Cited by 331Mobile Health and mHealth ApplicationsDigital Mental Health InterventionsTelemedicine and Telehealth Implementation

The DOI matches its Crossref record; 83 of the 84 references it cites were found in a registry or an index; none of the 34 sources its claims cite is checked for support yet.

Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence

Open access

Sieverink, Floor, Kelders, Saskia M, van Gemert-Pijnen, Julia EWC·2017·Journal of Medical Internet Research

DOI 10.2196/jmir.8578PMC PMC5738543

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Abstract

BACKGROUND: In electronic health (eHealth) evaluations, there is increasing attention for studying the actual usage of a technology in relation to the outcomes found, often by studying the adherence to the technology. On the basis of the definition of adherence, we suggest that the following three elements are necessary to determine adherence to eHealth technology: (1) the ability to measure the usage behavior of individuals; (2) an operationalization of intended use; and (3) an empirical, theoretical, or rational justification of the intended use. However, to date, little is known on how to operationalize the intended usage of and the adherence to different types of eHealth technology. OBJECTIVE: The study aimed to improve eHealth evaluations by gaining insight into when, how, and by whom the concept of adherence has been used in previous eHealth evaluations and finding a concise way to operationalize adherence to and intended use of different eHealth technologies. METHODS: A systematic review of eHealth evaluations was conducted to gain insight into how the use of the technology was measured, how adherence to different types of technologies was operationalized, and if and how the intended use of the technology was justified. Differences in variables between the use of the technology and the operationalization of adherence were calculated using a chi-square test of independence. RESULTS: In total, 62 studies were included in this review. In 34 studies, adherence was operationalized as "the more use, the better," whereas 28 studies described a threshold for intended use of the technology as well. Out of these 28, only 6 reported a justification for the intended use. The proportion of evaluations of mental health technologies reporting a justified operationalization of intended use is lagging behind compared with evaluations of lifestyle and chronic care technologies. The results indicated that a justification of intended use does not require extra measurements to determine adherence to the technology. CONCLUSIONS: The results of this review showed that to date, justifications for intended use are often missing in evaluations of adherence. Evidently, it is not always possible to estimate the intended use of a technology. However, such measures do not meet the definition of adherence and should therefore be referred to as the actual usage of the technology. Therefore, it can be concluded that adherence to eHealth technology is an underdeveloped and often improperly used concept in the existing body of literature. When defining the intended use of a technology and selecting valid measures for adherence, the goal or the assumed working mechanisms should be leading. Adherence can then be standardized, which will improve the comparison of adherence rates to different technologies with the same goal and will provide insight into how adherence to different elements contributed to the outcomes.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review of 62 eHealth evaluations finds that adherence is often operationalized as “the more use, the better” without an intended-use threshold, and even when a threshold is given, justification is usually missing. The authors argue adherence should be defined against a justified intended use tied to the technology’s goal or assumed working mechanisms.

Key findings

Of 62 included studies, 34 used Category A (“more use, the better”), 23 provided an intended-use threshold without justification (Category B), and 5 provided a justified threshold (Category C); the abstract reports 6 justified among 28 threshold studies.
Mental health technologies lagged: 20/31 had Category A operationalizations, while Category C was more equally distributed across mental health, lifestyle, and chronic care.
Most operationalizations used ≤2 measures (49/62); 10/13 with ≥3 measures were Category A. Adherence to unstructured technologies more often used logins/sessions (P=.03), features accessed/used (P<.001), and time spent (P<.001); structured technologies used modules/lessons completed (P<.001).
Technologies were mostly Web-based (51/62); 29 were structured, 18 unstructured, and 15 hybrid, with half targeting mental health.

Methods

Systematic review; searched Scopus, Web of Science, ScienceDirect, and PsycINFO; 7005 records identified, 62 full texts included after title, abstract, and full-text screening.
Included health-related technologies intended for repeated use, with objective quantifiable usage measures and an adherence operationalization; excluded offline treatment adherence, protocol adherence, simple information-exchange tools, conference abstracts, and unavailable full texts.
Data were extracted and adherence operationalizations categorized as A/B/C; differences were tested with chi-square test of independence, using Monte Carlo correction when expected counts were low, at alpha .05.

Limitations

Stated: only studies using adherence as an outcome or explicitly stating a proxy were included, so studies using related terms (nonusage attrition, engagement, drop-out, [non]usage) may have been missed.
Stated: adherence operationalizations were categorized per study, not per technology, though the same technology could have different operationalizations across studies.
Evident from the text: the abstract and results differ on the number of justified operationalizations (6 vs 5), and the review is descriptive/categorical without meta-analytic synthesis.

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Integrity signals

Registry

Crossref · 10.2196/jmir.8578

Cites

83 of 83 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 34 cited sources checked · 0 supported · 0 flagged

A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“In 34 studies, adherence was operationalized as “the more use, the better,””
- Also stated in: § Operationalization of the Adherence Definition · plain
  “Out of the 62 included articles, 34 reported adherence only in terms of how often the technology was used (Category A operationalization)”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Abstract > Results
Load-bearingStrength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“However, to date, little is known on how to operationalize the intended usage of and the adherence to different types of eHealth technology.”
- Also stated in: § Determining Adherence · plain
  “However, to date, little is known about how to operationalize the intended usage of and thus the adherence to different types of eHealth technology.”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Abstract > Background
Load-bearingStrength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes

Show all 57 claims

Probably not a substantial claim. 28
It may state two separate claims as one. 20
The quote only partly states this claim. 2

A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“In total, 62 studies were included in this review.”
- Also stated in: § Study Selection · plain
  “After screening of the titles, abstracts, and full texts, 62 full texts were included in this review.”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Abstract > Results
Strength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“Carolan et al describe a protocol for a study to be conducted to understand the optimum adherence to the technology in relation to the outcomes [78].”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Results > Operationalization of the Adherence Definition
What the sources say
- Not checked yetcites [78] source
Strength:plain· not yet calibrated
Tests✗ Asserted: fails✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The authors may not put it forward as true. The paper’s conclusions may not depend on it.
In the paper
“Beatty et al considered a user to be highly adherent when a therapeutic dose of 66% of the intervention was received [76]. This threshold for a therapeutic dose was obtained from previous studies.”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Results > Operationalization of the Adherence Definition
What the sources say
- Not checked yetcites [76] source
Strength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
In the paper
“In the study by Mertens et al, technology use was represented in relation to medication use, and users were therefore seen as adherent when the technology was used in accordance with the recommendations for medication use [77].”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Results > Operationalization of the Adherence Definition
What the sources say
- Not checked yetcites [77] Mertens, A, 2017, Advances in Human Factors and Ergonomics in Healthcare source
Strength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“In the study by Zeng et al, the technology consisted of different elements that were all evaluated as effective in other studies [75]. Users were considered adherent if they used all elements.”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Results > Operationalization of the Adherence Definition
What the sources say
- Not checked yetcites [75] source
Strength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Therefore, it can be concluded that adherence to eHealth technology is an underdeveloped and often improperly used concept in the existing body of literature.”
- Also stated in: § Conclusions · plain
  “it can be concluded that adherence to eHealth technology is an underdeveloped and often improperly used concept in the existing body of literature.”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Abstract > Conclusions
Load-bearingStrength:boosted· not yet calibrated
Tests✓ Asserted: passes? Checkable: unclear✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
In the paper
“This is unexpected because the majority of mental health technologies is based on (principles of) CBT, which is the most studied treatment for depression and has proven effective in many studies [79].”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Discussion > Principal Findings
What the sources say
- Not checked yetcites [79] Cuijpers, P, 2013, Can J Psychiatry source
Strength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
In the paper
“On the basis of the definition of adherence, we suggest that the following three elements are necessary to determine adherence to eHealth technology: (1) the ability to measure the usage behavior of individuals; (2) an operationalization of intended use; and (3) an empirical, theoretical, or rational justification of the intended use.”
- Also stated in: § Determining Adherence · hedged
  “To summarize, based on the definition of adherence, we suggest that the following three elements are necessary to determine adherence to eHealth technology: (1) the ability to measure the usage behavior of individuals; (2) an operationalization of intended use; and (3) an empirical, theoretical, or rational justification of the intended use.”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Abstract > Background
What the sources say
- Not checked yetcites [10] Sabaté, E, 2003, Adherence to long-term therapies: evidence for action
Load-bearingStrength:hedged· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
Probably not a substantial claim. It may state two separate claims as one.
In the paper
“An important reason for the lack of justifications for the intended use of eHealth technologies might be that there is a lack of knowledge regarding the working mechanisms of technology-based applications [8].”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Discussion > Implications and Recommendations
What the sources say
- Not checked yetcites [8] source
Strength:hedged· not yet calibratedCausal:conditional· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“Moreover, definitions of engagement usually incorporate the more subjective attributes of challenge, positive affect, endurability, and aesthetic and sensory appeals [12], whereas adherence is mostly based on measures for usage behavior.”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Introduction > Adherence to eHealth Technologies
What the sources say
- Not checked yetcites [12] SmithWPlodererBWadleyGWebberSBorlandRTrajectories of Engagement and Disengagement with a Story-Based Smoking Cessation App20172017 CHI Conference on Human Factors in Computing SystemsMay 6-11, 2017Denver, ColoradoACM304556
Load-bearingStrength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“However, a technology can be designed for multiple target groups and, depending on the individual user goals and the desired outcomes, technology can be used in many different ways in terms of the features that are used, as well as the frequency, time, and place of use [13,14].”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Introduction > Determining Adherence
What the sources say
- Not checked yetcites [13] source
- Not checked yetcites [14] source
Load-bearingStrength:plain· not yet calibratedCausal:correlational· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.
In the paper
“Kaushal and Rhodes found that exercising for at least four times per week for 6 weeks is a minimal requirement for establishing exercise habits [81].”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Discussion > Implications and Recommendations
What the sources say
- Not checked yetcites [81] source
Strength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passes
Probably not a substantial claim. The paper’s conclusions may not depend on it.
None of the sources cited for this claim have been checked yet.
In the paper
“the intended use or the “therapeutic dose” can be justified just as well using existing guidelines for healthy living and medication use [74,77] or using previous research regarding other technologies [75,76].”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Discussion > Implications and Recommendations
What the sources say
- Not checked yetcites [74] source
- Not checked yetcites [77] Mertens, A, 2017, Advances in Human Factors and Ergonomics in Healthcare source
- Not checked yetcites [75] source
- Not checked yetcites [76] source
Load-bearingStrength:plain· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
Probably not a substantial claim. It may state two separate claims as one.
In the paper
“In turn, the percentage of people who adhered to the intervention can be calculated, making adherence a more objective and standardized concept [1].”
§ Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence > Discussion > Implications and Recommendations
What the sources say
- Not checked yetcites [1] source
Load-bearingStrength:plain· not yet calibratedCausal:direct· not yet calibrated
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
It may state two separate claims as one.

40 of 40

Claims other papers make about this one

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Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

Abstract reports six justified studies, but results report five
Minor
The abstract says 6 studies justified their intended-use threshold, whereas the results identify 5 Category C studies. This changes the reported number meeting the paper's justification criterion.
Category A and B denominator is one too low
Minor
There are 34 Category A and 23 Category B operationalizations, totaling 57 rather than the stated 56.
Reported 56 · recomputed 57
Chronic-care percentage in Category C is incorrect
Minor
Table 4 gives one chronic-care study among five Category C studies, which is 20%, not 40%.
Reported 40 · recomputed 20
Claim of no measure differences conflicts with Table 4
Minor
The discussion says no significant differences were found between the kinds of measures used across the three categories, but Table 4 marks the days/weeks/months measure as significant (aP<.05).
Time-spent percentage in Category C is incorrect
Minor
Table 4 gives one study using time spent among five Category C studies, which is 20%, not 17%.
Reported 17 · recomputed 20
Smartphone-app count differs between prose and Table 3
Minor
The prose reports five smartphone apps, but Table 3 reports six, distributed as 3 structured, 2 unstructured, and 1 hybrid.

6 of 6

Adherence to Long‐Term Therapies: Evidence for Action
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Self-citation
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A Meta-Analysis of Cognitive-Behavioural Therapy for Adult Depression, Alone and in Comparison with other Treatments
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A Systematic Review of the Impact of Adherence on the Effectiveness of e-Therapies
Donkin, L., Christensen, H., Naismith, S. L., Neal, B., Hickie, I. B., & Glozier, N. (2011) · Journal of Medical Internet Research · doi:10.2196/jmir.1772 · Cited by 876
Developing and evaluating digital interventions to promote behavior change in health and health care: recommendations resulting from an international workshop
Michie, S., Yardley, L., West, R., Patrick, K., & Greaves, F. (2017) · Journal of Medical Internet Research · doi:10.2196/jmir.7126 · Cited by 865 · cited 3×
“For every technology, a proportion of the users will not use the intervention at all, will stop using the technology after a period, or will not use the available elements of the technology as intended [1,6-8].”
Background
Efficacy of internet-delivered cognitive-behavioral therapy for insomnia— a systematic review and meta-analysis of randomized controlled trials
Zachariae, R., Lyby, M. S., Ritterband, L. M., & O'Toole, M. S. (2016) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2015.10.004 · Cited by 704 · cited 1×
“Although a longer treatment duration is associated with better effects [80], this still implies that users do not necessarily need to finish the complete program to experience reduction of their complaints, and that there should be a threshold for intended use.”
Background
Adherence to a Smartphone Application for Weight Loss Compared to Website and Paper Diary: Pilot Randomized Controlled Trial
Carter, M. C., Burley, V. J., Nykjaer, C., & Cade, J. E. (2013) · Journal of Medical Internet Research · doi:10.2196/jmir.2283 · Cited by 666
Adherence to Internet-Based and Face-to-Face Cognitive Behavioural Therapy for Depression: A Meta-Analysis
van Ballegooijen, W., Cuijpers, P., van Straten, A., Karyotaki, E., Andersson, G., Smit, J. H., & Riper, H. (2014) · PLoS ONE · doi:10.1371/journal.pone.0100674 · Cited by 409

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SmithWPlodererBWadleyGWebberSBorlandRTrajectories of Engagement and Disengagement with a Story-Based Smoking Cessation App20172017 CHI Conference on Human Factors in Computing SystemsMay 6-11, 2017Denver, ColoradoACM304556
Batterham, PJ, 2008, Patient Prefer Adherence, 2, 97
An, LC, 2006, Nicotine Tob Res, 8, S7
Wangberg, SC, 2008, Patient Prefer Adherence, 2, 57

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Authors: Sieverink, F., Kelders, S. M., & van Gemert-Pijnen, J. E.
Affiliations: University of Twente (NL)
North-West University (ZA)
Corresponding author: Sieverink, Floor
ORCID: Sieverink, Floor
Kelders, Saskia M
van Gemert-Pijnen, Julia EWC
Venue: Journal of Medical Internet Research
Publisher: JMIR Publications Inc.
Published: 2017-12-06
Volume: 19
Issue: 12
Pages: e402
ISSN: 1438-8871 (ISSN-L)
DOI: 10.2196/jmir.8578
PMC: PMC5738543
OpenAlex: W2774320409
Semantic Scholar: a1db2bb515ffdc128b4290c1c2d3f04a5b280310
Cited by: 331
References: 84
Citations by year: 2026: 28 · 2025: 33 · 2024: 35 · 2023: 38 · 2022: 45 · 2021: 51 · 2020: 48 · 2019: 31 · 2018: 21 · 2017: 1
FWCI: 4.86
Type: journal article
Language: en
Open access: gold
doi.org
Licence: cc-by
Locations: Journal of Medical Internet Research (publishedVersion, cc-by)
PubMed Central (publishedVersion, cc-by)
PubMed (publishedVersion)
University of Twente Research Information (publishedVersion, cc-by)
University of Twente Research Information (submittedVersion, cc-by)
Topics: Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
Keywords: eHealth technologies, technology adherence, intended use, mental health technology, eHealth evaluation, operating mechanism
MeSH terms: Humans, Patient Compliance, Telemedicine, Biomedical Technology

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Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence

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