The contradictions of e-health intervention experience of users toward its outcome: a systematic review

Document Type : Systematic review/Meta analysis


1 Department of Medical Education, Research center for social determinant of health, Jahrom University of Medical Sciences, Jahrom, Iran

2 Department of Nursing, Jahrom University of Medical Sciences, Jahrom, Iran

3 Student in Public Health, Student Research committee, Jahrom University of Medical Sciences, Jahrom, Iran


Background: Electronic Health is a kind of communication technology that covers a wide range of healthcare activities, from diagnosis to treatment. This study aimed to investigate the conflicts caused by e-health interventions in patients’ attitude and its influence on consequences of the disease in a Meta synthesis study.
Methods: Present study is a systematic review and meta-synthesis qualitative research according to articles found by Medline searching the keyword “E-health” published, collected, and reviewed from 2000 to 2019,. Then the search was narrowed down using the keywords “qualitative studies”, “patients’ attitudes”, “Patients’ view” about E-health. All English texts or abstracts were included in the study. Duplicated remote papers and paper with main and complementary treatment, also, web base, internet, software, and mobile mediated treatment process as an electronic way were included to the search process. All irrelevant, duplicated, and qualitative studies were excluded from study and totally 23 papers were extracted to review.
Results: Regarding the effective features of e-health, it has a significant beneficial effect by empowering patients, treatment through supportive networks, changing the traditional therapeutic algorithms in inducing a successful and influential treatment, successful outcomes with functionality, also being flexible and attractive. Patients also referred to its shortcomings in treatment and expressed the ability to implement it with aura, parallel, and non-variable coverage.
Conclusions: Due to the perceptions and positive outcomes of the method, it is necessary to consider ways and means to neutralize or minimize the negative effects of technology on treatment, therefore more efficient use of the electronic health system can be achieved.



The introduction of technology into the life of individuals has changed the way they communicate with others. In fact, it has made the communication, work, and leisure more feasible, and reduced the distances and the physical barriers, especially in the healthcare are, among people (1). Over the past decade, the e-health interventions and other e-health technologies have significantly and globally developed, and consequently, have changed the form of healthcare and clinical research(2). Electronic Health is a kind of information and communication technology software that covers a wide range of healthcare activities, from diagnosis to treatment (1). Naslund et al. found that e-health interventions are highly acceptable among individuals with severe mental illness (3). Van der Kriekle et al. also noticed that individuals with psychosis are able and willing to use e-health, through which have gotten better results in drug management (4). E-health interventions include personalized digital tools, drug tracking tools, home care systems, smartphone applications, SMS and web-based interventions (5). In fact, e-health is closely related to the health services of Mobile Health, which is the use of mobile devices for medical purposes and healthcare functions (1). Therefore, M Health as a subdivision of E Health plays an important role in development of healthcare and improves its quality and effectiveness (6). Statistics show that, with the advent of mobile devices, healthcare professionals, including doctors, nurses, and other professionals, use mobile phone Healthcare systems to improve their efficiency in healthcare (7). Nowadays mobile phones are really helpful in this arena because Mobile Health has eased accessing to healthcare services, especially in undeveloped countries where the provision of services and financial resources have been limited, and the prevalence of diseases is high (8). Meanwhile, World Bank reports that there are 6 billion mobile subscribers around the world, of which approximately 5 billion are living in developed countries (9). In 2015, only 12% of  people all over the world did not have a mobile phone, and 43% of them owned a smartphone (10). In our country, Iran, the penetration rate of mobile phones has reached 90% (11) and it is possible to send a message to each user, regardless of the device model and the type of its service provider (12). The traditional health training sessions are such that patients might not be able to attend due to inappropriate time, problems of traveling, or child care issues (13), while SMS services, besides being effective and low-cost, can disseminate health information to people who are out of reach (11). Moreover, sending messages is an applicable way for regions with a shortage of healthcare professionals (14). Therefore, some health care services have transformed from paper form to electronic form (e-health) (15). In related study conducted in India, researchers tried to encourage people to have a healthier lifestyle by sending mobile phone messages. In this study, researchers sent 60 to 80 messages to the intervention group over more than two years, with this content: don’t eat while watching TV, it may cause overeating. Eventually, they reported that the incidence of diabetes in  tested group was 40% lower than  controlled group (16). Zeinab et al. in their study on effects of sending mobile phone messages on the knowledge and practice of diabetic foot care in developed countries showed that this intervention is an economic, practical, and effective way to improve the diabetic foot care (9). Another study conducted by Haghani et al., investigates the effects of distance education programs, here sending mobile phone messages, on the awareness and satisfaction of pregnant women during their pregnancy. Findings of this study showed that this intervention in pregnancy training rises the awareness and satisfaction of pregnant mothers (11). On the other hand, statistics show that today, social media have become online tools which everybody, regardless of time and place, can access, use, and produce information (17). Social media can be used for a variety of purposes such as education, communication with patients, access to health information, healthcare, general health programs, and research (18). Studies show that social media in comparison with old forms of communication are more patient-centric and interactive (13). In this regard, the results of the study by Reich et al. in 2016, which examined the use of social media by patients with inflammatory bowel disease, showed that 62% of patients are willing to use educational programs through social media (19) Since the use of social media is on the rise, a  study in the Netherlands showed that one out of every four tends to use social media to communicate with healthcare professionals (20), since people see incoming messages even when they are busy (11). We conducted a meta-synthesis to examine the effectiveness of e-health interventions for patients by calculating the effect size and examining the characteristics of these interventions that may be related to program effectiveness.


Present study is a systematic review research conducted to examine the effectiveness of e-health app interventions for patients by calculating the effect size and examining characteristics of these interventions that may be related to program effectiveness.


Selection criteria


Only full text, peer reviewed, English published qualitative studies were included in the review; therefore, the present researchers excluded unpublished studies, dissertations, book chapters, and conference abstracts.

In this synthesis, the study aimed: (1) e health: meta synthesis form effect of e health on patient prospective, (2) to discern how e health could be efficient and what is the efficacy dimension in patients’ perspective, (3) to elucidate this evidence into the effect of this method in patients’ care, education and outcome.

As outlined by Sandelowski et al, our method was meta-synthesis form effect of e health on patient prospective. The systematic method was adapted from Gewurtz et al. The model by Gewurtz et al was subsequently used to conduct this review: (1) identifying relevant research questions, (2) setting inclusion and exclusion criteria, (3) identifying and retrieving studies, (4) assessing the quality of the studies, and (5) synthesizing findings from across the studies (2,21,22).

This review focused solely on academic qualitative studies from January 2000 to 2019, toward e-health: meta synthesis form effect of e health on patient prospective. A preliminary search found no evidence pre-1990.  Authors devised their inclusive parameters as follows: studies published in any country, peer-reviewed research, and English-language publications. The participants of the study were patients given e health for care and education and fallow up in wide range of diseases.

As per qualitative meta-synthesis methods, the exclusion criteria were quantitative articles; qualitative, mixed methods articles; review articles; meta-syntheses; literature reviews.

Search Strategy

The search strategy was developed by all authors in conjunction with a librarian and included keywords that would be transferable across a number of databases (in MeSH). Some of these keywords included truncation to allow for a wider gauge of results. Original academic research articles were sourced using the keywords “e health*   OR m health * e health AND patients’ opinion * e health AND patients’ perspective** e health AND patients’   satisfaction    * e health AND efficacy *        * e health AND patients’ perspective AND qualitative study or Meta synthesis*.  The search terms were input on MEDLINE, EMBASE, PsycInfo, Cochrane, EBSCO, CINAHL, SCOPUS, Web of Science, Academic Search Premier and Google Scholar. Each category consisted of a mixture of medical subject headings (MeSH).

 Total 114,000articles were identified as being potentially appropriate for this review. 52,500 articles were appropriate for e-health and patients. Key words limited to 32200 articles related to e health and patients’ outcome. 1324 articles were in PubMed. 286 articles were in google scholar, from which 824 articles from PubMed and 230 articles from another search engine were excluded. Full text articles were retrieved for further investigation when their title and abstract appeared to meet inclusion criteria.

Studies screening method

The titles and abstracts were reviewed by researchers.  471 articles were rejected for failing to meet the inclusion criteria. The remaining articles were extracted for full-text review. Duplicate articles were excluded and 23 articles were chosen for the study. Both authors reviewed the reference lists of the 23 articles. A total combination of 23 studies underwent quality appraisal.

Assessment of quality

Methodological quality of included studies was assessed independently by researchers. Also they have used the CASP qualitative appraisal tool to assess the credibility, relevance and rigour of each paper (23).


Table 1 shows the research, type of interventions, and outcome form patients’ report (24-43). This table shows different interventions used by electronic intervention in patients in different groups.

Table 2 shows the themes extracted from meta- synthesis and common results by researchers. This themes conclude efficacy, feasibility, benefit, and challenges.

Table 3 shows the themes concluding efficacy, feasibility, benefit, and challenges and main indicators by research samples.


The result of studying various articles about patients' attitudes towards the use of electronic health interventions included positive effects, challenges, and different barriers. Based on present analysis, the effects of electronic health on consequences of diseases were classified into three positive and two negative components. Positive components included efficiency of the method, utility, and practicality, and negative components were barriers and challenges of using intervention.

In terms of efficiency of the method, electronic health intervention exposed its competence through support, empowerment, informing, and skill training. In another perspective, the effect of electronic health on disease is identified through its use in empowering patients. Besides getting proper information, patients can handle their own problems with self-care and take necessary measures. In terms of the functionality of the method, availability, attractiveness, and suitability could be pointed out, since having the proper functionality can provide an effective field of application.

Regarding the efficiency of the method, it is important to mention the use of this intervention in development of psychological well-being, improvement of self-image, positive feeling of online discussion and its usefulness for those who are sexually distress (21). Other considerable outcomes of e-health are: empowering patients and their involvement in treatment and improvement, reducing mental dichotomy, reducing distrust in the treatment process (22), two-way communication, information sharing, promotion of support and balance in care (23), necessity and importance of  e-health care in health care (24), assuredness of monitoring, increasing awareness of symptoms and examination of hidden issues (25), replacing the role of therapists (26), facilitating personal experiences in confronting with obstacles (27), improving the consequences of the diseases (28), positive relationship between patient and therapist, reducing the duration of hospitalization and the importance of timely rehabilitation (29), understanding the interventions of the stability of nurses' professional roles is understandable (30) , redefining communication and relative coverage of the role of therapists (26), complementary therapy (31), increasing knowledge and self-care (32), providing physical and psychosocial information, and a way to work with the application in an IT platform and supportive care (33).

In regard to utility of method, evidences suggested that health-based electronic interventions are useful for following reasons: supporting peer groups (21), increasing the sense of security (34), creating positive perception of the disease in peer group with the same problem, reducing the transportation and its expenses, responsibility and commitment to the disease control and self-care (23), providing interventions to tackle the root of problems in a society (24), self-management in obtaining necessary information and supporting health care decisions (35), managing work and action towards obstacles or capabilities (25), formation of communication and positive interaction between patients and medical team, power of networking and change in professional behaviors of medical team (26), knowledge sharing and patient-centered care, consolidation and stabilization of medical services (28), creation of virtual trust to manage concerns (36), effective use of technology (30), receiving information on interventions (37), and improvement of potential clinical effectiveness (38).

In terms of practicality, this method can be called practical due to simplicity and ease of use, attractiveness, and acceptability(26), use of available infrastructures and technologies(30), ability to perform in different situations (37), and fulfilling   adult’s needs (38).

Two other aspects consisted of challenges and barriers of the method and intervention on the disease consequences. Challenges included the need to pay attention to the importance of patients (23), need to get feedback on the use of technology between patient and medical team and service providers (24), the need for a positive attitude towards the use of electronic technology services, importance of protecting individuals’ security and privacy (35), lack of trusting in adequate follow-up care and anxiety about using this type of treatment, concerns about reducing the treatment budget by using virtual methods (31), not considering individual differences (39), and the need for doing careful information analysis in various situations (32).

Other negative aspects included obstacles to the use of these methods which consisted of evidences about lacking individuals’ knowledge in how to collect information through applications (23) and electronic interventions, how to adapt them to their personal needs, how to have sufficient control over the side effects of drugs (36), the fact that the use of this method takes time for the medical team and may intervene in their work shifts (30).

The use of technology in medical fields is increasing. Examining its positive and negative consequences can help health policymakers in planning to ensure effective dimensions and managing its effects and consequences to help more efficient in e-health and services. Due to the recent use of technology in the field of health, it is necessary to do more research on its negative and positive effects and update the results of the analysis. Also it needs more research about users’ attitude as a meta-analysis to extract more meaning of e health in users.

Finally, after investigating patients’ attitude towards the role of electronic health toward the outcome of illness, advantages and disadvantages of this method and a way to uses it, it can be argued that this method with positive features such as applicability, usefulness, and efficiency, can overcome obstacles and challenges, and has an effective role in creating positive outcomes in patients' attitudes.

Ethical considerations 

Ethical issues including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc. have been completely observed by the authors.

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