Implementation factors and their effect on e-Health service adoption in rural communities: a systematic literature review.

0.32 MB·English

by  Hage, Eveline

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RESEARCH ARTICLE Open Access
Implementation factors and their effect on
e-Health service adoption in rural communities: a
systematic literature review
Eveline Hage*, John P Roo, Marjolein AG van Offenbeek and Albert Boonstra
Abstract
Background: Anageing population is seen as a threat to thequality of life and health in rural communities, and it
is often assumed that e-Health services can address this issue. As successfule-Health implementationin
organizations has proven difficult, this systematic literature review considers whether this is so for rural
communities. Thisreview identifies the critical implementation factors and, following the change model of
Pettigrew and Whipp, classifies them interms of“context”,“process”,and “content”. Through this lens, weanalyze
theempirical findings found inthe literature to address thequestion: How do context, process, and content factors
ofe-Healthimplementation influence itsadoptionin rural communities?
Methods: We conducted a systematic literature review. This review included papers that met six inclusion and
exclusion criteria and had sufficient methodological quality. Findingswere categorized in a classification matrix to
identify promoting and restraining implementation factors and to explore whether any interactions between
context, process, and content affect adoption.
Results: Ofthe 5,896 abstracts initially identified, only 51 papers metallour criteria and were included in the
review. We distinguished five different perspectives onrural e-Health implementationin thesepapers. Further,we
list thecontext,process,and content implementation factors found to either promoteor restrain rurale-Health
adoption. Many implementation factors appear repeatedly, but there are also some contradictory results. Based on
a further analysis ofthe papers’findings,we argue thatinteraction effects between context, process, and content
elements of change may explain thesecontradictoryresults. Morespecifically, threethemes that appear crucial in
e-Health implementation inrural communitiessurfaced:the dual effects of geographicalisolation,the targeting of
underprivilegedgroups, and thechangesinownershiprequired for sustainable e-Healthadoption.
Conclusions: Rural e-Health implementation is anemerging, rapidly developing, field. Too often,e-Healthadoption
fails due to underestimating implementation factors and their interactions. We argue thatrural e-Health
implementation onlyleads to sustainable adoption(i.e. it “sticks”) when the implementation carefully considers and
aligns the e-Health content (the“clicks”),the pre-existing structures inthecontext (the“bricks”),and the
interventions in theimplementation process (the“tricks”).
Keywords: e-Health services, Rural, Implementation, Adoption, Context, Process, Content
*Correspondence:[email protected]
DepartmentofInnovationManagement&Strategy,UniversityofGroningen,
PObox800,9700AV,Groningen,Netherlands
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Background Our research question is formulated as follows: How
Recently,therehasbeenincreasingawarenessoftheso- do context, process, and content factors of e-Health im-
cietal consequences of aging. Around the world, fertility plementation influence its adoption in rural communi-
rates are dropping and life expectancy is increasing ties? To answer this question we need to know 1) what
such that societies are faced with an ageing population e-Health services are implemented in rural communities
[1]. Aging will not only increase the need for healthcare and for what purposes, and 2) which factors promote or
services, and consequently increase healthcare costs restrain e-Health services adoption by the targeted
[2,3], it will have an impact on all spheres of human group ofresidents?
life: the economic, the social, as well as the political In our review, the term ‘e-Health services’ refers to
spheres [1,4]. any interactive communication and information techno-
Ruralcommunitieswillbeespeciallyaffectedbyagingas logy aimed at enhancing community quality of life and/
they are confronted with the out-migration of working- or individual health outcomes. This wide-ranging defi-
age adults from rural to urban areas and the in-migration nition was chosen for a number of reasons. First, since
of former urban dwellers, often at retirement age [1,5,6]. to the best of our knowledge no reviews have been con-
Thesedemographictrendshaveraisedconcernsaboutthe ducted on rural e-Health implementation factors, pro-
quality of life and health in rural communities [5,7]. viding a broad overview is a logical first step. At a later
e-Health services are seen as one solution to these con- stage such an overview can act as a starting point for
cerns [8-16], with e-Health as diverse as web portals and researchtargetedatspecifictypesofe-Healthimplemen-
domoticaa [17,18], and possibly encompassing both core tation. Second, as the rural community is of special
healthcareservicesandsocialinnovation(see,forexample, interest to this study, a general definition of e-Health
[19]). European policymakers are investing heavily in e- allows us to pay extra attention to community-directed
Healthdevelopments[20],bute-Healthimplementationis e-Health applications in addition to those directed at
not always successful. While e-Health implementation individual health. Thus, this definition allows including
within organizational settings is known to have adoption all potentially relevant e-Health initiatives in rural
problems[21],fewstudieshaveaddressedthepeculiarities communities.
andparticularitiesofe-Healthinruralcommunities.Avai-
lable studies report non- [22,23] or only partial [24,25] Theoreticalframework
adoption. A systematic overview of e-Health implementa- In view of the dispersed nature of the e-Health imple-
tion factors specific to rural communities, however, is mentation literature that originates from different scien-
lacking. The rural context deserves further study as rural tific disciplines, we needed a flexible, but also solid
communitiesmayhavegreaterneedfore-Healthservices, framework to coherently organize the selected papers’
not only because the aging process increases health care empirical findings. We draw on Pettigrew and Whipp’s
demand, but also because of local scarcity of alternative classic model of strategic management of change [26],
services and of health personnel. Moreover, implementa- which hasbeenwidelyapplied incomparative case study
tionofe-Healthservicesmaybeharder,duetoe.g.lackof research across many sectors and organizational con-
infrastructure. This makes rural e-Health implementation texts [27-29], as well as in studies on the implementa-
especially relevant and challenging at the same time. This tion of innovations in healthcare [30,31]. This model
the rationale for this study and leads to the following re- generates insightby analyzing three interactive elements;
searchaim. “context”, “process”, and “content” that together shape
any strategic change. A guiding assumption [32] is that
Studyaimandoverview not only the change content, i.e., the e-Health applica-
This systematic literature review aims to contribute to tion, but also the change contextandprocess havearole
our understanding of the implementation factors that in explaining change outcomes, i.e., adoption outcomes.
determinesuccessful e-Health adoptionin rural commu- Much evidence supports this assumption [33,34], inclu-
nities. Such an understanding could improve policies ding the interactive nature of their explanatory roles
and strengthen programs directed at enhancing living [20,35,36]. In our search for implementation factors that
conditions in rural communities and thereby the quality either promote or restrain e-Health adoption in rural
of life and health of their inhabitants. Following the areas, this model allows to systematically assign each
change model of Pettigrew and Whipp [26], this review surfacing factor to one of these three robust, yet well-
identifies and classifies implementation factors in terms defined categories.
of the “context”, “process”, and “content” of the health Change outcomes can be intended or unintended [37],
intervention studied. Moreover, we explore patterns in and can affect the individual as well as the community
which these implementation factors merge to trace pos- as a whole. In order to apply Pettigrew and Whipp’s
sible interactionsbetweenthem. model to e-Health implementation in a rural community
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context, we translated their conceptual definitions into conclusions on what is known about the implementation
operational definitions closely fitting our research do- andadoptionofe-Health inruralcommunities.
main(seeTable1).
Themethodsection belowexplainsthepaper selection Methods
and search procedures applied as well as our classifica- Aimingtoincrease understanding oftheimplementation
tion and data analysis methods. In the results section, factors that determine the success of e-Health adoption
we then examine the research perspectives adopted in in rural communities, we conducted a systematic litera-
the selected papers, and analyze their empirical findings ture review. The review followed a thematic analysis ap-
in terms of implementation factors that promote or re- proach, which is especially well equipped to handle both
strain e-Health adoption. In the discussion section, we qualitative andquantitativedata [40,41].
reflect on why the identified implementation factors
might influence e-Health adoption in rural communities Inclusionandexclusioncriteria
and how they may work together in doing so. This leads Before starting our search, we defined six inclusion and
to potential areas for future research. Finally, we draw exclusion criteria. Criteria concern study population
Table1Classificationframeworkwithconceptualdefinitions
Interactiveelementsandtheirdefinitions Factorswithineachelementandtheirdefinitions
Ruralcontext
Geographicalareawithlowpopulationdensity,limitedresourcebases, Socioeconomicvariables - Thesocialandmonetaryenvironmentin
relativeisolation,andculturalorethnichomogeneity[38],andthe whichthecommunityislocated.
accompanyingpolitical,economic,social,andtechnological
Individualresourcesandcapabilities- Factorsthatinfluencetheabilityof
developments.
ruralresidentstoadopte-Health.
Aneedfore-Health - Situationwheree-Healthcansubstituteforservices
thathavedisappearedorsupplementexistingservicesinawaythatrural
residentsperceiveasuseful.
Thirdpartyinvolvement - Involvementofactorsorstakeholdersthatdo
notbelongtothetargetedusergroup.
ImplementationProcess
“Streamsofactivityacrosstime”[26:39]undertakenwiththeaimof Implementationteam- Stakeholdersthatinitiateorpromotechange(a
implementinge-Health. singlestakeholderoracoalitionofstakeholders).
Implementationstrategies - Assumptionsofhowchangeneedstobe
executed,formulatedwiththeaimtoimplemente-Health.
Bottom-upstrategy - Implementationstrategybasedonsharedproject
ownershipbasedonhorizontalrelationshipsbetweenstakeholders.
Top-downstrategy - Implementationstrategybasedoncentralized
projectownershipwithverticalrelationshipsbetweenasingle
stakeholderandexternalactors.
Resourcemanagement -Strategicallocationofscarceresources.
Conflictmanagement - Managementofcompetingstakeholderinterests
aswellastheirideasontheproject.
Peopleandorganizationalissues- Problemsamongindividualsand
organizationsthatoccurwhenimplementinge-Health,suchaswith
technicalsupport.
e-HealthContent
Referstoanyinteractivecommunicationandinformationtechnology Projectdesign - Thesetofsharedideasaboutwhattheprojectis,
aimedatenhancingthequalityoflifeand/orhealthoutcomesinthe includingitsaims,costs,andconditionsforsuccess.
broadestsense[39].
e-Healthdesign - Technicalanduserfeaturesoftheimplementede-
Health.
Sustainability - Theenduringadoptionofthee-Healthcontent.
AdoptionOutcomes
Thedegreeofadoptionbythetargetedgroup,leadingtoindividualand Individualleveladoptionoutcomes - Theeffectsthattheimplementede-
community-leveloutcomes. Healthhasontheindividual’shealth.
Community-leveladoptionoutcomes - Theeffectsthattheimplemented
e-Healthhasonthequalityoflifeintheruralcommunity.
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(inclusion and exclusion criteria 1–2), type of e-Health Within this strategy only peer reviewed papers were
intervention (3–4) and study type (5–6). The inclusion allowed.
and exclusion criteria are: 1) the papers focused exclu- In the database “Embase”, the search was carried out
sivelyonruralcommunities,orexplicitly madeadistinc- according to search strategy 2; keyword from “category
tion between urban and rural communities (for a a” and keyword from “category b” and keyword form
definition of rural community seeTable 1); 2) the papers “categoryc”.Nofieldlimitswereapplied.
focused on the rural community as a whole, not on a In the database “MUSE”, the search was carried out
specific group or minor characteristic within the group according to search strategy 3; keyword from “category
(e.g. a specific disease); 3) e-Health was considered as an a” (in the field of “all fields”) and keyword from “cat-
interactive mechanism (e-Health is further defined in egory b” (in the field of “all fields”) and keyword from
Table 1); 4) there was a relationship between the three “categoryc”(inthefieldof“allfields”).
keyword categories such that category “c” influences cat- In the database “Web of Science”, the search was car-
egory “a” in an environment defined by category “b” ried out according to search strategy 4; keyword from
(keyword categories are laid out in the search strategy “category a” (in the field of “Topic”) and keyword from
section); 5) they were empirical studies addressing im- “category b” (in the field of “Topic”) and keyword from
plementation published in peer-reviewed scientific jour- “category c” (in the field of “Topic”). The last search was
nals; 6)thepapers were writteninEnglish. conducted on 31 May 2011. Identified studies were then
divided among two researchers (EH and JPR) and separ-
Searchstrategy ately analyzed.Inorderto reachaconsensus andmutual
In order to ensure that this review encompassed all understanding of the inclusion criteria, both researchers
the relevant literature on the latest developments in assessed and compared their interpretations. In this as-
e-Health adoptionin rural communities the four authors sessment, the researchers each independently selected
formed an interdisciplinary research team. Together we three papers that they interpreted as highly relevant to
outlined a specific search strategy that included five the research question and therefore fitting the inclusion
databases: “EBSCO1”, “EBSCO2” “Embase”, “MUSE”, criteria, three papers that did not match the criteria, and
and “Web of Science”. The “EBSCO” database was three papers where the researcher was not sure whether
divided into two separate databases. EBSCO1 focuses on to include or exclude the study. These papers were then
healthcare (“PsycINFO”, “CINAHL” and “MEDLINE”) evaluated by the other researcher. The research team
while EBSCO2 provides a broader view (“Business discussed the differences in interpretations or doubts
Source Premier”, “Academic Search Premier”, “EconLit” and this led to a further sharpening and refining of the
and “SocINDEX”). The search was conducted using inclusion criteria.
three categories of keywords: category a) “quality of life”, Alongside these inclusion and exclusion criteria, the
“social network”, “social cohesion”, “wellbeing”, “em- papers were subjected to a quality assessment. Two
power*”, “ownership”, “community participat*”; category methodological quality checklists, one focusing on quali-
b) “rural”, “deprived area”, “remote area”; and category tative research and the other on quantitative research,
c) “e-Health”, “e-care”, “tele*”, “ICT”, “information tech- were applied. These quality checklists were based on
nology”, “communication technology”, “communication previous checklists used in various research fields
system”, “information system”. In each search, one key- [42-45]reflectingtherangeofpapersselected.
word from each category was used, resulting in 168 As with the selection process, the quality assessment
search combinations. was also conducted independently by the two research-
A pilot research was conducted in the Web of Science ers. During an initial quality assessment trial, the two
database and detailed notes were kept of this process researchers (EH and JPR) each evaluated four papers’
(includingnotesonexact searchentrymethodandnum- methodologies and then compared their conclusions.
ber of hits per search combination). Nevertheless, as the Since there were only minor deviations (in less than 10
search engines of each database include slightly different percent of judgments), no corrective measures for asses-
search options, there was a short learning curve each singthemethodologicalquality weretaken.
time we started searching a new database. In order to As a final check on exhaustiveness, the reference lists
acquire all relevant papers, we attempted to create the of selected papers were scanned for any further relevant
widest search possible. studies. In addition, we scanned reference lists of articles
In the database “EBSCO1” and “EBSCO2”, the search key tothepapersunderreview.
was carried out according to search strategy 1; keyword
from “category a” (in the field of “left open”) and key- Dataanalysis
word from “category b” (in the field of “left open”) and Theresulting papers were each characterized interms of
keyword from “category c” (in the field of “left open”). the country or region of data collection, the research
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field, the research aim, and the type of research (qualita- 5,683 remaining papers were excluded because they did
tive/quantitative data, data collection method and num- not meet all the inclusion and exclusion criteria 3–6 (see
ber of cases/sample size). The papers were categorized Inclusion and exclusion criteria subsection above). Of the
according to the focus of the research question and data. 54papersremaining,11wereexcludedbecausetheirqua-
A classification matrix was used to carefully map each litywasjudgedinsufficientforourpurposes(seeInclusion
paper’sfocus, andwewillshowintheresultssectionhow and exclusion criteria subsection). A search of the refer-
the focus of the papers varied. Each paper’s empirical fin- encelistsofthese43includedpapersandofthereference
dings were categorized according to the classification listsoftheirkeyreferencesyieldedeightadditionalstudies.
matrix into factors belonging to “context”, “process”, and Thus, our final sample amounted to 51 papers that met
“content” elements, and related to the reported “adoption theinclusioncriteriaandsufficientlypassedthequalityas-
outcomes”.Finally,afteranalyzingtheresultingpromoting sessment, see Figure 1. Additional file 1 presents the
and restraining factors, propositions were formulated for selected papers and their main results. Of the 51 relevant
furtherresearch. and qualified papers, 26 papers adopted a quantitative re-
search approach, 14 used a qualitative research approach,
Results and11papersusedamixedapproach.Twopapers[22,23]
Includedstudies usedthesamedataandanalysisandwerethereforejointly
Throughthissearchstrategy,5,896paperswereidentified. analyzed. Other papers that studied the same cases
After an initial screening we excluded 213 papers that ([46-48] and [49,50]) or used similar datasets ([51-53],
wereeither duplicates or not written in English.Based on [54,55]and[56,57])wereanalyzedseparatelyas theywere
the title, abstract, and discussion, 5,629 papers of the toodissimilartocombine.
Categories of search keywords 168 search combinations
Web of Science: EBSCO 1 EBSCO 2 Embase: 182 MUSE: 3813
1106 potentially (healthcare): (socio-econ.): potentially potentially
relevant papers 564 potentially 231 potentially relevant papers relevant papers
relevant papers relevant papers
5896 papers retrieved for initial screening
213excluded
(duplicates /
non-English)
5683full text papersfor further
screening
5629excluded
based on title
and abstract
54relevant papersfor further
assessment
11excluded
based on
quality
43relevant & qualifiedempirical
papers
8 included
based on search
of reference lists
51relevant & qualifiedempirical
papers
Figure1Flowchartofstudyselectionprocess.
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Although some of the papers were more than ten years studied asamediumforreinforcing orchanging
old, the majority were much more recent, with a sharp socialstructuresinviewoflongtermhealthand
increaseinrelevantpublicationsin2010–11(seeTable2). wellbeing.Alarge shareofthenon-Westernstudies
Rural e-Health implementation can thus be seen as an focusedonprojectsimplementing
emergingandrapidlydevelopingfield. telecommunicationapplications.
4.Community networks[24,46-48,78-81]areanalyzed
Sub-question1:Whate-Healthservicesareimplemented fortheirabilitytoimproveaccesstoinformation,and
inruralcommunitiesandforwhatpurposes? particularlylocalinformation. Inaddition,
Thirty-five of the included papers reported on a specific communitynetworksarebelievedtohelpbridgethe
e-Health implementation project. An example is a study digitaldivide (such asbetweenruraland urbanareas
on the effectiveness of a telehealthvideoconferencing sys- and between lowand highincome groups) and to
tem[8].Theremaining16papersreportedonthepopula- empowerruralcommunities (project leveln=8).In
tion level and studied e-Health adoption patterns and additiontotelecommunication,alargeproportionof
outcomes in general, yet within a specific population. For thenon-Western studiesfocusedoncommunity
example, one study focused on general e-Health adoption networks.
outcomes based on healthcare practitioners’ perceptions 5.Webportals [12,82,83]areusually believedto
of telehealth adoption in rural settings [58]. Both sets of improveaccesstoinformation, suchashealth-related
papers focused on a variety of e-Health services, we dis- and marketinformation (project leveln=3).The
cernedsixcategories: studies onwebportalsalloriginatefromWestern-
orientedcountries.
1.Internetand social media [25,51-57,59-68]based 6.Acomputerlab [78,84,85]isusually implementedin
servicesaredevelopedforpurposes rangingfrom a schoolsettingand hasan(e.g. health) educational
economicdevelopmenttoempowermentand purpose(projectleveln=3).Althoughsmallin
bridging thedigitaldivide,asshownintheproject number,these studieswere conductedinWestern
levelstudies (n=7).Thepopulationlevel studies and non-Westernorientedregions.
(n=11)usually focusontheir adoption outcomes,
especiallysocialconnectivityand accessto Table 3 presents an overview of these six categories
information. Thesestudieswere conductedinboth andlinksthemtothee-Healthoutcomestargeted.
non-Westernand Western oriented(North-America,
Europe andOceania) regions.
2.Videoconferencing andtelehealth Papers’perspectives
[8-10,13,14,22,23,58,69-74]are typicallyappliedin The papers reflected different perspectives on how
servicesaimingtoenhance thequalityoflifeby e-Health is adopted in rural settings and we were able to
improvingboththeaccessibilityand quality ofthose identify five categories (A, B, C, D, and E), which we
healthservices(projectleveln=10,populationlevel outline below. While some papers took only one angle,
n=4).Weonlyfound studies onvideoconferencing others covered several perspectives. None of the papers
and telehealth inWesternorientedcountries. involved all the categories. Figure 2 summarizes the
3.Telecommunicationapplications(mobilephones) number of papers per perspective (see also Additional
[11,49,50,61,64,75-77].Likeinternetand socialmedia file1).
these areused toachieveawiderangeofoutcomes. A: Individual and community characteristics. Thisper-
Examples include savinghealthcare costsby spective considers the individual and community level
diagnosingapatient’sproblemsfrommobilephone contextual factors (e.g. age, income, education level, so-
photographs,andenabling learningamongrural cial structures, local political climate) that influence
womenkeepinggoatsbysendingthem voicemail e-Health adoption. Researchers adopting this perspective
messages(projectlevel n=5);Atthe populationlevel examine who is most likely to adopt e-Health. Linking
(n=3),telecommunicationapplications aremainly this perspective to the elements of strategic change
Table2Numberofpaperspublishedbyperiod
Year Paperno.
1995-99 47,74(n=2)
2000-04 8,23,24,46,48,49,56,57,64,73,80,83(n=12)
2005-09 11,12,13,22,25,50,51,53,54,58,59,62,65,68,69,71,77,78,79,81,82,85(n=22)
2010-11 9,10,14,52,55,60,61,63,66,67,70,72,75,76,84(n=15)
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Table3Typesandaimsofe-Health
Typeofe-Health Papernumbers Aimrelatedto
Internetandsocial 25,51,52,53,54,55,56,57,59,60,61,62,63,64,65,66,67,68 Socialcontact(51,52,53,60,61,63,66);Economicdevelopment
media (55,56,57,61,63,65,68);Accesstoinformation(52,53,62,64,67);Empowerment
(55,57,59,61,65,67);Health(55,59,62,67);Bridgingdigitaldivide(25,63,54,67);
Qualityoflife(general/other)(55,61,65);Education(55,61);Reducingcosts/
time(63).
Videoconferencing 8,9,10,13,14,22,23,58,69,70,71,72,73,74 Health(8,9,10,13,14,22,23,58,69,70,71,72,73,74);Bridgingthedigitaldivide
andtelehealth (13,14,58,69,70,71,72);Reducingcosts/time(13,22,23,58,73,74);Education
(8,10).Accesstoinformation(71);Socialcontact(10).
Telecommunication 11,49,50,61,64,75,76,77 Accesstoinformation(49,50,61,64);Education(61,75);Reductioncost/time
(mobiles) (11,50);Health(11,61);Qualityoflife(general/other)(61,77).Bridgingdigital
divide(50);Socialcontact(61);Economicdevelopment(61).
Community 24,46,47,48,78,79,80,81 Accesstoinformation(24,46,47,48,80,81);Bridgingthedigitaldivide
networks (46,47,48,80);Empowerment(47,78,79,81);Reducingcosts/time(24);Health
(78);Economicdevelopment(78,79);Education(78);Socialcontact(78).
Webportal 12,82,83 Accesstoinformation(12,82,83);Health(12,82);Bridgingthedigitaldivide
(83).
Computer 78,84,85 Education(78,84,85).
laboratory
proposed by Pettigrew and Whipp [26] emphasizes ways e-Healthcontentandthelocalcontextareadjustedtoeach
in which contextual factors can influence e-Health other(e.g.throughtrainingormanagementstrategies).
adoption. D:Communityshapingofe-Health.Thisfocusaddresses
B: e-Health shaping context. This perspective focuses howcommunitieshaveparticipatedduringtheimplemen-
on the contextual effects of e-Health adoption and con- tationphaseofane-Healthproject.Here,therelationships
ceptualizes the relationship between e-Health content between context and process, which were also present in
and context. Two sub-categoriescanbeidentified.Firstly, the previous focus (C), are also applicable. The difference
B1whereeffects aremeasuredonthe individuallevel and betweenperspectivesCandDisthatDemphasizesshared
papers discuss how individuals have been affected by projectownership,whereasCemphasizesanimplementa-
e-Health(e.g.intermsofaccesstoinformation,wellbeing) tion process that can have both centralized and shared
and, secondly, B2 where communities as a whole are the projectownership.
focus(e.g.widersocialnetwork). E: Individual appropriation of e-Health. These papers
C: e-Health implementation. Papers adopting this per- focus on how individuals adopt e-Health. They address
spectiveaddresshowe-Healthserviceswithspecificcharac- questionssuchas;howaree-Healthservicesincorporated
teristics are implemented in a particular context. The inanindividual’severydaylife?Theemphasisisonindivi-
emphasisisontheprocess(i.e.activities)throughwhichthe duals finding appealing and innovative ways to use
Different perspectives
Total 51
A 27
B1 22
B2 6
C 19
D 5
E 8
0 10 20 30 40 50 60
Figure2Numberofpapersperperspective.
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e-Health given the original functionalities. In terms of contribute by facilitating an easy way to communicate.
PettigrewandWhipp’sstrategicchangeelements,perspec- Those with ICT skills, or those who are familiar
tiveEstudieshowtheindividualcontextaffectstheappro- with other technologies, are also more likely to adopt
priationofthee-Healthcontent. e-Health. Furthermore, if individuals are highly involved
Figure 2 shows that only a few of the 51 papers intheircommunitytheymayidentifye-Healthasapublic
selected address perspectives B2, D, and E. This finding responsibility and start to maintain the e-Health service,
highlights the limited availability of data on how and through this maintenance usage will increase. The
e-Health shapes the community, and how communities third category emphasizes the need for e-Health. If alter-
shape e-Health through their involvement in the imple- native supply of information or services is low, e-Health
mentationprocessandthroughindividualsappropriating can serve as a substitute. Needs that motivated people to
e-Health. Nevertheless,these perspectives arerelevant as adopt e-Health included: having greater anonymity, be-
we will show in our discussion where we explore pos- coming self-reliant, helping others understand e-Health,
sible interaction effects between context, process, and andgainingaccesstoinformationandservices.
content elementsof change and develop propositionsfor Contextual factors restraining e-Health can be divided
futureresearch. into three categories;socioeconomic variables,individual
characteristics, and third parties (see Table 5). Some of
Sub-question2:Whichfactorspromoteorrestrain the previously listed promoting factors are also present
e-Healthservicesadoption? here as restraining factors in an antonymous form
We have identified the factors that have been reported (i.e. the different influences of low and high incomes).
as either promoting or restraining e-Health adoption. Firstly,socioeconomic variablescanfunctionasarestric-
Using Pettigrew and Whipp’s elements of change, these tion when it comes to accessing e-Health (e.g. older
factors have been classified as context, process, or con- population, low income/poverty, unemployment, geo-
tent factors. The factors are then categorized and linked graphical isolation). In addition, structural social in-
tothepaper’sreference numberandperspectives. equalities (e.g. gender inequalities, caste system) are
reflected in unequal e-Health access and therefore pat-
Context terns in adoption. Secondly, individual resources and
Contextual factors promoting e-Health can be divided capabilities can be a restraining variable when they di-
into three categories (seeTable 4). The first category fo- minish the ability of an individual to adopt e-Health.
cuses on socioeconomic variables. Living in a geograph- Reasons can be a lack of ICT skills, illiteracy, having
ically isolated area increases the need for “experiential local rather than non-local ties (making it unnecessary
information” [12], and therefore there is a positive rela- to adopt e-Health to communicate), lack of mobility to
tionship with e-Health adoption. Younger people and explore non-local ties, and a negative self-perception.
those with higher incomes are more likely to adopt Thirdly, third parties can influence the ability of the
e-Health. Further, familycomposition influencese-Health individual to access e-Health. Relevant factors here in-
adoption (positively for married couples and families clude a negative relationship with teachers (such as
with children). Secondly, an individual’s resources and women being afraid to go to training sessions because
capabilities can be a promoting factor. When an indivi- theteacher istoointimidating),unwillingandcompeting
dual has a network of non-local ties, e-Health can third parties (preventing the e-Health implementation
Table4Contextfactorspromotinge-Healthimplementation
Category Factor Paperno. Paper
perspective
Socioeconomicvariables Geographicalisolation 12,13 A,B1,E
Demographics(lowage,male,married,familycomposition 11,14,24,48,49,51,53,54, A,B1,B2,C,E
includeschildren) 60,62,63,69,79,83
Highoccupationstatus,highincome 47,48,49,53,54,62,63,64,79 A,B1,B2,E
Individualresourcesand Havingnon-localties 52,53 A,B2
capabilities
ICTexperienced 14,47,48,54,72,82 A,B1,C
Highlyeducated,highliteracy 47,49,53,61,62,63,69,79 A,B1,B2,C,E
Politicalandcommunityinvolvement 46,47,48,52,53,85 A,B2,C,D
Aneedfore-Health Lackoforbarrierstoservices/information 8,12,13,24,52,59,78 A,B1,B2,C,E
Fulfillingaspecificneed 13,25,49,54,76,59 A,B1,B2,C,D,E
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Table5Contextfactorsrestraininge-Healthimplementation
Category Factor Paperno. Paper
perspective
Socioeconomicvariables Demographics(highage,female,single,havingno 11,14,24,48,49,51,53,54,60,62,63,69,83 A,B1,B2,C,E
children)
Unemployment,lowoccupationstatus,lowincome 24,46,47,49,54,57,60,83 A,B1,C,D,E
Geographicalisolated 9,24,62,63,64 A,B1,B2,C
Genderedsociety,castesystem 24,49,75 A,B1,C,D,E
Individualresourcesand LackofICTskills 12,52,59,61,63,64,75,83 A,B1,B2,C,D,E
capabilities
Loweducated,illiteracy 49,60,75,80,83 A,B1,B2,C,D,E
Havinglocalties 51,52,53,66 A,B2,E
Inadequatephysicalormentalcondition 12,14,22,23,72 A,B1,C,E
Thirdparty Teacher/studenthierarchy 75 B1,D,E
Unwillingthirdparty 24,52,60 A,B1,B2,C
Availablealternativesforreceivingservices/information 22,23,51 A,B1,C,E
achieving a solid form), and parties that facilitate alter- practices; bottom-up strategy; and top-down strategy
native media (such that the demand for care or commu- (see Table 6). Firstly, if the implementation team is regio-
nication ismetbyother,non-e-Health, programs). nally based this is considered to be a promoting factor
because this will make it more likely that they understand
Process thelocalissuesandthevillagers.Notsurprisingly,whenthe
Processfactorspromotinge-Healthcouldbe classifiedinto project staff members are more capable, better skilled, and
four categories: implementation team; implementation motivated this will have a positive effect on e-Health
Table6Processfactorspromotinge-Healthimplementation
Category Factor Paperno. Paper
perspective
Implementation Regionallybasedimplementationstaff 22,23,80 B1,B2,C
team
Capable,skilled,motivatedimplementationstaff 22,23,70,77,84,85 A,B1,C,D
Implementation Training 8,10,14,24,25,48,55,63,75,78,80,83,84, A,B1,B2,C,D,
practices 85 E
Implementationstrategytomotivatepeople(bothfromwithinandwithout) 47,49,79,80 A,B1,B2,C,E
Bestpractices 10,22,23,70,84,85 A,B1,C,D
Quickwins 65,70 C,D
Evaluationandfeedbackloopsbothbottom-upandtop-down 22,23,25,84 B1,C,D
Bottom-up Workwithexistinglocalcommunitynetworks 48,63 A,C
strategy
Partnership:localresidentsaspartnersfromanearlystageaddvalueandknow 65 C,D
theirneeds;objectivesandrolesshouldbetransparent
Inpublicallyfinancedprojects,civicleadersneedthesupportofpolitically 48 A
activecitizens
Unbiasedmediatorrole 25,65 C,D
Useofpilotimplementationprojects 65,85 A,C,D
Top-down Planneddiffusionstrategywithaneed-basedproduct/service 58 B1
strategy
Whencomputerresourcesarelefttothemarketplace,economyfactorswill 48 A
dominate
Implementationleadership,creatingcollectivelearningthroughopenness 80 B1,B2,C
Top-downdecision-makingthroughlocalpoliticians 9 B1
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adoption. Secondly, the most valuable implementation for success. This will promote e-Health adoption when
practice is training the users so as to facilitate them in the design includes the following factors: the e-Health
adoptinge-Health.Thisalsoincludesstrategiestogetusers project is tailored to specific and agreed needs; the tech-
involved with e-Health. Moreover, best practices, quick nology is publicly available and accessible; technological
wins,evaluation,andfeedbackareallfactorsthatpositively artifacts are similarly interpreted by stakeholders; and
influence e-Health adoption. Thirdly, for the promoting realistic and pragmatic goals are set for both develop-
factorofa“bottom-upstrategy”,itisvitaltoworkwiththe ment and adoption in line with the available funding.
local community. Moreover, through cooperating with The second type of promoting factor in the e-Health
equal partners and politically active citizens, needs and content is an appropriate e-Health design, which essen-
roles can be aligned. Furthermore, it is important to have tially means that the technical design features have to fit
anunbiasedmediatorwhofocusesoncraftingasustainable the local context. Moreover, the technology needs to be
e-Health implementation. Fourth, a top-down strategy can reliable, flexible, mobile, ergonomic, user-friendly, and
alsobesuccessfulifitusesaplanneddiffusionstrategywith have a high image quality where applicable. The third
an identified needs-based e-Health service. Through using group of factors concerns sustainable e-Health content
the market place, economic factors are dominant in adoption. If stakeholders are made contractual partners,
e-Health adoption. Further, collective learning can take they become part of the e-Health implementation
place if one provides implementation leadership that com- process. Through such contracts, stakeholders commit
municateswithdiversegroups. to a long-term economic stake. Moreover, the collabo-
The process factors found to restrain e-Health were ration among stakeholders will benefit when their roles
assigned to three categories: insufficient resources; con- are transparent, in terms of objectives, benefits, and out-
flict potential; and people and organizational issues comes,andthisshouldbeanessentialpartoftheproject
(see Table 7). The first category, insufficient resources, design.
includes situations where projects lack the authority or Content factors that restrain e-Health can be classified
financial means to improve vital parts of the implemen- into two categories: project design; and e-Health design
tation process. As a consequence, these projects lack the (see Table 9). The “project design” category explores
capability to be successfully completed. Secondly, the those factors in the design of a project that restrict the
“conflict potential” category includes factors that reflect adoption or usage of e-Health services. Here we find
a lack of consensus and commitment among key stake- that low levels of availability and accessibility negatively
holders. Further, it includes the inadequate distribution affect e-Health adoption. The “e-Health design” category
of decision-making power (or ownership) among stake- covers restraining factors related to design features of
holders. Thirdly, the “people and organizational issues” the e-Health service, including having e-Health services
category describes problems among individuals and be- that do not meet a demand, funding problems, or an
tween organizations that can occur when implementing overly complex systemthatisdifficulttouse.
e-Health and includes factors related to technical sup-
portproblems,logisticalproblems,andregulatoryissues. Discussion
In the previous section we analyzed which factors pro-
Content mote or restrain e-Health service adoption within the
Three types of promoting factors in the content of context,process,andcontentelementsofchange.
e-Health can be discerned: project design; e-Health de- To summarize, we have identified, in all the elements
sign; and sustainability (see Table 8). Firstly, the project of change (context, process and content), key promoting
design should contain a set of shared ideas about what and restraining factors related to e-Health adoption in
the project is aiming for, the costs and the conditions rural communities. The identified factors in this review
Table7Processfactorsrestraininge-Healthimplementation
Category Factor Paperno. Paper
perspective
Insufficientresources Projectsthathavenoauthorityorfinancialmeansandlackthecapabilitytoimprovevital 24,58,84 A,B1,C,D
partsoftheimplementationprocess
Conflictpotential Lackofconsensus,decisionpower,andcommitmentamongkeystakeholders 24,25,58 A,B1,C,D
Peopleand Problemswithtechnicalsupport 24,78 A,B1,C
organizationalissues
Logisticalproblems 22,23,24,58,84 A,B1,C,D
Regulatoryissues 25 C,D