title: A systematic review of the impact of adherence on the effectiveness of e-therapies.
abstract: BACKGROUND
  As the popularity of e-therapies grows, so too has the body of literature supporting their effectiveness. However, these interventions are often plagued by high attrition rates and varying levels of user adherence. Understanding the role of adherence may be crucial to understanding how program usage influences the effectiveness of e-therapy interventions.
  
  
  OBJECTIVE
  The aim of this study was to systematically review the e-therapy literature to (1) describe the methods used to assess adherence and (2) evaluate the association of adherence with outcome of these interventions.
  
  
  METHODS
  A systematic review of e-therapy interventions was conducted across disease states and behavioral targets. Data were collected on adherence measures, outcomes, and analyses exploring the relationship between adherence measures and outcomes.
  
  
  RESULTS
  Of 69 studies that reported an adherence measure, only 33 (48%) examined the relationship between adherence and outcomes. The number of logins was the most commonly reported measure of adherence, followed by the number of modules completed. The heterogeneity of adherence and outcome measures limited analysis. However, logins appeared to be the measure of adherence most consistently related to outcomes in physical health interventions, while module completion was found to be most related to outcomes in psychological health interventions.
  
  
  CONCLUSIONS
  There is large variation in the reporting of adherence and the association of adherence with outcomes. A lack of agreement about how best to measure adherence is likely to contribute to the variation in findings. Physical and psychological outcomes seem influenced by different types of adherence. A composite measure encompassing time online, activity completion, and active engagements with the intervention may be the best measure of adherence. Further research is required to establish a consensus for measuring adherence and to understand the role of adherence in influencing outcomes.
authors.affiliation: Brain & Mind Research Institute, The University of Sydney, Camperdown, Australia. Liesje.Donkin@sydney.edu.au
authors.forename: Liesje
authors.initials: L
authors.lastname: Donkin
authors.forename: Helen
authors.initials: H
authors.lastname: Christensen
authors.forename: Sharon L
authors.initials: SL
authors.lastname: Naismith
authors.forename: Bruce
authors.initials: B
authors.lastname: Neal
authors.forename: Ian B
authors.initials: IB
authors.lastname: Hickie
authors.forename: Nick
authors.initials: N
authors.lastname: Glozier
mesh_terms: D003194:Computer-Assisted Instruction / Q000706:statistics & numerical data*; D003258:Consumer Behavior / Q000706:statistics & numerical data*; D054626:Consumer Health Information / Q000458:organization & administration*; D019317:Evidence-Based Medicine; D006301:Health Services Needs and Demand / Q000458:organization & administration; D006801:Humans; D033181:Information Dissemination; D020407:Internet / Q000458:organization & administration*; D009862:Online Systems; D013813:Therapy, Computer-Assisted / Q000458:organization & administration*