Introduction
Chronic kidney disease (CKD) is a prevalent yet under-recognised condition characterised by irreversible kidney dysfunction.1 Between 2017 and 2022, CKD affected 1 in 10 adults worldwide2; was the 12th-leading cause of global mortality3 and accounted for 35 million disability-adjusted life-years.4 People with CKD have a high risk of physical disability5 6 and cardiovascular mortality7 8 due to systemic complications such as cardiovascular and neuromuscular disorders.9–11 Furthermore, CKD incurs severe financial burden with the highest mean annual cost per person attributed to advanced stages requiring haemodialysis (INT$57 334) or transplantation (incident: INT$75 326; follow-up: INT$16 672).12 Despite its burden, CKD is largely under-recognised with poor rates of documentation in primary care13 14 and low recognition among people with biomarkers of kidney dysfunction.15 Proactive strategies are needed to develop disease awareness, increase access to life-extending care and minimise disease burden.
Diet and physical activity are key strategies to prevent deterioration of health outcomes,16 17 optimise health-related quality of life18 19 and maintain physical independence18 20 21 for people with CKD. However, consumers face numerous barriers to lifestyle management including low health literacy,22 23 funding constraints for allied health physical activity services24 and workforce limitations in rural settings.25 26 Complex dietary requirements27 and safety concerns relating to physical activity28 also make behaviour change challenging. These factors highlight the need to develop innovative strategies to increase access to lifestyle interventions and support self-management.
Digital health interventions (DHIs) may provide a useful mechanism to promote healthy lifestyles for people with CKD.29 DHI is defined as the use of health informatics to assist the delivery of healthcare (ie, provide education and instruction, record and display data, guide users’ behaviours, provider reminders and facilitate provider–consumer communication).30 31 In this review, DHI may include mobile health technology (eg, application software and short messaging services30), telehealth technology (eg, videoconferencing and audio call32), wearable technology (eg, step count monitor30), computerised systems (eg, websites33) or multicomponent interventions that use more than one type of technology. Digital lifestyle interventions in other cohorts such as diabetes,34 cardiovascular disease35 and mental illness36 have demonstrated efficacy to improve health outcomes.
Despite widespread advocacy for healthcare digitalisation,37–40 the preferences of people with CKD regarding digital interventions that promote a healthy lifestyle are unknown. ‘Preferences’ refer to attributes of digital lifestyle interventions that are desirable to achieve successful behaviour change.41 This reflects a broad scope of subjective experiences including intervention content, function and strategy that contribute to behaviour change. Incorporating consumers’ preferences can promote positive care experience,42 improve perceptions of self-management43 and enhance health outcomes.44 Without consumers’ preferences, health providers may develop interventions that do not align with consumers’ needs and goals.45 Therefore, this review aimed to synthesise the preferences of people with CKD regarding DHIs that promote healthy lifestyle.
Methods
This is a qualitative systematic review with a meta-ethnography approach,46 which involves synthesising data from primary studies to generate novel, whole-of-phenomenon understandings that transcend the scope of any one study. The review was registered with PROSPERO (number: CRD42023411511) and reported according to the meta-ethnography reporting guidelines46 (online supplemental table S1), Enhancing Transparency in Reporting the Synthesis of Qualitative Research statement47 (online supplemental table S2) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses48 (online supplemental table S3).
Supplemental material
Patient and public involvement
Patient and public were not involved in the design and conduct of this review. Findings of the review were informed by perspectives of people with CKD and will be disseminated at relevant consumers’ advocacy events.
Selection criteria
The selection criteria were developed using the PICOS principle49 and are as follows: Population: adults with CKD (≥18 years) including those receiving kidney replacement therapy, Intervention: DHIs that promoted diet, exercise, physical activity or a combination of these health behaviours, Comparator: any comparator, Outcome: participants’ subjective experiences of digital lifestyle intervention attributes, Study design: primary studies that employed qualitative exploration methods.41
Data sources and searches
A pilot search was conducted to generate search terms in databases CENTRAL; SPORTDiscus; MEDLINE and CINAHL. Medical Subject Headings terms were used to identify diverse terms with similar meaning. A database search, including CENTRAL, Scopus, MEDLINE, CINAHL and SPORTDiscus, was conducted between January 2000 and April 2023 to identify papers that used contemporary technologies. The number of screened and eligible papers was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.48 Records were imported to the online platform Covidence.50 After duplicates were removed, two independent reviewers completed title, abstract and full-text screening. Discrepancies were resolved by a third reviewer. Search terms are included in online supplemental table S4.
Quality appraisal
The Mixed Methods Appraisal Tool51 (MMAT) and Critical Appraisal Skills Programme checklist52 were used to appraise the quality of mixed-method and qualitative papers, respectively. Papers were assessed by two independent reviewers. This review did not exclude studies based on quality appraisal as lack of reporting did not indicate poorly conducted research.53 54
Data extraction
Two independent reviewers extracted descriptive data including study design; digital technology; data collection and analysis; sample size, age; CKD status and ethnicity. The Shapiro-Wilk test was conducted using SPSS V.26 to determine the normal distribution and calculate mean age.55 One reviewer (TBT) used NVivo V.12 to extract quotes and themes from eligible papers and organised them into ‘similar’ or ‘different’ categories based on underlying meaning.54 This was inspected by a second reviewer (MA) who confirmed the accuracy of data extraction. TBT created a synthesis document that noted similar, different or original meaning in each paper when compared with others.56 The synthesis document was inspected by a second reviewer (MA) to determine the degree of similarity across papers.
Data synthesis
The reviewers noted similar meanings between papers and conducted an inductive thematic synthesis using the Framework approach.57 Two reviewers used Microsoft Word and NVivo V.12 to form initial codes via line-by-line coding. These codes were refined collaboratively and organised into initial categories. These categories were further refined with other reviewers via iterative discussions to generate an analytical framework. Using this framework, the reviewers identified preliminary themes and subthemes that captured common meanings across multiple papers. This process optimised study rigour and ensured the analysis encapsulated the depth of qualitative data. Two independent reviewers developed a conceptual framework to represent the relationship between themes.56 A final version was approved by all reviewers.
Result
Literature search
Database search yielded 5761 records. An additional record was included following communication with a primary author.58 After 284 duplicates were removed, 5478 underwent title and abstract screening and 53 full texts were assessed. 15 papers were eligible58–72 (figure 1).
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of search process and study selection.
Study characteristics
There were nine qualitative58 59 62 66–69 71 72 and six mixed-method papers60 61 63–65 70 (table 1). 13 papers were from English-speaking countries, including USA (n=5),64 67 69 70 72 Australia (n=4)58 61 62 65; Canada (n=2)63 71 and the UK (n=2).59 60 One study came from the United Arab Emirates66 and one from China.68 These papers reported consumers’ preferences on a wide range of technologies, including websites (n=3)59 60 63; telehealth (n=3)58 64 65; mobile application (n=2)66 67; mobile phone text (n=2)61 62; unspecified mobile health (n=1)69 and unspecified technology (n=1).71 Furthermore, three papers explored consumers’ preferences on more than one type of technology, including telephone call and mobile application70; information communication technologies and website68; and activity trackers and mobile applications.72 A description of the function of each type of DHI was included in online supplemental table S5.
Study characteristics
Consumers’ characteristics
Two papers were supplementary publications that included the same cohort from another paper, including one on people with haemodialysis61 62 and one on people with CKD 3–4.58 65 Therefore, descriptive data was extracted from thirteen studies to avoid over-representation of any groups. This provided a sample of 197 consumers (mean age 51.0±7.2 (range 20–80)), including 83 with CKD 1–5 (42%); 61 kidney transplant recipients (31%); 31 on haemodialysis (16%) and 22 with an unspecified form of dialysis (11%). Two studies targeted consumers from regional70 and rural settings68 (n=28, 14% of the total sample). Sex distribution was reported in 11 studies (total=182 people), including 53% male and 47% female. 12 studies reported ethnicity (total=190 people), comprising white (45%); African (21%); Asian (19%); Pacific Islander (3%); Hispanic (2%); Indigenous (2%) and mixed heritage (2%). 16 consumers (8%) had unspecified ethnic backgrounds. Details can be found in online supplemental table S6.
Quality appraisal
All qualitative papers had clear aims, appropriate design and data collection methods.58 59 62 66–69 71 72 Seven included coherent methodological frameworks.58 59 62 67–69 71 Three reported how the relationship between researchers and consumers was considered59 67 71 and four had clear statements of findings.58 59 62 68 Detailed information is included in online supplemental table S7.
Four papers were appraised using MMAT tool for randomised quantitative, mixed-method design.60 61 64 65 All four provided adequate rationale for mixed-method design.60 61 64 65 Two demonstrated effective integration of quantitative and qualitative data.64 65 One did not demonstrate effective integration60 and another provided insufficient details on how integration occurred.61 Detailed information is included in online supplemental table S8.
Two papers were appraised using the MMAT tool for non-randomised quantitative, mixed-method design.63 70 Only one provided adequate rationale for mixed-method design.63 Both addressed inconsistencies between quantitative and qualitative data.63 70 Detailed information is included in online supplemental table S9.
Qualitative data synthesis
There were 5 themes and 13 subthemes that typified consumers’ preferences for digital lifestyle interventions. They included simple instruction and engaging design, individualised interventions, virtual communities of care, education and action plans, and timely reminders and automated behavioural monitoring. Illustrative quotes are included in online supplemental table S10.
Simple instruction and engaging design
Convey ideas using plain language and simple instruction
Plain language and simple instruction were considered optimal strategies to deliver education—‘[The intervention has] given me simple tasks, simple methods … to improve the situation … basic stuffs that we can understand.’ (person with CKD 3–4, Australia
65). Consumers preferred everyday terms and cautioned against jargon which was only accessible to a specialised audience—‘[the messages] made sense and were easy [to understand], that’s why I liked it’ (person undergoing haemodialysis, Australia
62).
Organised and engaging programme design elevates user-experience
Consumers noted the importance of an organised and engaging user-interface to ensure they can use the technology to its full potential—‘the best part about the website was how it is laid out, [you can] see the levels of potassium and phosphorus, the nutritional information.’ (person with unspecified CKD, Canada
63). Consumers identified factors that may reduce user-experience, such as small font—‘On the Fitbit, [the font] is very small, and if I don’t have my readers on, I can’t read it’ (transplant recipient, USA
67) and complicated navigability—‘To navigate around [the website] … I found it a bit difficult at first, I didn’t really get it.’ (kidney transplant recipient, UK).
60 These quotes further emphasised the importance of suitable programme designs to optimise user-experience.
Individualised interventions
Personal and psychosocial factors influence motivation and capacity for change
Consumers identified personal and psychosocial health determinants as factors which may affect motivation and capacity for change. Personal factors included health complications—‘I can’t get round the house with the sore foot’ (person undergoing haemodialysis, Australia
62) while psychosocial factors included caring for loved ones or unstable living environment—‘I have a lifestyle that didn’t fit with [the app] because I am not home much and have a lot of kids … so we eat out more than we probably should’ (person with CKD 1–3 a, USA
70).
Personalised interventions support engagement
Consumers emphasised the importance of individualised interventions to mitigate the effect of personal and psychosocial determinants of health—‘every person is going to be different… with [my coach] he can actually judge what your condition is and change the program to actually what’s happening to you.’ (person with CKD 3–4, Australia
58).
A virtual community of care
Promotes provider–consumer partnership
Digital interventions promoted provider–consumer partnership by allowing regular communication and support—‘[My coach] supported me over the weeks, the phone calls every now and again… to have someone there to pat you on the back … and explain different things you don’t think of…’ (person with CKD 3–4, Australia
58).
Connects people with common care experience
Consumers suggested digital intervention could facilitate connections between people with similar care experiences ‘If they also have social media network built into [the app], that would be cool for kidney transplant patients where they could follow each other and talk.’ (transplant recipient, USA
69) and advocated for future interventions to incorporate knowledge from people with lived experience—‘[the] doctor can only give what they’ve learned. They haven’t necessarily experienced going through surgery … You need a bit of a balance [between clinician & patient-expert] (transplant recipient, UK
60).
Provide education and action plan
Increase coverage of lifestyle information
Consumers noted the potential of digital interventions to increase coverage of lifestyle information—‘[Patients] need something like this… there was lot of things when I had the transplant that I was thinking I didn’t know… [The website] makes it a lot easier’ (transplant recipient, UK
59).
Inform healthy decision-making
Consumers considered digital interventions to be an important tool to increase health literacy and inform healthy choices—‘I didn’t know that one cup of soft drink contains 5 teaspoons of sugar and I don’t eat biscuits anymore, not too much… I will just taste a small one but not the usual amount I had.’ (person undergoing haemodialysis, Australia
62).
Provide encouragement for healthy behaviours
Consumers expressed that digital interventions enabled them to achieve small, gradual changes, which provided encouragement to attempt more comprehensive modification—‘That’s what encouraged me to go on [with the intervention], because I could see the change, as I was making little [dietary] adjustments… all these little adjustments amount to great leaps and bounds’ (person with CKD 3–4, Australia
58).
Consolidate knowledge and prevent misinformation
Consumers noted the lack of digital sources that were clinically tailored which may lead to misinformation— ‘Online knowledge of food with high potassium is not detailed and sometimes conflicting.’ (person with CKD 5, China
68). To support self-management, consumers indicated the importance of clinically tailored digital interventions to consolidate knowledge—‘… you know rather than going on the internet… other websites and stuff I found that [on] this particular website that there was a lot on there to help.’ (transplant recipient, UK
60).
Timely reminders and automated behavioural monitoring
Timely and personalised reminders prompt action
Consumers affirmed the utility of reminders to prompt action and expressed the need for reminders to be timely and personalised according to their needs—‘Getting the [dietary text] messages while I was doing dialysis clicked off something in the back of my mind… If I have got them on a [non-dialysis day], I don’t think I would have taken any notice.’ (person undergoing haemodialysis, Australia
62).
Monitoring behaviour promotes accountability
Behavioural monitoring was perceived as an important strategy to promote personal accountability and adherence to the programme—‘… in terms of being accountable… you are being accountable to a system… you need to you know, every week you need to be putting in the [weight and activity]’ (transplant recipient, UK
60).
Automated data capture enhances behavioural monitoring
Consumers suggested automated data capture could help overcome the difficulty with manual tracking and allow them to accurately monitor their progress—‘[Monitoring parameters in] the app is easier and much more convenient than recording them in a notebook.’ (person undergoing peritoneal dialysis, China
68).
Conceptual framework
Consumers’ preferences were represented as a conceptual framework to illustrate their relationships and inform the conduct of future digital lifestyle interventions (figure 2). At its base, the framework includes consumers’ preferences for simple instruction, engaging design and individualised interventions. Simple instruction and engaging design are key characteristics of a user-friendly DHI. Consumers also outlined the need for providers to be aware of personal and psychosocial determinants of health and individualise their advice and interventions accordingly. Consumers then identified three requirements for change: virtual communities of care, education and action plans and provision of timely reminders and automated behavioural monitoring. Virtual communities of care involving relevant providers and consumers with similar care experiences were recommended to promote provider–consumer partnership and facilitate social support. Consumers recommended the provision of education and action plans to develop health literacy and inform healthy decision-making. Finally, timely reminders and automated behavioural monitoring were recommended to promote accountability. As behaviour change is a dynamic process, providers are recommended to address the requirements of change regularly by maintaining clinical rapport and reinforcing education.
Conceptual framework of consumers’ preferences regarding digital lifestyle interventions with illustrative quotes. The framework demonstrates a foundation of simple instruction, engaging design and individualised interventions that underpin an inter-related cycle of behavioural change strategies.
Consumers’ preferences for different types of DHIs
The papers in this review did not comprehensively evaluate consumers’ preferences between different types of digital solutions that promoted healthy lifestyle. However, one paper suggested people with CKD 1–5 (including peritoneal dialysis) preferred application software over websites as applications were considered more accessible.68 Across all eligible papers, qualitative data and lines of questioning suggested participants who used websites tended to express preferences for diverse modes of delivering lifestyle education (eg, interactive webinars63 or combining clinicians and patient-experts’ input59) while participants who used mobile health technology noted the importance of timely reminders62 and tracking data related to lifestyle behaviours (eg, nutrition, fluid and levels of physical activity67 69 70). A summary of participants’ preferences in each paper was included in online supplemental table S5.
Discussion
DHIs were considered important mechanisms to access lifestyle services for people with CKD. In addition to user-friendly technology, consumers’ preferences illustrated the importance of appropriately qualified health providers to personalise behaviour change strategies, provide lifestyle education and action plans and facilitate timely reminders. The conceptual framework of consumers’ preferences in this review may inform the design and conduct of future digital lifestyle interventions.
People with CKD expressed the importance of designing user-friendly technology by incorporating simple instruction and engaging design. Preferences for simple instruction reflected health promotion research where language characterised by concise sentences73–76 and conversational styles77 78 is preferred to deliver education. Preferences for organised and engaging user-interface encapsulate the concept ‘system design characteristics’ from the Technology Acceptance Model.79 ‘System design characteristics’ are theorised to influence the degree which the system would be free of difficulty80 and degree which the system may enhance users’ capacity to perform a task.81 Previous research recommends specific design characteristics such as arranging content by order of sequence82 or perceived importance83; using meaningful, illustrative media84 85 and applying specific typographic features73 such as serif font type86 87; large font sizes88 and specific colour schemes to maximise contrast between words and background.86 Emerging research also recommends codesign of digital interventions to identify user-specific features,89–91 reduce consumers’ anxiety92 and enhance confidence in digital systems.93 94 In the context of DHIs, codesign may be enhanced by user-testing workshops with think-aloud interviews followed by periods of independent use with retrospective semistructured interviews and iterative changes.95 Although think-aloud interviews have been shown to be effective at identifying factors that limit usability,95 only one paper in this review implemented a user-testing workshop with concurrent, think-aloud feedback.59 Future digital lifestyle interventions may benefit from more pre-emptive strategies to address factors affecting usability, increase intention to use and promote system usage.
Another important finding was that consumers recognised the influence of personal and psychosocial factors on capacity for change and advocated for individualised interventions to mitigate their effect. These preferences are similar to qualitative research in other clinical cohorts, including people with mental illness96; cancer97 and chronic pain.98 Collectively, they establish a common requisite for lifestyle interventions to be tailored to consumers’ needs and preferences. A potential framework to inform lifestyle intervention design could be the Behaviour Change Wheel (BCW).99 The BCW is a framework for behaviour interventions that centres around three requirements for change100: capability (physical and psychological), opportunity (social and physical) and motivation (automatic and reflective).101 The BCW provides recommendations for intervention functions that are specific to each requirement for change,99 such as training and education to develop physical and psychological capability102 (eg, supporting healthy dietary patterns with recipes endorsed by governing bodies like Kidney Health Australia103), environmental restructuring to increase physical and social opportunity104 (eg, increasing opportunities for clinician-led exercise with online platforms like the Kidney Beam programme105) and persuasion to promote reflective and automatic motivation106 (eg, setting personalised goals to promote reflective motivation for increasing physical activity107). Previous research in people with CKD suggests the BCW may provide a useful framework to identify barriers associated with requirements for change23 108 and determine appropriate intervention functions to address consumers’ specific needs. Although research suggests theory-driven interventions may increase the prospect of successful behaviour change for people with chronic diseases,109 110 evidence regarding the effect of theory-informed digital interventions for people with CKD is limited. Future research that employs digital technology may consider applying the BCW as a framework to inform intervention functions and evaluate the effect of digital interventions on consumers’ self-efficacy and health outcomes.
Consumers in this review highlighted the role of digital interventions to foster provider–consumer partnerships and connect consumers to others with similar care experiences. This reflects the concepts of virtual care teams and virtual support groups. Virtual care teams refer to digitally connected multidisciplinary teams that provide coordinated interventions and communication across diverse geographic settings using specialised information and communication technologies.111 112 Virtual support groups are peer-to-peer systems which allow consumers with similar care experiences to exchange knowledge and provide support.113 114 Collectively, these functions help form a virtual community of care with relevant providers and consumers. While these functions may help overcome sociogeographical barriers115 and connect consumers to others with common care experiences,116 the administration of virtual communities of care also presents challenges. Research suggests participation in virtual support groups does not guarantee active self-management as consumers vary in their involvement as either active collaborators or passive observers.117 Increasing use of information and communication technologies is theorised to reduce opportunities for in-person interaction, leading to a process called ‘progressive dehumanisation’ of interpersonal relationships.118–120 This is, however, in contrast with findings in this review which suggest digital solutions may enhance rapport by enabling regular communication and support. Research also suggests virtual support groups may facilitate misinformation if consumers’ inputs are not monitored,121 indicating the need for health providers’ oversight. Furthermore, the effect of virtual communities of care on self-efficacy and health outcomes of people with CKD is unclear. This review identified several implementation strategies to support virtual communities of care including patients’ forums,63 social media networks67 and group telehealth conferencing.64 However, as yet, there is little consensus regarding the optimal strategy to promote consumers’ engagement in virtual communities of care.117 122 Future research may consider applying the implementation strategies identified in this review and evaluate the effect of a virtual community of care on health outcomes and self-efficacy for change.
In this review, consumers identified four avenues through which digital interventions enhance the delivery of lifestyle education and action plans: increasing coverage of information, informing healthy decision-making, providing encouragement and preventing misinformation. Qualitative research in other cohorts such as people with diabetes123 and mental illness124 also emphasises the role of digital interventions to increase access to lifestyle information. In this review, digital interventions were regarded as a valuable platform to develop health literacy, which, in turn, informs healthy decision-making. The association between health literacy and healthy living is well documented in people with CKD,125–127 which suggests future digital lifestyle interventions may consider health literacy as an essential target for behaviour change. Consumers in this review highlighted that they were encouraged to attempt more comprehensive lifestyle modification following initial modest changes. This is consistent with previous research in behaviour change which counsels initial gradual changes to support ongoing engagement and accumulate health benefits.128 129 Finally, consumers suggested digital interventions could empower behaviour change by preventing misinformation. The current literature recognises that consumers regularly engage in information-seeking behaviours130 but cautions the use of digital sources outside the health sector as they may disseminate information that is inconsistent with evidence-based research.131 132 Exposure to information outside the health sector can lead to confirmation bias,133 where consumers select sources that validate prior, harmful beliefs despite their lack of scientific rigour.132 Resources from healthcare providers are needed to guide information- seeking behaviours, prevent misinformation and inform healthy lifestyle choices.134 These strategies may be considered by future digital interventions to enhance lifestyle education and promote successful behaviour change.
Finally, this review highlighted the importance timely reminders and automated behavioural monitoring to prompt action and promote accountability. This is not unique to people with CKD as previous research suggests reminders that are not tailored to users’ lifestyle may have low receptivity and pose confidentiality risks.135–137 Consumers in this review recommended that the timing, content and mode of delivering reminders should be tailored to optimise receptivity, maintain users’ confidentiality and promote ongoing engagement. The challenges described by consumers regarding difficulties with manual data tracking suggest automated data capture may provide a useful strategy to accurately monitor progress. This is currently the case with technologies such as accelerometer138 139 and peripheral devices.140 However, caution is needed when using peripheral devices produced outside the health sector due to concerns with data governance and consumers’ confidentiality.141 142 Raw data from peripheral devices comes under the ownership of the manufacturers,143 which raises concerns regarding consumers’ control over potentially sensitive information.144 Although manufacturers claim anonymity in data storage, research suggests consumers’ activity and location may generate ‘digital traces’ that disclose sensitive information.143 Future research may consider using sensors that are embedded within mobile devices and can facilitate direct data transfer to clinician-facing platforms. This places the responsibility of data governance with healthcare providers and consumers and minimises confidentiality risks associated with third party ownership. Future research may also consider generating individualised reminders that are receptive to health consumers and capable of securing their privacy.
Strengths and limitations
To our knowledge, this is the first review to synthesise the preferences of people with CKD regarding DHIs that promote a healthy lifestyle. The meta-ethnography approach generated novel, whole-of-phenomenon understandings that transcend the scope of any single study. However, there are limitations. 10 papers that form the synthesis excluded people with low English proficiency,58 60–65 67 70 72 meaning the synthesis may not apply to people with English as a second language who face distinctive barriers to care such as language discordant interventions.145–149 Consumers had a large age range (20–80, mean 51.0±7.2), which suggests their preferences may have limited generalisability to older people150 with specific barriers to behaviour change such as cognitive impairment.151 152 Furthermore, 8/13 of the eligible studies explored the preferences of people with kidney replacement therapy (online supplemental table S6). People with CKD 3–5 without kidney replacement therapy comprised a small proportion of consumers in this review (n=40, 20%) despite having the largest representation in tertiary kidney care settings.153 Therefore, the results of this review may have limited generalisability to CKD cohorts not receiving kidney replacement therapy. People from rural settings (n=28, 14%)68 70 and people with Pacific Islander; Indigenous and Hispanic heritage were under-represented (online supplemental table S6). Under-representation of these groups is common in clinical research154–156 despite the disproportionate prevalence of CKD157–160 and numerous sociogeographical barriers to care such as shortage of health providers and distance from health facilities.161–163 These factors reflect an urgent need to generate community-specific knowledge and develop accessible healthcare platforms to serve the needs of these disadvantaged groups.
Future research
Future research may consider comparing consumers’ experiences with different modes of technology to determine their preferences for specific forms of DHIs or combinations of complementary technologies such as interactive webinars to instruct exercise, apps to record and display data and telehealth to facilitate provider–consumer communication. Future research may also consider exploring the preferences of cohorts that were under-represented in this review such as people not receiving kidney replacement therapy, people with low English proficiency; older people; people from rural communities and people with ethnic minority membership. Finally, the conceptual framework of consumers’ preferences in this review may be used to develop and evaluate the effect of a digital lifestyle intervention on self-efficacy and health outcomes.
Conclusion
People with CKD consider DHIs to be an important platform to promote a healthy lifestyle. Consumers’ preferences for digital lifestyle interventions included simple instructions and engaging design; individualised interventions; virtual communities of care; education and action plans; and timely reminders and automated behavioural monitoring. Future research may consider applying the conceptual framework of consumers’ preferences in this review to design and evaluate the effect of a digital lifestyle intervention. Future research may also generate acceptability data for people with CKD 3–5 without kidney replacement therapy whose preferences appear limited in current research. These findings would support the integration of digital solutions in clinical practice and increase opportunities for healthy living in a population with numerous challenges for behaviour change.
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