The number of eHealth applications has increased exponentially over the last years. In general, eHealth can be defined as “the use of technologies to improve health, well-being, and healthcare” [1]. Nonetheless, the implementation of eHealth technology remains challenging and often cannot be sustained over time [2-4]. The use of eHealth is more challenging for people with intellectual disabilities (IDs) compared with the general population, as the technologies often do not fit the complex needs and living circumstances of people with IDs [5,6]. In the rapidly changing digital environment, people with IDs often need support when using eHealth because they experience difficulties in acquiring digital literacy skills and using digital devices or the internet [7-9]. These difficulties show the translational gap that exists between the developed technology and these users’ needs and capabilities, although there are approaches available to overcome this mismatch [10-12], for example, by involving users in the development and implementation processes of the technology. However, more knowledge is needed on these inclusive eHealth trajectories. Therefore, this scoping review examined how inclusive approaches have been used in the design, development, and implementation of eHealth for people with IDs.

IDs can be defined as considerable limitations in both intellectual functioning and adaptive behavior as expressed in conceptual, social, and practical adaptive skills [13]. People with IDs have heterogeneous needs for health and support and are strongly dependent on their social environment for access to, and use of, eHealth [3]. This dependency also causes struggles in communication, personal care, traveling, and living [14]. Reviews by Burke [15] and Vázquez et al [16] showed that eHealth has the potential to increase the level of independence of people with IDs and to support their higher demand for personalized care [15,16]. However, technological innovations are often too complex for people with IDs to use independently [10,11]. One explanation is that eHealth is often developed and implemented without the involvement of key stakeholders, such as people with IDs and their caregivers and care provider organizations that use the eHealth applications [1,17]. Including these stakeholders in the development and implementation of eHealth ensures that eHealth is adjusted to their living environment and needs for health and support, thereby increasing the sustainability of eHealth use over time [1,18,19]. This can be achieved by applying inclusive research and design and giving end users and key stakeholders an active role as experiential experts, co-designers, or coresearchers throughout the process [20-22].

Several approaches can be applied to technology design, development, and implementation. For example, design thinking is used to explore the context of complex problems and generate solutions in an iterative process by keeping the users’ needs central [23]. Universal design aims to maximize usability by individuals with a wide variety of characteristics by applying 7 principles (eg, equitable use, flexibility in use, and perceptible information) [24]. Another example is the Consolidated Framework for Implementation Research, which has been developed to guide the systematic assessment of implementation, formative evaluations, and the identification of factors that might influence intervention implementation [25,26]. Although these approaches are widely used in practice, they do not focus specifically on health care–related technologies [26,27]. Frameworks that focus on such technologies (eg, the Health Technology Assessment–inspired Model for Assessment of Telemedicine applications and the eHealth value model) [28,29] provide evaluation tools to assess the value and effectiveness of health care technologies but only marginally give practical guidance on inclusive design, development, and implementation.

The Centre for eHealth Research and Disease management (CeHRes) road map is an example of this and is based on existing evidence-based models, frameworks, and methods such as participatory development and business modeling. This road map can be used to guide the development, implementation, and evaluation of eHealth technologies [1,17]. Another example is the Nonadoption, Abandonment, and challenges to the Scale-up, Spread, and Sustainability (NASSS) framework, which reviews the implementation of health care technology in multiple domains (eg, technology, value proposition, adopters, and organization) [30]. According to the NASSS framework, the development of technology is a never-ending process in which the technology can be adjusted to fit each specific setting and context [31]. The NASSS framework has been widely applied in eHealth research and extended with the practical NASSS-Complexity Assessment Tool (NASSS-CAT) [32-35]. Both the CeHRes road map and the NASSS framework assess eHealth technology in which iterative processes play a central role in the design, development, and implementation while involving end users and other key stakeholders [1,30].

The term eHealth is broad and has various definitions [36]. For example, Oh et al [36] described it as “characterizing not only a technical development, but also a state of mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology,” whereas Eysenbach [37] described it “as the cost-effective and secure use of information and communications technologies in support of health and health-related fields, including health care services, health surveillance, health literature, and health education, knowledge, and research.” In this study, we specified the general definition to the context of people with IDs who often live within health care organizations or assisted living facilities [1]. Therefore, we did not focus on technologies with an educational purpose without health, well-being, or health care–related content or medical technologies such as hospital equipment and implanted devices.

In this scoping review, we aimed to identify the inclusive approaches that were used for the design, development, and implementation of eHealth for people with IDs. In addition, we reviewed how and in what phases people with IDs and other stakeholders were included in the process. We used components identified from the CeHRes road map and NASSS framework to examine the current literature on eHealth design, development, and implementation processes.

We used the scoping review methodology that is proposed by Levac et al [38] and is based on the framework developed by Arksey and O’Malley [39] to guide the review process. This methodology consists of five stages: (1) identifying the research questions; (2) identifying relevant studies; (3) selecting relevant studies; (4) charting the data; and (5) collating, summarizing, and reporting the results [38].

The objective was divided into four subquestions: (1) What theories or frameworks are used in the design, development, and implementation of eHealth for people with ID? (2) Who is involved in the process of eHealth design, development, and implementation for people with ID? (3) In what phases and activities of eHealth design, development, and implementation are people with ID and stakeholders involved? and (4) What components from the CeHRes road map and the NASSS framework can be identified in the design, development, and implementation of eHealth for people with ID?

A search string was developed with assistance from an information expert, using the Population, Intervention, Comparison, and Outcome approach [40]. The following 7 databases were searched: PubMed, Embase, PsycINFO, CINAHL, Cochrane, Web of Science, and Google Scholar. Multimedia Appendix 1 [1,13,41-43] shows the full search strings used for PubMed, consisting of blocks with terms describing “intellectual disability” [AND] “eHealth” [AND] “design” [OR] “development” [OR] “implementation,” which was then adopted for each subsequent database. The terms design, development, and implementation were connected by [OR] to search for a combination of the phases in which the process was described or the studies that described them separately. Gray literature, peer-reviewed reports, and non–peer-reviewed reports, such as Dutch unpublished documentation, were included by contacting 2 intermediate organizations that share the knowledge of producers with knowledge users and 7 care organizations for people with IDs via email for (unpublished) literature. The websites of relevant (health care) organizations were also examined for documentation. Additional articles were identified by manually searching the reference lists of the included articles, including searching for previous or follow-up articles of the included articles.

The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) [44] guided the selection process (Table 1). The search included literature published between January 1995, when the internet is first introduced in health care [35], and January 2022. Studies were included if at least 1 of the 3 process descriptions (ie, design, development, or implementation) was present in the article. Both title and abstract and full-text screenings were performed by 1 researcher (JFEC). If the inclusion of a title and abstract was unclear, it was included in the full-text screening and reviewed by another independent reviewer (KEB) in 3 eligibility stages.

First, the following key information was extracted from each paper: authors, title, year of publication, origin or country, article type, aim or purpose, study population (target end user population), sample size, methodology, and intervention type (purpose of the eHealth) [1]. Next, the theories, frameworks, and approaches used in the design, development, and implementation were extracted. Moreover, the people involved and how and in what phases or activities they were involved were reviewed. The extraction of the design, development, and implementation processes was guided by 9 domains identified from the CeHRes road map and NASSS framework, as described in the following paragraph.

The CeHRes road map describes clear development activities and combines participatory development, human-centered design, business modeling, and persuasive design in 5 intertwined phases and connecting cycles (formative evaluations): contextual inquiry, value specification, design, operationalization, and summative evaluation [1]. The NASSS framework studies the complexity of 7 domains: the condition (ie, the nature of the condition, sociocultural factors, and comorbidities); technology; value proposition; adopters; organization; wider system; and embedding and adaptation over time [30]. The NASSS framework emphasizes that the technology needs to fit each specific setting and context and shows important preconditions for implementation. After combining the phases from the CeHRes road map and the domains from the NASSS framework, the following nine main domains with their corresponding components were defined for this study:

Multimedia Appendix 2 shows a table with the 9 domains and their corresponding descriptions used for data extraction. The data extraction chart table was created iteratively based on feedback from the authors and a sounding board consisting of coresearchers and eHealth project managers from disability health care organizations. A test analysis was performed on 3 studies by using the first version of the data extraction chart table. The test analysis was used to refine the data extraction chart table. The Results section covers these 9 domains, following the research questions specified in the Identifying Research Questions section.

The identification phase resulted in 10,639 records. There were 1784 duplicates, and these together with 3 studies from before 1995 were removed, leaving 8852 (83.20%) studies. Title and abstract screening was performed using the inclusion and exclusion criteria (Table 1). In the screening phase, the main reasons for exclusion were that the target group did not fit our criteria and that the technology did not match the definition of eHealth used in this study. The absence of a description of how the eHealth was developed, designed, or implemented (referred to as process description in this study) was the main reason for exclusion in the eligibility phase. Of the 8852 studies, 8778 (99.16%) studies were removed, resulting in 74 (0.84%) studies whose full texts were read by the first author (JFEC) to screen for inclusion. In the event of doubt, the studies were read by another independent reviewer (KEB). After the full-text screening, 15 (20%) of the 74 studies were eligible for inclusion. The same method was applied to the gray literature, in which 2 studies were included, leaving a total of 17 studies included (Figure 1).

An overview of information obtained from the included studies is presented in Table 2. Table 2 shows the distribution of the studies across the continents. Of the 17 studies, most studies (n=10, 59%) were conducted in Europe, 4 (24%) studies were performed in the United States, and the remaining 3 (18%) studies were conducted in Australia. These studies included a variety of topics and purposes of eHealth technologies, such as supporting and training life skills and communication. End users of the eHealth technologies included, for example, adults with intellectual and developmental disabilities and people with IDs and other impairments such as sensory and speech impairments.

We identified 10,639 studies with our search strategy. Of these identified studies, only 17 (0.16%) provided a process description of eHealth design, development, or implementation for people with IDs, and these were analyzed based on the 9 domains. Regarding the first domain, 14 (82%) of the 17 studies [19,46-48,51,55-58,60,62-65] applied participatory development by involving end users and other stakeholders in different phases. For the second domain, 13 (76%) of the 17 studies [19,46-48,51,56,58,60-65] performed an iterative process through continuous evaluations, the use of prototypes, and the retrieval of user requirements. The third domain was reflected in 11 (65%) of the 17 studies [19,46,50,51,56-58,61,62,64,65], which performed a value specification or part of it, such as the description of end users’ characteristics and the identification of other stakeholders besides end users. Similarly, in 7 (41%) of the 17 studies [47,48,55,59,60,62,63], only small parts were written about the fourth domain, value proposition, such as the values retrieved and the origin of these values. In all (17/17, 100%) studies, information on the fifth domain regarding technological development and design was provided, in which the development of prototypes based on requirements and testing of the prototypes was described. Only 1 (6%) of the 17 studies [19] provided information about the sixth and seventh domains concerning the organization and the external context. In total, 7 (41%) of the 17 studies [19,46-48,50,56,65] referred to the eighth domain, implementation, with implementation accounted for from the start and future implementation mentioned. The last and ninth domain, evaluation, was mentioned by 9 (53%) of the 17 studies [46,51,56,57,59-61,63,65] describing uptake and 7 (41%) of the 17 studies [19,48,50,57,58,65] showing impact.

This study was the first to review inclusive approaches used in eHealth design, development, and implementation processes for people with IDs and assessed 9 domains based on the CeHRes road map and the NASSS framework. Our findings showed that the domains participatory development, iterative process, and technological development and design use inclusive approaches that were applied reflectively and iteratively and based on participatory approaches including human- or user-centered design and participatory development. End users were involved primarily early in the process to ascertain their needs and during usability testing, whereas their and other stakeholders’ involvement was mostly lacking in later phases. The domains external context, organizational context, and the financial side of the value proposition were underrepresented in the literature because the focus was predominantly on the individual use of eHealth technologies. However, members of the target group rely on their (social) environment for care and support. Involving these key stakeholders in the ID sector during the design, development, and implementation phases and giving more attention to the underrepresented domains can improve the fit between the technology, end user, and context.

By combining the CeHRes road map and the NASSS framework for technologies within health care, we created a broad perspective regarding the design, development, and implementation processes of eHealth for people with IDs [32,68]. CeHRes road map describes clear development activities and elements, and the NASSS framework shows important preconditions for implementation [17,30]. The 9 identified domains can be used in every iteration to ensure and report stakeholders’ involvement in every domain of the process. Our study demonstrates the applicability of integrated frameworks and their potential to investigate and describe eHealth design, development, and implementation in future studies and supports the use of inclusive approaches in each domain. Reporting the process of inclusive design, development, and implementation along the 9 different domains of our integrated framework facilitates the sharing of experiences and knowledge about inclusive eHealth development and implementation.

The studies using inclusive approaches [19,46-48,51,55-58,​60,62-65] showed that specific problems experienced by people with IDs as end users (eg, difficult language use and usability issues) can be addressed only through a user-centered approach [17]. Notably, the included studies focused mainly on people with IDs as end users, and they often strongly depend on support persons (eg, caregivers) for access to and use of eHealth services. Therefore, future research should investigate the roles of support persons in relation to eHealth solutions and include them in the development and implementation processes [3]. This also raises the question of whether a universal design is a plausible goal. Persons with disabilities, particularly IDs, are a very heterogeneous group in which this goal could be difficult to reach [10]. However, when developing eHealth for people with IDs, it does provide access to a large group of people because elements such as accessibility, usability, cognitive capacity, digital skills, and low literacy are taken into account. In addition, our study showed that inclusive approaches go hand in hand with iterative processes, such as iterative design and RAID. These approaches allowed for improvements to the design by performing continuous evaluations. Iterations were identified mainly in the design and development processes of the included studies. However, by performing these iterations during the implementation, usability issues that emerge after implementation in practice can be addressed [17]. Altogether, the development, implementation, and evaluation overlap and are iterative rather than separate linear phases [69]. It is important to consider this overlap to reduce the misuse and abandonment of technologies and to ensure that important barriers to implementation are not overlooked during development [1]. We suggest that future eHealth trajectories consider at the start whom they need to involve and when to improve the use of, and access to, eHealth by people with IDs [1,18]. By performing iterations together with end users and stakeholders, a good fit between the technology, context, and users can be ensured [1].

This review further indicates that the organization and external context domains are less addressed in the included papers. A possible explanation is that the described technologies focused mainly on the individual use of eHealth applications, with the result that less attention was given to the organization and external context. Themes related to the organizational context (eg, capacity and readiness to innovate and changes in organizational routines) and themes related to the external context (eg, political context and legal issues) can influence implementation at the individual and organizational levels. In line with this, financial values, such as the profitability of technologies, were also addressed marginally. However, these are important preconditions for sustainable implementation and can facilitate the adoption and spread of the technology [30,32].

This scoping review included a broad, comprehensive, and systematic search performed to identify and select both published and unpublished gray literature and peer-reviewed scientific literature. The search strategy did not include studies on the evaluation process of eHealth technology after the implementation phase, although this can provide useful and important information about implications for development and implementation. We suggest that future studies explore other literature, for example, on the evaluation of the effectiveness and feasibility of eHealth for people with IDs, to collect more evidence on the evaluation process of eHealth for people with IDs. Second, the wide variety of terminology presented a challenge for the formulation of the search strategy. The term eHealth is regularly used as an umbrella term with diverse definitions [36] and different focuses, with the term, in a broader sense, characterizing not only a technical development but also a state of mind to improve health care by using information and communication technology [37] and indicating cost-effectiveness and secure use of information and communications technologies [70]. In addition, different terms are used for inclusive approaches in design, development, and implementation processes such as participatory development and design and user-centered design, thereby complicating the identification of inclusiveness in these approaches. We attempted to create a complete picture of the literature and avoid bias as much as possible by applying a wide search strategy (Multimedia Appendix 1) developed with the assistance of an information expert. A more specific mention of inclusiveness in the design, development, and implementation process of eHealth helps to make inclusive eHealth research easier to identify.

This scoping review has demonstrated the applicability of the integrated frameworks—the CeHRes road map and the NASSS framework—and the potential of the 9 identified domains to investigate and describe eHealth design, development, and implementation processes in future studies. Participatory development, an iterative process, and technological development are the primary domains that surfaced. Most studies showed end user involvement and iterations in the design and development phases, whereas only a few studies involved end users and iterative processes during the implementation phase. The external and organizational context domains, the financial side of the value proposition, and the application of inclusive approaches with stakeholders other than the end user received little attention. However, members of this target group specifically rely on their (social) environment for care and support. By paying more attention to these underrepresented domains and including key stakeholders further on in the process, the translational gap that exists between the developed technologies and user needs, capabilities, and context can be reduced. This study is the first step toward creating a better understanding of inclusive eHealth design, development, and implementation processes for people with IDs.