The Report of Access and Engagement With Digital Health Interventions Among Children and Young People: Systematic Review

Background Digital health interventions are increasingly used to deliver health-related interventions for children and young people to change health behaviors and improve health outcomes. Digital health interventions have the potential to enhance access to and engagement with children and young people; however, they may also increase the divide between those who can access technology and are supported to engage and those who are not. This review included studies that reported on the access to or engagement with digital health interventions among children and young people. Objective This review aims to identify and report on access and engagement in studies involving digital health interventions among children and young people. Methods A systematic review following the Joanna Briggs Institute methods for conducting systematic reviews was conducted. An electronic literature search was conducted for all studies published between January 1, 2010, and August 2022, across sources, including MEDLINE, CINAHL, and PsycINFO. Studies were included if they examined any aspect of access or engagement in relation to interventions among children and young people. The quality of the included papers was assessed, and data were extracted. Data were considered for meta-analysis, where possible. Results A total of 3292 references were identified using search terms. Following the exclusion of duplicates and review by inclusion criteria, 40 studies were independently appraised for their methodological quality. A total of 16 studies were excluded owing to their low assessed quality and flawed critical elements in the study design. The studies focused on a variety of health conditions; type 1 diabetes, weight management and obesity, mental health issues, and sexual health were the predominant conditions. Most studies were conducted in developed countries, with most of them being conducted in the United States. Two studies reported data related to access and considered ethnicity and social determinants. No studies used strategies to enhance or increase access. All studies included in the review reported on at least 1 aspect of engagement. Engagement with interventions was measured in relation to frequency of engagement, with no reference to the concept of effective engagement. Conclusions Most digital health interventions do not consider the factors that can affect access and engagement. Of those studies that measured either access or engagement or both, few sought to implement strategies to improve access or engagement to address potential disparities between groups. Although the literature to date provides some insight into access and engagement and how these are addressed in digital health interventions, there are major limitations in understanding how both can be enhanced to promote equity. Consideration of both access and engagement is vital to ensure that children and young people have the ability to participate in studies. Trial Registration PROSPERO CRD42020170874; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=170874


Background
Worldwide, access to many public services including health information and service provision is available through digital platforms [1].The COVID-19 pandemic has accelerated the digital shift and highlighted the value it can bring to enabling access to health services and enhancing social connectedness [2].However, equitable distribution of resources crucial for engaging with digital platforms-such as access to equipment, financial support for connectivity, and digital literacy-is uneven among populations.Consequently, certain groups have greater access to digital services than others [3,4].It is crucial to focus on equity concerning access to digital health services, ensuring that the gap between those who can and cannot access these services is not widened further [5].
A plethora of literature exists on equity in health and health care; however, the key principles remain the same: that there should be equal access to health care for those in equal need of health care; equal use of health care for those in equal need of health care; and equal (equitable) health outcomes, for example, quality-adjusted life expectancy [6,7].Equal access for equal need requires horizontal equity, conditions whereby those with equal needs have equal opportunities to access health care [8].
Health care providers are increasingly using digital technologies such as smartphones, websites, or SMS text messaging to communicate information to address health needs and in the delivery of health interventions [9].Digital health interventions are programs that provide information and support for physical and mental health using digital technologies [10,11].These interventions can be automated, interactive, and personalized, using user input or sensor data to shape feedback, treatment decisions, and treatment delivery [12].
Digital health interventions for children are increasing because of rapid technological advancements and the increasing interest of children and young people in technology [13].Digital health interventions have been proposed to create opportunity to increase access to health care [14][15][16].However, unless access to health care is equitable so that children and young people as consumers of health care within wider communities can use appropriate services in proportion to their need, inequities will create a divide in outcomes [17,18].
Although there is evidence for the effectiveness of digital health interventions developed for children and young people [19,20], understanding how issues related to access and variations by individuals, families, and communities are areas that have not been reviewed and require further discussion.

Objective
This review aimed to identify the reports of access to, and engagement with, digital health interventions among children and young people.The review includes a report of data on access and engagement in studies that report on the effectiveness of digital health interventions as well as evaluations of strategies to increase access and engagement.

Methods
The review followed the Joanna Briggs Institute (JBI) methodology for systematic reviews [21] in design and was conducted according to the PROSPERO protocol (CRD42020170874).The review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement.

Search Strategy
A scoping search was conducted to identify key papers and search terms to inform the search strategy.This included the key terms and medical subject headings engagement or equity of access or access to health care and digital health or mobile health or electronic health.
The search strategy was reviewed and refined by a research librarian.The base search strategy was developed on CINAHL.A total of 4 web-based databases, including CINAHL, MEDLINE, PsycINFO, and Embase, were searched for English language publications between January 2010 and August 2021 and updated in August 2022.A manual search in Google Scholar was also conducted.Gray literature sources including OpenGrey, ProQuest Dissertation and Theses (ProQuest), and Google and Google Scholar were also searched to identify unpublished studies.Multimedia Appendix 1 provides the full search strategy.EndNote (Clarivate) was used to remove duplicate citations before screening.

Inclusion and Exclusion Criteria
The review included studies that reported data on access or engagement when reporting the effectiveness of digital health interventions for children and young people.The participants included school-aged children and young people aged 5-18 years.Parents or caregivers of children receiving health services were also included; however, studies that only reported the parent experience were excluded.Studies reporting on health interventions involving 1-way and 2-way communication including web-based platforms, mobile apps, videoconferencing, and SMS text messaging on access or engagement outcomes were included.Qualitative and quantitative studies were included in this review.

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Studies that included children aged ≤4 years and ≥19 years were excluded.Studies that reported health professionals, such as nursing staff, medical personnel, health care management and administrators, or researchers, as the primary users of the digital health intervention were excluded.Studies reporting a telephone-based intervention with no additional technological function or where the intervention focused on health records such as patient portals or personal health records were excluded.

Screening
The titles, abstracts, and full papers of the selected records were screened independently by 2 reviewers (SR and MJ) using the abovementioned inclusion and exclusion criteria.Any discrepancies were discussed, and disagreements were resolved by a third reviewer (LW).The reference lists of all included studies were reviewed to identify relevant papers that were not found in the electronic search.

Assessment of Methodological Quality
The quality of the screened papers was critically appraised independently by reviewers (SR and LW) using the appropriate standardized critical appraisal instruments from JBI, including the Checklist for Randomized Controlled Trials, Checklist for Quasi-Experimental Studies, Checklist for Cohort Studies, Checklist for Analytical Cross Sectional Studies, and the Checklist for Qualitative Research [21].

Data Extraction
Data were extracted from the included studies using an adapted version of the standardized data extraction tool from JBI [22].Two reviewers (SR and MJ) extracted the data from the included papers, and a third reviewer (LW) verified the accuracy of the extracted data, with any disagreement resolved through discussion.
The extracted data included specific details about the study setting and context; the aim and objectives of the study; study design; the sampling of participants, sample size, and the characteristics of the study sample; and details about the interventions and engagement and access outcomes.All data were extracted following a thorough reading of the text to identify qualitative or quantitative findings relevant to the objectives and questions for the review.A second reviewer checked all the data extracted from each paper to enhance certainty.

Data Synthesis
Owing to the heterogeneity between the studies on outcome measures, research design, and the intervention, a meta-analysis was not possible.The findings have been presented in narrative form including tables and figures to aid in data presentation.The process of data synthesis followed the JBI approach of meta-aggregation.The meta-aggregative approach is sensitive to the practicality and usability of the findings extracted and does not seek to reinterpret these findings.A strong feature of the meta-aggregative approach is that it enables the generation of statements in the form of recommendations that can guide researchers, practitioners, and policy makers.In this way, meta-aggregation contrasts with meta-ethnography or the critical interpretive approach to qualitative evidence synthesis, which focuses on reinterpretation and theory generation rather than aggregation.

Study Inclusion
In total, 3292 references were identified using the search terms.The addition of secondary searches of reference lists and gray literature resulted in the identification of no further references.The exclusion of 1143 duplicates resulted in 2149 references.The titles and abstracts of the references were independently reviewed to determine if they met the inclusion criteria, and 2032 references were excluded.The remaining 117 references were retrieved in full text papers and reviewed by 3 reviewers (SR, MJ, and LW) using the inclusion criteria.A total of 77 studies were excluded as they did not meet the inclusion criteria.Of the 77 studies, 45 (58%) were excluded because the age of the child was outside the inclusion range, 27 (35%) did not report on access or engagement, 2 (3%) did not include a digital intervention, and 3 (4%) were opinion pieces or letters to the Editor.A total of 40 studies met the inclusion criteria (Figure 1).

Methodological Quality
A total of 40 studies that met the inclusion criteria were independently appraised for their methodological quality.A total of 16 studies were excluded where the quality of the studies was assessed as low and critical elements of the study design were flawed (Tables 1-5).A cutoff was applied for each research design.A total of 5 randomized controlled trials (RCTs) were excluded because they were unclear or did not report on ≥6 items out of 13 items (Table 1).In addition, 7 quasi-experimental studies were excluded because they were unclear or did not report on ≥4 out of 9 (Table 2).All qualitative studies were retained (Table 3).The 1 cohort study was excluded because it did not meet 5 of the 11 items (Table 4).One cross-sectional study was excluded because it did not meet 4 of the 8 criteria (Table 5).Of note, the mixed methods study was assessed using the criteria for RCTs and qualitative studies for the relevant sections as per JBI guidance.

Characteristics of the Studies
Of the 24 studies included in the review (Table 6), 7 (29%) used an RCT design, 12 (50%) were quasi-experimental studies, and 3 (13%) used a qualitative study design.One study used an analytical cross-sectional study design and 1 used a mixed methods design.

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Anderson et al [33], 2018 ease to promote disease knowledge, adherence, and patient-provider communication.
Of the 24 studies included in the review, 10 (42%) recruited participants from outpatient clinics, 1 (4%) recruited from the hospital setting, 4 (17%) recruited in schools, and 8 (33%) within community settings.One study recruited participants from both a school and a community setting.
In more than half of the studies (16/24, 67%), more females were recruited than males.In 3 studies, the gender of the child was not provided [23,33,51].

Type of Digital Interventions
Overall, 38% (9/24) of the digital health interventions were web based, 21% (5/24) of the interventions were mobile apps, 29% (7/24) of the interventions used SMS text messaging, 4% (1/24) of the interventions used a website and a mobile app, 4% (1/24) of the interventions were a telemedicine intervention with participants logging in on their home computer or tablet, and 8% (2/24) of the digital interventions combined a website and digital wearable glasses and an app and wearable tracker (Table 6).

Access to Digital Health Interventions
The 2 studies that reported access and digital health interventions included 1 that reported on access related to race and ethnicity and access by income and 1 that reported on gender differences in accessing services (Table 7).Zhang et al [32], 2018 a USE: Usefulness, Satisfaction, and Ease of use.
b Data not reported.

Race and Ethnicity
Equity of service use based on race and ethnicity was explored in 1 study.Whittemore et al [29] reported that Black, Hispanic, or mixed-race youths with type 1 diabetes were less likely to enroll in digital health interventions than White and high-income youths.However, once enrolled, youths of diverse races and ethnicities with type 1 diabetes were as highly satisfied with the eHealth programs as White youths.The results suggest that eHealth programs have the potential to reach diverse youth groups and to be relevant to them; however, considerations relating to access need to be addressed in the study design.
One study reported on access related to gender.Brown et al [35] reported that the digital intervention had a significant positive effect on psychological barriers to and antecedents of service access among females.Males reported greater confidence in service access than females and significantly increased service access by the second follow-up.Equity of service use based on income was explored in 1 study.Whittemore et al [29] reported that low-income youths were less likely to participate, possibly because of access.However, once enrolled, youths of diverse races and ethnicities and low-income youth with type 1 diabetes were as highly satisfied with the eHealth programs as White youths and those with higher income.

Overview
Engagement with the digital health intervention was measured by the frequency and intensity of engagement, satisfaction with the digital health intervention, and changes in knowledge or behavior.Of the studies that reported on engagement, most used system use data to capture how the intervention was used by each participant.The studies reported on various aspects of use data including initial log-in, frequency, intensity, and duration of engagement with the program, as described in Table 7.

Initial Log-In
Once enrolled in a digital health intervention, most participants logged in and engaged with the intervention.The percentage of enrolled participants logging in at least once to the digital intervention ranged from 35.6% [23] to 100% [30,34,35,37,50].One study did not provide this information [22].In 16 studies, more than three-quarters of the participants logged on at least once to the digital intervention (Table 7).

Frequency of Engagement
Frequency of engagement was measured by the log-in data, number of log-ins recorded per participant, average log-ins per unit of time or total for intervention duration, visits to the site, number of visits per participant, average per unit of time, or total time of visits.Overall, 42% (10/24) of the studies reported the average number of log-ins per unit of time.The measurement of frequency varied across the studies with either daily or weekly measurement with the unit of measurement dependent on the study aims and the frequency of the delivery of the intervention.
Overall, 21% (5/24) of the studies reported on engagement on a daily basis with between 49% [44] to 100% [37] of the participants engaging daily with the intervention.Moreover, 29% (7/24) of the studies reported weekly engagement with the digital health intervention, 13% (3/24) of the studies reported the percentage of participants engaging weekly, and 17% (4/24) of the studies reported the average weekly engagement with the website or app.
The most frequent measurement of the frequency of engagement was daily or weekly response to text messages by participants as reported in 6 studies.
Zhang et al [32] found that adolescent sex was significantly related to engagement (t=2.42;P=.02), with boys demonstrating higher response rates (88%) than girls (67%).However, Whittemore et al [29] found no significant gender difference in enrollment and participation in an eHealth program for adolescents with type 1 diabetes.

Intensity of Engagement and Type of Behavior
The intensity of engagement was measured by pages viewed, modules viewed, number of emails sent, number of posts, and number of experts accessed.Three studies measured the number of log-ins per participant and reported the number of times an app or web page was visited.Zhang et al [32] reported that race and ethnicity were significantly related to engagement (t=3.48;P=.04), with White, non-Hispanic youths responding to more messages (80%) than youths in racial and ethnic minority groups (45%).
One study measured functions used stating the number and percentage of participants who used the 5 functions within the intervention platform [40].

Completion of Modules and Courses
Most studies measured either completion of modules or completion of the course, with completion rates ranging from 3.6% to 100%, with most studies reporting >80% of participants completing modules or the course.Completion of modules, web pages, and courses were measured in 16 studies.In the study with the lowest completion rate [42], completion of all 10 sessions was low (3.6%), but 48% of the participants completed some sessions [40].Although completion rates were reported in 16 studies, understanding whether these were higher or lower than expected or in direct comparison to face-to-face or other nondigital intervention approach was not clear.Completion of the intervention sessions was high in several studies (Table 7); for example, 84% of the participants completed the intervention in 2 studies [33,37], 95% of the participants completed the intervention in another study [50], to 100% of the participants completing the intervention [37].The results did not provide insight into whether the digital nature of the intervention increased, decreased, or had a neutral impact on completion rates.

Satisfaction
Satisfaction was measured in 14 studies, with satisfaction measurement methods varying across the studies (Table 7).Of the 14 studies that assessed satisfaction, participants were generally satisfied with the digital intervention, and in 1 study [49] participants were more satisfied with telephone calls than the digital alternative.When reported, satisfaction rates were high, ranging from 42% [33] to 93% [31].

Principal Findings
This review found that few studies have reported on how they addressed access and engagement of children and young people in digital health interventions.Most studies (23/24, 96%) included in the review were conducted in developed countries, mainly the United States.Only 2 studies reported data related to access, and no study reported the use of strategies to enhance or increase access.All studies included in the review reported on at least 1 aspect of the engagement of children and young people in interventions.Engagement was assessed in relation to frequency but did not consider whether the level of engagement achieved could be considered effective.
Access to health care includes both the availability of services and the ability of individuals and populations to access services.Inequities in access to health care tend to affect the most susceptible people in our communities and those with the most complex health care needs [17,57].Until now, the examination of young people's access to digital health interventions has primarily focused on reviewing their engagement after enrollment in the study.However, there has been minimal consideration of equity issues regarding access before enrollment or engagement after enrollment among different groups.There is much work to be done in carefully mapping the factors that may affect access within a population during the conception of a study and planning for how to improve equity in relation to access before recruitment begins.The World Health Organization [58] has developed a framework for planning, developing, and implementing youth-centered digital health interventions.The framework provides guidance on the key considerations at each stage, including whether a digital solution is the best approach and consulting with young people.Examples of considerations for researchers and others to deliberate include ownership of, and access to, digital devices; connectivity in a geographical area; and community consultation to understand the cultural, social, family, and individual beliefs and behaviors related to technology, health, and behavioral change to create a user-centered designed intervention.
Variability in the measurement of engagement with digital health interventions reflects the diversity, complexity, and multiple aims of the digital health interventions.Although there is variability in the measurement of engagement, most young people in the studies included in this review engaged with the digital health interventions once enrolled.The measurement of engagement with interventions was based on use data, frequency and intensity of engagement, and user satisfaction data.There has been no exploration of the relationship between engagement with the digital intervention and the outcome measures.The concept of "effective engagement" [19] was not explored in the papers included in the review.The concept of promoting effective engagement rather than simply more engagement is an area that could yield valuable insights into how to support young people to achieve the goals and intended outcomes of a digital health intervention.Exploring and recognizing the combination of measures to promote and support "effective engagement" is an area for development with the potential to test multidimensional models of engagement [1,59].
The digitalization of health has the potential to improve health outcomes by empowering young people to become active custodians of their own health.There is the potential to improve access and health outcomes for traditionally underserved groups where smartphone ownership and use are higher than the general population [60,61].However, caution has been advised regarding the digitalization of health, as it tends to favor certain groups while potentially having negative impacts on others.Although there has been exponential growth in the use of the internet, access to health information remains unequal [61].
Equal use for equal need requires conditions whereby those who have an equal need for health care make equal use of health care.Compared with equal access for equal need, this equity principle requires more proactive efforts.Areas related to fiscal and social policy, that influence education, housing conditions, and nutrition, are highly influential and speak to fundamental determinants of health.To promote access and engagement, researchers must first recognize the importance and value of considering these factors and preempt, plan, and document their efforts to make progress.

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The limitations of this review include the search for, and inclusion of, papers published in English only.The heterogeneity of the papers meant that a meta-analysis was not possible and a narrative summary was completed.The review included studies that reported on either access or engagement or both; however, improving or addressing these concepts was not the primary aim of the studies.Where the 2 concepts are fundamental to the design and effectiveness of digital interventions, a strength of the review lies in the inclusion of all studies that report on the consideration of access and engagement.

Conclusions
The review identified several gaps and raised important questions for further investigation.Most of the studies reporting on access or engagement, did not seek to improve access to digital technology and focused on the frequency of engagement.Future work should explore how access and engagement can be considered preemptively and assessed throughout the intervention, with the goal of improving the equity of access and effective engagement with digital interventions.

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Figure 1 .
Figure 1.PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart of the study selection and inclusion process.
d iCBT: internet-based cognitive behavioral therapy.e ASD: autism spectrum disorder.f STD: sexually transmitted disease.

Table 7 .
Report of access and engagement.