The introduction of digital technologies has influenced many aspects of modern living, including health care [1,2]. Digital health technologies (eg, wearable activity trackers and mobile phone apps) provide opportunities for effective patient care. They can improve communication between health care providers [3], facilitate connectivity with clinicians and peers [4,5], enable remote health monitoring [6], and empower patients to play an active role in their long-term care [3,7-9].

In the context of elective surgeries, there is a strong association between preoperative physical and psychological preparedness and improved postoperative outcomes [10-12]. More specifically, improvements in physical activity levels [13], dietary intake [14], and smoking cessation [15] have been linked to improved recovery after surgery, reduced risk of complications, better tolerance of postsurgical adjunctive treatment, and prevention of long-term disease [16-19].

Although health behavior changes made in the pre- and postoperative periods can be fundamental in determining the outcomes and success of elective surgeries [19-21], there are variable amounts of support and education currently provided to patients undergoing elective surgery to motivate these health behavior changes [22-24]. A recent study evaluating patient attitudes to health behavior changes found that although preoperative patients understood the health benefits of improved behaviors, they lacked the confidence to make such changes without intervention or support [19]. Many physical and mental health interventions offered in elective care pathways use face-to-face, in-person delivery for individuals or small groups of patients. Such approaches are resource- and time-intensive for staff already working in high-pressure health care sectors [25-27]. In addition, geographic isolation, travel costs, and the time burden of attending classes can all negatively affect patient engagement with postoperative appointments [28,29]. Understanding the potential unmet needs of patients undergoing elective surgery is central to motivating health behavior changes. Integrating digital technologies within the elective surgical pathway could be one strategy to remotely deliver behavioral change advice and lifestyle support, consequently improving patient engagement and postoperative success rates [12,30].

This review uses a meta-ethnographic approach to analyze and synthesize qualitative findings. Meta-ethnography was originally developed by Noblit and Hare [31], but it has recently been used in health care–based social science research by Britten et al [32], Campbell et al [33,34], Pound et al [35], and others. It is an inductive and interpretive approach involving the translation of papers into one another. Meta-ethnographies encourage researchers to understand and transfer ideas, themes, and metaphors across different studies to gain a deeper understanding or to inform the development of broader concepts [31,36].

There are still unanswered questions relating to the optimization of digital technologies to support patients undergoing elective surgery, especially in the cohorts of bariatric, cancer, and orthopedic surgery. We seek to synthesize findings from existing qualitative research to determine whether digital technologies are effective in supporting patients undergoing elective surgery to change their health behaviors, specifically focusing on physical activity, weight, dietary intake, and mental health support (eg, cognitive behavioral therapy).

 A comprehensive and systematic literature search was conducted in October 2019 across 6 electronic databases: MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and Scopus. No limit on the publication date was applied. Additional papers were identified via gray literature using Google Scholar, and we manually searched the bibliographies of all included studies. A full list of search terms is included in Multimedia Appendix 1.

This meta-ethnography focused on elective surgical procedures, specifically bariatric, cancer, and orthopedic surgeries. Patients undergoing these elective procedures may have improved surgical outcomes owing to pre- and postoperative health behavior changes and therefore can benefit from the support of digital health technologies. Acute, unplanned surgeries and emergency trauma procedures were excluded from this review.

Only the studies that had encompassed the use of digital health interventions to support behavior changes (such as weight changes, dietary intake, physical activity levels, and/or mental health strategies) in adult patients undergoing elective surgery (>18 years) during the pre- or postoperative period were included. There were no restrictions placed on participants’ sex, ethnicity, or nationality. The included studies must be qualitative or mixed method studies containing a significant qualitative component to analyze participant perspectives (eg, patient interviews or focus groups).

Exclusion criteria included studies employing behavior changes achieved by nondigital interventions; participants who were not scheduled to undergo an elective bariatric, cancer, and orthopedic surgery; studies where the intervention was mainly focused on perspectives of health care professionals; nonqualitative studies (eg, quantitative studies, systematic reviews, or protocols); and studies in languages other than English.

Two authors (UO and AR) reviewed the titles and abstracts from the database search. Full texts were retrieved for articles that met the inclusion criteria and for those that could not be rejected with certainty. Two authors (UO and AR, with an agreement rate of 94.7%) independently screened the full texts of eligible articles. Disagreements (on 3 of the 56 articles) were resolved through discussion with a third reviewer (AH). Figure 1 shows a PRISMA flowchart for the study selection process.

Two authors (UO and AR) closely read and re-read the included studies to ensure close familiarity with the work. Data extraction was performed across the full primary study (by UO and AR) [36] and carried out using a customized data extraction form, including the study and author details, method of intervention delivery, population data, inclusion criteria, and original quotes and/or concepts developed by the authors of primary studies (within their original context). Both authors worked independently before comparing their work; disagreements were resolved through discussion with a third reviewer (AH) where necessary. Quality appraisal was conducted independently by UO and AR using the Critical Appraisal Skills Programme (CASP) questions to understand qualitative research [37]. No papers were excluded on the grounds of quality.

Meta-ethnographic approaches were applied to this review, as determined by the 7 phases of meta-ethnography by Noblit and Hare [31]: (1) getting started, (2) deciding what is relevant to the initial interest, (3) reading the studies, (4) determining how studies are related, (5) translating the studies into one another, (6) synthesizing translations, and (7) expressing the synthesis.

The findings (concepts and metaphors) from the primary studies were compared to determine how they are related. Noblit and Hare [31] suggested that phase 5, where findings are translated into one another, follows something like “one case is like another, except that...”. This phase of a meta-ethnographic approach is termed “reciprocal translation,” and it enables the development of themes and subthemes for interpretive synthesis [31,33]. According to this, we developed 4 overarching themes (or third-order constructs) and subsequent subthemes that were consistent with the original results but also extended beyond them.

When translating the studies into one another to develop themes (and subthemes), we arranged each paper chronologically and compared the themes from paper 1 with those of paper 2, then those of paper 2 with those of paper 3, and so on. As we compared each study, we grouped similar themes and continually reviewed and refined them until they were coherent and distinctive. Two reviewers (UO and AR) were involved in the study translation at all times; however, if agreement was not reached between these, discussions with a third author (AH) helped to establish a consensus.

To adhere to recommendations for conducting meta-ethnographies, we used the term “theme” to describe the third-order construct and subthemes to describe third-order construct subthemes [36]. The development of these overarching themes enables meta-ethnographies to delve further into a topic as compared with a traditional systematic review and contribute new insights to the literature [32].

We report on the overall effectiveness of digital health technologies to support behavioral change in patients undergoing surgery through 4 established themes: (1) motivational support, (2) patient engagement with interventions, (3) the facilitation of peer networking, and (4) intervention specificity to meet patients’ individual needs.

A total of 316 citations were retrieved from the database searches. A total of 5 additional records were identified through gray literature and searching references manually from relevant studies. Following the removal of duplicates (n=112), 204 papers were screened, of which 148 were excluded based on their titles and abstracts. A total of 56 full-text papers were assessed for eligibility; 38 of these were excluded due to reasons detailed in the PRISMA flowchart in Figure 1. The remaining 18 studies were included in this meta-ethnographic systematic review; of these, 68% (n=13) were qualitative and 32% (n=7) were mixed methods studies.

All 18 included papers were published between 2013 and 2019. The study was conducted in 8 different countries: United States (n=6) [38-43], United Kingdom (n=3) [44-46], Canada (n=3) [47-49], Australia (n=2) [50,51], Ireland (n=1) [52], Norway (n=1) [53], South Korea (n=1) [54], and China (n=1) [55].

The 18 studies covered 3 different surgery types: bariatric (n=2, 11%), cancer (n=13, 72%), and orthopedic (n=3, 17%) surgeries. Further study characteristics, including the method of intervention delivery and original themes extracted from the study, are detailed in Multimedia Appendix 1 [35,37-55].

A total of 3 main intervention delivery methods were identified in the 18 included studies. These included internet-based interventions (eg, emails, e-platforms, virtual reality, tele-rehabilitation) [38,40,42,44,46,48,49,53,54], mobile phone–based interventions (eg, text messages, smartphone apps) [39,45,55], and wearable interventions (eg, activity trackers) [43,47,50-52]. Only 1 study reported the use of a combination of 2 intervention methods (dual approach), including wearable- and phone-based interventions [41].

Multimedia Appendix 1 contains details of the quality appraisal conducted using the CASP tool for qualitative studies. Of the included studies, Shaffer et al [38], Phillips et al [39], Alberts et al [40], and Argent et al [52] were identified as having the highest quality.

Multimedia Appendix 1 presents the metaphors and patients’ perspectives from each of the included studies. Reciprocal translation and refutation of these concepts enabled the development of 4 overarching themes and subthemes for this meta-ethnography; they are outlined in Figure 2. The 4 overarching themes and subthemes appear to be key in understanding and determining the effectiveness of digital and mobile health interventions to support behavior change in patients undergoing surgery.

The qualitative data synthesis can be found in Multimedia Appendix 1, with each table representing one of the 4 overarching themes. These tables showcase examples of direct quotations (first-order constructs) from study participants, the authors’ interpretations of the original findings from the included studies (second-order constructs), and our interpretation (third-order constructs) and subthemes.

To our knowledge, this is the first meta-ethnographic systematic review examining the effectiveness of digital and mobile technologies to support health behavior change in patients undergoing elective surgery. Using reciprocal translation, our findings indicate 4 themes that appear to be key in determining intervention effectiveness to support health behavior change in patients undergoing surgery: (1) providing motivational support, (2) addressing patient engagement, (3) facilitating peer networking, and (4) meeting individualized patient needs. Future studies could use these findings to inform future design frameworks for specific surgical cohorts while embracing digital transformations in health care.

Although meta-ethnographies offer an opportunity to synthesize findings to develop new or deeper understandings on a subject, the process is largely interpretive [31]; other conclusions from the same included studies may be possible but still equally as valid. It is also important to note that the focus of this meta-ethnography was solely elective cancer, bariatric, and orthopedic surgeries, and as such, the meaning of our findings may not be generalizable for acute surgeries or other specialties.

Digital and mobile technologies act as a catalyst to engage with healthy behaviors, such as loss of weight, improved dietary intake, and increased physical activity levels. Messages of positive reinforcement were viewed as useful, particularly when tailored to an individual’s surgical type and readiness to make behavioral change. Existing literature suggests that individualized goal setting helps combat sedentary behavior [57-59]; personalized feedback and messages of encouragement provide a sense of accomplishment [25,39]; and visual tracking of step count has been reported as motivational [50,58]. Recent contributions to the health behavior change literature have cited the importance of empowered patient-centered strategies and use of self-regulation [60] and self-determination theoretical frameworks [61,62] to improve patient motivation. Digital technologies underpinned by behavior change theory can promote a proactive and holistic strategy to influence behavior change in a modern health care system such as the UK National Health Service [21].

In the context of patients undergoing surgical cancer, internet-delivered cognitive behavioral therapy (iCBT) was associated with numerous benefits [40,44]. Following digital intervention usage, there have been improvements related to fatigue, sleep [63], depression [64], and psychological distress [65]. In addition, our findings suggest that iCBT can also educate participants around various coping strategies to manage fears of treatment and disease recurrence [40].

Technologies enabling connectivity to health care professionals have been positively acknowledged. Two-way telemedicine consultations, emails, and text message discussions facilitated improved information delivery, real-time goal setting, psychosocial outcomes, and decision making [66-68]. Participants felt motivated, reassured, and encouraged to adhere to postoperative advice through remote monitoring. Having access to health care professionals behind a screen also helped patients overcome their personal barriers and raise unmet needs beyond routine clinical questioning [53,67]. From the perspective of clinicians, digital and mobile health technologies provided them with a means to monitor patient progress, which enabled individualized advice to be given to reinforce beneficial behavior change [43,69].

Despite the benefits of digitally enabled communication, it is worth considering social norms with patient-professional relationships [70]. For some, the continuity of face-to-face appointments is essential to provide empathetic interaction and social support [70,71]. Empathy, rapport, and compassion through nonverbal behavior and body language is difficult to establish when communicating digitally. Despite this, Kairy et al [48] reported close relationships and trust between the therapist and patients when communicating via telerehabilitation. Perhaps, complementing traditional face-to-face appointments with digital health interventions could be a way to maintain patient-professional relationships.

Usability has been reported as a key determinant to induce and maintain health behavior change, where interventions should be easy to use as well as aesthetically and visually appealing. Patient preferences should be taken into account when it comes to the design and tailoring of interventions [50,72,73]. It is worth considering ways to overcome digital health literacy barriers to further promote usability and engagement. Additional technical support might be beneficial when targeting older adult populations to increase their engagement and thus better support health behavior change [50,74].

One reported advantage of digital interventions is the accessibility they offer [29,51,75]. Postoperative breast cancer survivors living in rural settings experienced greater depressive symptoms compared with those with shorter commutes owing to the long travel distances required to access health services [76,77]. Where telerehabilitation was implemented for postoperative orthopedic follow-ups, participants reported improved continuity of care with the same physician and improved ability to control the timing of appointments and intensity of the rehabilitation service [78].

In addition to bridging access to health services, digital and mobile health technologies are being increasingly used as networking and peer-support tools. Patients undergoing similar procedures or diagnosed with similar conditions are able to communicate and share personal experiences and coping strategies with others [53]. Peer support and behavior change have been previously reported in elective care [50,79-82], where increased social support and decreased patient isolation are associated with postsurgical success [81,83]. Although digital technologies offer opportunities to interact with peers on an educational level, concerns have been raised about the accuracy and credibility of shared information [79,84-86]. Health care professionals should caution patients when interpreting discussions on forums or online groups, given the potential detriments that may arise from following inaccurate information [53,86,87].

The optimal time point in the surgical pathway to initiate digital and mobile technologies remains uncertain, with findings suggesting that this may vary depending on the type of surgical group. Despite this, what remains clear is the potential benefit of capitalizing on a teachable moment to empower and educate patients about the underlying benefits of health behavior changes [88-90]. Evidence suggests that preoperative interventions based on education of lifestyle changes are significantly more effective in managing postoperative complications and patient expectations [91].

Our research has synthesized numerous design considerations that should be examined when producing future interventions to support patients undergoing surgery. It was found that internet-based interventions may benefit from adding a search tool to locate target information [38], the comfort of wearable technologies should be addressed [43,50], and negative connotations with using the color pink for patients undergoing cancer builds on the cancer culture divide [92]. The possible benefits of incorporating open-access features within interventions were also discussed. Previous research has shown that opening care access, to include relatives or caregivers, provided patients undergoing an increased sense of pre- and postoperative support [93-95]. This approach has strengthened bonds with family members, improved patient experience, resulted in effective engagement with digital interventions, and therefore supported superior outcomes in lifestyle changes [96-98]. This review synthesizes existing research to gain a deeper understanding of the ways in which digital tools can support elective surgical cohorts and identify key design features that support elective surgical patients to change their health behaviors, and thus have a greater impact on postoperative health. Considering the rapidly progressive nature of digital health interventions and digital assistive technology research, cocreation of a person-centered digital support network may help surgical patient cohorts to benefit from pre- and postoperative behavior changes on both a short- and long-term basis [19,99].

This meta-ethnographic synthesis developed 4 key themes that are important in determining the success of technologies to support behavior change. Our novel findings have the potential to influence the future design of patient-centered digital and mobile health technologies. This study demonstrates the important role of digital tools in the elective surgical pathway; not only can they help to motivate physical behavior change, such as improved activity levels and dietary intake, but they can also successfully provide psychological support. By synthesizing patient-informed suggestions, we have identified key areas for improvement, both to meet the general desires of patients undergoing surgery and to meet more specialized surgery-specific needs throughout the perioperative pathway. In particular, digital technologies should optimize the inclusion of tailored content specific to individual patients, with the inclusion of self-regulatory features such as goal setting to provide structured and individualized support. We believe that there is a significant rationale for involving patients in the cocreation of digital health technologies to enhance engagement, better support behavior change, and improve overall surgical outcomes for patients.