The Author(s) BMC Health Services Research 2016, 16(Suppl 5):290

DOI 10.1186/s12913-016-1522-3

RESEARCH Open Access

The use of e-health and m-health tools in

health promotion and primary prevention
among older adults: a systematic literature
review
Ramon Kampmeijer1, Milena Pavlova1*, Marzena Tambor2, Stanisława Golinowska2 and Wim Groot1,3

Abstract
Background: The use of e-health and m-health technologies in health promotion and primary prevention among
older people is largely unexplored. This study provides a systematic review of the evidence on the scope of the use
of e-health and m-health tools in health promotion and primary prevention among older adults (age 50+).
Methods: A systematic literature review was conducted in October 2015. The search for relevant publications was
done in the search engine PubMed. The key inclusion criteria were: e-health and m-health tools used, participants’
age 50+ years, focus on health promotion and primary prevention, published in the past 10 years, in English, and
full-paper can be obtained. The text of the publications was analyzed based on two themes: the characteristics of
e-health and m-health tools and the determinants of the use of these tools by older adults. The quality of the
studies reviewed was also assessed.
Results: The initial search resulted in 656 publications. After we applied the inclusion and exclusion criteria, 45
publications were selected for the review. In the publications reviewed, various types of e-health/m-health tools
were described, namely apps, websites, devices, video consults and webinars. Most of the publications (60 %)
reported studies in the US. In 37 % of the publications, the study population was older adults in general, while the
rest of the publications studied a specific group of older adults (e.g. women or those with overweight). The
publications indicated various facilitators and barriers. The most commonly mentioned facilitator was the support
for the use of the e-health/m-health tools that the older adults received.
Conclusions: E-health and m-health tools are used by older adults in diverse health promotion programs, but also
outside formal programs to monitor and improve their health. The latter is hardly studied. The successful use of
e-health/m-health tools in health promotion programs for older adults greatly depends on the older adults’
motivation and support that older adults receive when using e-health and m-health tools.
Keywords: Older adults, e-health, m-health, Telemedicine, Health promotion, Prevention

* Correspondence: [email protected]
1
Department of Health Services Research, CAPHRI, Maastricht University
Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht
University, PO Box 6166200, MD, Maastricht, The Netherlands
Full list of author information is available at the end of the article

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
The Author(s) BMC Health Services Research 2016, 16(Suppl 5):290 Page 468 of 479

Background older adults. The review identifies gaps in the research

In the healthcare sector, e-health and m-health tools are area that can be used for setting up new studies as men-
increasingly being used. E-health and m-health can be tioned above.
any kind of electronic device or monitoring system that The review is relevant for policy and society because
is applied by physicians in the healthcare practice or by of the ageing of the population and the increase in
individuals to monitor or improve their health status. multi-morbidity which consequently lead to greater de-
E-health typically refers to on-line and off-line computer- mand for healthcare and higher healthcare expenditure.
based applications while m-health refers to applications Therefore, it is important to know whether and how the
for mobile phones [1, 2]. Such tools can be used to emerging new technologies, specifically e-health and
stimulate a positive health behavior change or assist per- m-health tools, can be used by older adults to prevent
sons to lead a healthier life style, or to support diagnosis diseases and help older adults to have not only longer but
and treatment of diseases. also a healthier life.
E-health and m-health technologies are mostly used by
younger people. The potential of this technology for older Methods
adults is generally recognized although the application of This study uses a systematic literature review to analyze
e-health and m-health tools in health promotion and the use of e-health and m-health tools for health promo-
primary prevention for older persons has been largely tion among older adults. The methodology of a system-
unexplored [2]. atic literature review outlined in Grant and Booth (2009)
Positive changes in health-related lifestyle among older is applied [8]. The study starts with a systematic litera-
adults offer the opportunity for health benefits. It is rec- ture search based on predefined search terms and selec-
ognized that promoting health among this population tion criteria. Then, the articles selected for the review
group may contribute to more healthy life years and in- are appraised and their relevant findings are synthesized
creased life expectancy [3]. Many diseases among older narratively based on the objective of the review, with the
adults are partly or fully preventable if individuals en- support of descriptive tables. The applied review method
gage in a healthy lifestyle [4]. For example, physical allows for a comprehensive overview of the current
activity and a proper diet can help to prevent obesity, knowledge in a specific research field. This distinguishes
heart diseases, hypertension, diabetes and even premature our systematic review from other review methods such
mortality [5, 6]. Although the importance of a healthy life- as scoping review and meta-analysis.
style is known, older adults (50+ years) are frequently Given the aim for this review, three components are
physically inactive [3, 7]. The use of e-health and m-health used to build the search terms for the identification of
technologies could help older adults to improve or main- studies on the use of e-health and m-health tools in health
tain their health. But to what extent is the use of such promotion and primary prevention among older adults:
tools by older adults reported in the literature? (1) elderly or old or senior; (2) health promotion or pri-
This study aims to provide insight in the scope of the mary prevention; (3) telemedicine or e-health or m-health.
use of e-health and m-health tools for health promotion Different forms of the above words as well as relevant
and primary prevention among older adults using the synonyms are taken into account. This results in the
method of a systematic review. Hitherto, no in-depth following chain of keywords, which is used to search
overview of this topic is provided in the literature. for relevant literature in search engine PubMed:
Therefore, our review is an initial step that explores the
scope of the use of e-health and m-health tools in health (“aged”[MeSH Terms] OR “aged”[All Fields] OR
promotion and primary prevention among older adults. “elderly”[All Fields] OR “old”[All Fields] OR
We include the use of such tools within health promotion “senior”[All Fields] OR “seniors”[All Fields]) AND
programs as well as the use of such tools by older adults (“health promotion”[MeSH Terms] OR “health
outside formal programs with the goal to monitor and im- promotion”[All Fields] OR “promotion”[All Fields] OR
prove their health. In this way, our review may provide a “primary prevention”[MeSH Terms] OR “primary
base for subsequent more specific reviews focused on a prevention”[All Fields] OR “prevention”[All Fields])
certain type of e-health and m-health tools, and its use in AND (“telemedicine”[MeSH Terms] OR
health promotion programs, as well as reviews on the ef- “telemedicine”[All Fields] OR “tele-medicine”[All Fields]
fectiveness of e-health and m-health promotion programs OR “telehealth”[All Fields] OR “tele-health”[All Fields]
within a specific group of older adults and specific setting. OR “mhealth”[All Fields] OR “m-health”[All Fields] OR
Our review focuses on two dimensions: the character- “ehealth”[All Fields] OR “e-health”[All Fields])
istics of e-health and m-health tools used for monitoring
and improving the health of older adults and the deter- In the search, MeSH terms (bibliographic thesaurus)
minants of the use of e-health and m-health tools by were also included to ensure uniformity and consistency
The Author(s) BMC Health Services Research 2016, 16(Suppl 5):290 Page 469 of 479

in the literature search. The search was done in October application of e-health tools (what scheme/program/
2015. initiatives?); target group or user group (who use
Various inclusion and exclusion criteria are applied. e-health and m-health tools?); characteristics of the
To be included in the review, the publication should be setting (where and what location/country features?)
published in the last 10 years, should be in English, and ▪ Determinants of the use of e-health and m-health
the full-paper can be obtained. There are no limitations tools/programs: facilitating factors for the use (what
with regard to the institution, which provides the e-health motivates and enables the use?); barriers to the use
or m-health tools, i.e. papers that present e-health (what prevents or discourages the use?)
and m-health tools provided by state, insurers, employers
and others are considered as relevant. We include papers Based on these groups of themes, the data extraction
which present the application of e-health and m-health is done. The results are presented per group of themes
tools not only within health promotion programs but also in a narrative manner and are complemented by descrip-
the use of such tools by older adults outside formal tive tables. The quality of the publications (research de-
programs with the goal to monitor and improve their sign and findings of the study reported) is assessed in a
health. The publications could present data collected qualitative manner. We classify a study as reliable if the
among older adults or among healthcare providers who methods of data collection and analysis are well defined
provide services to older persons. Publications that discuss in the publication, and are potentially repeatable. Simi-
the topic in general as well as opinion papers and edito- larly, we classify a study as valid if the publication pro-
rials are excluded. vides clear indications of consistency of the results with
Also, publications are selected if the age of participants stated study hypotheses, expectations and/or results of
(study group) is 50 years or older and if the focus is on other similar studies. The generalizability of the study is
health promotion and primary prevention. Based on defined based on indications for possible extrapolation
Kenkel (2000), health promotion and primary prevention of the findings to the larger population. The quality of
are defined in this review as activities that aim to reduce this review is also checked using the Prisma 2009 check-
the probability of illness by stimulating a healthy lifestyle list (see Additional file 1).
and providing services that might decrease the future in-
cident of illnesses [9]. Hence, publications that deal with Results
the use of telemedicine in home care to assist disable The chain of keywords shown above yields 656 publica-
persons are excluded, as well as publications that report tions, which are included in the initial screening. The re-
on the use of electronic devices and computer-based sys- sults of the screening are presented in Fig. 1. In the first
tems in secondary and tertiary prevention (e.g. monitor- screening, 454 publications are excluded after reading
ing of chronic conditions in case of specific diseases). the abstract based on the inclusion/exclusion criteria. In
The first screening of the publications that appear total, 202 publications are included in the second
after searching in PubMed with the chain of keywords screening. For the second screening, the publications are
given above, is based on the title and abstract of the downloaded. The full-paper cannot be obtained for 35
publications. At this stage, publications are considered publications, and hence, these articles are excluded. The
potentially relevant if their title and abstract have a link text of the remaining 167 articles is reviewed. From
with the review topic. For the second screening, the these 167 articles, 122 publications are excluded after
publications are downloaded and the text of the publica- reading the full text. The reasons of exclusion are: (1)
tion is fully screened. Publications that fit the inclusion publications are not about health promotion or primary
criteria outlined above are classified as relevant and are prevention; (2) there is no e-health or m-health tool
selected for the review. studied; (3) older adults are not a study group; (4) a
After the screening, the method of directed (relational) combination of these above reasons. Thus, after the sec-
content analysis of Hsieh and Shannon (2005), is used ond screening, 45 publications are selected for this sys-
for the analysis of the publications [10]. This type of tematic review. A detailed description of the articles is
analysis requires the identification of categories (themes) presented in Additional file 2.
relevant to the review objective, extraction of informa-
tion related to categories and synthesis of the informa- General description of the selected publications
tion classified in each category. The groups of themes The main characteristics of the included publications are
that are used for the review and which form the units of presented in Table 1. The majority of the publications
analysis, are: have been published in the last 4 years. In the last 2 years
only, 33.3 % of the publications are published. The ma-
▪ Characteristics of the e-health and m-health tools: jority of the studies have an explanatory aim (quantita-
types of e-health tools (what tools and for what?); tive studies investigating relations and determinants)
The Author(s) BMC Health Services Research 2016, 16(Suppl 5):290 Page 470 of 479

Fig. 1 Search results and publication selection procedures

and only nine publications are explorative or descriptive prevention among older adults are outlined. In the first
(qualitative or mix-methods studies providing more category, the type of tool is mentioned. In 21 publica-
insight on the topic). tions, a website is reported for e-health services. One
There are four different research approaches in the website for instance, offers a help program to reduce
publications reviewed. The majority (32 publications) are weight, where participants can enter their data and plan
quantitative studies with primary data collection. Five their goals. Then, the website helps with feedback to
publications use secondary data. In 28 publications, achieve these goals. Other website-related interventions
randomization was reported. There are two systematic re- deliver information for health prevention or health
views conducted, both are about telehealth. Seven methods promotion. Two publications report on a smartphone
of data collection are reported. Most publications use app. In 15 publications, the use of various devices is re-
biomedical test results as input data. These test results are ported. These devices are often used to gather health-
measured by a healthcare professional or are provided by related data, for example, a pedometer to count steps.
the participant through a self-report. Five publications, There are 4 publications that report on the use of video
including the two systematic reviews, use secondary data consults so that patients do not need to go to a healthcare
or patient records for data analysis. In one publication, ob- facility. Participants can use programs like Skype to have a
servation techniques are used for the data collection. Focus video consultation with the nurse or general practitioner.
group discussions are reported in two publications. Seven In 13 publications, the use of telehealth is reported.
publications report unstructured or semi-structured Telehealth is used to deliver online webinars. Here,
interviews for data collection. The other publications use people can participate in a course or program. There
standardized questionnaires or online questionnaires. are webinars to help older adults to get active or to work
In Table 1, our qualitative assessment of reliability, valid- on their healthy behavior.
ity and generalizability is also presented. If the publications Virtually all e-health and m-health tools reported are
are clear about their methods of data collection and ana- related to a health promotion or primary prevention pro-
lysis, they are considered reliable. In total, 19 publications gram for older adults. Only, one publication describes a
have a clear and reliable description of the methods. In 16 tool without a health promotion or prevention program,
publications, some aspects of validity are mentioned. this tool is a phone-based diary (app). The majority of the
Generalization is clearly outlined in 11 publications. publications report on computer tailored lifestyle pro-
grams (computer-based e-health programs). Specifically, a
Characteristics of the use of e-health and m-health tools computer tailored lifestyle program has the aim to change
among older adults unhealthy behaviors. Such program helps older adults
In Table 2, the characteristics of the e-health and m- with personal goal setting and achieving these goals.
health tools used for health promotion and primary In addition, ten programs that we identified, are based on
The Author(s) BMC Health Services Research 2016, 16(Suppl 5):290 Page 471 of 479

Table 1 General description of publications included in the analysis (45 publications reviewed)
Classification category Sub categories N (%) Reference index in Additional file 2
Year of publication 2014–2015 15 (33.3) 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 20, 28
2012–2013 12 (26.7) 14, 15,16,17, 18, 19, 21, 22, 23, 24, 25, 26,
2010–2011 6 (13.3) 27, 29, 30, 31, 32, 33,
2008–2009 6 (13.3) 34, 35, 36, 37, 38, 44
2006–2007 6 (13.3) 39, 40, 41, 42, 43, 45
Aim/type of study Descriptive 6 (13.3) 6, 8, 21, 23, 31, 38
Explorative 3 (6.7) 1, 5, 27,
Explanatory 36 (80) 3, 4, 6, 7, 9, 10, 11, 13, 14, 15, 16, 17, 18, 19, 20, 22, 24, 25,
26, 28, 29, 30, 32, 33, 34, 35, 36, 37, 39, 41, 40, 42, 43, 44, 45
Research approach Qualitative (primary data) 6 (13) 2, 5, 7, 23, 31, 38
Quantitative (primary data) 32 (69.6) 3, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 22, 24, 25, 26, 27, 28,
29, 32, 33, 34, 35, 36, 37, 39, 40, 41, 42, 43, 44, 45
Mixed (primary data) 3 (6.5) 1, 4, 30
Desk research (secondary data) 5 (10.9) 6, 8, 12, 13, 21
Design Qualitative 7 (15.2) 1, 2, 5, 7, 23, 31, 38
Quantitative - randomized controlled trial 28 (60.9) 3, 4, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 22, 24, 25, 26, 27,
28, 29, 33, 34, 37, 40, 41, 42, 43, 44
Qualitative - not randomized controlled trial 9 (19.6) 6, 13, 23, 30, 32, 35, 36, 39, 45
Systematic review 2 (4.3) 8, 21
Data collection/design Observations 1 (2) 1
Focus group discussion 2 (4) 2, 16
Unstructured/semi structured interviews 7 (13)) 1, 3, 5, 7, 31, 38, 40
Standardized questionnaires/interviews/surveys 9 (17 11, 14, 18, 20, 30, 33, 37, 42, 43
Online web based questionnaires/assessments 10 (19) 4, 10, 17, 25, 26, 27, 28, 29, 40, 44
Secondary data/patient records 5 (10) 8, 9, 12, 13, 21
Test results/self-report 18 (35) 6, 11, 15, 18, 19, 22, 23, 24, 25, 32, 33, 34, 35, 36, 37, 39, 41, 45
Reliability// Reliability is clear 19 (42.2) 1, 2, 5, 7, 8, 12, 14, 15, 16, 20, 21, 22, 24, 27, 38, 40, 41, 43, 44
Reliability is unclear 22 (48.9) 6, 9, 10, 11, 13, 17, 18, 19, 23, 25, 28, 29, 31, 32, 33, 34, 35,
36, 37, 39, 42, 45
Reliability is not analyzed 4 (8.9) 3, 4, 26, 30,
Validity Validity is clear 16 (35.6) 1, 2, 3, 5, 8, 15, 16, 20, 21, 30, 36, 38, 41, 42, 43, 44
Validity is unclear 22 (48.9) 4, 6, 9, 11, 13, 14, 18, 19, 22, 23, 24, 25, 28, 29, 31, 32, 34,
35, 37, 39, 40, 45
Validity is not analyzed 7 (15.6) 7, 10, 12, 17, 26, 27, 33
Generalizability Generalizability is clear 11 (24.4) 1, 5, 6, 8, 9, 14, 16, 22, 42, 43, 45
Generalizability is unclear 20 (44.4) 2, 3, 11, 12, 13,17, 18, 19, 20, 24, 25, 28, 29, 31, 34, 37, 39, 40, 41, 44
Generalizability is not analyzed 14 (31.1) 4, 7 10, 15, 21, 23, 26, 27, 30, 32, 33, 35, 36, 38,
The sum of N per category can exceed 45 as papers can be classified in multiple sub-categories

providing feedback. Feedback is provided with an inter- older adults to access their health. To increase informa-
active voice response, with the use of internet, or it is tion for health prevention or health promotion among
a face-to-face feedback. These programs do not have older adults, 4 publications report on the use of online
to be tailor-made but could provide the same feedback for health information.
an entire group. Telehealth offers different programs that The third category in Table 2 portrays the study
are studied in 12 publications. There are telehealth pro- groups. All publications report on the use of e-health
grams to increase physical activity among older adults. and m-health tools among older adults, older adults being
Other telehealth programs provide information, for ex- defined as 50 years and older. The majority of the publica-
ample, on stroke prevention. Telehealth programs help tions (17 publications) do not have further limitations of
The Author(s) BMC Health Services Research 2016, 16(Suppl 5):290 Page 472 of 479

Table 2 Characteristics of e-health and m-health tools used in health promotion and primary prevention among older adults
Classification category Sub categories N (%) Reference index in Additional file 2
Type of e-health and Apps 2 (3.6) 1, 26
m-health tools
Website 21 (38.2) 2, 5, 6, 9, 10, 14, 15, 16, 17, 19, 22, 25, 27, 28, 29,
35, 37, 38, 40, 43, 44
Device 15 (27.3) 3, 4, 7, 11, 12, 15, 21, 22, 24, 31, 32, 33, 36, 37, 42
Video consult (skype) 4 (7.3) 8, 39, 41, 45
Webinars 13 (23.6) 3, 8, 13, 18, 20, 21, 23, 25, 28, 29, 30, 32, 34,
Type of use of e-health Use without program (phone diary) 1 (2.2) 26
and m-health tools
Use in computer tailored lifestyle program 18 (40) 2, 6, 9, 12, 14, 15, 17, 18, 22, 24, 25, 27, 28, 29, 35, 37, 43, 44
Use in program providing support/feedback 10 (22.2) 1, 3, 4, 7, 10, 11, 16, 23, 34, 36
(Internet/face-face)
Use in online health information 4 (8.9) 5, 19, 38, 40
Use in telehealth programs 12 (26.7) 8, 13, 20, 21, 30, 31, 32, 33, 39, 41, 42, 45
Study groupa No specific requirement 17 (37) 2, 4, 7, 9, 16, 17, 20, 21, 30, 31, 32, 33, 36, 39, 40, 41, 44
Women only 3 (6.5) 3, 10, 26
With risk/signs of specific disease 4 (8.7) 1, 19, 35, 45
Physical conditions (overweight) 14 (30.4) 6, 10, 11, 12, 13, 18, 22, 25, 27, 28, 29, 34, 37, 43
(Risk) Behaviors-lifestyle 3 (6.5) 14, 23, 24
Cultural group (migrants/Latino’s/African American) 3 (6.5) 5, 15, 42
Based on setting: in clinics/community 1 (2.2) 8
Low computer knowledge 1 (2.2) 38
Country location Europe 10 (22.2) 1, 2, 7, 14, 19, 21, 26, 27, 32, 44
United states 27 (60) 3, 4, 8, 9, 10, 11, 12, 13, 15, 16, 17, 20, 22, 23, 24, 25,
28, 29, 30, 31, 33, 34, 35, 40, 42, 43, 45
Canada 3 (6.7) 6, 39, 41
Australia 2 (4.4) 5, 18
Asia 3 (6.7) 36, 37, 38
The sum of N per category can exceed 45 as papers can be classified in multiple sub-categories
a
All groups are older adults (at least 50 years old)

the study group. Fourteen publications mention specific devices and webinars are used in computer tailored
physical requirements. Most of them are health programs lifestyle programs and program providing health-related
that aim at people who suffer from overweight. There are support or feedback. Telehealth programs involve the use
three studies focused on older women, and three that aim of devices, video consults and webinars.
at older adults from a specific cultural group. One publi- In Table 4, a cross-tabulation is given to show which
cation reports on older adults with limited computer types of e-health and m-health tools are reported in
knowledge. which year and in which country. For Asia, there are
The majority of the publications come from the United three publications, each from the period 2008–2009.
States (27 out of the 45 publications reviewed). Ten They all report on the use of e-health tools in programs.
publications come from Europe. There are three publica- For Canada, there are two publications in the period
tions from Asia, of these, two are from Japan, and one 2006–2007, both about telehealth. The other publication
from Hong Kong. The other five publications come from in Canada is published in the period 2014–2015 and is
Canada and Australia. about the use of web-site in a computer-tailored lifestyle
In Table 3, a cross-tabulation is given to show which program.
types of e-health and m-health tools in what programs The majority of the publications (17 publications) are
are reported. Apps are used for the provision of health- published in the last 4 years and most come from the
related feedback to older adults within a health promotion United States. The main focus in the US studies is on
program, as well as outside a formal program. Websites the use of e-health and m-health tools in computer-
are also used within health promotion programs to pro- tailored lifestyle programs for older adults. In Europe,
vide health-related information to older adults. Websites, the number of publications focused on older adults that
The Author(s) BMC Health Services Research 2016, 16(Suppl 5):290 Page 473 of 479

Table 3 Cross-tab for type of e-/m-health tools and type of use of e-/m-health tools among older adults
Type of e-health and m-health tool Type of use of e-health and m-health tools N (%) Reference index in Additional file 2
Apps Tool without program 1 (50) 26
Computer tailored lifestyle program - -
Program providing support/feedback 1 (50) 1
Online health information - -
Telehealth - -
Website Tool without program - -
Computer tailored lifestyle program 15 (71.4) 2, 6, 9, 14, 15, 17, 22, 25, 27, 28, 29, 35, 37, 43, 44
Program providing support/feedback 2 (9.5) 10, 16
Online health information 4 (19.1) 5, 19, 38, 40
Telehealth - -
Device Tool without program - -
Computer tailored lifestyle program 5 (33.3) 12, 15, 22, 24, 37
Program providing support/feedback 5 (33.3) 3, 4, 7, 11, 36
Online health information - -
Telehealth 5 (33.3) 21, 31, 32, 33, 42
Video consult (skype) Tool without program - -
Computer tailored lifestyle program - -
Program providing support/feedback - -
Online health information - -
Telehealth 4 (100) 8, 39, 41, 45
Webinars Tool without program - -
Computer tailored lifestyle program 4 (30.8) 18, 25, 28, 29
Program providing support/feedback 3 (23.1) 3, 23, 34
Online health information - -
Telehealth 6 (46.1) 8, 13, 20, 21, 30, 32
The sum of N per category can exceed 45 as papers can be classified in multiple sub-categories

we reviewed did not increase much during the past providing support and feedback, and one publication is
10 years. There is an increased focus on programs based focused on telehealth. Studies on telehealth most often
on the use of e-health tools for providing support and include older adults in general. Three publications re-
feedback for a healthy lifestyle. From the 10 publications port on the use of e-health and m-health tools by older
with such focus, eight have been published in the last women in a computer-tailored lifestyle program and
4 years. These publications are from the USA and programs focused on providing health-related support
Europe. E-health tools in telehealth programs are reported and feedback.
before 2012.
Table 5 presents a cross-tabulation of the study group Facilitating factors and barriers to the use of e-health and
and the type of use of e-health and m-health tools. Most m-health tools in health promotion among older adults
publications with a specific study group are about phys- For the use of e-health and m-health tools, barriers and
ical conditions. There is only one publication that re- facilitating factors are reported in the publications
ports on telehealth that aims to help older adults who reviewed. These factors are described in Table 6. It
live in a clinic. The only publication that is focused on should be underlined however, that most of the factors
older adults with limited computer knowledge is a pro- listed in Table 6, such as motivation, self-regulation, in-
gram about online health information. Some publica- formation and rewards, are important determinants of
tions report on the use of e-health and m-health tools in behavior change in general and not necessarily direct de-
computer-tailored lifestyle programs to help older adults terminants of the use of e-health and m-health tools per
get physically active. Other publications for older adults se. At the same time, other factors in Table 6, such as
with specific physical conditions report on the use of e- usability and accessibility can be directly related to the
health and m-health tools in programs focused on use of e-health and m-health tools.
The Author(s) BMC Health Services Research 2016, 16(Suppl 5):290 Page 474 of 479

Table 4 Cross-tab for year, country and type of use of e-health and m-health tools among older adults
Country or location Year of publication Type of use of e-health and m-health tools N (%) Reference index in
Additional file 2
Europe 2014–2015 Computer tailored lifestyle program and program providing 3 (30) 1, 2, 7,
support/feedback
2012–2013 Computer tailored lifestyle program, online health information, use 3 (30) 14, 19, 26
without program
2010–2011 Computer tailored lifestyle program and telehealth 2 (20) 21, 27
2008–2009 Computer tailored lifestyle program and telehealth 2 (20) 32, 44
2006–2007 - -
United states 2014–2015 Computer tailored lifestyle program, telehealth, and program 10 (37) 3, 4, 8, 9, 10, 11, 12, 13, 20, 28
providing support/feedback
2012–2013 Computer tailored lifestyle program and program providing 7 (25.9) 15, 16, 17, 22, 23, 24, 25
support/feedback
2010–2011 Computer tailored lifestyle program and telehealth 4 (14.8) 29, 30, 31, 33,
2008–2009 Computer tailored lifestyle program and program providing 2 (7.4) 34, 35,
support/feedback
2006–2007 Online health information, computer tailored lifestyle program 4 (14.8) 40, 42, 43, 45
and telehealth
Canada 2014–2015 Computer tailored lifestyle program 1 (33.3) 6
2012–2013 - -
2010–2011 - -
2008–2009 - -
2006–2007 Telehealth 2 (66.7) 39, 41
Australia 2014–2015 Online health information 1 (50) 5
2012–2013 Computer tailored lifestyle program 1 (50) 18
2010–2011 - -
2008–2009 - -
2006–2007 - -
Asia 2014–2015 - -
2012–2013 - -
2010–2011 - -
2008–2009 Program and program providing support/feedback, computer 3 (100) 36, 37, 38
tailored lifestyle program and online health information
2006–2007 - -
The sum of N per category can exceed 45 as papers can be classified in multiple sub-categories

Seven types of facilitating factors are reported in the the nature of the tool also help to facilitate the use of the
publications. The most often mentioned facilitating tool. According to three publications, it is helpful if there
factors are motivation, support and feedback. These is a reward system. The reward system can be based on
are reported in 12 publications. Specifically, support re- both the use of the e-health/m-health tool and concrete
ceived from other participants in the e-health or m-health changes in health-related behavior. This could be a finan-
program is a key factor to help to change behavior. Motiv- cial reward, or a reward in the sense that the participants
ation or feedback from other participants is also important can notice progress. Three publications mentioned user-
to observe progress. This also contributes to adherence to friendliness as facilitating factors of the tools. If the elec-
the e-health or m-health programs. Four publications in- tronic device is simple and works easily, older adults are
dicate that it is necessary to let older adults participate in more willing to keep using it. Two publications indicate
accordance with their own planning to change. This could the accessibility to the tools or programs as a facilitating
be accomplished by self-regulation and goal setting. Goal factor. It is be better if the programs or tools are provided
setting and insight in how they perform, is a way to keep in multiple languages so that older adults could use it in
them motivated. Information on individual progress and their native language. For some older adults, it is better to
The Author(s) BMC Health Services Research 2016, 16(Suppl 5):290 Page 475 of 479

Table 5 Cross-tab for study group and type of use of e-health and m-health tools among older adults
Study groupa Type of use of e-health and m-health tools N (%) Reference index in Additional file 2
No specific study group Tool without program - -
Computer tailored lifestyle program 5 (25) 2, 6, 9, 17, 44
Program providing support/feedback 3 (15) 4, 7, 16
Online health information 4 (20) 40
Telehealth 8 (40) 20, 21, 30, 31, 32, 33, 39, 41
Women only Tool without program 1 (33.3) 26
Computer tailored lifestyle program - -
Program providing support/feedback 2 (66.7) 3, 10
Online health information - -
Telehealth - -
With risk/indication of specific disease Tool without program - -
Computer tailored lifestyle program 1 (33.3) 35
Program providing support/feedback - -
Online health information 1 (33.3) 19
Telehealth 1 (33.3) 45
Physical conditions (overweight) Tool without program - -
Computer tailored lifestyle program 10 (71.4) 6, 12, 18, 22, 25, 27, 28, 29, 37, 43
Program providing support/feedback 3 (21.4) 10, 11, 34
Online health information - -
Telehealth 1 (7.1) 13
(Risk) Behaviors-lifestyle Tool without program - -
Computer tailored lifestyle program 2 (66.7) 14, 24
Program providing support/feedback 1 (33.3) 23
Online health information - -
Telehealth - -
Specific cultural group Tool without program - -
Computer tailored lifestyle program 1 (33.3) 15
Program providing support/feedback - -
Online health information 1 (33.3) 5
Telehealth 1 (33.3) 42
Based on setting: In clinics/community Tool without program - -
Computer tailored lifestyle program - -
Program providing support/feedback - -
Online health information - -
Telehealth 1 (100) 8
Low computer knowledge Tool without program - -
Computer tailored lifestyle program - -
Program providing support/feedback - -
Online health information 1(100) 38
Telehealth - -
The sum of N per category can exceed 45 as papers can be classified in multiple sub-categories. aAll groups are older adults (at least 50 years old)

have access to different forms of information, for example, often mentioned facilitating factor. This is the case in
if there is also a printed version beside the online informa- eight publications. The benefit of this remote help at
tion. Access to remote help at home is the second most home is often the lack of travel distance.
The Author(s) BMC Health Services Research 2016, 16(Suppl 5):290 Page 476 of 479

Table 6 Factors influencing the use of e-health and m-health tools for health promotion and primary prevention among older
adults
Classification category Sub categories N (%) Reference index in Additional file 2
Facilitating factors Motivation/support/feedback 12 (35.3) 1, 2, 3, 4, 12, 18, 21, 29, 30, 34, 39, 43
Self-regulation/goal setting 4 (11.8) 9, 17, 18, 36
Information (progress, usefulness, awareness) 2 (5.9) 1, 31
Reward (financial, noticed physical change) 3 (8.8) 4, 6, 39
Usability 3 (8.8) 1, 7, 26
Accessibility (language, form – online or print) 2 (5.9) 5, 9
Remote help at home (no travel distance) 8 (23.5) 13, 28, 29, 30, 31, 33, 35, 39
Barriers to use Personal choice lack of time/priority/cost 6 (20) 2, 3, 17, 23, 24, 34
Lack of adherence or motivation/support 8 (26.7) 3, 4, 12, 17, 24, 34, 42, 44
Unclear device or information/wrong interpretation/lack of guidance 3 (10) 1, 7, 38
Barriers related with technology/device 4 (13.3) 1, 3, 26, 45
Socio demographical barriers (age, educational level, skills with electronic device) 6 (20) 2, 5, 15, 17, 38, 45
Lack or resource for telecare 1 (3.3) 31
Policy/reimbursement changes required 2 (6.7) 28, 29
The sum of N per category can exceed 45 as papers can be classified in multiple sub-categories

In the publications, barriers to the use of e-health and sociodemographic barriers are mentioned. The sociode-
m-health tools for health promotion and primary pre- mographic barriers are related to educational level and
vention among older adults are also mentioned. These age. Three publications indicate barriers that are related
barriers are presented in Table 6. There are seven cat- to policy or to a lack of resources to implement the e-
egories of barriers. The first two categories are related to health program or tool.
personal barriers. Six publications mention barriers to
use of e-health and m-health tools related to personal Discussion
choice. This choice refers to the lack of time or other This systematic literature review presents evidence on
priorities. A solution that is indicated is to have a tool the scope of the use of e-health and m-health tools for
that can be paused and the use can be resumed when health promotion and primary prevention among older
the older adult has time. Some publications mention adults, as well as the factors that influence the use of these
that the monetary costs of use are too high. As men- tools. There are different kinds of e-health and m-health
tioned for the facilitating factors, the lack of motivation tools used for health promotion and primary prevention
and support is also most often reported as a barrier to among older adults. These include apps, websites, devices,
the adherence to e-health or m-health health promotion video consults and webinars. Many of the health promo-
programs. When there is an online support group, the tion and primary prevention programs for older adults
group could be used to motivate each other. If the online that utilize such tools, have websites with information
support group is not used or only filled with negative on health-related aspects. This is for example the case
comments, then the support has a negative influence with computer-tailored lifestyle programs and telehealth
and becomes a barrier. According to the publications programs. The majority of the publications on e-health
reviewed, there is also a lack of motivation when partici- and m-health tools that we reviewed, study the general
pants cannot reach their goals. When devices are used or older adult population. Only few publications report
information is provided, it should be clear how the device studies focused on a specific older adult group. The most
works and the users should be able to understand the common specific study group consists of older adults with
information that they receive. The lack of information a certain physical limitation, most often the need of weight
or the lack of comprehensible information is mentioned reduction. This is not surprising as many diseases can
in three publications. Barriers related to the technology be prevented through physical activity or maintenance
used and the device is reported in four publications. of a healthy weight [11–13]. This could explain why
There are examples of problems with the use of internet there is a strong focus on older adults with weight
or with the device. Problems with the electronic devices problems as a study group. The publications with this
can also be caused by sociodemographic barriers. Some- study groups most often report the use of e-health and m-
times older adults do not have the proper skills to work health programs in a computer tailored lifestyle program.
with e-health or m-health devices. In four publications, This is also reported by the systematic reviews focused on
The Author(s) BMC Health Services Research 2016, 16(Suppl 5):290 Page 477 of 479

e-health interventions for physical activity and dietary be- indicates rewards as a facilitating factor. This could be not
havior change [14]. only a financial reward, but also the achievement of the
During the past 10 years, the amount of publications health goals [13, 17]. To help with the motivation, ad-
reporting on the use of e-health and m-health tools in equate goal setting is an important facilitating factor [18].
health promotion and primary prevention among older When older adults have a personal aim and reachable
adults, has been increasing. Also, the focus of the publi- goals, they are more likely to pursue the targeted behavior
cations has changed through the years. At the beginning change and therefore, continue to use the e-health
of the period covered by our review, there were more and m-health tools offered. If the goals are too difficult to
publications about telehealth. In the past 4 years, publi- reach then, this has negative effects, and the goal setting
cations more often report on the use of e-health and m- becomes a barrier [18, 19].
health tools in computer tailored lifestyle or programs Some of the publications that we reviewed point to
that provide support and feedback for a healthy lifestyle. sociodemographical barriers. For some older adults for
The results show that for different study groups, differ- example, it is problematic to work with new technolo-
ent e-health and m-health tools are used. The choice of gies. This could be due to a low educational level or lim-
an adequate tool depends on the specificities of the par- ited skills with electronic devices. When the e-health
ticipants. This could explain why there are many differ- and m-health tools use technologies, which older adults
ent e-health tools and programs reported [15]. Another already know, the ease of use is a facilitating factor. This
explanation for this diversity is the rapid change in the tool should also present the information in a clear and
available e-health m-health tools [2]. Thus, although comprehensible way. Also, the older adults’ access to
40 % of the publications we reviewed, report the use of health promotion or primary prevention programs, can
telehealth for older adults in general, this might change be facilitated through telehealth [20]. With the use of
in the near future as new m-health tools (such as apps) this type of e-health, older adults do not have to travel
are becoming available [16]. Most probably, some of to benefit from such programs [21].
these tools are already used by older adults, but are not Although our review was systematic and we took care
yet studied and reported in the literature. to assure its quality (see Additional file 1), we still need
In this review, we also outline the evidence on the fa- to acknowledge some key limitations. A limitation of this
cilitating factors and barriers to the use of e-health and review is that the search for relevant publications is done
m-health tools for health promotion and primary pre- in one search engine by a single researcher. Although
vention among older adults. The results show different PubMed is the most relevant search engine with regard to
facilitating factors and barriers. When the barriers are our topic and it includes an enormous volume of publica-
studied, over 25%of the publications mentioned the lack tions, we may have missed publications on commercial e-
of motivation, support and feedback as obstacles. At the health or m-health tools. Also, a certain bias in selecting
same time, the results for the facilitating factors also relevant publications is present since only one researcher
show that strong motivation as well as adequate support did the selection. Another limitation is that we assessed
and feedback are important for the continuity of the the study designs in a qualitative manner without applying
health program based on e-health and m-health tools. It a standardized protocol that could have helped us to
is recognized hewer that these factors are important de- quantify the strengths and weaknesses of the study de-
terminants of behavior change and not necessarily direct signs. Therefore, our review should be only seen as a first
determinants of the use of e-health and m-health tools attempt to bring together evidence on the use of e-health
[13]. When health promotion and primary prevention and m-health tools for health promotion and primary pre-
programs offer support or feedback, older adults are more vention among older adults.
likely to keep using the e-health and m-health tools With regard to the scope of our review, we only ad-
offered by the program. Motivation can be stimulated dress the use of m-health and e-health tools for primary
in different ways [17]. The most frequently mentioned prevention while the use of these tools is equally rele-
motivator is feedback on the extent to which people vant in secondary and tertiary prevention and in treat-
have achieved their goals. Such feedback can come ment. Such applications of m-health and e-health tools
from a professional or a peer-support group. We find are widely reported in the literature [22, 23]. Also, our
evidence however, that the use of an online support review is exclusively focused on older adults while a
group can have both positive and negative effects. If valuable starting point in future reviews could be the in-
the feedback is formulated positively, it can be a motiv- clusion of more population groups or a comparison with
ation for further achievement. But if the group mostly fo- the general population [24–26]. In addition, as stated at
cuses on the negative aspects of the use of e-health the outset of this paper, our review should be seen as an
and m-health tools, and provides more negative com- initial step that explores the scope of the use of e-health
ments, then, it can turn into a barrier. One publication and m-health tools for health promotion and primary
The Author(s) BMC Health Services Research 2016, 16(Suppl 5):290 Page 478 of 479

prevention among older adults. We were unable to ex- Publication co-financed from funds for science in the years 2015–2017
plore the effectiveness of e-health and m-health tools allocated for implementation of an international co-financed project.

among older adults. Specifically, our review captures stud- Declarations

ies with very different objectives. For example, some of the This article has been published as part of BMC Health Services Research
studies focus on the effectiveness of e-health and m- Volume 16 Supplement 5, 2016: Economic and institutional perspectives on
health promotion activities for older persons. The full contents of the
health programs, while others not. Even if we only exam- supplement are available online at http://bmchealthservres.biomedcentral.
ine studies that specifically focus on the effectiveness of e- com/articles/supplements/volume-16-supplement-5.
health and m-health programs, the focus is not necessarily
on the effectiveness of the e-health and m-health tools Availability of data and materials
PRISMA 2009 Checklist for systematic review and/or meta-analyses is filled in
but rather on the effectiveness of the programs in and included in Additional file 1. The list of papers reviewed and key content
general. Thus, the outcomes measured do not reflect the used in this review can be found in Additional file 2.
effects of e-health and m-health tools, but the more gen-
eral objective of the study. Subsequent more specific re- Authors’ contributions
RK contributed to the development of the study design, carried out the
views focused on the effectiveness of e-health and m- literature search and analysis, drafted and improved the manuscript,
health tools and programs for older adults within specific approved the final version and agreed to be accountable for his
settings need to be conducted to obtain a better under- contribution. MP contributed to the development of the study design,
reviewed the literature search and analysis, and reviewed and commented
standing of how such programs should be designed and on the preliminary drafts and final version of the paper, approved the final
implemented. version and agreed to be accountable for her contribution. MT contributed
to the development of the study design, and also reviewed and commented
on the preliminary and final paper drafts paper, approved the final version
Conclusions and agreed to be accountable for her contribution. WG assessed the study
design, reviewed and commented on the literature search and analysis, and
The results of this systematic literature review show that also reviewed and commented on preliminary paper drafts and the final
the relevance of e-health and m-health tools in health version paper, approved the final version and agreed to be accountable for
promotion and primary prevention among older adults his contribution.
is recognized and that there are a variety of uses of such
Authors’ information
tools. Also, the research focused on this issue is increasing RK is alumni of Master program Health Policy Innovation and Management at
since more publications have appeared in recent years. It Maastricht University, the Netherlands. MP is Associate Professor of Health
seems however, that the use of e-health and m-health Economics at the Department of Health Services Research, Maastricht
University, the Netherlands. MT is Assistant Professor of Health Economics at
tools in health promotion programs for older adults, is Jagiellonian University Medical College in Krakow, Poland. WG is Professor of
mostly an isolated initiative, especially outside the US. Health Economics at the Department of Health Services Research, and also
European countries for example, that experience a fast Professor of Evidence Based Education at Maastricht University, the Netherlands.

population aging, could specifically benefit from the use of Competing interests
e-health and m-health tools in health promotion and pri- The authors declare that they have no competing interests.
mary prevention programs among older adults. If these
programs are designed with caution to avoid potential bar- Consent for publication
Not applicable. This is a systematic literature review.
riers (as those outlined here), and if the cost-effectiveness
of the programs can be demonstrated in future studies, Ethics approval and consent to participate
governments might be willing to consider their expansion Not applicable. This is a systematic literature review.
and funding. In this regard, more evidence on the effect-
Author details
iveness and cost-effectiveness of e-health and m-health 1
Department of Health Services Research, CAPHRI, Maastricht University
health promotion programs for older adults is needed. Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht
University, PO Box 6166200, MD, Maastricht, The Netherlands. 2Faculty of
Health Sciences, Department of Health Economics and Social Security,
Additional files Institute of Public Health, Jagiellonian University Collegium Medicum, ul.
Grzegórzecka 20, 31-531 Krakow, Poland. 3Top Institute Evidence-Based
Education Research (TIER), Maastricht University, PO Box 6166200, MD,
Additional file 1: PRISMA 2009 Checklist. (PDF 135 kb) Maastricht, The Netherlands.
Additional file 2: Description of the articles reviewed. (PDF 263 kb)
Published: 5 September 2016

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