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Web-based mindfulness programs may be beneficial in improving the well-being outcomes of those living with chronic illnesses. Adherence to programs is a key indicator in improving outcomes; however, with the digitization of programs, it is necessary to enhance engagement and encourage people to return to digital health platforms. More information is needed on how engagement strategies have been used in web-based mindfulness programs to encourage adherence.
The aim of this study is to develop a list of engagement strategies for web-based mindfulness programs and evaluate the impact of engagement strategies on adherence.
A narrative systematic review was conducted across the MEDLINE Complete, CINAHL Complete, APA PsycINFO, and Embase databases and followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Articles were screened using the population, intervention, comparator, and outcome framework. Adults aged >18 years with chronic health conditions were included in the study. Mindfulness interventions, including those in combination with mindfulness-based cognitive therapy, delivered on the web through the internet or smartphone technology were included. Interventions lasted at least 2 weeks. Studies with a randomized controlled trial design or a pilot randomized controlled trial design were included. Engagement strategies, including web-based program features and facilitator-led strategies, adherence, and retention, were included.
A total of 1265 articles were screened, of which 19 were relevant and were included in the review. On average, 70.98% (2258/3181) of the study participants were women with a mean age of 46 (SD 13) years. Most commonly, mindfulness programs were delivered to people living with mental health conditions (8/19, 42%). Of the 19 studies, 8 (42%) used only program features to encourage adherence, 5 (26%) used facilitator-led strategies, and 6 (32%) used a combination of the two. Encouraging program adherence was the most common engagement strategy used, which was used in 77% (10/13) of the facilitator-led studies and 57% (8/14) of the program feature studies. Nearly two-thirds (63%) of the studies provided a definition of adherence, which varied between 50% and 100% completion across studies. The overall mean participant compliance to the mindfulness programs was 56% (SD 15%). Most studies (10/19, 53%) had a long-term follow-up, with the most common follow-up period being 12 weeks after intervention (3/10, 30%). After the intervention, the mean retention was 78% (SD 15%).
Engagement strategies in web-based mindfulness programs comprise reminders to use the program. Other features may be suitable for encouraging adherence to interventions, and a facilitator-led component may result in higher retention. There is variance in the way adherence is measured, and intervention lengths and follow-up periods are inconsistent. More thorough reporting and a standardized framework for measuring adherence are needed to more accurately assess adherence and engagement strategies.
Mindfulness is the act of bringing awareness to the present moment in a nonjudgmental and accepting way [
Evidence shows that mindfulness skills can be improved through greater engagement with meditation, home practice, face-to-face contact with a facilitator, and a higher number of sessions per week [
Mindfulness programs are increasingly being adapted to web-based platforms, providing opportunities for more people to participate compared with conventional face-to-face sessions [
Adherence to web-based programs in previous reports has varied between 39.5% and 92% [
Engagement refers to the frequency and duration of use of the interventions, such as logging in and out of programs [
The influence of engagement strategies on program adherence has not been compared across studies; however, it is an important consideration when designing and implementing web-based interventions. In this review, we explored the engagement strategies applied in web-based mindfulness programs and evaluated whether these strategies had an impact on program adherence and retention.
The following research question was used in the study: how can engagement strategies be incorporated into web-based mindfulness programs to improve adherence and retention?
The objectives of this study are (1) to develop a list of engagement strategies for web-based mindfulness programs and (2) to evaluate the impact of engagement strategies on adherence.
This systematic review was guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) framework [
To guide the eligibility and screening process, the PICO (population, intervention, comparator, and outcome) framework [
Adults aged ≥18 years with a diagnosed chronic health condition or self-reported anxiety or depression were included in the study.
Mindfulness interventions delivered on the web through the internet or smartphone technology were included. Mindfulness programs were defined as those focusing specifically on mindfulness-based practice, including programs using a combination of mindfulness and cognitive behavioral therapy (mindfulness-based cognitive therapy).
To allow for engagement strategies and adherence to be analyzed, the interventions had to be at least 2 weeks in duration. There is limited research to describe how long interventions should be to warrant the inclusion of engagement strategies. Previously, engagement was measured by reflecting on the previous 2 weeks [
Studies were required to have a comparison group with a randomized controlled trial (RCT) or a pilot RCT design.
Mindfulness programs developed by research groups for specific populations or commercially available mindfulness programs were tested in controlled trial settings.
Program adherence, study retention rate (%), and strategies such as web-based program features and facilitator-led features were included.
Retrieved articles were uploaded and managed by Endnote X9 (Clarivate Analytics). Duplicates were removed, and titles and abstracts were screened by 1 author (NH). Full-text articles were uploaded to
A data extraction tool was developed in Microsoft Excel to standardize the extraction. Data were extracted by 1 author (NH), and 10% were cross-checked by the second author (PL).
Study data including author, year of publication, country, design, number of participants, intervention type, intervention duration, follow-up measurements, prior mindfulness experience, recruitment method, financial compensation, commercial app name, primary outcome, and primary findings were extracted.
Gender, age, race, ethnicity, type of chronic illness or condition, and patient and caregiver status were extracted.
Studies were included in the review when they reported per-protocol and intention-to-treat analyses. Because of variance in reporting the intervention, adherence was assessed in 3 different ways depending on the data available:
As a percentage of compliance with the intervention protocol. For example, some authors defined adherence as 80% program completion, and in this review, we recorded the percentage of the sample that was adherent with 80% program completion.
In groups defined by the study authors. For example, in an 8-week program, some authors reported the percentage of people who were adherent with 0- 3 sessions, 4- 6 sessions, and 7-8 sessions. In this review, we recorded the percentage of the sample that was adherent with the highest group of completion, for example, 7-8 sessions.
Summarized findings of the frequency and duration of use.
Retention rates were reported for the intervention group at postintervention measurements and subsequent follow-up points.
Engagement strategies were categorized into following 3 groups:
Program features, including chat rooms, discussion boards, diaries and reflective processes, automated reminders, social support, goal setting, mood tracking, customization of content, demonstrations of meditation practice, and immediate feedback on meditation practice;
Facilitator-led strategies, including reminders from the research team to continue practice, contact with the research team to discuss practice or monitoring, and response to well-being scores throughout the intervention; and
A combination of program features and facilitator-led strategies.
Study characteristics, participant characteristics, adherence, and retention rates were analyzed using descriptive statistics.
Data analysis consists of the following:
Exploring adherence: how adherence was defined, the impact of adherence on outcomes, impact of financial compensation on adherence, and impact of intervention length on adherence.
Describing retention at postintervention measurements and the last data collection point.
Describing engagement strategies (program features, facilitator-led strategies, or a combination): engagement strategies were categorized and summarized using frequency statistics.
Assessing the impact of engagement strategies on adherence: the relationship between engagement strategies and adherence was analyzed by comparing the type of engagement strategy (program features, facilitator-led strategies, or a combination) with the percentage of people who reached program adherence or the percentage of people who adhered with the highest group of sessions (eg, those who completed 7-8 sessions in an 8-week program, as defined by the study authors).
Assessing the impact of engagement strategies on retention: the relationship between engagement strategies and retention was measured by comparing the type of engagement strategy with the intervention length, retention at the postintervention measurement and retention at the last follow-up points.
A total of 1922 articles were retrieved from the databases and reference lists. After removing duplicates, a total of 1265 articles were screened by title and abstract. Full texts were retrieved for 126 articles, of which 19 were included in the review (
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) diagram of the search process.
A total of 8 (47%) studies focused on psychological measures as their primary outcome [
A total of 34,601 participants were included in the trials. The mean sample size was 165 (SD 134; range 21-500). On average, 71% of the participants were women (SD 18; range 46-100) and 46 years old (SD 13; range 21-76). A total of 8 (42%) studies reported the ethnicity of the participants [
A total of 8 (42%) studies used only program features to encourage adherence, 5 (26%) used only facilitator-led strategies, and 6 (32%) used a combination of the two (
Within the facilitator-led strategies (n=13) [
Types of engagement strategies used across studies and their adherence rates.
Study | Program engagement | Facilitator engagement | Adherence with study protocol (%) |
Chandler et al [ |
✓ | ✓ | 39 |
Compen et al [ |
✓ | ✓ | 79 |
Kladnitski et al [ |
✓ | ✓ | 66 |
Kubo et al [ |
✓ | ✓ | 56 |
Stjernsward and Hansson [ |
✓ | ✓ | 57 |
Thompson et al [ |
✓ | ✓ | NRa |
Gotink et al [ |
✓ | N/Ab | 50 |
Hearn and Finlay [ |
✓ | N/A | 72 |
Henriksson et al [ |
✓ | N/A | 58 |
Huberty et al [ |
✓ | N/A | NR |
Moberg et al [ |
✓ | N/A | NR |
Rosen et al [ |
✓ | N/A | NR |
Russell et al [ |
✓ | N/A | NR |
Younge et al [ |
✓ | N/A | 53 |
Bostock et al [ |
N/A | ✓ | 27 |
Lindsay et al [ |
N/A | ✓ | NR |
Tavallaei et al [ |
N/A | ✓ | NR |
Wahbeh et al [ |
N/A | ✓ | NR |
Wahbeh [ |
N/A | ✓ | NR |
aNR: not recorded.
bN/A: not applicable.
Within program feature strategies (n=14) [
Contact initiated by facilitators or program reminders was most commonly delivered by email (9/14, 64%) [
Nearly two-thirds (12/19, 63%) of the studies provided a definition of program adherence [
Among studies that used only program features (n=8) [
When examining studies that used program features, of the studies that used 1 strategy (n=6) [
A total of 10 (53%) studies analyzed the relationship between outcome variables and adherence [
Of the 6 studies that provided any type of compensation, 2 measured adherence with a mean of 42% (SD 15%; range 27-56) [
The impact of the intervention length on adherence was analyzed. Of the 5 studies with an intervention <8 weeks, none recorded adherence. Those with an 8-week intervention recorded an average of 58% (SD 16%) adherence (6/10, 60% of the studies measured adherence) [
Most (10/19, 53%) studies conducted pre-post analysis with additional follow-up points [
Studies that applied only facilitator-led strategies, on average, were 6 weeks in duration (SD 2; range 2-8) and had a retention rate of 93% (SD 10; range 73-100) compared with studies with a combination of program features and facilitator-led strategies with a mean duration of 16 weeks (SD 10; range 8-52) and a retention rate of 75% (SD 5%; range 69-84) and those with only program features with a mean duration of 8 weeks (SD 2; range 4-12) and retention rate of 67% (SD 15%; range 30-79).
Of the studies that used facilitator-led strategies only, 40% (2/5) had follow-up periods after postintervention follow-up [
Studies that used only program reminders as engagement strategies (n=4) [
In this review, we described the engagement strategies applied to web-based mindfulness programs and their impact on adherence rates. The use of program features only was associated with program adherence but not with maintaining study retention. Engagement strategies were largely reminders to use the program and, to a lesser extent, the ability to customize program content, interact with features, or engage with content on a deeper level through reflections, homework activities, and discussions of content with facilitators. There was little difference between the type of engagement strategy used and adherence to programs or retention rates.
The need to accurately report study and program attrition to better understand the associations between program adherence and health outcomes has been established [
Similarly, the ability to measure the impact of engagement strategies on study attrition is limited. The findings suggest that studies using only facilitator-led strategies were favorable for maintaining study retention [
Most studies in this review showed that web-based mindfulness resulted in improvements in either psychological or physiological outcome measures [
Program features applied throughout studies to enhance engagement varied according to the type and number of features available to users. Furthermore, the number and type of features included had similar impacts on program adherence and study retention, suggesting that there may not be one superior feature to be included in programs. Features such as diaries, reminders, and social connectedness are commonly used in interventions as behavior change techniques [
Across studies, there was a large variance in interventions and in reporting adherence. These factors made it difficult to draw any firm conclusions from the data.
The sample of the included studies was predominately White and female, which limits the generalizability of these findings to other population groups.
This review aims to describe the influence of engagement strategies on adherence and retention among people living with chronic illnesses or conditions. Other studies measuring adherence to mindfulness in the general population may have provided additional information on the impact of engagement strategies. However, there is a need to evaluate engagement and adherence to web-based interventions, specifically in people living with chronic illness. People with chronic illness may be more likely to experience depression and anxiety symptoms than those without a chronic illness [
Furthermore, the primary outcome of the review was to assess adherence, retention, and engagement strategies rather than to draw conclusions about the effectiveness of interventions on patient outcomes. As a result, the risk of bias assessment was less relevant.
Engagement strategies in web-based mindfulness programs largely comprise reminders to use the program. The impact of other features such as personalization, self-reflection activities, and lesson summaries on adherence requires further investigation. There is variance in the way adherence is measured, and intervention lengths and follow-up periods are inconsistent. More thorough reporting and a standardized framework for measuring adherence are needed to more accurately assess adherence and engagement strategies.
Study demographics, examples of search strategy, and adherence, retention, and engagement strategies and outcomes.
randomized controlled trial
None declared.