Understanding and Promoting Effective Engagement With Digital Behavior Change Interventions

This paper is one in a series developed through a process of expert consensus to provide an overview of questions of current importance in research into engagement with digital behavior change interventions, identifying guidance based on research to date and priority topics for future research. The first part of this paper critically reflects on current approaches to conceptualizing and measuring engagement. Next, issues relevant to promoting effective engagement are discussed, including how best to tailor to individual needs and combine digital and human support. A key conclusion with regard to conceptualizing engagement is that it is important to understand the relationship between engagement with the digital intervention and the desired behavior change. This paper argues that it may be more valuable to establish and promote “effective engagement,” rather than simply more engagement, with “effective engagement” defined empirically as sufficient engagement with the intervention to achieve intended outcomes. Appraisal of the value and limitations of methods of assessing different aspects of engagement highlights the need to identify valid and efficient combinations of measures to develop and test multidimensional models of engagement. The final section of the paper reflects on how interventions can be designed to fit the user and their specific needs and context. Despite many unresolved questions posed by novel and rapidly changing technologies, there is widespread consensus that successful intervention design demands a user-centered and iterative approach to development, using mixed methods and in-depth qualitative research to progressively refine the intervention to meet user requirements.

Introduction

Engagement with health interventions is a precondition for effectiveness; this is a particular concern for digital behavior change interventions (DBCIs), that is, interventions that employ digital technologies such as the Internet, telephones, and mobile and environmental sensors.¹ Maintaining engagement can be especially difficult when DBCIs are used without human support, typically leading to high levels of dropout and “non-usage attrition,”2, 3 whereby participants do not sustain engagement with the intervention technologies. This paper discusses current approaches to conceptualizing and measuring engagement, and considers key issues relevant to promoting effective engagement.

This paper is one in a series developed through a process of expert consensus to provide an overview of questions of current importance in research into engagement with DBCIs, and to identify outstanding conceptual and methodologic issues.¹ An international steering committee invited established and emerging experts to form a writing group to contribute to this process. The scope, focus, and conclusions were formulated initially by the committee and writing group, and then further discussed and modified with input from 42 experts contributing to a multidisciplinary international workshop. As such, the paper is necessarily selective and does not exhaustively review the relevant literature or propose particular models or solutions, but provides a critical reflection on the state of the art. The insights gained from this process are summarized in the concluding table as guidance based on research to date and priority topics for future research.

Some of the insights into engagement that emerged are specific to DBCIs, which have features that are not shared with other forms of intervention delivery—in particular, the potential to automatically record and respond to how the user is engaging with the intervention. However, many of the challenges confronting DBCI use are shared with other types of intervention—for example, the need for users to engage with the behavior change. Consequently, the unique potential of DBCIs to record engagement and behavior in detail over time is likely to generate important new insights that have relevance to engagement with other behavior change interventions.