Impact of Different Onboarding Strategies on Low Adoption and Engagement With a Self-Monitoring and Management App...

Suboptimal adoption and engagement rates of digital health applications present challenges to their effectiveness, particularly in chronic disease management such as fibromyalgia. Up to half of patients do not download the prescribed digital health applications or actively engage with them, making effective onboarding a critical opportunity for improvement.

We aimed to investigate the impact of 3 different patient onboarding strategies on adoption, adherence, and engagement with a digital health application for the symptom management of chronic pain syndromes.

We conducted a 4-week nonrandomized prospective study comprising patients (aged ≥18 years) with chronic musculoskeletal pain who fulfilled the fibromyalgia criteria and were using a new self-monitoring and management application after onboarding. The pain organizer and companion system consists of symptom reporting, symptom monitoring, and an advice and exercise section. Participants in group 1 (standard) received an email-based onboarding with detailed instructions on application download, registration, use, usability data capture, data security, and study procedures without any in-person assistance. Group 2 (video) received the same email plus a video tutorial explaining the application's use also without any in-person assistance. Group 3 (assisted) underwent an enhanced in-person onboarding, which included hands-on support for application setup and guided instructions from a health care professional. Primary outcomes included adoption, engagement, and adherence, measured respectively by successful application download with at least 1 log-in, cumulative activations, and connection at least once per week over 4 weeks.

A total of 48 patients were recruited (mean age 45.7, SD 12.2; range 19-79 years). In the assisted group, all 15 participants in the assisted onboarding group downloaded the application compared to 63% (10/16) in the standard group and 77% (13/17) in the video group. A significant difference in adoption between the in-person onboarding group (group 3) and the remote groups (groups 1 and 2) with P=.009 was observed. Overall engagement, measured by cumulative app activation, ranged between 0 and 28 log-ins, with no significant difference (P=.18) in mean log-ins across the 3 groups. Overall adherence was low with 27% (13/48) of participants meeting adherence criteria and a retention rate of 46% (22/48) at week 4. Responses to the System Usability Scale survey were limited to 8 responses but achieved a score of 70.31, indicating good usability of the application.

Unassisted downloading and account creation might be barriers to adopting a digital health app among patients with chronic musculoskeletal pain.