14 Chapter 1 1 Challenge two: user non-adherence and disengagement A significant challenge encountered in the use and uptake of eHealth is nonadherence, referring to the extent that users use or keep using the intervention in the desired way (27, 28). One key factor contributing to non-adherence is the lack of user engagement with the technology or engagement for a brief time (29, 30). Engagement encompasses a broader set of psychological and behavioural factors related to individual’s interaction and involvement with digital health technologies (31). As such, it reflects the level of interest, motivation, and connection users have with the technology (32). To enhance user-engagement gamification principles are increasingly being integrated into the design of eHealth, aiming to make the digital health technology more appealing, motivating and engaging for users. These game design elements can be very specific, such as the inclusion of “badges” or “levels” in the interface, or they can be more comprehensive, such as incorporating a storyline to clarify personal behaviour change goals or stimulate enduring play (33). Persuasive game design has been applied in behaviour change-based eHealth interventions as means to encourage people to modify their behaviour (34), for instance by influencing people’s attitudes to certain behaviour or by building new skills within the game world that can be applied in real-life situations (35). While engagement plays a significant role in the adoption of and adherence to eHealth intervention, it is important to note that disengagement does not always imply non-adherence. The duration or frequency of use required to achieve the desired (behavioural) outcomes (e.g. increased medication adherence) may vary among different technologies and user groups (27). This is particularly true with digital health technologies that target behaviour change as the desired outcome. In such cases, disengagement from eHealth may be justified if the desired behaviour change has been accomplished, through for example the formation of a habit (36). Non-engagement is in these instances is not a consequence of, for example, losing interest. Challenge three: missing those who benefit most While the technology itself plays an essential role in engagement to and use of eHealth solutions specific user characteristics are equally important (29). Studies investigating demographic factors associated with lower eHealth usage have found that older adults, individuals with chronic diseases living alone, and those with lower income and/or education were less likely to use eHealth solutions (37). Another study showed that having a lower socio-economical position, indicated by lower levels of education and income, was associated with limited access to digital technologies and digital healthcare services (38). Consequently, individuals with lower socio-economic position are more likely to have lower levels of digital health literacy and health literacy compared to those with higher socio-economic position. Considering the association between limited health and digital literacy with lower eHealth usage and the recognized role of (digital) health literacy in reducing health inequality,
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