IT-Enabled Self-Monitoring for Chronic Disease Self-Management:

An Interdisciplinary Review

Jinglu Jiang*

Department of Information Technologies, HEC Montreal

3000, chemin Côte-Sainte-Catherine

Montréal, QC

H3T 2A7

CANADA

[email protected]

Ann-Frances Cameron

Department of Information Technologies, HEC Montreal

3000, chemin Côte-Sainte-Catherine

Montréal, QC

H3T 2A7

CANADA

[email protected]

* Jinglu Jiang is the corresponding author on this paper.

1
 IT-Enabled Self-Monitoring for Chronic Disease Self-Management:

An Interdisciplinary Review

ABSTRACT

Self-monitoring is a strategy that patients use to manage their chronic disease and chronic

disease risk factors. Technological advances such as mobile apps, web-based tracking programs,

sensing devices, wearable technologies, and insideable devices enable IT-based self-monitoring

(ITSM) for chronic disease management. Since ITSM is multidisciplinary in nature and our

understanding is fragmented, a systematic examination of the literature is performed to build a

holistic understanding of the phenomenon. We review 159 studies published in 108 journals and

conferences between 2006 and 2017. By adapting Affordance Actualization Theory, we develop

an overarching framework to organize the existing literature on ITSM for chronic disease

management. Four themes emerge: key ITSM functionalities that enable affordances; effects on

ITSM system use; effects on the achievement of chronic care goals; and the role of intermediary

outcomes. For each theme, we identify what is known, what is unknown, and opportunities for

future research. We also discuss cross-theme opportunities for future research where more

diverse theoretical perspectives can contribute to our understanding of the phenomenon. This

work provides research directions for IS researchers studying ITSM for chronic disease self-

management.

Keywords: IT-based self-monitoring, chronic disease self-management, literature review, ITSM

use, affordance actualization theory

2
Acknowledgements:

This research was supported by the Social Sciences and Humanities Research Council of

Canada. The authors wish to thank the senior editor, Dr. Elena Karahanna, for her exceptional

advice and guidance on our work. We also thank Dr. Jane Webster, Dr. Suzanne Rivard, the

members of the HEC Montréal Research Group on Information Systems (GReSI), and

anonymous reviewers for their helpful comments on earlier versions of this work.

Author bios:

Jinglu Jiang is a Ph.D. candidate at HEC Montreal. She received her MSc in Management

Information Systems from the Smith School of Business, Queen’s University in Canada, and her

B.S. from Shanghai University of Finance and Economics in China. Her research focuses on

consumer health informatics, digital platforms and individual IS use and impacts.

Ann-Frances Cameron received her Ph.D. from Queen's University in Canada. She is an

associate professor of IT at HEC Montreal and holds the Professorship of Information

Technology and Multitasking. She has published in a variety of journals including Information

Systems Research, Organization Science, Information & Management, and Journal of

Occupational Health Psychology. Her research interests include the use and impact of new

technologies for inter- and intra-organizational communication.

3
 IT-Enabled Self-Monitoring for Chronic Disease Self-Management: An Interdisciplinary

Review

Chronic diseases, such as diabetes, obesity and asthma, are among the most prevalent and costly

health problems worldwide (Bauer et al. 2014, WHO 2014). Chronic diseases are also highly

preventable, and many of them share common risk factors, such as lack of exercise, nutrition

deficiency, being overweight, smoking, and excessive drinking (CDC 2016). Mitigating these

risk factors is key for chronic disease management. For patients with chronic disease(s), chronic

disease management involves using complex combinations of strategies to manage the disease(s)

so as to slow progression or to manage the high-risk factors associated with chronic health

conditions (Mallery and Rockwood 1992; WHO 2007). These strategies aim to help patients

manage their chronic health conditions on a day-to-day basis. They include both clinical

interventions as well as home-based self-management which encourages the involvement of

individuals and their families in their own care (Martin 2007; WHO n.d.).

Self-monitoring (SM) is often considered an essential component in chronic disease self-

management (shortened to “chronic care” hereinafter) and patients’ willingness to self-monitor

largely affects the achievement of positive health outcomes (Huygens et al. 2017, McBain et al.

2015). Self-monitoring is the “awareness of symptoms or bodily sensations that is enhanced

through periodic measurements, recordings and observations to provide information for

improved self-management” (Wild and Garvin 2007, p. 343). SM involves self-recording of

symptoms and behaviors, interpreting the self-recorded data, adjusting behaviors accordingly,

and applying treatments or seeking professional help as a result of self-awareness (Epstein et al.

2008, McBain et al. 2015). Historically, most SM systems were paper-based and memory-based,

and while useful for patient empowerment, various problems—such as low compliance, recall

4
bias, and difficulties in tracking moment-to-moment information—hindered their potential

effectiveness (Faurholt-Jepsen et al. 2016).

The recent growing interest in IT-based self-monitoring for chronic care (ITSM)

potentially overcomes the difficulties of the traditional systems (Chen and Yeh 2015, Faurholt-

Jepsen et al. 2016, Panagioti et al. 2014). Technological advances such as mobile apps,

affordable sensing devices, wearables, insideable technologies (e.g., in-body implants, under-

skin sensors, or ingestible smart pills) improve the capabilities of SM-based healthcare programs.

For example, the interactive visualization of ITSM technologies helps people better understand

health patterns over time (Cuttone et al. 2013). Persuasive functions such as adaptive

recommendations help users connect with their health professionals at the appropriate moment

(Fairburn and Rothwell 2015). Connectivity and mobility allow people to manage their

information seamlessly (Grönvall and Verdezoto 2013b). The pervasiveness of ITSM is also

evidenced by the increasing popularity of these tools among healthcare consumers and the

general population. It is forecasted that by 2019, more than 245 million smart wearable devices

will be sold, representing more than $25 billion for smartwatches and fitness trackers

(CCSInsight 2017). Thus, ITSM has great potential to help people control and manage the high-

risk factors related to their chronic diseases (Kennedy et al. 2012, McBain et al. 2015).

ITSM is ongoing and practically important, yet the accumulation of knowledge in this

area is fragmented, and several research disciplines examining ITSM have developed

(Chomutare et al. 2011, James et al. 2019; Lehto and Oinas-Kukkonen 2011, Lupton 2014). Each

of the emerging research streams tends to focus on specific aspects of ITSM, and – to our

knowledge – no comprehensive framework exists to tie the disparate streams of research

together. For example, medical research on chronic disease mainly focuses on the

5
implementation and effectiveness of clinical interventions with ITSM as a regular intervention

component. This stream of research generally treats IT and the use of IT as a black box and

largely ignores the impacts of user perceptions and experiences. Another key stream of research

is found in IS and computer science, which focuses on how to design more effective and useful

SM tools by understanding how SM systems are used and experienced in practice (Chung et al.

2016, Epstein 2015). This research stream examines IT in detail (Ayobi et al. 2016) but largely

ignores the chronic disease context and patients’ specific needs. While ITSM is multidisciplinary

by nature, these different streams of research have not been woven together into a cohesive

understanding of ITSM for chronic care and this failure to capture the multifaceted nature of

ITSM may cause a disjointed accumulation of knowledge. Thus, a synthesis of the current

research which makes connections between divergent literatures is needed in order to develop a

more holistic understanding of this phenomenon and build a cumulative knowledge tradition.

To address this opportunity, the primary aim of this article is to provide a systematic

cross-disciplinary synthesis of the literature that contributes to our understanding of ITSM for

chronic care and provides research directions for IS researchers studying ITSM. This aim is

achieved by: (1) organizing the research based on an overarching framework, specifically,

affordance actualization theory (Strong et al. 2014); (2) using the framework to synthesize the

results to identify what we know and do not know; and (3) identifying future research

opportunities. We are not suggesting that future researchers limit themselves to the actualization

affordance lens, however, our detailed framework should help researchers identify areas of

interest and specify how their own research complements, replicates, or diverges from the larger

body of ITSM for chronic care research.

6
 Our synthesis of the literature makes several contributions. First, it provides an

overarching theoretical framework to organize extant research. The organizing framework

enables an overview of the current status of ITSM research related to chronic care from several

disciplines and provides a repository of accumulated knowledge on ITSM. It also helps us

surface gaps in our understanding and identifies future research directions. For example, recent

technological advancements should increase ITSM use and enhance positive outcomes but are as

of yet largely under-examined in the literature. User learning and social support from peers or

providers are two intermediary mechanisms highlighted in practitioners’ chronic care practices,

which also lack research. Outcomes specific to medication and chronic conditions have received

less attention given that a high proportion of studies focusing on physical activity and weight

management outcomes. Second, the framework also helps us discover several key overarching

issues in this field of research, namely that the research on ITSM for chronic care is largely

fragmented, there is a shallow understanding of the role of IT, and there is a paucity of strong

theory. Third, our overarching theoretical framework is IS-centric. It emphasizes the role of IT

functionalities and highlights four sets of ITSM affordances and their associated intermediate

outcomes.

BACKGROUND

Chronic Disease Self-Management and Self-Monitoring

Chronic disease management is “an intervention designed to manage or prevent a chronic

condition using a systematic approach to care and potentially employing multiple treatment

modalities” (Weingarten et al. 2002, p. 2). As opposed to acute disease, chronic disease is

lengthy, not curable and usually gradual, thus requiring longitudinal supervision and reciprocal

knowledge between the patient and healthcare providers (Lorig 1996). Chronic disease

7
management is a broad term that encompasses chronic disease prevention and efforts to reduce

or control risk factors (Peytremann-Bridevaux and Burnand 2009). We limit our review to focus

on an individual’s chronic disease management, rather than chronic disease management for

entire populations.

The important role of self-management in chronic care has been highlighted (Lorig et al.

1999). While managing disease was traditionally viewed as the responsibility of doctors, modern

chronic disease management recognizes the importance of a strong partnership between patients,

healthcare providers and families (Barr et al. 2003; Coleman et al. 2009; Wagner et al. 2001). As

a result, more attention is now given to patients’ self-management of chronic conditions, which

requires skills such as detecting bodily symptoms, using monitoring machines, understanding

measurements and communicating self-monitored information (Paterson et al. 2001).

Self-monitoring (SM) is one essential strategy for self-management (Bartholomew et al.

1993; Bodenheimer et al. 2002; Farmer et al. 2007; Norris et al. 2001). Whereas self-

management is a broad term encompassing treatment adjustment, symptom management and

self-motivation, SM is a more specific term that encompasses the activities necessary to track

and use one’s own information.1 SM is different from providers’ monitoring of the patients

where the accessibility of the information on the patients’ side is limited. The healthcare

literature does not define SM consistently and uses multiple terms interchangeably, such as self-

management, self-care, symptom management, self-tracking, and self-recording (Legorreta et al.

2000; Minet et al. 2010; Schilling et al. 2002). We adopt the term SM, which includes self-

recording of symptoms and behaviors, interpreting the self-recorded data, adjusting behaviors

1
In cases where patients need assistance to use their own information, families, acquaintances, or trusted entities
who are involved in this self-care process may also have access to this information. While important, these are
outside of the scope of the current review.

8
accordingly, and applying treatments or seeking professional help as a result of self-awareness

(Epstein et al. 2008; McBain et al. 2015).

IT-enabled Self-Monitoring for Chronic Care

People may use any tool, including paper and pencil, to keep track of their information, but the

recent developments in digital technologies offer new opportunities and increase the complexity

of SM systems. The result has been an increase in research on ITSM in various contexts

including healthcare, education, the workplace and one’s personal life. We define ITSM as the

use of digital technologies to enable patient SM – i.e., the use of digital technologies to support

self-recording of symptoms and behaviors, interpreting the self-recorded data, and adjusting

behaviors accordingly.

It is important to note that ITSM technology users, usually the patients or healthcare

consumers, are both the providers and the users of the information (Marx 2002). Even when the

use of ITSM is mandated by a physician as part of treatment, it is still the patients (and their

personal care attendants or family members in cases where the patients need assistance) who

record their own information and use this information to better manage their chronic diseases.2

Thus, ITSM in healthcare is an emerging medical approach where the patient maintains

significant control (Swan 2009). Patients usually have ultimate control over what data are

entered into the ITSM, when to input the data, and whether or not they share their data with

physicians, family members, or other ITSM users.

ITSM can be illustrated using Li et al.’s (2010) five-stage process of personal

informatics3. First, patients prepare to use the system, which can include activities such as

2
If it is the healthcare provider who exclusively views or uses this information, it operates more as a surveillance
rather than a SM system.
3
Li et al.’s model is for all types of ITSM and is not specific to ITSM for chronic care.

9
education on system use and setting goals and targets. Second, patients need to observe the

information about themselves and record this information. Sometimes the patient needs to track

the information independent from the activity that occurred (e.g. eating followed by the

recording of calories), and sometimes the system automatically tracks the information (e.g.

automatic tracking of steps while walking). Third, the collected data is integrated and displayed

by the system for further analysis and interpretation by the patients, their acquaintances and/or

healthcare professionals. Fourth, patients and healthcare professionals need to understand and

reflect on the information produced by the system to discover patterns, correlations, and insights

related to patients’ health statuses. Lastly, patients need to act on what they have learned. Based

on the information produced by the ITSM systems, patients may individually change their

behaviors or work with healthcare professionals to adjust treatment of their chronic disease.

OVERARCHING FRAMEWORK: ITSM AFFORDANCE ACTUALIZATION

We develop an overarching framework with which to organize the extant research by adapting

Strong et al.’s (2014) affordance actualization theory. IT affordances are not simply the

technology’s physical characteristics, but the action possibilities permitted by the IT

functionalities (Gibson 1979). The potential embedded in these affordances is realized during the

actualization process, defined as “the actions taken by actors as they take advantage of one or

more affordances through their use of the technology to achieve immediate concrete outcomes in

support of organizational goals” (Strong et al. 2014, p.70). The actualization process includes

both actions (e.g., use of IT) and the immediate outcomes of those actions (i.e., the expected

immediate outcomes that are perceived as useful for achieving the ultimate goals). The link

between action and the immediate outcomes is iterative with the immediate outcomes providing

feedback to influence subsequent ITSM actions. These immediate outcomes are also the link

10
between users’ actions and achieving ultimate goals. Finally, there are various external factors

(e.g. work environment) that support and constrain this actualization process (Strong et al. 2014).

The affordance-actualization lens is appropriate as an overarching framework for

organizing the research on ITSM for chronic care for several reasons. First, this lens includes the

influence of IT functionalities on both use and outcomes. Second, it has previously been used to

study individual-level IT use and impacts (e.g. Anderson and Robey 2017; Lehrig et al. 2017;

Thapa and Sein 2018), as well as to study non-chronic disease SM for the general population

(e.g. Mettler and Wulf 2019). Third, affordance-actualization theory highlights important links

that – theoretically – should exist by focusing on how IT results in specific outcomes. This strong

theoretical foundation on which to synthesize the diverse ITSM for chronic disease management

literature helps surface gaps that are opportunities for future research.

We adapt affordance actualization theory to our ITSM context (see Figure 1). Strong et

al. focused on immediate concrete outcomes, but we i) expand these to also include

psychological, cognitive and affective outcomes which are relevant in the context of ITSM for

chronic care, and ii) change the term to intermediate outcomes to reflect that some of the

outcomes are not instantaneous and to put the focus on their potential role as important links

between ITSM use and chronic care goal achievement. While Strong et al. took a multilevel

approach and focused on achieving overarching organizational goals, our ITSM review focuses

on an individual’s chronic care goals. Finally, we contextualize the external factors that support

and constrain the actualization process as the non-IT complementary components of a medical

intervention (hereinafter abbreviated as “non-IT components”) that impact the actualization

process.

11
 Non-IT Complementary Components of a
Medical Intervention

ITSM Affordances Affordance Actualization

ITSM
Functionalities
Actions Intermediate Chronic Care Goal
ITSM use Outcomes Achievement
Patient
Characteristics

Figure 1. Overarching Framework for ITSM research (adapted from Strong et al. 2014)

METHODOLOGY

We mapped existing research across multiple disciplines to our overarching theoretical

framework. This enabled us to synthesize extant research, develop a holistic understanding of

what has been studied, and examine the theoretical foundations suggested for those relationships.

It also enabled us to surface gaps and propose directions for future research.

We followed a formal systematic literature review process for searching and screening

articles, which is presented in Figure 2 (Okoli and Schabram 2010; Webster and Watson 2002).

The search strategy we adopted, while not exhaustive, included as many studies as possible.

Eight digital libraries were searched: EBSCO host (including MEDLINE), ABI/INFORM, ACM

digital library, ScienceDirect, IEEE Xplore, JSTOR, PsycINFO, and Web of Knowledge. Titles

and abstracts (or titles and topics for Web of Knowledge) of English articles published in peer-

reviewed journals and conference proceedings from 2006 to 2017 were searched using the

following terms: “self-monitor*”, “self-surveillance”, “self-track*”, “personal informatics”,

“personal analytics”, and “electronic personal archive”.

12
 Identification
Articles indentified through database searching Search terms: Self-monitor* self-surveillance self-
EBSCO: 1332 ABI/Inform: 276 ACM: 1078 track* personal informatics personal analytics electronic
ScienceDirect: 197 IEEEXplore: 47 JSTOR: 22 personal archive
Web of Knowledge: 1623 PsycInfo: 577 Qualification: year 2006 to 2017/ English/ Peer-reviewed
journal and conference proceedings/ Search in title or abstract
Screening

Articles screened for inclusion based on titles and

abstracts
(N=5152) Articles excluded with reasons:
(n=3313)
1. Do not meet inclusion criteria: 2335
2. Duplicates: 751
3. Non-empirical: 227
Eligibility

Full text downloaded and assessed for eligibility

(N=1839)

Articles excluded with reasons:

(n=1705)
Screening

1. No IT involved: 310
Forward & backward searching 2. Incompatible SM definition: 843
(+25) 3. Only focus on technical development or
measurement validation: 103
5. Unrelated to chronic disease management: 400
6. Other reasons: 49
Inclusion

Studies included for further systematic data extraction

(N=159)

Figure 2. Literature Review: Searching and Screening Process

Articles were screened based on a review of titles and abstracts, with researchers reading

the full text when needed. The identified studies were screened according to the inclusion and

exclusion criteria presented in Table 1. The database search resulted in 5,152 studies. After

removing the duplicates, forward and backward searching, and iteratively applying the inclusion

and exclusion criteria, 159 studies remained for further analysis (articles with asterisk in the

reference list).

While the affordance actualization framework was used to guide our synthesis, these

studies did not explicitly examine “affordances” or use an affordance-based perspective.

However, five concepts from our framework were explicitly used to analyze the literature: ITSM

technological functionalities, ITSM use, intermediate outcomes, chronic care goal achievement

and non-IT components of the medical intervention (i.e. external factors in the original

framework). The affordance actualization theory also involves feedback loops to create an

13
iterative process. Feedback loops were not coded as an independent concept, but the direction of

relationships between constructs were captured where applicable. Each study’s constructs were

mapped onto these main concepts. Next, the long list of constructs in each of these concepts are

distilled into a set of sub-constructs through iterative discussion between the researchers until we

reached consensus. In addition, new concepts were allowed to emerge if they did not fit the

affordance actualization framework.

Table 1. Inclusion and Exclusion Criteria for Article Screening

Inclusion criteria
1. Empirical research articles
2. Studies that examine a specific chronic disease4, or chronic disease prevention and management
for those with a chronic condition
3. Studies that examine at least one of the following aspects regarding ITSM systems: usability
evaluation of new ITSM design, implementation of ITSM systems, ITSM systems adoption or post-
adoption use, and the impact of using ITSM systems
Exclusion criteria
1. Non-empirical articles (e.g. editorials, abstracts, workshop/conference summaries, research
proposals, reports based on descriptive data without examining scientific relationships and results,
clinical protocols, intervention designs without testing, literature reviews, conceptual papers)
2. Not related to any chronic disease
3. No IT involved (e.g. studies which only include paper-based SM, memory-based SM or medical
devices such as traditional weight scales that do not have the capacity to store, transmit, and
retrieve historical information)
4. Incompatible definition of SM: e.g., patients are not allowed to use their own information (e.g.
clinical self-assessment where the results are only provided to healthcare providers); self-
monitoring as a personality trait that focuses on how people control their expressive behavior to
accommodate social cues; firms’ self-monitoring of their business performance; individuals not
monitoring their “self” information (e.g. monitoring electricity consumption of a house)
5. Studies that only focus on technical development or new measurement development (e.g.
hardware and algorithm improvement studies, and clinical measurement design that uses SM as a
data collection method)
6. SM used only as a measurement instrument in the study
7. No primary and/or human data related to use or impacts collected (e.g. the descriptive analysis of
SM app features without showing their implementation, use or impacts)
8. Studies only providing descriptive statistics without further investigating any relationships (e.g. the
number of users for the SM app)

4
The list of chronic diseases was obtained from the website for the Council for Medical Schemes
(https://www.medicalschemes.com/medical_schemes_pmb/chronic_disease_list.htm).

14
 PROFILE OF STUDIES AND ITSM RESEARCH TRENDS

A general profile of the 159 studies is presented in Table 2, which displays publication trends by

discipline, methodology, research objectives, chronic condition, and IT type. Research interest

in ITSM is increasing, with over 70% of ITSM studies appearing from 2014 to 2017. The

majority of studies in all three time periods were published in medical journals, with the second

largest group being published in intersection journals. Almost half of the studies focused on

research objectives related to medical intervention designs and evaluations (N=79), and over half

employed experimental methodologies (randomized controlled trial experiments N=68, non-

randomized experiment or intervention N=42), which may be unsurprising given the significant

proportion of studies from the medical field. A wide range of chronic conditions are present in

the studies, with the most frequent being obesity (N=53), diabetes (N=37), and psychiatric

conditions (N=16). ITSM studies involving psychiatric conditions experienced a large increase in

research attention, from zero studies in 2010-13 to 15 studies in 2014-17. A wide range of IT

devices are also represented in the studies, with the most frequently used being mobile or tablet

apps (N=58), followed by web-based SM (N=42), and medical devices (N=36). One general

trend is a move towards using smarter and more connected ITSM devices, with smart wearables

becoming frequently used between 2014 and 17 (N=15) and some recent studies investigating

insideables (e.g., Mathieu-Fritz et al. 2017; Polonsky et al. 2017).

While a variety of ITSM types were used for different chronic conditions (see Appendix

A, Table A3), a few patterns are noticeable. Medical devices (such as glucometers) are

particularly popular for diabetes while wearables (such as smart fitness trackers) are often used

for obesity. ITSM for psychiatric conditions most often employs mobile or tablet apps that allow

questionnaire-based SM for moods and symptoms.

15
Table 2. Profile of the Studies by Discipline and Year
2006 - 2009 2010 - 2013 2014 - 2017 Grand
Total Total Total
IS Med Both Other IS Med Both Other IS Med Both Other Total

Total 1 8 2 1 12 3 20 7 1 31 11 72 28 5 116 159

Methodology
Randomized Controlled Trial (RCT) 0 3 0 0 3 0 16 4 0 20 0 34 9 2 45 68
Non RCT intervention/experiment 0 5 1 0 6 1 3 0 1 5 1 20 8 2 31 42
Qualitative & ethnography 0 0 0 1 1 2 0 2 0 4 5 7 4 1 17 21
Field usability test 1 0 1 0 2 0 1 1 0 2 5 5 5 0 15 19
Survey 0 0 0 0 0 0 0 0 0 0 0 4 1 0 5 5
Retrospective analysis 0 0 0 0 0 0 0 0 0 0 0 2 1 0 3 3
Research Objectives*
Intervention design/evaluation 0 7 0 0 7 0 14 3 1 18 0 40 10 4 54 79
ITSM development and assessment 1 0 1 0 2 0 1 3 0 4 6 15 8 0 29 35
Use experience & perceptions 0 0 1 1 2 2 5 1 0 8 9 6 8 0 23 33
Chronic care outcome explanation 0 1 0 0 1 0 4 0 0 4 0 7 2 0 9 14
Other 0 0 0 0 0 0 1 0 0 1 1 0 1 1 3 4
IT Types*
Mobile/tablet app 1 0 0 0 1 0 4 5 0 9 10 26 12 0 48 58
Website 0 0 1 1 2 0 4 3 1 8 1 19 10 2 32 42
Medical device 0 2 0 0 2 1 1 1 1 4 0 19 9 2 30 36
Smart wearable 0 0 0 0 0 0 1 0 0 1 3 9 3 0 15 16
Pedometer 0 1 0 0 1 0 1 2 0 3 0 9 0 1 10 14
IVR 0 2 0 0 2 0 0 1 0 1 0 2 1 1 4 7
PDA 0 3 1 0 4 0 7 0 0 7 0 1 0 0 1 12
PC software 0 2 0 0 2 0 3 0 0 3 1 1 0 0 2 7
Other 0 0 0 0 0 1 1 0 0 2 5 7 3 0 15 17
Chronic Condition Types*
Overweight/obese 1 2 0 0 3 0 14 3 0 17 1 26 6 0 33 53

16
 Table 2. Profile of the Studies by Discipline and Year
2006 - 2009 2010 - 2013 2014 - 2017 Grand
Total Total Total
IS Med Both Other IS Med Both Other IS Med Both Other Total

Diabetes 0 1 0 0 1 0 1 2 1 4 3 21 6 2 32 37
Psychiatric 0 1 0 0 1 0 0 0 0 0 3 8 4 0 15 16
Cardiac 0 1 0 0 1 0 0 0 0 0 1 0 3 1 5 6
Cancer 0 0 0 0 0 0 0 0 0 0 1 4 1 0 6 6
Nerve-related 0 0 0 0 0 0 0 0 0 0 2 1 0 1 4 4
HIV 0 1 0 0 1 0 0 0 0 0 0 3 0 0 3 4
Hypertension 0 0 0 0 0 1 1 0 0 2 1 0 1 1 3 5
Other 0 2 2 1 5 1 4 3 0 8 5 4 9 0 18 31
*One study can have multiple research objectives, examine multiple chronic conditions and use multiple IT.

17
 RESULTS

The 159 studies in our sample are synthesized using the affordance actualization framework,

extended to include a high-level summary of the key concepts and relationships which emerged

(see Figure 3). Through the analysis of a concept matrix (Webster and Watson 2002) and

iterative discussions between the researchers, four themes emerged which represent the research

in this area: ITSM affordances and related IT functionalities, effects on ITSM use and

experience, effects on chronic care goal achievement, and the role of intermediate outcomes. The

first theme on ITSM affordances is descriptive in nature, themes two and three are DV-centric,

and theme four is concept-centric.

ITSM Characteristics
ITSM Presence/Absence Chronic Care Goal
(Introduction of ITSM as a whole)
Achievement
ITSM Mode Comparison Intermediate Outcomes
ITSM Use Behavior Behavior Change
(e.g. web vs. mobile vs. paper) (e.g. number of entries, SM Patient-Provider Co- - Physical activities
frequency, duration, misuse, Management - Dietary behavior
descriptive use pattern)
ITSM Functionality Patient Learning & Self- - Other
Reflection
Complex ITSM-Based Intervention
ITSM Perceptions & Intervention Satisfaction &
ITSM Presence/Absence Compliance Health Improvement
OR
Experiences
(e.g. perceived usefulness, - Weight related
Introduction of Key ITSM satisfaction, overload) Social Interaction
Functionality - Wellbeing & quality of life
- Disease & symptom related
Non-IT Complementary - Medication related
Components

User Characteristics
- Sociodemographics
- Baseline conditions
- Motivation/ Goal/ Personality

Figure 3. High-level Synthesis of Research on ITSM for Chronic Care

Theme 1: Identification of ITSM Affordances and Related IT Functionalities

Theme 1 is descriptive in nature and attempts to capture and categorize the IT functionalities –

and the affordances they enable - that are present in the ITSM devices used in the studies.

Multiple ITSM devices which provide a range of IT functionalities are represented in the

literature, but these affordances and functionalities were seldom directly investigated in the

studies (ITSM characteristics is used in Figure 3 as a more general term to indicate the broad

18
range of ways in which ITSM was investigated in the studies).5 Although seldom directly

examined, it is still worth untangling the functionalities and affordances of ITSM: while the

technology itself is rapidly advancing, the associated affordances are likely to evolve more

slowly. By understanding ITSM functionalities, we can identify key affordances, understand how

these affordances are currently delivered, and reflect on how they may be delivered in the future.

We first coded IT functionalities present in the studies and, drawing on Li et al.’s (2010)

model, identified four categories of ITSM affordances. Table A4 in Appendix A presents the

ITSM affordances, their associated IT functionalities, and the studies with ITSM that included

these functionalities.

Preparation Affordance

The importance of training and motivating the actors who engage in chronic care is an essential

step (Bodenheimer et al. 2002). The general expectation is that if users are well trained and

highly motivated, they are more likely to have sustained engagement which produces better

outcomes (Standage et al. 2008; Suh 2018). We have identified two key IT functionalities that

support user preparation. First, IT is a low-cost medium to deliver educational content regarding

the use of ITSM devices, the knowledge of diseases, the benefit of treatments, and self-

management techniques (e.g. Cadmus-Bertram et al. 2013; Dorsch et al. 2015; Or and Tao

2016). These educational materials are often provided as web pages or video clips. Second, many

ITSM technologies provide goal setting functionalities that either recommend or prescribe a goal

and/or allow users to set or adjust their own goals (e.g. Painter et al. 2017). Some systems are

5
The affordance-actualization lens views affordances as possibilities for action arising from both IT functionalities
as well as actors’ needs and goals. In our sample, research often states the chronic conditions under study, with the
implied intervention goal being to reduce or manage the symptoms related to the chronic condition. However, an
actor’s specific internal goals and needs are not explicitly investigated. Thus, our synthesis focuses almost
exclusively on IT functionalities.

19
more flexible, allowing users to create detailed action plans, so that they can track goals over

time (e.g. Dennison et al. 2014). Although goal setting is very common for chronic care, it is

traditionally prescribed by physicians orally or in a written document. More recent studies tend

to leverage IT functions to assign the goal, update the goal based on self-tracked progress and

keep track of the goal changes digitally.

Data Collection Affordance

Since recording is the core activity of ITSM, all ITSM devices should provide functionalities to

support data collection and/or data entry, either fully automated or requiring a certain level of

human effort. Many ITSM systems have a data entry interface that enables user-initiated entry of

SM data. For example, the user may have to manually measure certain SM data of interest (e.g.

weighing dietary intake, self-assessing mood), and then use the ITSM interface to record it in the

system. The data entry user interface may involve different levels of flexibility such as guided

response (e.g. structure daily questionnaire, Tsanas et al. 2016) or open entry (e.g. journaling,

Hales et al. 2017).

Due to the development of sensor technologies, various activities, positions, proximities

and body conditions can be detected automatically without active human effort, making it one of

the most significant advantages of ITSM over traditional paper- or memory-based approaches

(Lupton 2014). The most widely-used devices with auto data capture functionalities are

wearables such as fitness trackers and pedometers. While wearables such as pedometers have

been used for many years, more recent studies employ smart wearables which support multiple

affordances in an integrated manner (e.g. automatic data capture, interactive data display, goal

updating, pushed tips). There is increasing attention in recent years regarding insideables, such

as under-skin continuous glucose monitoring devices. Although the technology has been

20
available for over 15 years, major health insurances companies in Europe and North American

have only started to cover the devices in recent years (Heinemann and DeVries 2016). The

increasing availability and popularity may foster future studies on the use and implementation of

these new ITSM technologies. In recent years, ITSM with automated data capture is becoming

more widely used and more frequently studied. Despite the convenience, fully automated data

capture is not possible or appropriate for all SM tasks. Many diary SM tasks still require

significant manual measurement (e.g., weighing the food) with user entry. For some tasks where

automated data capture is possible, a data entry interface may still be required where users can

override the automatically captured data or correct erroneous readings (Selvan et al. 2017).

User Reflection Affordance

Three key IT functionalities emerged in our review related to data display, push messages and

gamification, which should contribute to user reflection and informed action, a key stage of SM

(Li et al. 2010). According to the definition of SM, if patients are not allowed to view and/or use

their own data, it is surveillance rather than SM. With data displays being increasingly digital,

there is a trend towards increased transparency provided to patients rather than physicians

controlling the flow of data (Cade 2017; Piras and Miele 2017). Three levels of graphical,

numerical, or text feedback of the SM results have been found: (1) raw data is presented in

graphs, tables or text (e.g., readings from a glucometer); (2) aggregations of the data are

presented, such as total number, average and calculated indices (e.g. energy expenditure based

on activity energy consumption and diet energy intake, Allen et al. 2013); and (3) evaluative

information is provided that relates the data to a target, goal or threshold. This last type is

commonly presented using colored traffic light systems (e.g. blood glucose levels, Greenwood et

al. 2015), progress bars to show performance as compared to the desired goal (Carels et al.

21
2017), or textual messages that provide personalized assessments (Wolin et al. 2015). Usually,

these data displays are the result of requests from the user to access this information (a “pull”

type of communication). The data display influences users’ ability to make sense of their data,

thus supporting user reflection and action.

We have also found some devices provide “push” communication, where feedback is sent

to users in the form of prompts, alarms, reminders, and push notifications (e.g. Ambeba et al.

2015; Chambliss et al. 2011). Push messages are an important tool in persuasive computing

(Oinas-Kukkonen and Harjumaa 2009) and should have positive effects on user awareness and

engagement in ITSM. Two types of push messages emerged in the reviewed literature: pre-set

and data-driven. Pre-set push messages are usually time-based, with users or algorithms setting

alarms or reminders for specific SM tasks (Swendeman et al. 2015). Data-driven messages are

usually triggered by events related to users’ performance or progress (e.g. prompts after a

prolonged period of inactivity, Biddle et al. 2017).

Gamification – defined as using game design elements in non-game contexts (Deterding

2015) – is one often used approach in persuasive computing that is considered an effective way

to enhance user experience and promote performance in many different contexts (Mekler et al.

2017), Thus, it should positively influence user motivation and engagement in ITSM and is a

functionality to support reflection and action. Some ITSM represent the SM task in a gamified

way (e.g. simulations and challenges), or the data are displayed with gamified elements such as

reward points and leader boards (e.g., Hales et al. 2017; Hostler et al. 2017). The design and use

of gamification in ITSM is quite rare in our sample until 2017, when 13 studies were published

that often involve design science research focusing on specific feedback or incentive

mechanisms.

22
Social Connection Affordances

Support for social connections is not included in Li et al.’s (2010) five stages; however, its

importance is recognized by chronic care practitioners (Wagner et al. 2001). Two categories of

IT functionalities that enable such affordances emerged from the literature. The first category

supports patient-provider connections by providing contact information of the healthcare team or

allowing synchronous or asynchronous online communication (e.g. Greenwood et al. 2015; Iljaz

et al. 2017; Webber et al. 2010). The second category supports peer-to-peer interaction, where a

virtual space is created for peers (including other patients and any non-provider trusted entities

such as friends, acquaintances and caregivers) to exchange information and influence each other

(e.g. Cadmus-Bertram et al. 2013; Mummah et al. 2017). Some virtual spaces function using

private groups of existing external social networks or online communities (e.g. Cadmus-Bertram

et al. 2013; Carter et al. 2013; Partridge et al. 2016), while other recent mobile-based trackers

include embedded social functions for within-app communities or links for sharing to

mainstream social media platforms (e.g. Eikey et al. 2017; Hales et al. 2017).

ITSM Affordances and Bundles by Disease type

SM requirements should align with chronic care goals, and – in practice – the choice of ITSM

device largely depends on disease type. Thus, we further analyzed the presence of ITSM

functionalities and the associated affordances by disease type to examine which combinations are

being studied (see Table 3).

It is not surprising that all studies have at least one type of data collection method since

self-recording is a fundamental task for SM. SM tasks for obesity usually involve physical

activity and dietary intake, so both automatic data capture (for exercise) and manual input (for

dietary intake) are very common. Diabetes self-management usually involves blood glucose

23
monitoring, thus auto-capture by medical device is more common. Whereas older approaches

usually involve two devices (glucometer plus another database-type application with manual data

transmission between the two, Roblin 2011; Sevick 2008), recent research usually investigates

glucometers with mobile or web applications that allow automatic data transmission or sync

functions (Garg et al. 2017; Sieber et al. 2017). Moreover, with the increasing popularity of

under-skin sensors for continuous blood glucose monitoring, patients no longer need to worry

about data capture and entry (Polonsky et al. 2017). Managing psychiatric conditions usually

involves answering questionnaires regarding mood or psychological issues; thus, guided manual

entry is dominant.

Data display is the second most common functionality. However, the majority of studies

only display raw data or descriptive information after simple aggregation (e.g. Aguiar et al.

2017). This is more apparent for studies using pedometers and older-style glucometers that only

support basic data collection and display. Push messages and gamification are two functionalities

that have started to receive attention in recent years. Most of them are used for exercise and diet-

related SM tasks, both related to obesity, perhaps because the system can more easily generate

meaningful time-based push messages (e.g., reminders to enter meal information three times per

day, reminders for physical activity after long periods of sedentary behavior). Data-driven push

messages are rare (for an exception, see Coppini et al. 2017), requiring more personalized

messages and data analytics effort.

While by definition, SM requires some level of data collection and reflection (whether

IT-based or not), preparation and social connection seem to be optional affordances. Recent

years have witnessed an increasing number of studies with IT-supported education, goal setting,

patient-provider connection and peer-to-peer interaction. Most of the preparation affordances are

24
present in obesity self-management through mobile or web applications, making it easy for

digital materials to be presented and adjusted during the longitudinal intervention. Although goal

prescription is a common strategy for most healthcare interventions, IT-based goal setting and

adjustment functionalities mostly appear in fitness tracking and diet applications and are

therefore most common for obesity SM. The patient-provider connection function is increasing,

even though only part of the interaction may be directly supported by the SM device (e.g.

physician receives system notification then sends email to the patient). Instant communication

with healthcare providers within the same device is limited. The incorporation of this kind of

functionality may be largely constrained by clinical practices, such as healthcare providers not

constantly monitoring patients’ conditions, or the clinical infrastructure not being able to support

this particular channel of communication. Similarly, peer-to-peer interaction via social

components in ITSM appears more common for exercise and diet SM, which is partially due to

the fact that exercise and diet information is less sensitive, and peer comparison has been shown

to be a useful approach to promote exercise and weight loss by controlling for diet (Finnerty et

al. 2010; Luszczynska et al. 2004; Mueller et al. 2010; Thompson et al. 2006).

Table 3. Presence of ITSM Affordances by Chronic Disease Type

Chronic Disease Type

Affordance Nerve- Hyper-

Functionalities Obesity Diabetes Psychiatric Cardiac Cancer HIV
related tension

Total 53 37 16 6 6 4 4 5

Education 16 7 2 2 2 1 1 2
Preparation
Goal 13 1 1 0 0 0 0 0

Data entry 45 15 14 2 2 2 4 2
Data
collection
Auto capture 21 30 2 4 3 3 0 2

Data display 40 32 12 5 3 3 3 4
Reflection
and Action
Push message 24 9 5 1 2 1 2 3

25
 Table 3. Presence of ITSM Affordances by Chronic Disease Type

Chronic Disease Type

Affordance Nerve- Hyper-

Functionalities Obesity Diabetes Psychiatric Cardiac Cancer HIV
related tension

Total 53 37 16 6 6 4 4 5

Gamification 4 2 3 0 0 1 0 0

Patient-
provider 5 8 3 0 2 1 0 0
Social connection
Connection
Peer-to-peer
14 1 1 0 0 0 0 0
interaction

It should be noted that the ITSM process is longitudinal, flexible, and iterative, and for

the use of a specific ITSM device multiple affordances may be bundled to provide different

action possibilities (i.e. termed affordance bundles in Strong et al. 2014). For example, if

personalized education can be delivered at the right time (e.g. when the indicator goes above a

certain threshold) with push messages, patients may be more capable of understanding the data

and take appropriate action as necessary, such as initiating a conversation with physicians (e.g.

Caballero-Ruiz et al. 2017; Velardo et al. 2017). Thus, the effectiveness of ITSM may depend on

bundles of affordances and their actualization, rather than an isolated functionality and its

associated affordance.

Theme 1 Discussion and Future Directions

A summary of key results and future research directions for theme 1 are shown in Table 4. The

IT functionalities synthesized above afford users the ability to perform a multitude of key SM

steps (Li et al. 2010) by allowing users to complete these tasks more efficiently (e.g., smart

fitness trackers that automate data collection and provide real-time data display, Abrantes et al.

2017) or by allowing users to complete new tasks that were not easily accomplished by pure

human effort (e.g. continuous blood glucose capture, Polonsky et al. 2017). Ideally, ITSM

26
affordances will enable individuals to perform SM tasks, increase their SM motivation and

preparedness, and better incorporate SM results into their chronic care practices.

It should be noted that some functionalities and affordances are more basic and

fundamental (e.g. data collection and data display), whereas others are complementary to provide

added value and may be delivered in a separate device (e.g. using social media in addition to the

wearables for peer support). There is a general trend of ITSM devices becoming increasingly

multifunctional and interconnected. As technologies advance, how these affordances can be

delivered (i.e. IT functionalities) may change dramatically. By linking IT functionalities into

higher-level ITSM affordances, we bring to light the key capabilities that an ITSM system could

deliver and describe current IT functionalities used to provide these capabilities. However,

despite the effort that has been made to design the new applications and system prototypes (e.g.

Cai et al. 2017; Coppini et al. 2017), less is known regarding whether the emerging

functionalities universally improve delivery of the designated affordances and ITSM efficacy.

Moreover, as new medical technologies become increasingly mature (e.g. insideables, artificial

intelligence applications), these devices in various forms and formats may bring new affordances

or make existing affordances obsolete, which may bring interesting synergistic effects that we

cannot foresee with the current generation of technology.

Accordingly, we propose three promising areas for future research. First, future research

can focus on investigating how to better deliver the four ITSM affordances that have been

identified. For example, as a basic function, data display and feedback functionalities are

currently built around simple descriptive statistics, which can be trivial given the complexity of

patients’ experience living with chronic conditions. With the advancement of data analysis

techniques such as machine learning and natural language processing, it is possible to provide

27
personalized and explanatory feedback that can reveal the causal linkages behind the patient’s

living trajectory (Piwek et al. 2016). Studies on wearables and mobile-based self-tracking for

general populations have made various attempts to design the system with better usability and

entertainment (e.g. Leinonen et al. 2017; Liang et al. 2017; Tay et al. 2017). ITSM for chronic

care can incorporate these research achievements and develop more context-specific solutions.

Second, there are many emerging technologies that are not currently widely used in the

market but are promising and may have already shown profound impacts in other areas. For

example, artificial intelligence (AI) has received tremendous attention in many areas, and in

healthcare, AI also has potential for a wide range of applications, from diagnostics to operations

(e.g., fraud detection, virtual nursing, medical error reduction, automated diagnosis, Kalis et al.

2018). These new trends bring advanced functionalities and capabilities that may not only

improve healthcare efficiency but also shift how patients and providers perform ITSM. For

example, AI may be particularly useful for chronic diseases where the link between cause and

effect for a particular patient (e.g., triggers for a patient’s migraines) are not always evident. For

these chronic diseases, using ITSM with advanced AI functionalities that can discern the

complex patterns between triggers and symptom onset for one specific patient may help that

patient predict (and ultimately, avoid) these triggers. Future research should explore new

technological developments, the impacts of their associated functionalities and if these

technologies modify how affordances are delivered in ITSM.

Finally, we propose that future research should highlight the context of new applications

and investigate the conditions under which those advanced functionalities and add-on

affordances engender positive effects versus conditions that may yield negative consequences.

Existing studies have reported some functional barriers in adoption and use of ITSM (e.g.,

28
Chung et al. 2015) and potential negative side-effects such as information overload (Mathieu-

Fritz et al. 2017), and gamification elements acting as distractions from the main SM tasks (Sage

et al. 2017). Research on social support is nascent and further research is needed to examine the

role of social connections. For example, future ITSM may include functionality which shares

data with caregivers at opportune moments, especially in cases where the patient can’t help

themselves or the nature of the disease makes it unlikely that they will seek help (e.g., a system

that notifies the caregivers when patient SM data shows an increase in markers related to the

disease). Future research should investigate both positive and negative aspects of advanced

functionalities and add-on affordances.

Table 4. Summary of Theme 1

What is known
• Current ITSM has four key affordances:
o Preparation.
o Data collection
o User reflection and action.
o Social connection.
• Some affordances are more fundamental to all ITSM (e.g. data collection, user reflection and
action), while others may enable ITSM (preparation) or act as optional add-ons (social
connection).

What is unknown and suggestions for future research

• If emerging IT functionalities universally improve delivery of these affordances.
• Whether new and emerging IT functionalities generate new affordances or make existing
affordances obsolete.
➢ Determine how to better design IT functionalities to improve delivery of these ITSM
affordances.
➢ Investigate how future and emerging IT functionalities change how these affordances are
delivered.
➢ Explore concept of new affordances and affordance obsolescence.

• Whether optional add-on affordances add value to or provide a distraction from SM.
➢ Examine under which conditions add-on functionalities and affordances engender
positive effects and under which conditions they act more as distractions from the main
SM tasks.

Theme 2: Effects on ITSM Use and User Experience

Theme 2 examines two closely related components of the affordance actualization process:

ITSM system use (shortened to ITSM use) and user experience. Given that intervention

29
compliance is especially important for chronic care (Hamine et al. 2015), both sufficient usage of

ITSM devices and positive patients’ experiences should be essential. Seventy-two studies report

evidence regarding patients’ use of ITSM and their perceptions. These studies employ various

research methods (e.g. experiment, survey, secondary data analysis, field study, interview, and

focus group). The majority focus on ITSM use frequency, with a small number examining use

duration, misuse, appropriation, use patterns, etc. ITSM use frequency is usually measured by

number of SM entries, number of days with logins, frequency of feature use, or frequency of SM

website visit. The key constructs and relationships empirically investigated for theme 2 are

shown in Figure 4 and Table 5.

ITSM Characteristics

ITSM Presence/Absence
(Introduction of ITSM as a whole)

ITSM Mode Comparison

(e.g. web vs. mobile vs. paper) ITSM Use Behavior
- Number of SM entries
Specific ITSM Functionality - SM frequency
(e.g. data display formats,
personalized push information, data - SM duration
entry approaches) - Input reliability
- Appropriation/ misuse
Complex ITSM-Based Intervention - Use pattern/habits (descriptive)
ITSM Presence/Absence
OR
Introduction of Key ITSM
Functionality
ITSM Perceptions & Experiences
Non-IT Complementary
Components - Perceived helpfulness/ usefulness/
(e.g. periodic clinic visits, face-to- ease of use/ playfulness/ satisfaction
face interview and feedback, - Tool preference
counselling) - Overload

User Characteristics
- Sociodemographics
- Baseline condition (drinking, disease
type, presence of symptom)
- Motivation/ goal/ anticipation/ big-five
personality types

Figure 4. Relationships Investigated impacting ITSM Use and User Experience

Five categories emerged from literature as major sources of impacts on ITSM use and

experience: ITSM presence, ITSM mode, specific ITSM functionality, complex ITSM healthcare

30
intervention, and user characteristics. Although in theory it is the actualization of specific ITSM

affordances enabled by one or multiple IT functionalities that facilitates goal achievement, the

extant studies seldom discuss the impacts of specific IT functionality or affordances. Instead,

ITSM is usually introduced as a whole system for the entire chronic care procedure or presented

as part of a complex intervention in which ITSM is supported by various non-IT healthcare

components. Consequently, a typical design of the study includes: (1) introducing and evaluating

a complete ITSM program for chronic care (i.e. ITSM presence, Johnston et al. 2009; Velardo et

al. 2017); (2) comparing ITSM modes by using different technologies or different SM designs

(with or without non-IT components), which in turn provides implications for potential

advantages of specific ITSM devices (Or and Tao 2016; Swendeman et al. 2015; Turner-

McGrievy et al. 2017); (3) designing new ITSM tools with an emphasis on specific

functionalities (Adams et al. 2017; Sage et al. 2017); and (4) introducing a complex ITSM

intervention (ITSM plus non-IT components, Partridge et al. 2016) or comparing multiple

complex ITSM interventions (Sevick et al. 2008; Spring et al. 2017). In the following section, we

present key constructs and relationships investigated for the impacts of ITSM characteristics on

ITSM use and user experience.

When presented with the ITSM as a whole, the studies generally have positive results

regarding both SM use (i.e., number of days with entries or acceptable SM rate, Roblin 2011;

Tsai et al. 2007) and usability (e.g. usefulness, ease of use and satisfaction, Festersen and

Corradini 2014; Timmerman et al. 2016; Gu et al. 2017). Such positive usability evaluations

facilitate ITSM frequency (Ma et al. 2013) and engagement (Adams et al. 2017). However, when

specific functionalities are selectively assessed, some studies report negative evaluation and use

behaviors. For example, during an evaluation of a newly developed system allowing users to

31
freely tag their SM activities, participants report reluctance to use the feature due to difficulties

in understanding the new display format (Storni 2011). Similarly, participants negatively

evaluate a newly developed app with gamification functions because it requires extra effort,

which hinders their engagement (Sage et al. 2017). When patients feel overwhelmed by the

system functionalities, they are more likely to misuse the device, develop workarounds, or return

to sub-optimal SM practices (Mathieu-Fritz and Guillot 2017).

Several studies formally compare SM frequency and user satisfaction for different modes

of ITSM and generally support the superiority of automated SM (e.g. web-based, mobile-based,

pedometer) as compared to a paper-based approach. Paper-based SM is rated as inconvenient,

embarrassing and less fun (Hutchesson et al. 2015; Fuller et al. 2017), whereas web-based and

mobile-based SM exhibits higher use frequency (Or and Tao 2016), is less burdensome

(Matthews et al. 2017), has fewer recording errors (Selvan et al. 2017) and is preferred by more

users (Hutchesson et al. 2015). However, when comparing web-based and wearable-based SM

for diet tracking, Turner-McGrievy et al. (2017) do not find differences in SM frequency. This

may be because diet SM data collection – whether web-based or wearable – is not automatic and

thus wearables do not provide a significant advantage over other ITSM modes in this context.

The effects of implementing complex ITSM interventions on ITSM use and user

experience are highly mixed. Several studies report a “novelty effect” where the ITSM frequency

declined rapidly after initial use (Carter et al. 2013; Glasgow et al. 2011; Laing et al. 2015; Stark

et al. 2011; Wolin et al. 2015). Such a decline in use may be temporarily averted with IT or face-

to-face feedback that is either continuous or novel (i.e., personalized and non-repetitive pushed

messages). For example, patients who attend a group counseling session continue ITSM use

while use declines for those who missed the session (Sevick et al. 2010). Surprisingly, the post-

32
adoption decline in use is greater among SM web users than interactive voice response system

(IVR) users (Wolin et al. 2015). This may imply that while newer modes of ITSM – which are

thought to reduce user burden – increase ITSM use initially, the reduced burden and near

invisibility of the newer ITSM may make it harder for users to develop sustainable habits.

However, due to the complexity of interventions and how they are investigated, it is difficult to

know whether novelty effects are due to the IT functionalities or to the non-IT components.

Additional studies are needed in this area while newer technologies that automate data capture

and entry may largely eliminate human effort in use, they may also yield unintended

consequences. For example, ITSM with automatic data capture may not afford users as many

opportunities to actively think, learn from, and be aware of their health-related behaviors and

conditions.

User characteristics often also influence when and how ITSM is used. In the context of

chronic care, user baseline health status is an important factor. A couple of studies examine the

impacts of user baseline status on their subsequent use behaviors, including sociodemographic

factors such as age, gender and education (Di Bartolo et al. 2017; Sevick et al. 2010; Wolin et al.

2015), current disease condition (such as presence of depression (Steinberg et al. 2014)), family

history of diabetes (Cosson et al. 2017), motivation (Webber et al. 2010), conscientiousness

(Hales et al. 2017), and SM objectives (maintain normalcy vs. self-stabilization, Mattews et al.

2017). No conclusion can be made with regard to the impact of sociodemographic factors due to

the limited number of studies and inconsistent results for each factor. For example, there is

conflicting evidence on whether or not older people use ITSM more than younger ones (Berry et

al. 2015; Glasgow et al. 2011; Krukowski et al. 2013; Sevick et al. 2010). There are no

significant associations between education (Glasgow et al. 2011; Krukowski et al. 2013; Sevick

33
et al. 2010) or marital status (Berry et al. 2015; Krukowski et al. 2013) and ITSM use. These user

characteristics are most often examined in healthcare journals, most likely because the research

tradition in healthcare recognizes that a patient’s sociodemographic information may influence

the feasibility and applicability of a given treatment. Thus, user characteristics are treated as

predictors in this type of research. However, little theory or explanation is provided for why

certain user groups should exhibit more ITSM use than others.

Finally, two studies identify users’ conscientiousness and autonomous motivation as

predictors of ITSM use (Hales et al. 2017; Webber et al. 2010). In behavior change research, user

motivation indicates their willingness and psychological preparedness to adopt a medical

intervention or engage in a volitional process (DiClemente et al. 2004; Prochaska and

DiClemente 1982). ITSM is largely a volitional process, and a certain level of psychological

preparation is necessary to plan the intervention strategy and facilitate long-term user

commitment (Biener and Abrams 1991; Daley and Duda 2006; Holt et al. 2010).

Table 5. Impacts on ITSM Use and User Experience

Impacts on ITSM use from:
ITSM presence Roblin (2011), Storni (2010), Tsai et al. (2007), Tsanas et al. (2016), Welch et al. (2007),
Boyd et al. (2017), Isetta et al. (2017), Velardo et al. (2017)
ITSM mode Raiff and Dallery (2010), Selvan et al. (2017)
[Or and Tao (2016), Turner-McGrievy et al. (2017)]
ITSM functionalities Kendall et al. (2015), Murnane et al. (2016)
[Chung et al. (2015), Storni (2014)]
Complex ITSM Burke et al. (2012), Cadmus-Bertram et al. (2015), Carter et al. (2013), Cushing et al.
intervention (2011), Sevick et al. (2010), Sevick et al. (2008), Turk et al. (2013), Wolin et al. (2015), di
Bartolo et al. (2017), Spring et al. (2017)
[Aharonovich et al. (2006), Conroy et al. (2011), Glasgow et al. (2011), Laing et al.
(2015), Morgan et al. (2014), Partridge et al. (2016), Stark et al. (2011), Thomas et al.
(2015), Turner-McGrievy et al. (2013), Wharton et al. (2014), Aguiar et al. (2017)]
User characteristics Aharonovich et al. (2006), Berry et al. (2015), Chung et al. (2015), Hall and Murchie
(2014), Webber et al. (2010), Wolin et al. (2015), Cosson et al. (2017), Hales et al.
(2017), Matthews et al. (2017a), McDonald et al. (2017)
[Glasgow et al. (2011), Karhula et al. (2015), Krukowski et al. (2013), Sevick et al.
(2010), Steinberg et al. (2014), di Bartolo et al. (2017), McKnight et al. (2017), Selvan et
al. (2017)]
Other influencing Sevick et al. (2010), Turner-McGrievy et al. (2013), Adams et al. (2017), Chen et al.
(2017), Isetta et al. (2017), Mathieu-Fritz et al. (2017), Matthews et al. (2017a)
factors
[Ma et al. (2013)]

34
 Impacts on ITSM perceptions and experiences from:
ITSM presence Festersen and Corradini (2014), Caballero-Ruiz et al. (2017), Johnston et al. (2009),
Nakano et al. (2011), Roblin (2011), Timmerman et al. (2016), Tsai et al. (2007),
Abrantes et al. (2017), Boyd et al. (2017), Coppini et al. (2017), Gu et al. (2017), Gell et
al. (2017), Isetta et al. (2017), McDonald et al. (2017), Mouzouras et al. (2017),
Olafsdottir et al. (2017), Welch et al. (2007)
ITSM mode Hutchesson et al. (2015), Raiff and Dallery (2010), Swendeman et al. (2015), Fuller et al.
(2017), Matthews et al. (2017a)
ITSM functionalities Hall and Murchie (2014), Hinnen et al. (2015), Andersen et al. (2017), Cai et al. (2017),
Edge et al. (2017)
[Adams et al. (2017), Sage et al. (2017)]
Complex ITSM Cadmus-Bertram et al. (2013), Laing et al. (2015), Morgan et al. (2014), Sevick et al.
(2008)
intervention
[Carter et al. (2013), Ma et al. (2013), Biddle et al. (2017)]
User characteristics Ramanathan et al. (2013)
[Hall and Murchie (2014)]
Note. Studies in italicized brackets have non-supportive or mixed results.

Theme 2 Discussion and Future Directions

The key findings of theme 2 – along with directions for future research – are outlined in Table 6.

Research on ITSM use mostly focuses on SM frequency, which is an essential building block of

adherence to chronic care programs. ITSM mode matters with users generally preferring

technologies that impose less of a burden.

Only a few theoretical perspectives are used in theme 2 and over two thirds of the studies

do not employ any theoretical lens. For those that do, social cognitive theory is the most widely

cited. However, it is usually used to inform overall intervention design (e.g., Allen et al. 2013) or

to interpret study results (e.g., Cadmus-Bertram et al. 2013, Hales et al. 2017), rather than to

support hypotheses specific to theme 2. Theoretical lenses including TAM and UTAUT are also

used in a few studies, but only for measurement development (e.g. Laing et al. 2015, Ma et al.

2013). Thus, the extant studies in theme 2 rarely provide theoretical explanations regarding why

users adhere to certain ITSM tools or interventions and therefore use them more frequently.

However, IS research includes several theories – such as those related to coping (e.g., Beaudry &

Pinsonneault 2005, Stein et al. 2015) and habit (e.g., Polites and Karahanna 2013, Wilson et al.

35
2010) – which could be used in future theme 2 research to better understand why patients with

chronic conditions use (or avoid) ITSM (see below for brief illustrations).

In theme 2, ITSM is often presented as a whole, thus we do not know how specific ITSM

functionalities fulfill users’ needs and expectations, nor how these needs influence use. It is also

unclear whether new and more advanced functionalities such as sophisticated data display and

gamified SM tasks (e.g. challenges, raising virtual pets) increases ITSM use or are a distraction

from the main SM task. Moreover, since the majority of the studies under this theme used

complex ITSM interventions (ITSM + non-IT components), it is difficult to tease apart the

effects of multiple intervention components. Thus, we do not know whether the mixed results are

due to the ITSM or the non-IT components.

A novelty effect is reported in multiple studies, and negative evaluations are reported for

newly developed functionalities such as innovative data display. It is possible that users with

chronic diseases are a group that may not react to novelty as well as other user groups due to the

crucial nature of the SM task. For example, diabetes patients who are already familiar with

traditional glucometer measuring approaches may be very hesitant to use new continuous

glucose monitoring technologies, in order to avoid any possible errors which may impact their

health.

We propose three promising areas for future research. First, although overall evaluation

of an ITSM is useful, more research should be conducted to understand how specific ITSM

functionalities increase use and enhance user experience. Sources of negative experience and

barriers to ITSM use should also be examined, especially as some of the negative experiences

emerge in studies of ITSM involving newer functionalities such as gamification (Sage et al.

2017) and more advanced data display formats (Chung et al. 2015, Storni 2014). Theoretical

36
lenses – such as coping theory (Beaudry & Pinsonneault 2005, Stein et al. 2015) that examines

IT events, user evaluation, user responses, and nonconforming use patterns – can be useful for

understanding negative user experience with ITSM. Second, new forms of ITSM may

completely shift how the technology is used, and even how we define ITSM use. With automatic

data capture, SM frequency may be of less concern. With insideables that are implanted in the

body, SM duration and frequency may not be an issue for intervention adherence. However,

issues such as properly applying the tool, data usage and connections with providers are still

essential parts of effective ITSM. Future research, drawing on existing IS theories of habit and

sporadic use (e.g., Polites and Karahanna 2013, Wilson et al. 2010), can go beyond ITSM use as

frequency to more deeply examine different patterns of ITSM use and to examine how emerging

IT functionalities influence these use patterns.

Third, the preference of less burdensome ITSM and perception of learning new
technologies or functionalities as a burden create an interesting paradox: new ITSM
technology may be less burdensome, but it may hinder patients from changing their existing
ITSM practices. Introducing new functionality may be difficult for these groups of users where
any errors made during the initial learning period with a new ITSM may directly impact their
health. Future research should untangle this paradox and examine potential risks and user
effort in ITSM for chronic care. Table 6. Summary of theme 2
What is known
• Studies emphasizing new ITSM tool development and usability assessment generally report
positive evaluations when the system is introduced as a whole.
• ITSM use is measured by use frequency in a majority of the studies.
• Certain barriers impede ITSM use: several studies report negative opinions of specific ITSM
functions such as unfamiliar data display formats and gamification.
• Users generally prefer ITSM technologies that impose less of a burden on them (e.g. automated
SM is preferred over paper-based SM).
• A “novelty effect” for complex ITSM interventions exists where initial use drops off over time.
What is unknown and suggestions for future research
• How specific IT functionalities influence ITSM use and perceptions.
➢ Study which specific IT functionalities of ITSM increase use and enhance user
perceptions.
➢ Investigate sources of negative user experience and barriers to SM use.
➢ Go beyond ITSM use as frequency to more deeply examine different patterns of ITSM
use and to examine how emerging IT functionalities influence these use patterns.

• If more advanced IT functionalities (e.g., for automatic data capture) increase ITSM use.

37
 ➢ Untangle the observed paradox of how newer automated technologies with less
burdensome data collection are preferred for chronic care, as well as whether this
technological novelty can also be a barrier for users with chronic diseases.
➢ Investigate the potential roles of effort and risk on ITSM use.

• Whether and how user characteristics such as age, education, and lifestyle influence ITSM use
and use perceptions.
➢ Empirically examine the impact of a broader range of user characteristics.

Theme 3: Effects on Chronic Care Goal Achievement

Studies examining impacts on chronic care goal achievement are represented by two main

pathways: effects of ITSM characteristics (N=79) and impacts of ITSM use and user experiences

(N=30). Two frequently examined outcomes required for chronic care goal achievement are

behavior change that is related to the task being monitored (e.g., a certain number of steps to take

each day), and health improvement that is related to the overarching chronic care goals (e.g.,

weight loss) (see Figure 5).

ITSM Characteristics Chronic Care Goal

Achievement
ITSM Presence/Absence
(Introduction of ITSM as a whole) Behavior Change
ITSM Use Behavior
- Number of SM entries - Physical activities
ITSM Mode Comparison - SM frequency - Dietary behavior
(e.g. web vs. mobile vs. paper) - SM duration
- Times of visits - Other (e.g. drinking, smoking,
- SM accuracy social participation)
Complex ITSM-Based Intervention
- Use pattern (descriptive)
ITSM Presence
OR Health Improvement
Introduction of Key ITSM - Weight-related
Functionality - Wellbeing & quality of life
ITSM Perceptions & - Disease & symptom related
Non-IT Complementary Experiences - Medication-related
Components
(e.g. periodic clinic visits, face-to- - Satisfaction
face interview and feedback, - Perceived helpfulness
counseling)

Figure 5. Relationships Investigated for Chronic Care Goal Achievement

Effects of ITSM Characteristics on Behavior Change

Thirty-six studies examine the direct impacts of ITSM characteristics – whether as ITSM

presence, ITSM mode, or complex ITSM interventions – on behavior change. The majority of

38
these studies use randomized controlled trial (RCT) experiments. Two main behavior changes

examined in the literature are improving physical activity such as increasing daily steps, physical

activity time and reduction of sedentary time (e.g., Cadmus-Bertram et al. 2015; Goto et al.

2014), and improving dietary behavior such as increasing fiber intake, increasing vegetable

intake, and balancing calorie consumption (e.g., Ambeba et al. 2015; Jakicic et al. 2017). Some

studies examine other behaviors such as the reduction of drinking and smoking (e.g. Swendeman

et al. 2015; Aharonovich et al. 2017), both of which are risk factors for psychiatric diseases

including depression and bipolar disorder.

The studies suggest that ITSM characteristics generally improve physical activity. Mobile

applications and wearables (including pedometers and accelerometers) are the most frequently

studied ITSM devices to track steps and physical activity time. ITSM mode comparison studies

show that ITSM is better than flexible self-care with periodic counseling (Ruotsalainen et al.

2015), and IT-based SM is more efficient than paper-based SM (Conroy et al. 2011). Type of

device (e.g. web-based vs. wearable-based SM) does not seem to influence behavior change. It

may be that the presence of ITSM – either using a standalone smart device or multiple connected

devices – can perform the simple SM tasks required for physical activity. However, evidence

shows that devices providing supportive data display and reflection functions are more effective

in improving physical activity (Goto et al. 2014). Several studies report no improvements related

to physical activity (see Table 7 for a complete list of studies). Potential reasons for these non-

supportive results could be using measures that are not directly related to SM tasks, such as

sedentary time instead of physical activity time (Biddle et al. 2017; Jakicic et al. 2017) or

moderate-to-vigorous PA time instead of PA in general (Abrantes et al. 2017). It should also be

noted that the majority of this research employs complex ITSM interventions where the ITSM is

39
combined with multiple non-IT components such as education on self-regulation skills (Morgan

et al. 2014), externally prescribed goals (Cadmus-Bertram et al. 2013), or periodic physician

reviews of SM results with medical feedback (Nicklas et al. 2014). Thus, it is difficult to clearly

attribute the effects of ITSM on physical activity (or lack thereof) to either the non-IT

components or the ITSM itself.

ITSM characteristics also have some positive impacts on dietary outcomes, but the results

are less conclusive regardless of the design of the intervention or the mode of IT being used.

There are two patterns in the non-supportive results: First, most intervention designs do find

positive change-from-baseline effects for those with the ITSM, but no significant differences are

found between the various ITSM and control groups (Acharya et al. 2011). Thus, the change-

from-baseline improvements show the effectiveness of particular ITSM interventions, but no

conclusions can be drawn regarding which ITSM intervention design is superior. Second, ITSM

characteristics significantly improve general dietary measures such as total calorie consumption,

but it does not consistently improve more specific diet indicators such as fiber, sodium, and fat

intake (Allen et al. 2013; Jakicic et al. 2016; Schroder 2011; Welch et al. 2013). This highlights

the complexity of dietary-related SM tasks, and more research is needed to investigate how to

improve specific dietary goals, as certain diseases are more closely linked with specific dietary

intakes (e.g. instead of controlling for total calorie consumption, diabetes patients should avoid

high carb intake).

Table 7. Effects of ITSM Characteristics on Behavior Change

Impacts on physical activity from:
ITSM presence/absence Gell et al. (2017)

ITSM mode Conroy et al. (2011), Turner-McGrievy et al. (2017)

[Goto et al. (2014), Ruotsalainen et al. (2015)]
Complex ITSM Cadmus-Bertram et al. (2015), Cadmus-Bertram et al. (2013), Conroy et al. (2011),
interventions Donaldson and Normand (2009), Fukuoka et al. (2011), Izawa et al. (2006), Nicklas

40
 et al. (2014), Jakicic et al. (2016), Morgan et al. (2014), Nicklas et al. (2014), Plow
and Golding (2017), Vogel et al. (2017), Wang et al. (2012)
[Allen et al. (2013), Abrantes et al. (2017), Biddle et al. (2017), Jospe et al. (2017a),
Jones et al. (2014), Laing et al. (2015), Sasai et al. (2017)]
Impacts on dietary behavior change from:
ITSM presence/absence Barakat et al. (2017), Mummah et al. (2017)
[Dowell and Welch (2006)]
ITSM mode [Welch et al. (2013), Turner-McGrievy et al. (2017)]

Complex ITSM Donaldson and Normand (2009), Fukuoka et al. (2011), Jones et al. (2014),
interventions Morgan et al. (2014), Nicklas et al. (2014), Wang et al. (2012), Acharya et al.
(2011), Ambeba et al. (2015), Turner-McGrievy et al. (2013), Kempf et al. (2017),
Jakicic et al. (2016)
[Allen et al. (2013), Laing et al. (2015), Schroder (2011), Jospe et al. (2017a)]
Impacts on other behavior changes from:
ITSM presence/absence Boyd et al. (2017)

ITSM mode Swendeman et al. (2015)

Complex ITSM [Aharonovich et al. (2006), Abrantes et al. (2017), Aharonovich et al. (2017b)]
interventions
Note. Studies in italicized brackets have non-supportive or mixed results.

Effects of ITSM Characteristics on Health Improvement

Sixty-four studies report the direct impacts of ITSM characteristics on health improvement. As

with the previous section, a majority of the studies employ complex ITSM interventions. Most of

the studies examine weight-related outcomes or disease/symptom improvement, whereas a

handful of studies examine quality of life self-assessment and medication change (see Table 8).

Table 8. Effects of ITSM characteristics on health improvement

Impacts on weight from:
ITSM mode Welch et al. (2013), Turner-McGrievy et al. (2017)
[Ruotsalainen et al. (2015)]
Complex ITSM Acharya et al. (2011), Burke et al. (2012), Cadmus-Bertram et al. (2013), Carter et
intervention al. (2013), Chambliss et al. (2011), Dennison et al. (2014), Karhula et al. (2015),
Morgan et al. (2014), Nicklas et al. (2014), Schroder (2011), Shuger et al. (2011),
Sidhu et al. (2016), Steinberg et al. (2013), Thomas et al. (2015), Turk et al.
(2013), Turner-McGrievy et al. (2013), Wharton et al. (2014), Aguiar et al. (2017),
Carels et al. (2017), Kempf et al. (2017), Jakicic et al. (2016), Moho Shaiful et al.
(2017), Munster-Segev et al. (2017), Nishimura et al. (2017)
[Allen et al. (2013), Jones et al. (2014), Laing et al. (2015), Wang et al. (2012),
Abrantes et al. (2017), Jospe et al. (2017a), Spring et al. (2017)]
Impacts on disease/symptoms from:
ITSM presence Dietrich et al. (2017), Downing et al. (2017), Sieber et al. (2017), Gell et al. (2017)
[Nørregaard et al. (2014), Umapathy et al. (2015)]

41
 ITSM mode Goto et al. (2014)
[Or and Tao (2016), Goffinet et al. (2017)]
Complex ITSM Chambliss et al. (2011), Karhula et al. (2015), Naylor et al. (2008), di Bartolo et al.
(2017), Haak et al. (2017), Hansen et al. (2017), Iljaz et al. (2017), Ji et al. (2017),
intervention
Kempf et al. (2017), Jakicic et al. (2016), Mantani et al. (2017), Moho Shaiful et al.
(2017), Munster-Segev et al. (2017), Nishimura et al. (2017), Sasai et al. (2017),
Steinberg et al. (2017)
[Abrantes et al. (2017), Garg et al. (2017), Jospe et al. (2017a), Simons et al.
(2017), Young et al. (2017)]
Impacts on quality of life from:
ITSM mode [Polonsky et al. (2017)]

Complex ITSM [Karhula et al. (2015), Ryan et al. (2012), di Bartolo et al. (2017), Young et al.
(2017)]
intervention
Impacts on medication from:
ITSM presence [Dietrich et al. (2017)]

Complex ITSM Naylor et al. (2008), Aharonovich et al. (2017a), Aharonovich et al. (2017b),
intervention Kempf et al. (2017)
[Pedersen et al. (2012), Plow and Golding (2017)]
Note. Studies in italicized brackets have non-supportive or mixed results.

Weight management is usually associated with physical activity and/or diet SM, and

ITSM demonstrates consistent improvement in weight management when compared to paper SM

(Morgan et al. 2014; Wang et al. 2012) or presented together with non-IT components such as

counseling and feedback (Cadmus-Bertram et al. 2013; Kempf et al. 2017). However, there is no

obvious trend regarding which device performs better, or which part of the complex ITSM

intervention is more essential. Several studies report non-significant between-group effects

(Jones et al. 2014; Shaiful et al. 2017), and when the weight outcome is measured by BMI or

body composition, the results become increasingly inconsistent, even for the change-from-

baseline effects (Jones et al. 2014; Ruotsalainen et al. 2015; Jakicic et al. 2016).

For disease and symptom-related improvement, the number of studies for each type of

symptom is small—for example, blood pressure in Laing et al. (2015), joint function in

Umapathy et al. (2015), depression in Faurholt-Jepsen et al. (2015) and asthma symptoms in

Ryan et al. (2012). All of these studies yield mixed results, so no general conclusions can be

made. A relatively frequent health outcome that has been reported is HbA1c (average blood

42
glucose sugar levels) for diabetes studies. However, the results are generally non-supportive

regardless of SM approach (tablet vs. paper plus glucometer, Or and Tao 2016) or complex

ITSM intervention used (e.g. with or without feedback, education or counseling, Greenwood et

al. 2015; Young et al. 2017).

Likewise, although positive results are reported regarding medication change and certain

aspects of self-rated quality of life, there are not enough studies to reach any general conclusions.

No study finds significant improvement for all aspects of quality of life, perhaps because the

measurement scale used (usually SF-36 questionnaire, Brazier et al. 1992) includes various

aspects of life which do not directly relate to SM goals.

Effects of ITSM Affordance Bundles on Chronic Care Goal Achievement

In the theme 3 studies, ITSM is often examined as whole systems which contain various bundles

of ITSM functionalities. Although studies did not explicitly investigate the effects of specific

affordances, we organize the ITSM affordance bundles from theme 3 in order to see if any

patterns emerge (see Appendix Table A1).

In general, automatic data capture with data display exhibits more consistent supportive

results across all types of goal achievement than interventions with manual data entry. When

push messages are employed, the intervention seems more effective regardless of the data

collection approach, except for symptom and medication-related outcomes. Surprisingly, ITSM

that supports goal setting and manual data does not exhibit improvement for behavior change and

health outcomes. One possible explanation is that patients might have a stronger tendency to

misreport the data or adjust goals in order to make the SM results look good and match goals

even when no real progress is being made. Since the studies do not report how patients set their

43
goals and perform SM data entry, more investigation is needed to understand under what

conditions goal setting, along with other functionalities, is beneficial.

Effects of Non-IT Components on Chronic Care Goal Achievement

Because ITSM is not delivered on its own in many cases but as part of a complex ITSM

intervention, we attempt to further explore the effects of the non-IT components. The extant

studies rarely employ the controlled factorial designs necessary to untangle and compare the role

of specific intervention components (for two notable exceptions, see Allen et al. 2013 and

Nishimura et al. 2017), so it is difficult to attribute the success or failure of an intervention to

either the ITSM or the non-IT components. Thus, we organize the existing interventions from

theme 3 by examining the presence of non-IT components (even if they were not directly

examined in the studies) to see if any patterns emerge (see Appendix Table A2).

When no non-IT components are present, the results are highly mixed across all

outcomes. Similarly, no patterns emerge regarding the effects of non-IT components on chronic

care goal achievement. However, four general types of non-IT components are often present, and

we describe these types in order to offer insights for future research. The first type is offline

education which involves face-to-face training and counseling regarding the disease and self-

management skills. This component is either implemented as a one-time education session

before the start of the intervention (e.g. motivation elicitation session, Aharonovich et al. 2017b)

or implemented periodically throughout the intervention (e.g. weekly coaching in self-regulatory

skills, Cadmus-Bertram et al. 2013). The intensity and adaptability of education content vary

across studies, but the majority of interventions adopted a pre-designed approach in which the

education material is released to the patients gradually without considering the patients’ progress

or ITSM use experiences. Employing a factorial experimental design, one study examines the

44
effects of both counseling intensity and mobile SM, finding that groups which had both

counseling and mobile SM lost more weight than the groups with only counseling or only mobile

SM (Allen et al. 2013). Future research can focus more on education delivery by exploring how

to use the data from the ITSM to deliver more personalized training.

The second type is goal-related components, namely goal prescription by physicians and

goal adjustment during the intervention (e.g. Aharonovich et al. 2017a). One study did carefully

isolate the effects of non-IT components: Nushimura and colleagues (2017) study the effects of

structured versus routine SM procedures for patients with diabetes while controlling for all other

non-IT components, finding that structured SM improves glycemic control while routine SM

improves patients’ own SM practices. Physicians may assign a specific target for the SM tasks

(e.g. 5% weight loss and at least 150 minutes of physical activity, Allen et al. 2013) or create a

detailed action plan (e.g. self-management plan, Karhula et al. 2015). These goals can be

process-oriented (e.g. number of SM recordings per day) or outcome-oriented (e.g. calorie

expenditure per day). Future research can employ goal theories (e.g. goal-setting theory, Locke

and Latham 2002) and explore the effectiveness of various goals under different conditions.

The third type of non-IT component is written and/or oral feedback provided by

healthcare providers after periodically reviewing the SM results. While IT-based feedback has

the advantage of being provided in real-time, written and/or oral feedback may feel more

personal, which may elicit better supervision and reinforcement effects. Future research can

further investigate feedback mechanisms and compare different modes of feedback to inform

better intervention design.

Lastly, offline social activities are used in several studies, including group exercise

sessions (e.g. Shaiful et al. 2017) and group-based competition (e.g. Spring et al. 2017).

45
Compared to online social activities in which IT helps construct virtual groups and peer support

infrastructures, offline social activities rely more on the organizer (i.e. interventionists) and the

requirement of physical presence may make this component difficult to implement during a

longitudinal intervention. However, future researchers could examine whether online social

mechanisms (usually easier and cheaper to implement) complement or are substitutes for offline

social mechanisms.

Appendix Table A2 also presents various combinations of non-IT components. All

combinations exhibit mixed results for most of the outcomes. The only evident pattern that

emerges is that non-IT educational components exhibit chronic care goal achievements related to

weight, and these effects hold when education is combined with feedback. One reason for this

effect may be the complex and non-linear relationship between dietary intake and weight

requires extra patient education for the ITSM to be effective. Future research is needed to

systematically examine the effects of various combinations of non-IT components. In summary,

it is difficult to draw conclusions regarding the impacts of the non-IT components based on

existing evidence, since the extant research exhibits many mixed results.

Effects of ITSM Use on Chronic Care Goal Achievement

ITSM use, as indicated by SM duration or frequency, has several benefits including improved

physical activity level (Conroy et al. 2011) and improved dietary behaviors (Glasgow 2011;

Jospe et al. 2017). ITSM misuse patterns such as obsessive use and app manipulation may

worsen eating disorders (Eikey et al. 2017). Frequency of ITSM entry and data usage can

generally predict weight loss (e.g. Kolodziejczyk et al. 2014; Ma et al. 2013; Painter et al. 2017)

and HbA1c change (Irace et al. 2017; Lee et al. 2017; Selvan et al. 2017). However, the impacts

46
on other disease-related outcomes are less clear (insulin and cholesterol level, Williamson et al.

2010; blood pressure, Wolin et al. 2015).

Among the twelve studies that simultaneously examine impacts of ITSM characteristics

and ITSM use on goal achievement (see Table 9), nine report positive results for both

relationships (Burke et al. 2012, Cadmus-Bertram et al. 2013; Conroy et al. 2011; Morgan et al.

2014; Spring et al. 2017; Thomas et al. 2015; Turk et al. 2013; Turner-McGrievy et al. 2013;

Turner-McGrievy et al. 2017). One reports that while the complex ITSM intervention has

positive effects on weight loss, it does not increase ITSM use (Steinberg et al. 2013). Two others

report that even when ITSM use and satisfaction are high, the intervention may not lead to

weight loss (Polonsky et al. 2017; Wang et al. 2012). No studies formally test mediation effects

of ITSM use on the relationship between ITSM characteristics and chronic care goal

achievement. In general, the abundance of studies that examine impacts of ITSM use on chronic

care goal achievement provide supportive evidence that it is not only the presence of ITSM, but

also the extent of use that drives chronic care achievements.

Table 9. Impacts of ITSM Use and User Experience on Chronic Care Goal Achievement
Impacts on behavior change from:
ITSM use Conroy et al. (2011), Glasgow et al. (2011), Turner-McGrievy et al. (2013),
Eikey et al. (2017), Jospe et al. (2017b)
[Steinberg et al. (2013)]
ITSM perceptions & experience Cadmus-Bertram et al. (2013)

Impacts on health improvement from:

ITSM use Berry et al. (2015), Burke et al. (2012), Conroy et al. (2011), Jongen et al.
(2015), Kolodziejczyk et al. (2014), Krukowski et al. (2013), Ma et al. (2013),
Morgan et al. (2014), Steinberg et al. (2014), Thomas et al. (2015), Turk et
al. (2013), Turner-McGrievy et al. (2013), Wang et al. (2012), Webber et al.
(2010), Hales et al. (2017), Irace et al. (2017), Jospe et al. (2017b), Lee et
al. (2017), Matthews et al. (2017a), Painter et al. (2017), Selvan et al.
(2017), Spring et al. (2017), Turner-McGrievy et al. (2017)
[Steinberg et al. (2013), Williamson et al. (2010), Glasgow et al. (2011),
Wolin et al. (2015)]
ITSM perceptions & experience Cadmus-Bertram et al. (2013)
[Polonsky et al. (2017)]
Note. Studies in italicized brackets have non-supportive or mixed results.

47
Effects of Behavior Change on Health Improvement

Six studies report the impacts of successful behavior change on improving health outcomes (see

Figure 6 and Table 10). Increased physical activity level in terms of time and daily steps (Conroy

et al. 2011; Painter et al. 2017; Turner-McGrievy et al. 2013) and lower fat intake

(Kolodziejczyk et al. 2014) are associated with successful weight loss. Impacts of physical

activity time on reduction in depression and anxiety are inconsistent, which may be due to the

method of measurement (e.g., general exercise vs. moderate-to-vigorous activities, Abrantes et

al. 2017). Other studies do not find correlations between physical activity and alcohol use

reduction (Abrantes et al. 2017) and between HbA1c improvement and self-rated quality of life

(Paula et al. 2017). Since chronic care is a long-term journey, patients may have nested

behavioral goals in addition to their overarching health goals. The design of the intervention and

related ITSM affordances should help users achieve those more actionable behavioral goals in

order to gradually achieve more challenging health goals.

Behavior Change Health Improvement

- Physical activities - Weight related

- Drinking - Disease & symptom related

- Dietary behavior - Wellbeing & quality of life

Figure 6. Effects of Behavior Change on Health Improvement

Table 10. Role of Behavior Change

Effects of behavior change on:
Other behavior changes [Abrantes et al. (2017)]

Health improvement Conroy et al. (2011), Kolodziejczyk et al. (2014), Turner-McGrievy et al.
(2013), Painter et al. (2017)
[Abrantes et al. (2017), Paula et al. (2017)]
Note. Studies in italicized brackets have non-supportive or mixed results.

Theme 3 Discussion and Future Directions

48
To summarize, ITSM research on chronic care goal achievement focuses on behavior change,

such as physical activity and diet, and health improvements such as weight management,

symptom relief, medication change and self-rated quality of life (see Table 11). Most of the

studies investigate obesity-related issues, which may explain why physical activity, diet and

weight SM have received more attention. Yet the results should have implications for other

chronic care contexts, since lack of exercise and being overweight are risk factors linked to many

chronic diseases (Fine et al. 2004). The results generally support the positive impacts of ITSM

on physical activity, diet and weight reduction, although inconsistent results are reported for

between-group differences and some specific measures (e.g. detailed diet indicators, sedentary

time, BMI). The results for improving HbA1c in diabetes management and self-rated quality of

life are often non-supportive. Overall, these mixed results demonstrate the challenge of using

ITSM to change behavior and improve chronic health conditions, although some results do show

the positive impacts of ITSM use on behavior change and health improvement.

Similar to theme 2, almost two thirds of the studies in theme 3 do not employ a

theoretical lens. For those that do, social cognitive theory is again the most widely used,

employed to inform overall intervention or program design (e.g., Allen et al. 2013; Hales et al.

2017) or to interpret study results (e.g., Abrantes et al. 2017; Aguiar et al. 2017). Several studies

draw on cognitive behavioral therapy – more of a treatment framework than a theory – to inform

intervention design (e.g., Barakat et al. 2017; Mantani et al. 2017). The transtheoretical model of

behavioral change (Prochaska and DiClemente 1982) is also used, largely for scale development

(e.g., Goto et al. 2014; Izawa et al. 2006). While some theme 3 studies draw on theory and

frameworks to inform intervention design, they seldom clearly explain the one-to-one

correspondence between theoretical mechanisms and practical intervention components. These

49
theories are mostly used as a background or overarching guidance for the intervention

development. For example, social cognitive theory is used to highlight the importance of

feedback as a reinforcement mechanism (e.g., Abrantes et al. 2017; Mummah et al. 2017).

However, these important mechanisms are not formally tested; instead, they are usually taken for

granted as already being part of ITSM. Future theme 3 research should more deeply engage with

existing theories (such as social cognitive theory) to examine the impacts of ITSM on goal

achievement.

There are several areas of theme 3 that require additional future research. First, chronic

care programs can be multifaceted, and complex ITSM interventions are often accompanied by

non-IT components. While it may be useful for healthcare practitioners to consider the chronic

care intervention as a whole, it is difficult to determine whether the noted improvements (or lack

thereof) in behavior and health can be attributed to ITSM alone or to the various non-IT

components (e.g., counseling and face-to-face feedback during clinical visits). More effort is

needed to untangle the effects of the ITSM intervention components in order to better assess

impacts and design more effective ITSM interventions. Such untangling is necessary to

understand the synergies between the ITSM and its multiple non-IT components: they may be

additive, complementary, or substitutive (Milgrom and Roberts 1995; Samuelson 1974; Titah

and Barki 2009). Negative effects may also emerge if the ITSM is too complex and is

overwhelming for the patients.

Future research can try to untangle these effects by (1) implementing better controlled

experiments with factorial designs, (2) conducting in-depth investigations of specific

mechanisms both with and without IT support (e.g. goal-setting mechanisms, feedback

mechanisms, social mechanisms), and (3) applying configurational logic (e.g. using qualitative

50
comparative analysis, Schneider and Wagemann 2010) to understand the necessary and/or

sufficient components of an effective ITSM design. One example of a better controlled design

examines the impacts of counseling by manipulating counseling content and intensity while

controlling for mobile SM procedures and feedback components (Allen et al. 2013). Similarly,

another study compares structured SM procedures with routine SM procedures while controlling

for all the other non-IT components (Nishimura et al. 2017). Both studies found significant

between-group differences, suggesting that carefully designing studies to account for the various

parts of the complex ITSM interventions may increase the chances of finding clear results.

Second, since ITSM is usually presented as a whole, it is unclear whether the devices

with more add-on features – such as an interactive display, real-time communication with

physicians, or gamification – yield better outcomes than devices with more basic features. Future

research should go beyond simple presence or absence of ITSM to investigate the effects of

specific IT functionalities and how they are delivered to impact goal achievement. For example,

the incorporation of an incentive system is a new trend in many fitness tracking devices (Hales et

al. 2017), and future research should investigate the impacts of incentive design (e.g. process-

based vs. event-based incentives, financial vs. virtual incentives). Similarly, with the help of

advanced data analysis techniques, future research can compare the effectiveness of different

feedback modes (Shin and Biocca 2017), such as comparing feedback format (image vs. textual),

timing (event-triggered vs. pre-set), and tone (human-like vs. system-like). Future research in

chronic care can focus on how to take advantage of emerging technologies and harness the

potential of their functionalities.

Third, more research is needed on health outcomes other than weight loss, as well as

behavior outcomes other than physical activity and dietary intake. There are many additional risk

51
factors that are common to multiple chronic diseases and are good candidates for ITSM, such as

infections, physiological markers specific to the disease (e.g. metabolome, blood lipids,

inflammation) and subclinical symptoms (Tzoulaki et al. 2016). While previous ITSM research

was limited by the self-measurement tools commonly available (e.g. pedometer for steps and

mobile app for dietary intake), recent technological advances provide more extensive data

capture capabilities for the personal collection of various chronic conditions and risk factors (for

example, insideables that can track blood glucose levels). A deeper understanding of these

technological advancements, how they are changing the delivery of ITSM affordances, and their

associated outcomes will allow researchers to investigate a wider range of chronic care issues.

Table 11. Summary of Theme 3

What is known
• ITSM presence can help improve physical activity, dietary behavior and weight management.
• IT-based SM is superior to paper-based SM for PA, diet and weight outcomes.
• Complex ITSM interventions exhibit change-from-baseline effects for PA and weight outcomes.
• ITSM presence does not currently improve diabetes management (i.e. does not improve HbA1c).
• ITSM presence does not currently improve self-rated quality of life.
• ITSM use as indicated by SM frequency exhibits positive impacts on PA, dietary and weight
management.
• Achieving behavioral goals (e.g. increased physical activity) is beneficial for achieving health goals
(e.g. weight reduction)
What is unknown and suggestions for future research
• Whether the noted improvements in behavior and health can be attributed to ITSM alone or to the
various components of the complex interventions (e.g., counseling and face-to-face feedback
during clinical visits).
➢ Employ more rigorous research designs capable of untangling the effects of complex
ITSM interventions.

• Whether the non-significant results of complex ITSM interventions are caused by the ITSM or
other components of the complex interventions that are competing sources of influence (e.g.,
ITSM may improve while gamification may impede health improvements).
• Whether ITSM devices with more add-on features (e.g. interactive display, real-time
communication with physicians, gamification) can yield better outcomes than more basic ITSM.
➢ Go beyond ITSM presence/absence and investigate the effects of specific IT
functionalities and how they are delivered to impact goal achievement.
➢ Examine ITSM system design with more focus on how to access the potential of more
recently available functionalities.

• Whether the impacts of ITSM presence on chronic care goal achievement is mediated by ITSM
use and/or intermediate outcomes.

52
 ➢ Employ longitudinal designs which capture and analyze the mediating effects of
intermediate outcomes.

• Whether ITSM is useful for managing more specific disease symptoms that require complex
measurement.
• Which ITSM functionalities are better than others for disease-specific chronic care goals.
➢ Examine ITSM impacts on a wider range of behaviors and health goals.

Theme 4: Intermediate Outcomes of ITSM

The intermediate outcomes of ITSM affordance actualization are the direct results that

individuals can achieve due to engaging in ITSM, including psychological or cognitive states

induced by the ITSM. The affordance actualization framework suggests that these intermediate

outcomes are key mechanisms that help achieve ultimate chronic care goals. The abundance of

studies in theme 3 that examine impacts of ITSM characteristics and ITSM use on chronic care

goal achievement yield many inconsistent results, implying the existence of these intermediary

outcomes. We analyze the ITSM intermediate outcomes in the literature and – through an

iterative process of coding, categorization, and research team discussion – find that four

categories emerge: patient learning and self-reflection, patient-provider co-management, social

interaction with family and peers, and ITSM intervention satisfaction and compliance. In total,

fifty-four studies investigate various factors that influence the impacts of, and/or the

relationships between, these intermediate outcomes. Although the number of studies for each

pair of relationships is small and results are often inconsistent, these studies provide initial

evidence regarding the black box between ITSM use and chronic care goal achievement.

Intermediate Outcome 1: Patient Learning and Self-Reflection

ITSM can enhance user learning and reflection by delivering education materials and presenting

SM data in meaningful ways. As a result, patients can have better comprehension of health

problems and SM data so that they can interpret the numbers, find trends, and identify patterns

between their SM and chronic conditions (Ayobi et al. 2017; Felipe et al. 2015; Hinnen et al.

53
2015; Murnane et al. 2016). Three types of intermediate outcomes related to patient learning and

self-reflection emerge from the literature: self-understanding, self-efficacy, and health literacy.

Figure 7 and Table 12 present the key constructs and relationships within this theme.

Intermediate Outcomes
ITSM Characteristics
Intervention Satisfaction &
ITSM Presence/ Absence Compliance
(Introduction of ITSM as a whole) -program engagement
ITSM Use Behavior
- Use pattern(descriptive)
ITSM Mode Comparison
(e.g. web vs. mobile vs. paper) ITSM Perceptions &
Experiences
- Satisfaction Patient Learning & Self-
Specific ITSM Functionality
(e.g. data display format, data entry Reflection
approach) Behavior Change
- Self-understanding
- Dietary behavior
Complex ITSM Intervention
- Self-efficacy
ITSM Presence/ Absence
OR - Health literacy
Introduction of Key ITSM
Functionality

Non-IT Complementary
Components Patient-Provider Co-Management
(e.g. periodic clinic visits, face-to-
face interview and feedback, -Provider s SM data use
counselling)

Figure 7. Relationships Investigated for Patient Learning and Self-reflection

Table 12. Role of Patient Learning and Self-reflection

Impacts on self-understanding from:
ITSM presence Ayobi et al. (2017), Bonilla et al. (2015), Murnane et al. (2016), Nørregaard et al.
(2014), Tsai et al. (2007), Andersen et al. (2017), McDonald et al. (2017), Velardo
et al. (2017)
[Felipe et al. (2015), Gell et al. (2017), Verdezoto and Gronvall (2016)]
ITSM mode Swendeman et al. (2015)
[Goffinet et al. (2017)]
ITSM functionalities Hinnen et al. (2015), Kendall et al. (2015), Mathieu-Fritz et al. (2017)

Complex ITSM Aharonovich et al. (2006)

intervention [Cadmus-Bertram et al. (2015), Greenwood et al. (2015), Jones et al. (2014),
Webber et al. (2010)]
ITSM use and Chung et al. (2015), Mathieu-Fritz et al. (2017)
experience
Patient-provider co- Chung et al. (2015), Andersen et al. (2017)
management
Impacts on self-efficacy from:
ITSM mode [Goto et al. (2014), Welch et al. (2013), Polonsky et al. (2017)]

Complex ITSM Izawa et al. (2006), Garg et al. (2017), Plow and Golding (2017)
intervention [Greenwood et al. (2015), Laing et al. (2015), Ryan et al. (2012), Rader et al.
(2017)]

54
 ITSM use and Matthews et al. (2017a), Polonsky et al. (2017)
experience
Impacts on health literacy
ITSM mode [Or and Tao (2016)]

Complex ITSM Pedersen et al. (2012)

intervention [Greenwood et al. (2015)]

Impacts of self-understanding on…

Behavior change Bonilla et al. (2015), Kendall et al. (2015)

ITSM use Eikey et al. (2017)

Intervention compliance Chung et al. (2015)

Note. Studies in italicized brackets have non-supportive or mixed results.

Patients can use their ITSM data to enhance understanding of their SM results. Patients

who habitually use ITSM become increasingly capable of interpreting the results, identifying the

correlations, and exploring the causal relations between their daily activities and health

conditions (Ayobi et al. 2017; Chung et al. 2015; Felipe et al. 2015; Kendall et al. 2015). Their

data interpretation proficiency can be improved through more efficient data display formats

(Hinnen et al. 2015) and guidance from clinicians (Anderson et al. 2017; Chung et al. 2015).

However, even patients who know how to interpret SM data may not know how to respond in

specific health situations and take the right actions (Verdezoto and Gronvall 2016). ITSM can

also improve patients’ awareness of their self-monitored behavior (e.g. excessive drinking,

Aharonovich et al. 2006; dietary intake, Bonilla et al. 2015) and health conditions (e.g. body

concern, Ayobi et al. 2017), which helps them foresee the health consequences and prompts

preventive and self-regulative actions (Felipe et al. 2015; Murnane et al. 2016; Nørregaard et al.

2014). Two experiments find that ITSM did not improve self-understanding and awareness

(Jones et al. 2014; Goffinet et al. 2017). It may be that such awareness is influenced by ITSM

design or IT use frequency (e.g. daily vs. bi-weekly SM, Swendeman et al. 2015). The mostly

qualitative and descriptive studies that report supportive results provide initial evidence of the

55
impacts on self-awareness, but quantitative analysis is needed to show the actual level of impacts

for these relationships.

The impacts on other intermediate outcomes related to patient learning and self-reflection

are less consistent. Self-efficacy and motivation level are the two frequently examined concepts

in the ITSM literature. Social cognitive theory – which is the theoretical foundation for many

ITSM intervention designs – suggests that improving a patient’s confidence in his/her ability to

self-manage chronic conditions should enhance chronic care goal achievement (Bandura, 1977).

A positive correlation between intervention satisfaction and patients’ confidence in self-

management has also been reported (Polonsky et al. 2017). Yet, evidence shows that it is

challenging to improve self-efficacy through ITSM even with carefully designed education

sessions (Laing et al. 2015; Rader et al. 2017; Ryan et al. 2012; Welch et al. 2013). One

beneficial approach is to help patients improve readiness and motivation, which is reported in

several studies (Polonsky et al. 2017; Tsai et al. 2007; Webber et al. 2010). In terms of health

literacy, only one study shows ITSM improves patients’ disease-related knowledge (Pedersen et

al. (2012); however this effect may be due to the other components of the complex ITSM

intervention.

Few studies examine the impacts of patient learning and self-reflection on chronic care

goal achievement. For example, one study mentions qualitative evidence regarding the beneficial

effects of patient awareness and motivation on improved eating habits (Bonilla et al. 2015). More

research is needed to investigate the impacts of these intermediate outcomes, as theory would

suggest that patients’ psychosocial conditions could have profound impacts on chronic care goal

achievement (Alderson 1998; Bandura 1998; Deci and Ryan 2008; Walker 2001).

Intermediate Outcome 2: Patient-Provider Co-Management of Chronic Conditions

56
Patient-provider interactions and shared medical decision making is a current trend in chronic

care (Bodenheimer et al. 2002; Frantsve and Kerns 2007; Nam et al. 2011). More ITSM devices

and interventions are starting to incorporate components that support patient-provider interaction

(see Appendix Table A4 for the list of studies with IT-enabled patient-provider connections).

Thirteen studies report findings regarding patient-provider co-management as a result of ITSM

or the impacts of co-management. Figure 8 and Table 13 display the key constructs and

relationships examined under this theme.

Intermediate Outcomes
ITSM Characteristics
Patient Learning & Self-Reflection
ITSM Presence/ Absence - Self-understanding
(Introduction of ITSM as a whole) (e.g. understanding of trends, self-
ITSM Use Behavior assessment & planning, data
interpreting proficiency)
ITSM Mode Comparison - Use pattern(descriptive)
(e.g. web vs. mobile vs. paper)
ITSM Perceptions &
Experiences
Complex ITSM Intervention Patient-Provider Co-Management
- Uncertainty & anxiety
ITSM Presence/ Absence -Provider s SM data use
OR (e.g. assessment, review,
Introduction of Key ITSM understanding, diagnoses)
Functionality - Patient-provider interaction
(clinic visits, treatment negotiation and
Non-IT Complementary update, active information sharing by
Components patients)
(e.g. periodic clinic visits, face-to- - Patient s expectation of providers
face interview and feedback,
counseling)

Figure 8. Relationships Investigated for Patient-Provider Co-management

Table 13. Role of Patient-Provider Co-management

Impacts on Patient-Provider Co-Management from:
ITSM Presence Bonilla et al. (2015), Felipe et al. (2015), Andersen et al. (2017), Zhu
et al. (2017), Murnane et al. (2016)
[Verdezoto and Gronvall (2016)]
ITSM Mode [Caballero-Ruiz et al. (2017)]

Complex ITSM Intervention Nishimura et al. (2017), Rader et al. (2017)

ITSM Use & Experience Chung et al. (2016), Mentis et al. (2017)

Effects of Patient-Provider Co-Management on:

ITSM Use & Experience Andersen et al. (2017), Piras and Miele (2017)

Patient SM Data Use & Self- Chung et al. (2015), Andersen et al. (2017)
Reflection

57
Note. Studies in italicized brackets have non-supportive or mixed results.

From the providers’ perspective, introducing ITSM as a whole or as part of a complex

intervention improves the quality and quantity of disease-related information obtained from

patients, facilitating assessment, diagnoses and counseling (Bonilla et al. 2015; Murnane et al.

2016). Automatic data-sharing functions reduce the time required by a clinician to integrate the

SM records, making it easier for clinicians to review and create personalized treatment plans

(Caballero-Ruiz et al. 2017; Zhu et al. 2017). As a result, physicians may change a treatment

plan more frequently when ITSM is used (Nishimura et al. 2017).

However, barriers to patient-provider co-management are also reported. First, IT-based

tracking is not formally implemented by the majority of clinics (Murnane et al. 2016). Even

when ITSM is formally supported, the clinicians may not be fully aware of the system’s

suggestions or may not trust system-generated information. For example, Caballero-Ruiz et al.

(2017) report that the majority of insulin advice provided by the ITSM system was rejected or

initially ignored by the medical team. Second, a patient may not be willing to share their self-

monitored data with providers (Verdezoto and Gronvall 2016). Patients have their own SM goals

and habits which may not align with providers’ goals. For example, Chung et al. (2016) describe

three types of SM – namely self-reflective, action-oriented and affective-oriented. It may be that

while action-oriented SM may be more aligned with providers’ expectations, self-reflective and

affective-oriented SM can be very personal and align more with patient expectations. Lack of

alignment between the patients’ and providers’ SM orientation may influence their interaction

patterns.

Regarding the impacts of patient-provider co-management, some unexpected results are

reported. ITSM may create new expectations on the patients’ side in that they may expect more

timely feedback from the clinicians and hope the clinicians show sympathy. When it takes time

58
for the clinicians to formally assess the information, not knowing what SM will reveal creates

negative feelings of uncertainty and anxiety in patients (Andersen et al. 2017). No studies

examine the impact of patient-provider co-management on chronic care goal achievement.

Intermediate Outcomes 3: Social Interactions with Family and Peers

Social interaction with family and peers has received relatively less attention compared to other

intermediate outcomes, and yet the results are promising. Social functionality has become

increasingly common for many commercialized ITSM devices such as fitness trackers, but in the

medical context, it seems that sharing data and personal status with peers is seldom promoted by

healthcare providers. Four studies report evidence regarding ITSM and social interaction (see

Figure 9 and Table 14). Participants describe that the ability to share chronic care experiences

and information through ITSM allows them to emotionally and instrumentally support – and be

supported by – their peers (Fukuoka et al. 2011; Roblin 2011). One experiment that allowed both

parents and adolescents to access ITSM found that parents’ participation is positively associated

with adolescents’ SM rate and weight reduction (Tu et al. 2017). However, some patients feel

reluctant to share with others as the patients may feel uncomfortable with how other people

perceive them and do not want to attract attention to their disease (Kendall et al. 2015).

A number of studies purposefully incorporated social media or virtual communities as

part of their complex ITSM interventions (e.g. Fukuoka et al. 2011; Glasgow et al. 2011; Jones et

al. 2014; Partridge et al. 2016), providing IT affordances for sharing information with peers and

families. However, formal investigation regarding the role of social interaction in a virtual

environment, its delivery method, and its impacts, is particularly scant. Future research can

further investigate this intermediate outcome as the preliminary results demonstrate the potential

power of social and external support.

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 Intermediate Outcomes

Social Interaction Health Improvement

ITSM Presence - Information sharing with peers
(Introduction of ITSM as a whole) - emotional/social support - Weight reduction
- reluctance
ITSM Use Behavior
- Use pattern(descriptive)
- SM rate

Figure 9. Relationships investigated for social interaction

Table 14. Role of social interaction

Impacts on Social Interactions with Peers from:
ITSM presence Fukuoka et al. (2011), Roblin (2011)

ITSM use [Kendall et al. (2015)]

Effects of Social Interactions with Peers on:

ITSM use Tu et al. (2017)

Health outcome Tu et al. (2017)

Note. Studies in italicized brackets have non-supportive or mixed results.

Intermediate outcome 4: Intervention Satisfaction and Compliance

Intervention compliance (or adherence) refers to the degree to which a patient correctly follows

the intervention (also termed treatment, medication, or experiment depending on the study

design) on schedule and as prescribed (Chakrabarti 2014). Intervention compliance may overlap

with ITSM use (most often measured by SM frequency); however ITSM is often part of a larger

complex intervention and involves specific instructions or targets beyond simple frequency. As

the current practice of chronic care usually involves non-IT components for education,

counseling and feedback, patients’ compliance and satisfaction with the entire intervention can

be important intermediate outcomes. Sixteen studies report relevant results (see Figure 10 and

Table 15).

Participants generally report positive evaluations of the whole intervention (i.e.

satisfaction and acceptability, Aguiar et al. 2017; Aharonovich et al. 2017; Goffinet et al. 2017;

Pedersen et al. 2012; Rader et al. 2017; Steinberg et al. 2013). However, when assessing specific

60
parts of the intervention, two studies report negative evaluations— Fukuoka et al. (2011) report

negative perceptions due to strict SM data input timeframe, and Welch et al. (2013) report low

perceived benefits regarding certain indicators (e.g., sodium and fluid adherence in diet SM).

These findings imply that procedural barriers such as inflexible rules and insufficient

understanding of the intervention purpose may impede intervention compliance and satisfaction.

The actual compliance behavior, usually represented as attendance or participation, is influenced

by intervention design. For example, intensive counseling may be more effective than light

counseling in compelling participants to fully comply with the intervention (Allen et al. 2013);

email or text prompts are a better approach for follow-up participation than phone-based

reminders (Hall and Murchie 2014); and adding mobile SM facilitates patients’ adherence to a

given medical therapy as compared to standard care (Hostler et al. 2017).

Four studies examine health goal achievement as a result of intervention satisfaction and

compliance. Patients’ level of participation in the intervention program is associated with total

weight loss and BMI reduction (Tu et al. 2017; Turner-McGrievy et al. 2017), but reduction in

waist circumferences is not significant (Tu et al. 2017). Paula et al. (2017) found patients’

perceptions of intervention benefits have a positive correlation with quality of life measures.

Though the evidence is limited, it highlights the potential role of intervention satisfaction and

compliance as an intermediating mechanism. Future research can further investigate the ITSM

factors which influence intervention satisfaction and compliance as well as its impacts on

chronic care goal achievement.

61
 Complex ITSM Intervention Intermediate Outcomes
Intervention Satisfaction &
ITSM Presence
OR Compliance
Introduction of Key ITSM -program participation (e.g. Health Improvement
Functionality material downloads, session
attendance, follow-up attendance) - Weight-related
Non-IT Complementary -program acceptability: - Quality of life
Components satisfaction/ perceived
(e.g. periodic clinic visits, face-to- effectiveness/ perceived benefits
face interview and feedback,
counseling)

Figure 10. Relationships investigated for intervention acceptance

Table 15. Role of intervention satisfaction and compliance

Impacts on Intervention Satisfaction and Compliance from:
Complex ITSM Allen et al. (2013), Pedersen et al. (2012), Steinberg et al. (2013), Abrantes et al. (2017),
intervention Aguiar et al. (2017), Aharonovich et al. (2017b), Hostler et al. (2017), Rader et al. (2017),
Goffinet et al. (2017)
[Dennison et al. (2014), Fukuoka et al. (2011), Hall and Murchie (2014), Welch et al.
(2013)]
Effects of Intervention Satisfaction and Compliance on:
Health Paula et al. (2017), Turner-McGrievy et al. (2017)
improvement [Tu et al. (2017)]
Note. Studies in italicized brackets have non-supportive or mixed results.

Theme 4 Discussion and Future Directions

Key takeaways and future research suggestions are presented in Table 16. By identifying and

categorizing the key intermediate outcomes of ITSM, we find four intermediate outcomes that

may help to facilitate ultimate chronic care goal achievement. As patients develop ITSM

routines, their ability to learn from data improves, which may enhance their self-understanding

and increase their beliefs in one’s ability to perform health self-management actions, thus

facilitating ultimate goal achievement. The social connection affordance provided by ITSM

opens new opportunities for patients to share data with providers and peers through which they

may obtain additional emotional and instrumental support, which is beneficial for successful

behavior change and health improvement. From the providers’ perspective, having access to

patients’ SM data gives them new sources of information, which is helpful in diagnosing and

creating personalized treatment plans. Yet, IT functional barriers and patients’ reluctance to

62
share data may impede social interaction and patient-provider co-management. Since the

intervention can be longitudinal and complex, overall satisfaction with the intervention may

facilitate compliance, which is generally considered a necessary part of successful chronic care.

As in themes 2 and 3, the majority of the studies do not employ any theoretical lens to

examine the relationships of theme 4. Despite the potential roles of these intermediate outcomes,

existing studies only provide initial evidence, and most of them are qualitative and descriptive,

without deep theoretical explanation. One notable exception is Chung and colleagues (2016)

which draws on Lee’s (2007) model of boundary negotiation artifacts to understand the

importance of these artifacts in supporting patient-provider collaboration. In another study, a

sociocultural perspective is used to highlight the potential for technology and media – of which

ITSM is one example – to distort body image in patients with eating disorders (Eikey 2017).

However, the general lack of theory in theme 4 means that many unknowns remain regarding

how and why these intermediate outcomes arise. For example, we do not know if or how ITSM

improves these intermediate outcomes such as self-efficacy and motivation, how self-

understanding develops and influences chronic care goal achievement, or how patient-provider

co-management is facilitated and constrained by ITSM functionalities. Future research related to

theme 4 could draw on social representation theory (Wagner and Hayes 2005), the concept of IT

identify (Carter 2015), or employ a practice lens (Feldman and Orlikowski 2011) to better

understand the role of intermediate outcomes in ITSM (see below for a few illustrations).

In addition to the general lack of theory, these intermediate outcomes are proposed as

mechanisms linking ITSM and goal achievement, but seldom do existing studies test the actual

impacts. Thus, we do not know whether or not improving patient learning and interactions with

providers and peers can indeed generate positive effects on goal achievement.

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 Accordingly, we propose three broad areas of future research. First, the role of

intermediate outcomes is generally understudied, and more rigorous investigation is needed to

investigate their mediating effects on chronic care goal achievement. For example, longitudinal

research can be conducted in order to understand how ITSM influences patient-provider co-

management, which in turn influences chronic care goal achievement. Patient SM practice can be

relatively flexible, while clinical procedures can be very structured, creating reluctance on the

part of providers if they do not trust the patients’ collected data. Future research can focus on

how ITSM promotes or constrains co-management, and a practice lens (e.g., Feldman and

Orlikowski 2011) can be used to understand micro-processes that bring about the effects.

Similarly, ITSM affordances that support social interaction with families and peers may change

dramatically with the emergence of new communication and social media technologies. New

technological support of virtual presence may influence how people behave and interact in

virtual spaces with their sensitive health issues, which further influences chronic care goal

achievement. Social representation theories (Wagner and Hayes 2005) and theories on IT

identity (Carter 2015) can be used to explore how patients’ virtual and illness-related identities

influence information sharing and digital participation on ITSM-related social platforms.

Another interesting point is the mediating role of intervention compliance. Studies in

other healthcare contexts have tested the mediating role of treatment compliance for various

outcomes, some finding supportive evidence and others finding none (e.g. Ilgen et al. 2006; Turk

et al. 2013; Wang et al. 2012). With the introduction of ITSM and the digitization of various

treatment components previously delivered offline, the form of compliance may change, and

future studies can investigate the ITSM factors, either technological or otherwise, that influence

64
intervention satisfaction and compliance as well as their impacts on chronic care goal

achievement.

Building upon this suggestion, future research can also investigate potential interactions

of these intermediate outcomes. For example, patients’ expectancy and perceived control may

influence their further treatment adherence (Gonzalez et al. 2015; Westra et al. 2007).

Investigation of how intermediate outcomes are connected and influence each other is also in line

with the idea of affordance bundle and path dependence of affordance actualization in the theory

(Strong et al. 2014). Since affordances are usually bundled, SM processes may have a cascading

effect in that latter stages of ITSM intervention cannot be successfully performed if the former

stages have not been accomplished (Li et al. 2010). Since users may deal with multiple

affordances at the same time to achieve interrelated goals (e.g. successful self-assessment

depends on accurate capturing of SM outcomes and meaningful data presentation), ITSM

efficacy may largely depend on the emergence and actualization of these nested affordances.

Thus, understanding how patients actualize the affordances (i.e. result in various intermediate

outcomes) and their path dependence (i.e., the interaction between the actualized outcomes) has

theoretical significance to unfold how ITSM promotes chronic care.

Finally, a feedback loop may exist during ITSM, which should be an important

mechanism since it can further promote the actualization of additional intermediate outcomes.

Although the affordance actualization framework suggests such feedback from actualized

affordances (i.e. intermediate outcomes) to the affordance potentials, we did not find studies

explicitly examining this type of relationship. However, several studies reported goal update in

ITSM devices during the treatment, usually in a periodic manner (e.g. Abrantes et al. 2017;

Painter et al. 2017). As per goal setting theories, goal specificity influences task execution

65
strategy and performance, yet the level of ability, efficacy beliefs and outcome feedback also

influence an individual’s commitment to the goal and goal setting (Earley et al. 1990; Greenlees

et al. 2000; Hollenbeck et al. 1989; Klein et al. 1999). Thus, feedback loops from intermediate

outcomes (e.g. patient learning) and behavior change (e.g. physical activity performance) to

ITSM use are possible. Future research can explore various possibilities of feedback

mechanisms, including positive and negative reinforcement, and unfold the theoretical reasons

behind them.

Table 16. Summary of Theme 4

What is known
• ITSM can help patients understand and learn from their data to make links between their daily
activities and health conditions.
• IT functionalities, such as automated data sharing, enhance patient-provider co-management
beyond traditional periodic face-to-face data review.
• Patient-provider co-management may be impeded by IT functional barriers and physician’s
mistrust of the system or data.
• ITSM that incorporates social functionality can enable emotional and instrumental support from
peers.
• Intervention satisfaction and compliance is beneficial for achieving health goals (e.g. weight loss)
What is unknown and suggestions for future research
• Whether and how ITSM improves intermediate outcomes such as patient satisfaction, patient
self-efficacy and motivation, patient awareness, patient-provider co-management, and social
interaction with peers.
• Whether these improvements in intermediate outcomes ultimately influence achievement of
chronic care goals.
➢ Investigate and more rigorously test if these intermediate outcomes mediate the effects
on ITSM use on chronic care goal achievement.
➢ Longitudinally examine how ITSM influences patient-provider co-management and the
ultimate impacts on chronic care goal achievement.
➢ Further study the role of ITSM-enabled social interaction in achieving chronic care goals.
➢ Investigate the ITSM factors that influence intervention satisfaction and compliance, as
well as their impacts on chronic care goal achievement.
➢ Investigate the potential interactions between these intermediate outcomes.

• How to design ITSM interventions so that procedural barriers are minimized, and intervention
satisfaction and compliance are improved.
➢ Investigate the impacts of new technologies on the actualization of intermediate
outcomes.

• Whether feedback loops actually exist and how they work.

➢ Investigate the multiple possible feedback mechanisms that could influence ITSM use.

DISCUSSION

66
This paper reviews the literature on IT-based self-monitoring for chronic disease and develops a

framework to help guide future research. Drawing on the affordance actualization framework

(Strong et al., 2014), our synthesis focuses on four key themes: ITSM functionalities (that enable

ITSM affordances), ITSM use and user experiences, intermediate outcomes, and chronic care

goal achievement. The key findings find some support for the potential usefulness of ITSM –

either presented as a standalone system or as part of a complex intervention – and its positive

impacts on certain behavior change and health improvement outcomes, namely physical activity

and weight reduction. Our synthesis also reveals three overarching issues related to research on

ITSM for chronic care, which– along with related opportunities for future research – are outlined

next (see Table 17).

Table 17. Overarching Research Issues and Future Research Suggestions

Issue Future Research Suggestions
Fragmentation of ITSM for chronic Pursue a more complete approach connecting ITSM
care research characteristics – through use and intermediate outcomes – to
chronic care goal achievement.

Use our framework to specify how future research adds to the

ongoing investigation of ITSM for chronic care.

Shallow Understanding of the Role Pursue an in-depth understanding of the transformational role of
of IT IT in chronic care. For example:
- Understand how ITSM transforms patient engagement in
chronic care
- Understand how patient-initiated ITSM transforms healthcare
practices and the role of healthcare providers
- Understand how ITSM transforms patient record management
(e.g. integration of informal patient-generated information into
standardized clinical information, issues of information quality)
Paucity of Strong Theory Pursue more diverse perspectives of ITSM for chronic care.
Pursue multi-level explanations of ITSM implementation, use
and impacts. For example:
- Cognitive and behavioral level explanations for human-IT
interaction.
- Interpersonal-level explanations for patient-provider co-
management and peer-to-peer interaction.
- System-level explanations for emerging attributes and
capacities due to synergistic effects of various intermediate
outcomes.

67
 Research Issue 1: Fragmentation of ITSM for Chronic Care Research

ITSM for chronic care is multidisciplinary by nature in that people, IT and healthcare practices

are intertwined pillars transforming chronic disease self-management. Drawing on these

stakeholders, multiple intermediate outcomes emerged from the extant studies (patient learning

and self-reflection, patient-provider co-management, social interactions with families and peers,

and intervention satisfaction and compliance). These intermediate outcomes may serve as

important mechanisms between ITSM use and chronic care goal achievement; however,

additional examination is needed to reach definitive conclusions. Instead, the reviewed studies

exhibit a fragmented landscape in which a large proportion of studies only examines the direct

impacts of ITSM on goal achievement (ignoring the multiple mechanisms through which the

ITSM impacts goal achievement) while another large proportion only examines ITSM design

and mechanisms (ignoring ultimate impacts on goal achievement).

While individual studies may reasonably concentrate on a single aspect of this complex

process (e.g. effects of ITSM design on use), too few studies take a more comprehensive

approach that is necessary to build a solid chain of evidence connecting ITSM characteristics –

through use and intermediate outcomes – to chronic care goal achievement. This limits the

development of the field by restricting the definitive conclusions that can be drawn and the

progress that can be made.

Our synthesized framework is a useful starting point for future research. It offers a more

integrative understanding of ITSM for chronic care, and future research should take a broader

focus by including concepts along the path from ITSM to ultimate impacts. It also helps future

researchers identify areas of interest and specify how their research adds to the ongoing

investigation of ITSM for chronic care.

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 Research Issue 2: Shallow Understanding of the Role of IT

The extant studies generally take a simplistic tool view of IT (for example, the presence or

absence of ITSM). How IT can transform multiple aspects of chronic care has received little

investigation. New ITSM technological developments – such as wearables, insideables, and

complex AI – may have far-reaching impacts on patients and their healthcare practices. A

shallow understanding of the role of IT may lead to missed opportunities, both in terms of

practice and research. To illustrate, three emerging transformations entwined with technology

developments are outlined for future examination.

Newer ITSM advances may transform patient engagement in chronic care. Current

studies have examined ITSM use frequency and satisfaction, which are important parts of

engagement. However, new insideable technologies may fundamentally shift how patients

interact with ITSM devices. The meaning of use frequency is unclear when an implanted ITSM

device is automatically transmitting data to the system and/or medical provider; patient

engagement and use do not occur through action, but rather through inaction (e.g., by not turning

off data capture functionality or by not removing an implanted device). Thus, patient

engagement may not link to use frequency but may be more closely related to continued

tolerance of the device. Rather than perspectives based on the theory of planned behavior,

theories of decision inertia from behavioral economics may be the key to understanding patient

engagement in future ITSM (Madrian and Shea 2001).

ITSM technological advancements also transform the role of the healthcare provider.

Traditional paper-based SM was often initially recommended by the patient’s healthcare

provider based on specific needs related to the patient’s chronic disease, and was accompanied

with specific medical protocols. The explosion of access to ITSM devices by the general public

69
(Gartner 2018) means that instead of generally being initiated by the provider, SM is now often

initiated by the patients themselves. While there are many benefits to the wider diffusion of

ITSM, the resulting SM practices may be less structured than provider-initiated SM, may deviate

from disease-specific SM protocols, and at times may lead to practices that are sub-optimal or

not recommended for the patient’s chronic disease (Gabriels and Moerenhout 2018). Thus,

provider influence and control over the SM process may be diminished as compared to paper-

based SM or ITSM with earlier technologies.

The transformational effects of ITSM on patient-generated information also create

opportunities and challenges for data management and use. Whereas traditional clinical

information is often standardized, structured, formal, and gathered according to specific

protocols (e.g., measurements taken at regular intervals using verified measurement tools, de Vet

2003), patients’ SM data are often unstandardized, unstructured, less formal, and gathered in an

ad-hoc way. While patient-generated SM information can complement the more traditional

patient health records, there are many obstacles to integrating the two. The clinical infrastructure

and practices may not support the storage and analysis of patients’ SM data, thus healthcare

professionals may consider it as extra work, or they may not have the relevant skills to

proficiently analyze these data and incorporate them into personalized treatment plans.

Moreover, information quality can be a major issue as patient-generated information may not be

reliable enough to support formal clinical processes (West et al. 2017). Finally, the significant

amount of data created by ITSM may make it difficult for physicians – who often have hundreds

of patients to follow – to closely monitor the SM data and appropriately adjust their clinical

recommendations. Emerging AI techniques have the potential to alleviate the pressure on busy

physicans by helping them monitor patients’ data (e.g. auto-detection of anomalies and

70
unexpected deviations) and make treatment decisions (e.g., automatic diagnoses and proactive

interventions based on data trends). Thus, future research should investigate patient health record

management issues caused by the technological advances and the integration of patient SM data.

Research Issue 3: Paucity of Strong Theory

Our examination of the literature shows that, in all parts of our overarching framework, ITSM

for chronic care research is not theory-rich. One hundred studies (63% of the sample) do not use

any theory or develop new theories, and those studies that do use theory do not contribute back

to or extend the original theory. The majority of these studies cite theory to inform interventions,

tool design, or measure development, but do not use theory to explain the relationships under

investigation. The main theories used and their corresponding studies are listed in Table 18.

Many of the medical studies focus on description and prediction rather than on

explanation: this may be appropriate since the purpose of much healthcare research is evaluating

intervention effectiveness rather than contributing to theory. However, abstracting to a

theoretical understanding is also important. Given the fast pace of technological change and the

complexity of the healthcare ecosystem, a theoretical understanding of ITSM’s abstracted

functionalities and the underlying causal mechanisms for their effects enables the accumulation

of knowledge about ITSM for chronic disease management and avoids a plethora of piecemeal

and fragmented studies.

Table 18. Theory Used in the Extant Studies

Theory* Studies that reference the theory
Social cognitive theory Allen et al. (2013), Bonilla et al. (2015), Cadmus-Bertram et al. (2015),
Dorsch et al. (2015), Fukuoka et al. (2011), Kendall et al. (2015),
Schroder (2011), Stark et al. (2011), Turk et al. (2013), Abrantes et al.
(2017), Hales et al. (2017), Jakicic et al. (2016), Mummah et al. (2017),
Plow and Golding (2017), Tu et al. (2017)
Behavior change theories Ryan et al. (2012), Stark et al. (2011), Aguiar et al. (2017), Cai et al.
(2017), Chen et al. (2017), Hostler et al. (2017), Mummah et al. (2017),
Plow and Golding (2017), Tu et al. (2017)

71
 Control theory Spring et al. (2017), Kendall et al. (2015), Kolodziejczyk et al. (2014),
Schroder (2011)
Theory of planned behavior Laing et al. (2015), Stark et al. (2011), Stark et al. (2011), Storni
and extended theories (2010), Biddle et al. (2017)
Self-efficacy theory Fukuoka et al. (2011), Laing et al. (2015), Rader et al. (2017), Izawa et
al. (2006)
Chronic care model** Tu et al. 2017, Karhula et al. 2015, Partridge et al. 2016, Roblin 2011
Cognitive behavioral Barakat et al. 2017, Mantani et al. 2017, Zhu et al. 2017, Acharya et al.
therapy** 2011, Naylor et al. 2008, Nicklas et al. 2014, Zhu et al. 2017
* Only theories that were used in more than one study are included in this table.
**The chronic care model and cognitive behavioral therapy are not technically theories, but treatment
frameworks that were used in the extant studies to inform intervention design.

Based on our framework and literature synthesis, several potential avenues for using

additional theoretical lenses to deepen our understanding of ITSM for chronic care are proposed.

The future research examples provided are by no means exhaustive as our purpose is not to

outline all of the relevant opportunities, but to illustrate a few key potential avenues.

As demonstrated in our review, few ITSM studies take a comprehensive approach that is

necessary to understanding how ITSM characteristics – through use and intermediate outcomes –

influence chronic care goal achievement. Thus, little is known about how and why ITSM effects

occur. Moreover, the majority of studies take a deterministic view of the interventions without

more micro- and in-depth examinations of users, user behaviors, or interpersonal interactions.

While social cognitive theories and cognitive behavior therapy are often referenced in these

studies, this narrow focus can only investigate a limited range of phenomena and research

questions. Thus, more diverse perspectives of ITSM for chronic care are needed.

One starting point could be diversifying the level of explanation. First, instead of

focusing on ITSM interventions, research could take a more micro-level approach. In theme 2,

some patterns of temporary spikes and declines in ITSM use emerged. Future research could use

theories related to goals and motivation (e.g. Locke 1991; Ryan and Deci 2000) to perform

micro-level longitudinal investigations of the ebb and flow of ITSM use and how it is related to

chronic care goal attainment (e.g., when chronic care goals are reached, does ITSM use continue,

72
stop, or continue sporadically?). Research could also draw on theories of attitude change and

affect to explore the interactions between patients’ cognitions, affect and use behaviors (e.g.

Anderson 1971; Maddux and Rogers 1983; Zhang 2013). For example, various unintended

negative consequences of ITSM use emerged in theme 2, such as feeling overwhelmed, finding

sub-optimal workarounds, and overuse. Research could draw on coping theory (e.g.

Bhattacherjee et al. 2018; Stein et al. 2015) to understand how and why these unintended

negative consequences emerge and how patients manage them. For example, the repeated

visualization of one’s own data related to chronic disease may act as a constant negative

reminder, creating a type of stress and causing patients to ruminate too much on their health

issues and perform unintended impulsive behaviors which may, in turn, lead to negative

outcomes.

A second way of diversifying the level of explanation is to focus more on interpersonal

interactions. ITSM often involves families, peers and healthcare providers, and the interactions

between these groups are only rarely examined in the literature (see Table 13 and 14 for

exceptions). For example, patient-provider interactions are potentially a key outcome driving

chronic care goal achievement and should receive more research attention. A Foucauldian

perspective (Foucault 1980; 1982) – which simultaneously considers knowledge, power, and

practices as well as interactions between all three – could be used to provide a deeper

understanding of how ITSM can change the power dynamics between patients and providers.

During ITSM, patients produce various types of self-related knowledge. This knowledge is

produced (but also constrained) by ITSM practices. The acquisition of this self-knowledge may

change the power dynamics between patients and health providers. Alternatively, providers may

use knowledge gleaned from shared ITSM data as a way to exert influence over patients. The

73
effect of ITSM on the power dynamics of the patient-provider relationship has received little

research attention.

Finally, we can take a system-level perspective, conceptualizing ITSM as a system within

which various regulative mechanisms exist in different stages of SM in order to organize the

interacting entities (e.g. patients and providers) and activities (e.g. SM data capture and

reflection). By taking a systems perspective (e.g. Bailey 1994; Bertalanffy 1973), we allow the

emergence of new properties (e.g. IT identity) that are the result of the synergistic effects of the

structures (e.g. ITSM functionalities) and intermediate processes (e.g. patient learning and data

sharing). For example, researchers could borrow the key concepts and principles from control

theories (e.g. Hirschi 2017) to investigate the dimensions and specifications of the potential

control mechanisms (e.g. ITSM rules imposed by IT infrastructure and physician instructions)

and the impacts on ITSM outcomes. The advantage of a system perspective is that it can

potentially provide an integrative understanding of ITSM as a whole system, yet is dynamic

enough to allow the emergence of new mechanisms and attributes.

Limitations and Conclusions

This review of the ITSM literature outlined opportunities for future research in which more

diverse perspectives can contribute to our understanding of the phenomenon. As noted above, the

suggestions provided are by no means exhaustive. Our purpose was to not only recommend

specific research questions and theoretical lenses, but to highlight overall directions for future

research in order to diversify the phenomena under investigation. Nevertheless, there are several

limitations related to our systematic review.

First, our review included literature published between 2006 and 2017. While studies

published before 2006 examine self-monitoring for chronic disease management, the few that

74
examine ITSM involve capabilities that are not comparable with recent IT advances. Second,

although seeking to include as many relevant studies as possible, we only incorporate studies that

explicitly mentioned our search terms in the title or abstract, which may have limited our sample

pool. Some healthcare studies use terms such as “web-based intervention” or “mobile-based

intervention” in the title or abstract without mentioning our search terms. However, to keep the

number of screened articles to a manageable size (we screened the titles and abstracts of 5,152

articles), we did not expand our search to cover these more general terms. Third, we only

included studies that explicitly incorporated chronic disease in their research objectives. We

excluded studies investigating healthy behaviors for general populations (e.g. SM of physical

activity for the general population without any explicit research objectives related to chronic

disease management). While these studies can be related to health promotion, and the

implication may be applicable to the chronic care context, they do not fall under our definition of

chronic disease self-management. Future researchers may want to draw on this related work as

there is some overlap in the types of data being monitored and technologies being used.

In conclusion, our synthesis shows that ITSM has the potential to help people manage

their chronic diseases. However, additional studies are needed to address the research gaps

outlined for each of the themes above and to address the three overarching issues in this field of

research.

75
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 Appendix A

Table A1. Effects of ITSM Affordance Bundles on Chronic Care Goal Achievement

ITSM Outcome: Goal Achievement

Functionality Physical Other Behavior
Combinations Diet Weight Quality of life Symptom Medication
activity Change
Vogel et al. Kempf et al. (2017) Boyd et al. (2017) Carels et al. (2017), Kempf et al. di Bartolo et al. (2017), Kempf et al.
(2017) Kempf et al. (2017), (2017) Haak et al. (2017), Ji et (2017)
Nishimura et al. [di Bartolo et al. al. (2017), Kempf et al.
Auto, Display (2017) (2017)] (2017), Nishimura et al.
(2017)
[Goffinet et al. (2017)]
Donaldson and Donaldson and \ Karhula et al. (2015), [Karhula et al. Goto et al. (2014), \
Normand (2009) Normand (2009) Shuger et al. (2011), (2015)] Karhula et al. (2015),
Manual, Auto, [Goto et al. [Welch et al. (2013)] Welch et al. (2013), Downing et al. (2017),
Display (2014)] Shaiful et al. (2017) Shaiful et al. (2017),
[Shaiful et al. (2017)] Sieber et al. (2017)
Wang et al. Wang et al. (2012) \ Sidhu et al. (2016), \ Naylor et al. (2008) Naylor et al.
(2012) Thomas et al. (2015), [Simons et al. (2017)] (2008)
Manual, Push Turk et al. (2013)
[Wang et al. (2012)]

Manual, Conroy et al. Ambeba et al. (2015) Swendeman et al. Burke et al. (2012), \ \ \
(2011) (2015） Wharton et al. (2014)
Display, Push
\ Acharya et al. (2011), [Aharonovich et Acharya et al. (2011), \ \ \
Manual, Display Schroder (2011) al. (2006)] Schroder (2011),
[Schroder (2011)] Aguiar et al. (2017)

Manual, \ \ \ \ \ [Faurholt-Jepsen et al. [Pedersen et al.

(2015), Pedersen et al. (2012)]
Display, Push, (2012)]
Patient-Pro
Auto, Display, [Biddle et al. \ \ Munster-Segev et al. \ Munster-Segev et al. \
(2017)] (2017) (2017)
Push
Manual, Auto, Morgan et al. Morgan et al. (2014) \ Morgan et al. (2014), \ \ \
(2014) Steinberg et al. (2013)
Push
[Allen et al. [Allen et al. (2013); \ [Allen et al. (2013); \ [Jospe et al. (2017a)] \
Goal, Manual, (2013); Jospe et Jospe et al. (2017a)] Jospe et al. (2017a)]
Display al. (2017a)]
* There are 43 different combinations of ITSM functionality among the studies in theme 3. In this table, we only list the combinations used in at
least two studies.

99
** IT functionality: Goal - goal; Manual - manual entry; Auto - auto capture; Display - data display; Push - push message; Patient-Pro - patient-
provider connection. The other IT functionalities (education, gamification, and peer-to-peer interaction) do not appear in this table as they were not
among any of the combinations used in at least two studies.
*** Studies in italicized brackets have non-supportive or mixed results.

Table A2. Non-IT Components and Chronic Care Goal Achievement

Non-IT Outcome: Goal Achievement

components
combination Other Behavior
Physical activity Diet Weight Quality of life Symptom Medication
s Change
None Izawa et al. (2006), Turner-McGrievy Swendeman et al. Sidhu et al. (2016), Dorsch et al. Or and Tao (2016), [Dietrich et al.
Ruotsalainen et al. et al. (2013), (2015） Turner-McGrievy et (2015) Dietrich et al. (2017), Gell (2017)]
(2015), Gell et al. Mummah et al. al. (2013), Welch et et al. (2017), Mantani et
(2017) (2017) al. (2013) al. (2017)
[Jones et al. (2014), [Jones et al. [Jones et al. (2014), [Faurholt-Jepsen et al.
Laing et al. (2015), (2014), Laing et al. Laing et al. (2015), (2015), Laing et al. (2015),
Ruotsalainen et al. (2015), Welch et Ruotsalainen et al. Or and Tao (2016),
(2015)] al. (2013)] (2015)] Umapathy et al. (2015)]

Education Cadmus-Bertram et [Schroder (2011)] [Aharonovich et Cadmus-Bertram et di Bartolo et al. Goto et al. (2014), di [Pedersen et al.
al. (2013), Goto et al. al. (2006)] al. (2013) (2017) Bartolo et al. (2017), Garg (2012)]
only (2014), Vogel et al. Carter et al. (2013) et al. (2017), Nishimura et
(2017) Schroder (2011), al. (2017), Sieber et al.
[Goto et al. (2014), Shuger et al. (2017)
Biddle et al. (2017)] (2011), Steinberg et [Pedersen et al. (2012),
al. (2013), Aguiar et Garg et al. (2017),
al. (2017), Goffinet et al. (2017)]
Nishimura et al.
(2017)
Goal only Turner-McGrievy et [Turner-McGrievy \ Wharton et al. \ \ \
al. (2017) et al. (2017)] (2014), Turner-
McGrievy et al.
(2017)
Feedback \ Barakat et al. \ Cadmus-Bertram et [Polonsky et al. Haak et al. (2017), Iljaz et \
(2017) al. (2013) (2017)] al. (2017)
only
Education + Donaldson and Ambeba et al. [Aharonovich et Karhula et al. [Karhula et al. Karhula et al. (2015), Aharonovich et
Normand (2009), (2015), Donaldson al. (2017b)] (2015), Morgan et (2015)] Downing et al. (2017), al. (2017b)
Goal Morgan et al. (2014), and Normand al. (2014), Thomas Jospe et al. (2017a)
Wang et al. (2012) (2009), Morgan et et al. (2015) [Hansen et al. (2017),
[Allen et al. (2013), al. (2014), Wang [Allen et al. (2013), Jospe et al. (2017a)]
Jospe et al. (2017)] et al. (2012) Wang et al. (2012),
[Allen et al. Jospe et al.
(2017a)]

100
 (2013), Jospe et
al. (2017)]
Education + \ Acharya et al. \ Acharya et al. Kempf et al. Ji et al. (2017), Kempf et Kempf et al.
(2011), Kempf et (2011), Kempf et al. (2017) al. (2017), Munster-Segev (2017)
Feedback
al. (2017) (2017), Munster- [Young et al. et al. (2017)
[Dowell and Welch Segev et al. (2017) (2017)] [Simons et al. (2017),
(2006)] Young et al. (2017)]

Education + \ \ \ Shaiful et al. (2017) \ Shaiful et al. (2017) \

Social
Education + Cadmus-Bertram et Nicklas et al. [Abrantes et al. Burke et al. (2012), Ryan et al. Chambliss et al. (2011), Aharonovich et
al. (2015), Conroy et (2014) (2017)] Chambliss et al. (2012) Abrantes et al. (2017), al. (2017a)
Goal +
al. (2011), Nicklas et [Jakicic et al. (2011), Nicklas et Steinberg et al. (2017) [Plow and
Feedback al. (2014), Abrantes (2016)] al. (2014), Turk et [Greenwood et al. (2015), Golding (2017)]
et al. (2017), Jakicic al. (2013), Carels et Ryan et al. (2012),
et al. (2016), Plow al. (2017), Jakicic et Abrantes et al. (2017),
and Golding (2017) al. (2016) Jakicic et al. (2016)]
[Abrantes et al. [Abrantes et al.
(2017), Jakicic et al. (2017), Jakicic et al.
(2016), Plow and (2016)]
Golding (2017)]
Education + \ \ \ \ \ Naylor et al. (2008) Naylor et al.
(2008)
Feedback +
Social
Education + [Sasai et al. (2017)] \ \ Spring et al. (2017) \ Sasai et al. (2017) \
Goal +
Feedback +
Social
** Studies in italicized brackets have non-supportive or mixed results.

101
Table A3. Profile of the Studies by IT and Disease Type
PC
Mobile/tablet app Website Medical Device Wearable IVR PDA Other
software
Allen et al. (2013), Carter et Carter et al. (2013), Donaldson and Cadmus-Bertram et al. Steinberg et Acharya et al. Chambliss Chung et al.
al. (2013), Cushing et al. Dennison et al. (2014), Normand (2009), (2015), Shuger et al. al. (2014), (2011), et al. (2015),
(2011), Hutchesson et al. Hutchesson et al. (2015), Jospe et al. (2017b), (2011), Carels et al. Wolin et al. Ambeba et (2011), Chung et al.
(2015), Kolodziejczyk et Krukowski et al. (2013), Moho Shaiful et al. (2017), Jakicic et al. (2015), al. (2015), Schroder (2016),
al.(2014), Laing et al. (2015), Morgan et al. (2014), (2017), Painter et L. (2016), Moho Shaiful Steinberg et Burke et al. (2011) Williamson et
Partridge et al. (2016), Tsai et Partridge et al. (2016), (2017) et al. (2017), Painter al. (2017) (2012), al. (2010),
al. (2007), Turner-McGrievy Ruotsalainen et al. (2015), et L. (2017), Sasai et Conroy et al. Sidhu et al.
et al. (2013), Wharton et al. Shuger et al. (2011), Thomas al. (2017), Turner- (2011), Turk (2016), Sasai
(2014), Chen et al. (2017), et al. (2015), Webber et al. McGrievy et al. et al. (2013), et al. (2017),
Obesity Hales et al. (2017), Jospe et (2010), Wolin et al. (2015), (2017), Cadmus- Wang et al. Tu et al.
al. (2017a), Mummah et al. Carels et al. (2017), Fuller et Bertram et al. (2013), (2012), Yon (2017)
(2017), Sasai et al. (2017), al. (2017), Jakicic et al. Morgan et al. (2014), et al. (2006)
Spring et al. (2017), Turner- (2016), Painter et L. (2017), Nicklas et al. (2014),
McGrievy et al. (2017) Rader et al. (2017), Tu et al. Ruotsalainen et al.
(2017) (2015), Steinberg et
al. (2013), Aguiar et
al. (2017), Spring et
al. (2017), Tu et al.
(2017)
Or and Tao (2016), Roblin Glasgow et al. (2011), Greenwood et al. Edge et al. (2017), Glasgow et Sevick et al. Paula et al. Vaughn-
(2011), Storni (2014), Storni Greenwood et al. (2015), (2015), Hinnen et al. Glasgow et al. (2011), al. (2011) (2010), (2017) Cooke et al.
(2014b), di Bartolo et al. Hinnen et al. (2015), Raiff (2015), Or and Tao Biddle et al. (2017), Sevick et al. (2015)
(2017), Garg et al. (2017), Gu and Dallery (2010), (2016), Raiff and Kempf et al. (2017) (2008)
et al. (2017), Hansen et al. Caballero-Ruiz et al. (2017), Dallery (2010), Roblin
(2017), Irace et al. (2017), Iljaz et al. (2017), Irace et al. (2011), Sevick et al.
Munster-Segev et al. (2017), (2017), Kempf et al. (2017) (2008), Caballero-Ruiz
Piras and Miele (2017), et al. (2017), Cosson
Sieber et al. (2017) et al. (2017), di Bartolo
et al. (2017), Downing
et al. (2017), Garg et
al. (2017), Goffinet et
al. (2017), Haak et al.
Diabetes (2017), Irace et al.
(2017), Ji et al. (2017),
Kempf et al. (2017),
Lee et al. (2017),
Mathieu-Fritz et al.
(2017), Nishimura et
al. (2017), Olafsdottir
et al. (2017), Paula et
al. (2017), Polonsky et
al. (2017), Selvan et al.
(2017), Sieber et al.
(2017), Young et al.
(2017)

102
Table A3. Profile of the Studies by IT and Disease Type
PC
Mobile/tablet app Website Medical Device Wearable IVR PDA Other
software
Faurholt-Jepsen et al. Jones et al. (2014), Simons et al. (2017) Abrantes et al. (2017), \ \ Bauer et al. Murnane et
(2015a), Faurholt-Jepsen et Nørregaard et al. (2014), Boyd et al. (2017) (2009) al. (2016),
al. (2015b), Festersen and Tsanas et al. (2016) Matthews et
Corradini (2014), Scharer et al. (2017a),
Psychiatric al. (2015), Tregarthen et al. McKnight et
(2015), Tsanas et al. (2016), al. (2017)
Abrantes et al. (2017), Boyd
et al. (2017), Mantani et al.
(2017)
Karhula et al. (2015) Dorsch et al. (2015) Karhula et al. (2015), Izawa et al. (2006), \ \ \ Coppini et al.
Cardiac Andersen et al. (2017) Vogel et al. (2017) (2017)
Timmerman et al. (2016), Berry et al. (2015) Timmerman et al. Gell et al. (2017) \ \ \ Hall and
Mouzouras et al. (2017) (2016) Murchie
(2014),
Cancer Hermansen-
Kobulnicky
and Purtzer
(2014)
Ayobi et al. (2017) Jongen et al. (2015), Barakat \ Ayobi et al. (2017), \ \ Ayobi et al. Ayobi et al.
Nerve-related et al. (2017) Mentis et al. (2017) (2017) (2017)
Swendeman et al. (2015) Swendeman et al. (2015) \ Aharonovich et al. Aharonovich \ \ \
(2017b) et al. (2006),
HIV Aharonovich
et al. (2017a)
Kendall et al. (2015), Or and Wolin et al. (2015) Nakano et al. (2011), \ Wolin et al. \ Nakano et Storni (2010)
Hypertension Tao (2016) Or and Tao (2016) (2015) al. (2011)

Fukuoka et al. (2011), Langstrup and Winthereik Grönvall and Felipe et al. (2015), Naylor et al. Dowell and Welch et al. Bonilla et al.
Ramanathan et al. (2013), (2008), Felipe et al. (2015), Verdezoto (2013), Goto et al. (2014) (2008) Welch (2007) (2015),
Adams et al. (2017), Plow Johnston et al. (2009), Ma et Velardo et al. (2017) (2006), Stark Verdezoto
and Golding (2017), Ryan et al. (2013), Pedersen et al. et al. (2011), and Gronvall
al. (2012), Welch et al. (2012), Umapathy et al. Welch et al. (2016),
Other (2013), Cai et al. (2017), (2015), Dietrich et al. (2017), (2007) Chung et al.
Dietrich et al. (2017), Eikey et Hostler et al. (2017), (2015),
al. (2017), Hostler et al. McDonald et al. (2017) Chung et al.
(2017), Isetta et al. (2017), (2016)
Sage et al. (2017), Velardo et
al. (2017), Zhu et al. (2017)

103
Table A4. Key IT Functionalities that Enable ITSM Affordances
Studies that included this functionality
IT Functionality
2006-2009 2010-2013 2014-2017
Preparation Affordance
Deliver educational N/A Cadmus-Bertram et al. (2013), Dennison et al. (2014), Dorsch et al. (2015), Festersen and Corradini (2014),
Carter et al. (2013), Chambliss Greenwood et al. (2015), Hinnen et al. (2015), Kolodziejczyk et al.(2014), Or and Tao
content et al. (2011), Glasgow et al. (2016), Partridge et al. (2016), Timmerman et al. (2016), Umapathy et al. (2015),
(IT-delivered content for (2011), Krukowski et al. (2013), Wolin et al. (2015), Aharonovich et al. (2017b), Barakat et al. (2017), Cai et al. (2017),
increasing knowledge of Webber et al. (2010) Coppini et al. (2017), Dietrich et al. (2017), Hales et al. (2017), Hostler et al. (2017),
the device, the disease or Iljaz et al. (2017), Isetta et al. (2017), Jakicic et al. (2016), Lee et al. (2017), Mantani
of its self-management) et al. (2017), Mouzouras et al. (2017), Mummah et al. (2017), Rader et al. (2017),
Sage et al. (2017), Sasai et al. (2017), Tu et al. (2017), Turner-McGrievy et al. (2017),
Velardo et al. (2017), Young et al. (2017)

Goal setting Johnston et al. (2009) Allen et al. (2013), Cadmus- Cadmus-Bertram et al. (2015), Dennison et al. (2014), Steinberg et al. (2014),
(IT suggests or assigns Bertram et al. (2013), Carter et Abrantes et al. (2017), Eikey et al. (2017), Hales et al. (2017), Hostler et al. (2017),
al. (2013), Chambliss et al. Jospe et al. (2017a), Mummah et al. (2017), Painter et L. (2017), Plow and Golding
goals or allows users to
(2011), Sevick et al. (2010), (2017), Steinberg et al. (2017), Tu et al. (2017)
set and modify their own Stark et al. (2011)
goals)
Data Collection Affordance
Data entry interface Aharonovich et al. Acharya et al. (2011), Allen et Ambeba et al. (2015), Berry et al. (2015), Bonilla et al. (2015), Dennison et al. (2014),
(User-initiated SM data (2006), Donaldson al. (2013), Burke et al. (2012), Dorsch et al. (2015), Faurholt-Jepsen et al. (2015), Festersen and Corradini (2014),
entry. Can offer different and Normand (2009), Carter et al. (2013), Chambliss Goto et al. (2014), Greenwood et al. (2015), Hutchesson et al. (2015), Jones et al.
Dowell and Welch et al. (2011), Conroy et al. (2014), Jongen et al. (2015), Karhula et al. (2015), Kendall et al. (2015),
levels of flexibility of input
(2006), Johnston et (2011), Cushing et al. (2011), Kolodziejczyk et al. (2014), Laing et al. (2015), Morgan et al. (2014), Nicklas et al.
such as guided response al. (2009), Naylor et Glasgow et al. (2011), (2014), Partridge et al. (2016), Ruotsalainen et al. (2015), Sidhu et al. (2016),
or open entry) al. (2008), Sevick et Krukowski et al. (2013), Ma et Steinberg et al. (2014), Storni (2014), Swendeman et al. (2015), Thomas et al.
al. (2008), Tsai et al. al. (2013), Pedersen et al. (2015), Tsanas et al. (2016), Umapathy et al. (2015), Wharton et al. (2014), Wolin et
(2007), Welch et al. (2012), Raiff and Dallery (2010), al. (2015), Adams et al. (2017), Aguiar et al. (2017), Aharonovich et al. (2017a),
(2007) Roblin (2011), Ryan et al. Aharonovich et al. (2017b), Ayobi et al. (2017), Barakat et al. (2017), Caballero-Ruiz
(2012), Schroder (2011), Sevick et al. (2017), Dietrich et al. (2017), Downing et al. (2017), Eikey et al. (2017), Fuller et
et al. (2010), Shuger et al. al. (2017), Gu et al. (2017), Hales et al. (2017), Hansen et al. (2017), Hostler et al.
(2011), Stark et al. (2011), (2017), Iljaz et al. (2017), Isetta et al. (2017), Jospe et al. (2017a), Jakicic et al.
Steinberg et al. (2013), Turk et (2016), Lee et al. (2017), Mantani et al. (2017), McDonald et al. (2017), McKnight et
al. (2013), Turner-McGrievy et al. (2017), Moho Shaiful et al. (2017), Mouzouras et al. (2017), Mummah et al. (2017),
al. (2013), Wang et al. (2012), Painter et L. (2017), Plow and Golding (2017), Rader et al. (2017), Sage et al. (2017),
Webber et al. (2010), Welch et Selvan et al. (2017), Sieber et al. (2017), Simons et al. (2017), Spring et al. (2017),
al. (2013), Williamson et al. Steinberg et al. (2017), Tu et al. (2017), Turner-McGrievy et al. (2017), Velardo et al.
(2010) (2017)

104
Table A4. Key IT Functionalities that Enable ITSM Affordances
Studies that included this functionality
IT Functionality
2006-2009 2010-2013 2014-2017
Auto capture Donaldson and Cadmus-Bertram et al. (2013), Cadmus-Bertram et al. (2015), Felipe et al. (2015), Goto et al. (2014), Greenwood et
(Automatic measuring of Normand (2009), Carter et al. (2013), Nakano et al. (2015), Hinnen et al. (2015), Karhula et al. (2015), Kolodziejczyk et al.(2014),
SM efforts) Sevick et al. (2008) al. (2011), Raiff and Dallery Laing et al. (2015), Morgan et al. (2014), Nicklas et al. (2014), Or and Tao (2016),
(2010), Roblin (2011), Ryan et Partridge et al. (2016), Ruotsalainen et al. (2015), Timmerman et al. (2016), Abrantes
al. (2012), Shuger et al. (2011), et al. (2017), Andersen et al. (2017), Ayobi et al. (2017), Biddle et al. (2017), Boyd et
Steinberg et al. (2013), Welch et al. (2017), Caballero-Ruiz et al. (2017), Carels et al. (2017), Coppini et al. (2017),
al. (2013) Cosson et al. (2017), di Bartolo et al. (2017), Downing et al. (2017), Edge et al.
(2017), Garg et al. (2017), Gell et al. (2017), Goffinet et al. (2017), Gu et al. (2017),
Haak et al. (2017), Irace et al. (2017), Ji et al. (2017), Jospe et al. (2017b), Kempf et
al. (2017), Jakicic et al. (2016), Lee et al. (2017), Mathieu-Fritz et al. (2017), Mentis et
al. (2017), Moho Shaiful et al. (2017), Munster-Segev et al. (2017), Nishimura et al.
(2017), Olafsdottir et al. (2017), Painter et L. (2017), Paula et al. (2017), Piras and
Miele (2017), Plow and Golding (2017), Polonsky et al. (2017), Sasai et al. (2017),
Selvan et al. (2017), Sieber et al. (2017), Spring et al. (2017), Tu et al. (2017), Turner-
McGrievy et al. (2017), Velardo et al. (2017), Vogel et al. (2017), Young et al. (2017)

User Reflection and Action Affordance

Data display Aharonovich et al. Acharya et al. (2011), Allen et Ambeba et al. (2015), Berry et al. (2015), Bonilla et al. (2015), Cadmus-Bertram et al.
(IT offers graphical, (2006), Donaldson al. (2013), Burke et al. (2012), (2015), Dennison et al. (2014), Dorsch et al. (2015), Faurholt-Jepsen et al. (2015),
numerical, or textual and Normand (2009), Cadmus-Bertram et al. (2013), Felipe et al. (2015), Festersen and Corradini (2014), Goto et al. (2014), Greenwood et
feedback of the SM results Johnston et al. Carter et al. (2013), Chambliss al. (2015), Hinnen et al. (2015), Hutchesson et al. (2015), Jones et al. (2014), Jongen
(2009), Sevick et al. et al. (2011), Conroy et al. et al. (2015), Karhula et al. (2015), Kendall et al. (2015), Laing et al. (2015), Or and
with (1) raw data (2) (2008), Tsai et al. (2011), Cushing et al. (2011), Tao (2016), Partridge et al. (2016), Ruotsalainen et al. (2015), Steinberg et al. (2014),
simple aggregation, and/or (2007), Welch et al. Glasgow et al. (2011), Nakano Storni (2014), Swendeman et al. (2015), Timmerman et al. (2016), Tsanas et al.
(3) evaluative information (2007) et al. (2011), Pedersen et al. (2016), Umapathy et al. (2015), Wharton et al. (2014), Wolin et al. (2015), Abrantes et
that relates the data to a (2012), Raiff and Dallery (2010), al. (2017), Adams et al. (2017), Aguiar et al. (2017), Aharonovich et al. (2017b),
target, goal or threshold) Roblin (2011), Ryan et al. Andersen et al. (2017), Ayobi et al. (2017), Biddle et al. (2017), Boyd et al. (2017),
(2012), Schroder (2011), Sevick Caballero-Ruiz et al. (2017), Cai et al. (2017),Carels et al. (2017), Coppini et al.
et al. (2010), Shuger et al. (2017), Cosson et al. (2017), di Bartolo et al. (2017), Downing et al. (2017), Edge et
(2011), Stark et al. (2011), al. (2017), Eikey et al. (2017), Fuller et al. (2017), Garg et al. (2017), Goffinet et al.
Webber et al. (2010), Welch et (2017), Gu et al. (2017), Haak et al. (2017), Hales et al. (2017), Hansen et al. (2017),
al. (2013), Williamson et al. Hostler et al. (2017), Irace et al. (2017), Isetta et al. (2017), Ji et al. (2017), Jospe et
(2010) al. (2017a), Jospe et al. (2017b), Kempf et al. (2017), Jakicic et al. (2016), Mantani et
al. (2017), Mathieu-Fritz et al. (2017), McDonald et al. (2017), McKnight et al. (2017),
Mentis et al. (2017), Moho Shaiful et al. (2017), Mouzouras et al. (2017), Mummah et
al. (2017), Munster-Segev et al. (2017), Nishimura et al. (2017), Olafsdottir et al.
(2017), Painter et L. (2017), Paula et al. (2017),Piras and Miele (2017),Plow and
Golding (2017),Rader et al. (2017),Sage et al. (2017),Sasai et al. (2017),Selvan et al.
(2017),Sieber et al. (2017),Spring et al. (2017), Steinberg et al. (2017),Tu et al.
(2017), Turner-McGrievy et al. (2017),Velardo et al. (2017), Vogel et al. (2017),Young
et al. (2017)

105
Table A4. Key IT Functionalities that Enable ITSM Affordances
Studies that included this functionality
IT Functionality
2006-2009 2010-2013 2014-2017
Push messages Naylor et al. (2008); Burke et al. (2012), Carter et al. Ambeba et al. (2015), Berry et al. (2015), Dennison et al. (2014), Faurholt-Jepsen et
(IT delivers messages or Tsai et al. (2007) (2013), Chambliss et al. (2011), al. (2015), Greenwood et al. (2015), Jones et al. (2014), Kendall et al. (2015), Morgan
prompts which can be 1) Conroy et al. (2011), Cushing et et al. (2014), Partridge et al. (2016), Sidhu et al. (2016), Steinberg et al. (2014),
al. (2011), Glasgow et al. Swendeman et al. (2015), Thomas et al. (2015), Tsanas et al. (2016), Umapathy et al.
pre-set based on user
(2011), Nakano et al. (2011), (2015), Wharton et al. (2014), Wolin et al. (2015), Aharonovich et al. (2017b), Barakat
preference or schedule, or Pedersen et al. (2012), et al. (2017), Biddle et al. (2017), Caballero-Ruiz et al. (2017), Cai et al. (2017),
2) data-driven by users’ Steinberg et al. (2013), Turk et Coppini et al. (2017), Fuller et al. (2017), Hales et al. (2017), Hostler et al. (2017),
own SM data) al. (2013), Wang et al. (2012) Iljaz et al. (2017), Irace et al. (2017), Isetta et al. (2017), Jakicic et al. (2016), Mantani
et al. (2017), McDonald et al. (2017), Mouzouras et al. (2017), Mummah et al. (2017),
Munster-Segev et al. (2017), Piras and Miele (2017), Sage et al. (2017), Simons et al.
(2017), Steinberg et al. (2017), Tu et al. (2017), Velardo et al. (2017), Young et al.
(2017)
Gamification N/A Glasgow et al. (2011), Raiff and Jones et al. (2014), Abrantes et al. (2017), Adams et al. (2017), Ayobi et al. (2017),
(Gamify ITSM tasks or SM Dallery (2010) Cai et al. (2017), Dietrich et al. (2017), Eikey et al. (2017), Hales et al. (2017), Hostler
results display) et al. (2017), Mantani et al. (2017), Mummah et al. (2017), Sage et al. (2017), Sasai
et al. (2017), Tu et al. (2017)

Social Connections Affordance

Patient-provider N/A Chambliss et al. (2011), Ma et Faurholt-Jepsen et al. (2015), Festersen and Corradini (2014), Greenwood et al.
connection al. (2013), Pedersen et al. (2015), Jongen et al. (2015), Ruotsalainen et al. (2015), Timmerman et al. (2016),
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provider communication
(2017), Mouzouras et al. (2017), Painter et L. (2017), Piras and Miele (2017), Rader
and collaboration) et al. (2017), Velardo et al. (2017)

Peer-to-peer interaction N/A Allen et al. (2013), Cadmus- Jones et al. (2014), Kolodziejczyk et al. (2014), Laing et al. (2015), Partridge et al.
(IT-mediated social Bertram et al. (2013), Carter et (2016), Ruotsalainen et al. (2015), Cai et al. (2017), Dietrich et al. (2017), Eikey et al.
features that allow social al. (2013), Glasgow et al. (2017), Hales et al. (2017), Mummah et al. (2017), Rader et al. (2017), Spring et al.
(2011), Krukowski et al. (2013), (2017), Tu et al. (2017)
comparison or peer-to-
Turner-McGrievy et al. (2013)
peer interaction)

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