CVDa | Ad libitum |
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MasterYour Breath | The Netherlands | Web based | Chronic obstructive pulmonary disease | Physical activity, smoking cessation | Ad libitum |
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PATHway | Ireland, Belgium | Web based and sensor based | CVD | Physical activity (primary) and other CVD-related | Ad libitum |
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Diabetes Online Companion | Canada | Web based | T2D | Multiple, unspecified: related to T2D | Ad libitum |
aNCD: noncommunicable disease
bCVD: cardiovascular disease.
cT2D: type 2 diabetes.
Of the 7 interventions, 6 had a clear theoretical basis to support the concept and development, including behavior change theories such as social cognitive theory (SCT) [
Of the 7 studies, 4 conducted an early stage needs assessment before commencing development [
Of the 7 digital interventions, 4 took an iterative development approach [
In contrast, just one of the 7 interventions did not involve participants in the development process [
All 7 digital platform-like interventions were evaluated (
Of the 7 studies, 4 reported on physical activity behavior change [
Change in self-care behavior was the primary outcome for one of the studies that targeted diabetes [
Improvements in self-monitoring behavior were observed in 2 of the 7 interventions [
Smoking cessation [
Disease-specific clinical outcomes were reported in 4 studies at 6 months [
Health-related quality of life, disease-related quality of life [
Log-in data were measured in 6 of the 7 interventions [
Overall, the mean adherence to intervention trials at follow-up was 69% (SD 20%). In 4 of the 7 interventions, approximately 80% of participants successfully completed follow-up data collection at 6 months [
Of the 7 interventions, 6 reported on user satisfaction, which was evaluated through both qualitative and quantitative measures 71,73,78,85,88,94
Of the 7 studies, 4 used semistructured exit interviews to gauge user satisfaction [
Participants commented that they were satisfied with the intervention layout, navigation, and ease of use [
This review is the first of its kind to systematically examine the literature on digital platform-like interventions for the self-management of NCDs and health behavior change. Although no digital platforms were identified, an examination of digital platform-like interventions has contributed knowledge to the conceptualization and potential value of using digital platform architectures to support self-management of NCDs.
A total of 7 digital platform-like interventions were included in the review. Evaluations for effectiveness were disparate, and so a consensus on the overall effect could not be reached. Nevertheless, positive effects were reported for physical activity, disease-specific self-care, and self-monitoring behaviors, which is a promising finding in support of digital platform use for the self-management of NCDs. As a result of the findings mentioned earlier, 3 dominant themes emerged: development, optimizing change, and support and guidance for users.
This review found that comprehensive and systematic development processes were implemented for most platform-like interventions. Iterative, user-centered approaches are highly regarded in the field of digital health research because the proactive engagement of patients can be beneficial in the development of digital interventions [
All 4 of the aforementioned interventions [
The results presented in this review indicate the potential for digital platforms to affect behavior change, such as disease-specific self-care behavior. Significant differences were reported for sustained diabetes self-care behavior between users and nonusers of the Diabetes Online Companion intervention [
The self-care outcome measure covers a range of health behaviors, which address several key lifestyle risk factors (eg, dietary behavior, physical activity, glucose monitoring, and smoking) [
Lifestyle-related risk factors and their corresponding health behaviors are heavily influenced by one another, and thus modifying one health behavior using a digital platform may not necessarily generate sustainable improvements in the self-management of NCDs. For example, smoking behavior has been inversely linked to physical activity behavior, meaning that a lack of engagement with smoking cessation may inhibit physical activity progress [
Focusing on modest overall improvements in health behavior change may produce further consequential effects on sustained NCD self-management. Self-regulatory and self-efficacy theories for promoting self-management suggest that the greatest improvements in self-care of chronic conditions typically occur following some initial success in changing behavior (ie, mastery experience) [
A comprehensive approach could also provide a greater scope for successful self-management throughout the unpredictable health trajectories of NCDs, which are relatively unique to each individual [
The digital platform-like interventions included in this review had good adherence for up to 9 months, which could be attributed to the freedom for users to explore an array of digital features and identify the most relevant components for them as an individual. However, given that a digital platform would provide access to an extensive choice of discrete digital health interventions, it is important to note that the intention is not to overburden users [
Research indicates that using all available components is not necessarily more effective [
In view of this, our review has recognized the potential of applying existing theories and knowledge to create efficient, cost-effective automated guidance for users to make informed choices about their engagement. The digitally supported guidance offered to participants within the 7 interventions provided them with a supported pathway to choose behavior change components. This is in line with behavioral research that indicates that actively engaging participants in decision-making pathways for care can improve health outcomes [
One reason that people value human support is a sense of accountability [
The comprehensive development of these evidence-based, automated guiding decision pathways is another way to incorporate
In summary, the adaptive nature of a digital platform accommodates the requirement for flexibility in self-management support, which could facilitate a diverse range of users and life circumstances [
This review was prospectively registered, used comprehensive search strategies across multiple databases, and reported according to PRISMA. Searches and publication of results have been conducted in an up-to-date and timely fashion. The inclusive nature of this review accommodated a broad range of NCDs, which enhances the generalizability of the findings among a wider population.
This review was not without limitations. The novel concept of a digital platform was introduced for the first time, which made it difficult to identify relevant literature. Having broadened the inclusion criterion, discrepancies in terminologies could still have led to key studies being omitted from this literature search or the misinterpretation of intervention content. Current research is focused on the development of a comprehensive eHealth taxonomy, but this is not yet wide ranging enough [
Another limitation was that none of the interventions included in this review were readily available on the web to the reviewer, none provided a digital preservation URL, and intervention descriptions were not always sufficient to identify key features. There has been a call for improved reporting of digital health interventions to improve examination and evaluation of intervention characteristics. This limitation is an important reminder that future developments should use reputable reporting frameworks and guidelines to outline their work [
We have identified a gap in the research on comprehensive and flexible digital health for the self-management of NCDs. Thus, we proposed the contemporary concept of a digital platform, which supports the innovative use of already existing digital interventions for health behavior change. Initial searches indicated that no such digital platforms currently exist, which may indicate a missed opportunity to optimize user engagement with already developed, evidence-based digital interventions. In response, this review focused on digital platform-like interventions to provide an understanding of the development and contextual considerations required to optimally construct a digital platform.
Iterative, user-centered development may be associated with improved adherence and sustained use. Offering a palette of evidence-based interventions with an appropriate degree of guidance has the potential to facilitate disease-specific health behavior change and effective self-management among a myriad of users, conditions, or stages of care. This review and the novel concept of digital platform-like interventions contribute new knowledge to the rhetoric of digital health for the self-management of NCDs.
Search strategy for EbscoHost.
Star Rating Quality scoring of included studies. Mixed Methods Appraisal Tool (MMAT)-Version 2018.
Overview of summative evaluations.
Consolidated Standards of Reporting Trials of Electronic and Mobile Health Applications and Online Telehealth
chronic obstructive pulmonary disease
cardiovascular disease
Health Action Process Approach
glycated hemoglobin
metabolic equivalents of task-minutes
Mixed Methods Appraisal Tool
moderate-to-vigorous physical activity
noncommunicable disease
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
social cognitive theory
transtheoretical model
This work was funded by the Institute for Physical Activity and Nutrition and the Deakin University Postgraduate Research Scholarship fund.
ST contributed to the study design, acquisition, and analysis of data as well as leading the writing of the manuscript. RM was involved in the conceptualization of the study. ST and JR independently screened literature, with RM and KB resolving discrepancies. RM, JR, KB, LK, and FK each reviewed and provided significant feedback on the manuscript. All authors have read and approved the final version of the manuscript.
None declared.