We conducted a scoping review to explore and synthesize evidence on contemporary DHTs across various chronic diseases and to identify concepts of patient empowerment in relation to DHTs. The methodology of the scoping review was guided by the Joanna Briggs Institute scoping review framework [32] and followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) for reporting (Multimedia Appendix 1) [33]. A protocol was developed and registered on the Open Science Framework prior to commencing the review that outlined the intended approach and method [34], which are summarized below.

The population, concept, and context framework was used to ensure the comprehensive inclusion of relevant papers and the exclusion of irrelevant ones (Textbox 1).

Within each chronic disease group, we focused on the most prevalent ones: cardiovascular diseases (hypertension, coronary artery disease, and heart failure), diabetes mellitus, cancer (lungs, breast, prostate, colon, and rectum), chronic respiratory diseases (asthma and chronic obstructive pulmonary disease), and neurodegenerative diseases (Parkinson and Alzheimer disease). Although representing a heterogeneous patient group, these conditions share similar expectations that patient empowerment will enable them to effectively manage their condition over time [6,7].

Because of the diverse landscape of DHTs, we focused on patient-facing DHTs, as defined by the digital therapeutic alliance [8]. We acknowledge the potential overlap of this classification with features targeting physicians, payers, or health systems. However, this review specifically focuses on technologies with patient-facing features. We further excluded technologies that only supported information exchange without any aspect of patient interaction or behavior such as SMS text messaging, emails, and online health communities.

Database searches included PubMed, Scopus, and Web of Science between January 2013 and December 2023 to capture more recent technologies. We selected these databases for their comprehensive, interdisciplinary coverage of health care and digital health literature relevant to our research on the conceptualization of patient empowerment in the digital health context with limited redundancy. The search was later extended to April 8, 2024, to capture subsequently published papers. Gray literature was not searched.

The search strategy used a combination of search terms related to our underlying concepts (“patient empowerment” and DHTs), and these terms were adapted to fit the syntax of each database (Table S1 in Multimedia Appendix 2) [35-75]. Initially, a preliminary search was done on PubMed to identify relevant text words in the title and abstract as well as any index terms that could serve as alternate search terms. Subsequently, a more detailed search was conducted across all other databases. We manually searched the reference lists of all eligible studies to identify additional studies that met the inclusion criteria. The detailed search strategy used for PubMed, which is the basis for all other database searches, can be found in Table S1 in Multimedia Appendix 2.

The search terms did not include a specific term for chronic diseases due to the diversity of chronic conditions to maintain a broad scope and avoid restricting the search to predefined disease categories. Instead, the eligibility criteria were applied during the screening stage to identify studies relevant to the chronic disease of interest. This approach ensured that our search terms were manageable while minimizing the risk of unintentionally excluding relevant studies due to variations in disease terminology across databases and disciplines.

The paper selection was conducted by the first 2 authors (MF and LB) in 2 phases. In the initial phase, MF checked titles and abstracts to determine the relevance of papers for retrieval of the full text. In the second phase, both MF and LB performed a full-text screening against the inclusion and exclusion criteria in Textbox 1, documenting reasons for exclusion. Any discrepancies between screeners were resolved through discussion and consensus.

A predefined Microsoft Excel form was used to extract relevant information from each paper, including key findings and themes identified by the authors. The analysis aimed to highlight three main aspects: (1) resources in terms of the DHTs and their functional components identified from the description of technologies or digital health intervention in each study; (2) personal, social, and environmental conversion factors perceived by patients that hindered or supported their empowerment; and (3) capabilities related to empowerment inferred by patients in terms of values, enablement, or opportunities facilitated by DHTs. MF performed the data extraction and initial analysis, while IP verified the data extraction and analysis conducted.

Thematic analysis of the extracted data followed Braun and Clarke’s 6-step process [76]. MF initially coded text elements from each paper relating to capabilities based on its explicit meaning and content from the papers. The initial codes from all papers were then grouped together based on their similarities and differences captured in the meaning of the initial codes, forming potential subthemes. These subthemes represent emerging patterns in the data. Due to the persistent overlap between the subthemes, we further grouped them into broader overarching themes through a collaborative process with a multidisciplinary team. The team comprised medical doctors, psychologists, patient experts, social scientists, and health economists. They discussed, revised, and further grouped the initially developed subthemes into distinct, well-defined themes. Through a consensus, the team established the final thematic categories representing capabilities that grouped similar concepts together while ensuring that distinct ideas remained separate. Throughout this process, we relied on existing terminologies around patient empowerment from the patient perspective to develop our themes [13]. A deductive analytic approach was used to identify the functional components of DHTs, and the terminologies were adapted from the UK National Institute for Health and Care Excellence evidence standard framework [77] and digital therapeutic alliance classification framework [8].

The initial search identified 2856 studies containing 1263 duplicates, which were removed, leaving 1593 papers for the title and abstract screening against the inclusion criteria. We retrieved 158 papers for full-text reviews, of which 38 were eligible for the final analysis, with an additional 3 added after reviewing their reference lists. Figure 2 outlines the steps in detail. In addition, a summary of the included studies can be seen in Table S2 in Multimedia Appendix 2.

More than half of the studies were conducted in Europe and North America (35/40, 80%), with a minority in Asia, Middle East, and Oceania (Table 1). Of the studies included, the majority focused on patients with diabetes [35-49], while the others were on patients with cancer [50-57], cardiovascular diseases [58-63,75], chronic obstructive pulmonary disease [64,65], and Parkinson disease [66,67], and the rest were a combination of 2 or more pathologies. Different types of DHTs were used, such as mobile apps [37-39,45,47,51,55,58-61,68,69,75], web-based interventions [35,36,53,56,57,62,70], telemonitoring devices [48,65,71], connected devices, for example, connected to other medical devices like a glucometer or blood pressure monitor that enables 2-way transmission of collected data [46,68], wearable sensors [66], and a combination of 2 or more technologies, for example, wearable sensor, mobile app, and patient portal [40-42,44,52,72].

This review identified 6 functional components of DHTs as resources to achieve patient empowerment. These resources are informing patients, communication, monitoring, behavior change intervention, individualized feedback, and peer support (Table 2).

The review further identified 3 broad categories of conversion factors—personal, social, and environmental—which may be either internal or external to the individual. These categories are summarized as follows.

DHTs as resources enhanced all capabilities, albeit to different extents (Figure 5). This implies the choice of DHT, as a resource depends on the capability we want to enhance. For example, DHTs designed to inform patients about their health and provide monitoring support can enhance patients’ capabilities in both managing health information and engaging in effective self-management. Meanwhile, providing patients with individualized feedback mainly enhances their self-management capability. Very few DHTs as resources in the literature enhanced the emotional and social support capability.

Drawing on key concepts from the capability approach, this study presents a framework that helps us understand empowerment and its process through DHTs from the patient’s perspective. It identified relevant capabilities valued by patients to achieve empowerment, the different functional components that DHTs offer to support empowerment, and the conversion factors that shape how patients achieve these capabilities. This approach frames empowerment as a broader concept enabling patients to lead the lives they value and improve their health and well-being.

Our findings revealed 9 empowering capabilities when using DHTs that were further grouped into 3 core capabilities, namely, emotional and social support, self-management, and health information and knowledge management. These results align with existing conceptualizations or definitions of patient empowerment that encompass knowledge acquisition, development of skills, and motivation [12,78]. However, we found very few DHTs as resources addressing the emotional and social support capability, which highlights the importance of DHTs to address this capability. The value patients placed on emotional and social support is consistent with the conceptualization and operationalization of health capabilities [79] and relates to certain aspects of Nussbaum’s [31] capability lists of what constitutes a good life, such as bodily health, emotions, practical reason, affiliation, and control over one’s environment.

In line with the capability approach, capabilities not only involve expanding patients’ opportunities and freedom but also respecting their freedom not to act when they choose to [29]. We found that some patients chose not to use DHTs despite the opportunities they provided. For example, patients whose symptoms were well controlled or those experiencing anxiety from information overload did not see any value in using DHTs to become empowered [68]. Empowerment, therefore, is not solely about the expansion of one’s choices but also the freedom to reject certain options when they do not align with personal values or needs.

It is worth noting the interconnectedness of different capabilities, as this can aid in understanding how specific functional components of DHTs lead to these capabilities. For example, providing patients with health-related information enhances their understanding of their health condition and supports them to use this knowledge to improve their health (health information and knowledge management). This, in turn, allows patients to become independent, take necessary steps to improve their symptoms, and contribute more actively to the care relationship based on the available information (self-management). Likewise, patients’ abilities to undertake self-care maintenance activities can be linked to the knowledge they have about their condition and the emotional and social support they get, which increases their confidence in undertaking these activities. This dynamic interaction between patients’ capabilities and the opportunities created by the functional components of DHTs shows an alignment between what patients’ value for empowerment and what DHTs offer to achieve this empowerment.

Using the capability approach, we further identified conversion factors that influence the patients’ capabilities to achieve empowerment through DHTs. These represent the facilitating conditions that are both inherent and external to the individual, such as digital literacy, demographic and socioeconomic status, disease severity, sociocultural norms, doctor-patient relationships, and the cost related to acquiring DHTs. Technology-related factors such as perceived value, ease of use, and safety emerged as important conversion factors. If these barriers can be addressed, patients are more likely to value DHTs as a means to foster their empowerment, ultimately enhancing their health and well-being. These findings align with studies that highlight the barriers and facilitators that influence the uptake of DHTs [24,80,81]. Identifying and overcoming these conversion factors are crucial to enable patients to fully harness the potential of DHTs to achieve their empowering capabilities and integrate these technologies into clinical practice [80,82]. This approach sets our framework apart from prior conceptualizations of patient empowerment, which primarily focus on individuals’ abilities without considering the interplay of internal and external factors that shape their abilities to achieve valued health-related goals [12,78,83].

Surprisingly, very few studies assessed clinical characteristics, such as duration or severity of disease, and the presence of comorbidities [42,49] as useful personal conversion factors that could influence the attainment of capabilities. This gap can be attributed to the fact that studies often include healthier patients [62,70], with limited focus on how their disease state can influence the use of technology. For patients with chronic conditions (eg, those with Parkinson disease), knowing how their motor and cognitive impairments influence their capabilities will provide useful insight into how DHTs can be better adapted to meet their needs.

Our study also revealed that regardless of patients’ demographics or chronic conditions, patients seek similar capabilities and encounter similar conversion factors when using DHTs to achieve empowerment. These findings can be explained by the research context, as all patients were experiencing a chronic condition that necessitated the development of abilities needed to gain control of their lives. The need for patients to develop these abilities has been well documented in studies on the self-management of chronic disease [6,7]. Our results also suggested that patient views on empowerment extend beyond their medical care needs and include capabilities that enable them to pursue activities aligned with their life goals, build supportive relationships, and feel safe while participating in daily activities. Our findings align with current research demonstrating that patients develop capabilities not only to manage their health but also to navigate their personal lives [6,84].

The findings from our review align with and extend existing literature on patient empowerment and digital health [78,85,86]. Previous studies have largely focused on the benefit of DHTs on health outcomes or patient engagement, often without exploring the underlying capabilities that facilitate empowerment [3,22,87]. Our review complements these studies, as it adds information on the individual, interpersonal, structural, and technological aspects of empowerment [12,13,84]. Our use of the capability approach contributes to the field by framing empowerment through the opportunities that patients have when using DHTs to achieve broader health and life goals. This study adds value by demonstrating not only what DHTs offer, and the capabilities patients have to become empowered, but also how their impact can be maximized by addressing conversion factors, ultimately contributing to a more nuanced and actionable understanding of patient empowerment when using DHTs.

Our study is the first to apply the capability approach to conceptualize patient empowerment in relation to DHTs. It provides a new theoretical lens that shifts the focus from technology as a mere tool to its role in expanding patients’ substantive freedom and agency in managing their chronic illnesses. By using a theoretical framework, we can capture different empowering capabilities and contribute significantly to the literature on the role of DHTs in fostering empowerment. This is crucial, as the insights gained can directly enhance patient health and management by prioritizing and addressing patient-centered values. This review focused on 5 main chronic conditions; we believe it is broad enough and generalizable to other chronic disease populations with similar needs for empowerment to effectively manage their condition. Another strength of this study is the use of predefined quality criteria to inform our search criteria on different functional components of DHTs. The lack of established methods for reviewing newly developed technologies complicates reviews on DHTs.

Despite the merits of our study, certain limitations must be recognized. First, our search strategy excluded terms associated with patient empowerment in previous research, such as control, patient participation, enablement, or disease-related outcomes. We did not include these terms in our study, since our goal was to learn how patients perceive empowerment, not how researchers, clinicians, or theorists have interpreted it. Including these additional terms would have predetermined which concepts were related to empowerment, potentially shaping our findings based on our own understanding of the term. This exclusion probably resulted in the omission of related papers. However, our study was able to identify some of the disease-related outcomes, like self-efficacy, health literacy, and engagement, as important capabilities for patient empowerment, indicating some alignment with what patients’ value for their well-being.

Another limitation is the absence of a second reviewer at all stages of the review, especially in the qualitative analysis, which could skew our findings based solely on one person’s judgment. To mitigate this bias, we consulted with senior researchers to validate our approach at each step and during the qualitative analysis. Additionally, we followed the best practice guidelines outlined in the PRISMA-ScR checklist to further strengthen our research rigor. The majority of studies were from high-income countries, which represent the needs and states of their health care systems. Additionally, restricting our review to only papers published in English limits our understanding into how digital health interventions and patient empowerment are conceptualized and implemented in different cultural and health care contexts. Consequently, results from this review may not be generalizable to other lower- or middle-income countries and other health care settings.

This research fills an important gap by using concepts from the capability approach to develop a framework that highlights how patient empowerment occurs through DHTs for chronic disease management. It outlined key capabilities, functional components of DHTs, and conversion factors that contribute to patient empowerment. The capability approach is a valuable framework that helps to understand the personal preferences and variability of patients. Our study serves as a valuable resource for researchers, DHT developers, and policy makers by offering guidance on how to assess and tailor digital health interventions to effectively enhance valued opportunities and consider relevant conversion factors needed to achieve patient empowerment. Future research should strive to highlight and distinguish the effect of different functional components of DHTs on respective capabilities and validate this framework in specific health conditions.