title: The Effectiveness of Prompts to Promote Engagement With Digital Interventions: A Systematic Review.
abstract: BACKGROUND
  Digital interventions have been effective in improving numerous health outcomes and health behaviors; furthermore, they are increasingly being used in different health care areas, including self-management of long-term conditions, mental health, and health promotion. The full potential of digital interventions is hindered by a lack of user engagement. There is an urgent need to develop effective strategies that can promote users' engagement with digital interventions. One potential method is the use of technology-based reminders or prompts.
  
  
  OBJECTIVE
  To evaluate the effectiveness of technology-based strategies for promoting engagement with digital interventions.
  
  
  METHODS
  Cochrane Collaboration guidelines on systematic review methodology were followed. The search strategy was executed across 7 electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Web of Science, the Education Resources Information Center (ERIC), PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Databases were searched from inception to September 13, 2013, with no language or publication type restrictions, using three concepts: randomized controlled trials, digital interventions, and engagement. Gray literature and reference lists of included studies were also searched. Titles and abstracts were independently screened by 2 authors, then the full texts of potentially eligible papers were obtained and double-screened. Data from eligible papers were extracted by one author and checked for accuracy by another author. Bias was assessed using the Cochrane risk of bias assessment tool. Narrative synthesis was performed on all included studies and, where appropriate, data were pooled using meta-analysis. All findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
  
  
  RESULTS
  A total of 14 studies were included in the review with 8774 participants. Of the 14 studies, 9 had sufficient data to be included in the meta-analyses. The meta-analyses suggested that technology-based strategies can potentially promote engagement compared to no strategy for dichotomous outcomes (relative risk [RR] 1.27, 95% CI 1.01-1.60, I(2)=71%), but due to considerable heterogeneity and the small sample sizes in most studies, this result should be treated with caution. No studies reported adverse or economic outcomes. Only one study with a small sample size compared different characteristics; the study found that strategies promoting new digital intervention content and those sent to users shortly after they started using the digital intervention were more likely to engage users.
  
  
  CONCLUSIONS
  Overall, studies reported borderline positive effects of technology-based strategies on engagement compared to no strategy. However, the results have to be interpreted with caution. More research is needed to replicate findings and understand which characteristics of the strategies are effective in promoting engagement and how cost-effective they are.
authors.affiliation: eHealth Unit, Research Department of Primary Care and Population Health, University College London, London, United Kingdom. Ghadah.alkhaldi.12@ucl.ac.uk.
authors.forename: Ghadah
authors.identifier: http://orcid.org/0000-0001-9041-4546
authors.initials: G
authors.lastname: Alkhaldi
authors.forename: Fiona L
authors.identifier: http://orcid.org/0000-0002-3126-5074
authors.initials: FL
authors.lastname: Hamilton
authors.forename: Rosa
authors.identifier: http://orcid.org/0000-0003-0625-2228
authors.initials: R
authors.lastname: Lau
authors.forename: Rosie
authors.identifier: http://orcid.org/0000-0002-3946-5783
authors.initials: R
authors.lastname: Webster
authors.forename: Susan
authors.identifier: http://orcid.org/0000-0003-0063-6378
authors.initials: S
authors.lastname: Michie
authors.forename: Elizabeth
authors.identifier: http://orcid.org/0000-0002-8932-3695
authors.initials: E
authors.lastname: Murray
mesh_terms: D003362:Cost-Benefit Analysis; D015438:Health Behavior; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D008490:Medical Informatics / Q000191:economics; D012648:Self Care
keywords: adherence; digital interventions; engagement; prompts; systematic review