This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information, a link to the original publication on https://mhealth.jmir.org/, as well as this copyright and license information must be included.
Health consumers are increasingly taking a more substantial role in decision-making and self-care regarding their health. A range of digital technologies is available for laypeople to find, share, and generate health-related information that supports their health care processes. There is also innovation and interest in home testing enabled by smartphone technology (smartphone-supported home testing [smart HT]). However, few studies have focused on the process from initial engagement to acting on the test results, which involves multiple decisions.
This study aimed to identify and model the key factors leading to health consumers’ engagement and enablement associated with smart HT. We also explored multiple levels of health care choices resulting from health consumer empowerment and activation from smart HT use. Understanding the factors and choices associated with engagement, enablement, empowerment, and activation helps both research and practice to support the intended and optimal use of smart HT.
This study reports the findings from 2 phases of a more extensive pilot study of smart HT for viral infection. In these 2 phases, we used mixed methods (semistructured interviews and surveys) to shed light on the situated complexities of health consumers making autonomous decisions to engage with, perform, and act on smart HT, supporting the diagnostic aspects of their health care. Interview (n=31) and survey (n=282) participants underwent smart HT testing for influenza in earlier pilot phases. The survey also extended the viral infection context to include questions related to potential smart HT use for SARS-CoV-2 diagnosis.
Our resulting model revealed the smart HT engagement and enablement factors, as well as choices resulting from empowerment and activation. The model included factors leading to engagement, specifically various intrinsic and extrinsic influences. Moreover, the model included various enablement factors, including the quality of smart HT and the personal capacity to perform smart HT. The model also explores various choices resulting from empowerment and activation from the perspectives of various stakeholders (public vs private) and concerning different levels of impact (personal vs distant).
The findings provide insight into the nuanced and complex ways health consumers make decisions to engage with and perform smart HT and how they may react to positive results in terms of public-private and personal-distant dimensions. Moreover, the study illuminates the role that providers and smart HT sources can play to better support digitally engaged health consumers in the smart HT decision process.
“If we can get a test that everyone wakes up and, just like they put in their contact lenses, they take a test, and if it turns positive, they stay at home...it will stop the vast majority of transmission and cause these outbreaks to disappear in a matter of weeks” [
Health consumers are increasingly taking a more substantial role in decision-making and self-care of their health [
Health information technology (HIT) is now seen as a fundamental aspect of patient care as it stimulates patient engagement and encourages personal health management [
Smart HT content and features support engaged health consumers in testing safely and independently in their homes, learning how to manage their illness based on test results, learning how to manage the spread, and sharing test results for personal or public health networks electronically [
Consumer health tools, including smart HT, must be effectively designed and used [
For infectious disease management, the goal of using smart HT is for individuals to receive test results and take the best course of action based on their test results for themselves and society. A holistic understanding of this journey is required for smart HT to positively affect both individual and public health. Indeed, feasibility cannot be genuinely achieved until health consumers intending to use smart HT are aware, engaged, and empowered and ultimately respond actively to the test results.
Am I motivated to engage with the test? (state of engagement)
Am I enabled to perform the test? (state of enablement)
How am I empowered to act on the results of the test? (state of empowerment and activation)
It is important to note that this process model assumes that a health consumer is aware of and has access to smart HT. Awareness of smart HT can result from the potential user being the recipient of marketing or trial recruitment efforts (eg, through trial enrollment, marketplace, and provider) that promote the acquisition of smart HT. The factors associated with awareness have been addressed in prior research [
Smartphone-supported home testing (Smart HT)–Empowered Activation Model (research questions, RQ's, highlighted).
Engagement refers to individual motivation to participate in self-management behaviors.
Enablement comprises 2 components:
having appropriate knowledge, skills, and abilities to understand one’s health condition and make decisions.
having appropriate contexts to learn such knowledge, skills, and abilities
Empowerment is a consequence of enablement and engagement and takes a form of an emergent state and process:
As an emergent state, empowerment allows individuals to have an active role in their own care.
As a process, empowerment is a process of “activating” individuals, indicating that someone gains knowledge of how to manage their health condition and access appropriate health care.
Note: Descriptions derived from a literature review performed in Fumagalli et al [
According to Fumagalli et al [
As health consumers acquire engagement and enablement, they achieve an emergent state of empowerment and activation. When viewed as an emergent state, empowered health consumers possess a higher level of power and appreciation for their role in the health care process [
When empowerment is coupled with activation, possession of knowledge, skills, attitudes, and self-awareness can improve individuals’ life situations. In the context of smart HT, health consumers become empowered to enact behaviors that could affect them personally (eg, self-care) and affect the public (eg, self-isolation to prevent spread) upon receiving positive test results.
The attainment of enablement and engagement is affected by multiple factors. The extensive literature that informed the model in
HIT studies that address the antecedents of consumer health technology use [
This study aimed to gain a deeper understanding of the process related to achieving patient activation for smart HT by understanding the factors that affect decisions to move along the empowered activation process. We addressed this exploration in the context of respiratory viral infection (RVI), which is a serious public health threat [
RQ1: For a health consumer aware of smart HT for RVIs, what factors lead to the emergent state of engagement with smart HT?
RQ2: For a health consumer aware of smart HT for RVIs, what factors lead to the emergent state of enablement to perform smart HT?
RQ3: For a health consumer who is enabled and engaged with smart HT for RVIs, what choices result from the emergent state of empowerment to act upon the results (particularly positive test results) obtained through smart HT?
The focus of this project is a pilot study of an innovation called flu@home, a smart HT for influenza. This flu@home pilot is part of a more extensive research study called the Seattle Flu Study, which explored the feasibility of using home-based testing for the surveillance and public health management of viral outbreaks [
The flu@home pilot comprised four phases: (1) flu@home smart HT usability study, (2) trial of flu@home, (3) semistructured interviews regarding the experience of using flu@home, and (4) a survey of those who used flu@home.
Phase 1 (the flu@home smart HT usability study) focused on the development of flu@home to meet usability standards. Participants from phase 1 usability assessments used to inform the software development were not recruited for the subsequent phases.
After the development of flu@home, phase 2 (trial of flu@home) was conducted to determine its accuracy. During phase 2, the participants had a chance to experience the actual flu@home test. Phase 2 participants were also recruited for phases 3 and 4, which explored participants’ experiences with the flu@home test, various factors affecting engagement and enablement, and choices resulting from empowerment and activation.
These multiple phases of the flu@home pilot leveraged mixed methods (both qualitative and quantitative). Mixed methods can be valuable for developing and evaluating complex interventions such as smart HT [
The inclusion criteria for phase 2, which also applied to phases 3 and 4, involved eligible participants who were aged ≥18 years, spoke English, had an iPhone or iPad, and had an ILI (defined as the presence of a cough and at least one or more of the following symptoms: fever, chills or sweats, muscle, body aches, or feeling tired or more tired than usual). Recruitment was limited to individuals in the lower 48 states of the United States to ensure that they received their flu@home test kit within 2 days of enrolling in the study. Overall, 97.9% (724/739) of participants who completed phase 2 consented to be contacted for future, related research and were eligible to participate in phases 3 and 4.
Study phases (phases 3 and 4 [shown in orange] are the objectives that relate to the scope of this paper). PCR: Polymerase chain reaction.
Participants from phase 2 (trial of flu@home) were invited to participate in in-depth, semistructured interviews to share their experiences with the flu@home smart HT and their beliefs and attitudes toward using smart HT (for influenza) in the future. Semistructured interviews involved a series of predetermined, open-ended questions with probes and prompts to elicit further information about the phenomenon of interest [
Our interview guide (
Prior literature was reviewed to inform the semistructured interview questions and a priori coding schema for data analysis. We looked to the literature that would provide more insight and detail into elements of the conceptual framework used in this study, precisely, factors affecting engagement and enablement and choices resulting from empowerment and activation (
Fumagalli et al [
To inform categories of factors associated with enablement, we referred to applicable high-level concepts in the DIEGO [
Finally, to inform the interview questions and high-level codes for categories of choices resulting from health consumers’ empowerment and activation, we considered the different levels of impact (
The interview sample size was guided by data saturation, which is the point at which additional data collection no longer generates any new insights [
We recruited participants in 3 waves to include a diverse representation of geographic locations and ages (to accurately reflect the targeted user population). The first wave of the selection process comprised sorting participants into age groups (18-24, 25-34, 35-44, 45-64, and ≥65 years) and randomly inviting them to interviews, selecting participants from each group. During this initial recruitment wave, we sent 60 participants study invitations assuming that 50% of participants would sign up for an interview based on completion rates of home collection studies for other health conditions [
Confidential 40- to 60-minute semistructured interviews were conducted using Zoom videoconferencing [
Thematic analysis was conducted to code the deidentified interview transcripts. Thematic analysis allows the identification, analysis, description, and reporting of themes found in qualitative data [
First, we inductively coded (ie, created low-level codes) our interview transcripts without referring to our conceptual model (
Demographic data of the sample frame (phase 2 participants) used for semistructured interview (phase 3).
Phase (sample size) | Phase 2: trial of flu@home (n=724), n (%) | Phase 3: invited to participate in semistructured interviews (n=115), n (%) | Phase 3: completed semistructured interviews (n=31), n (%) | |
|
||||
|
18-24 | 86 (11.9) | 12 (10.4) | 3 (9.7) |
|
25-34 | 204 (28.2) | 34 (29.6) | 6 (19.4) |
|
35-44 | 199 (27.5) | 38 (33) | 11 (35.5) |
|
45-64 | 188 (25.9) | 21 (18.3) | 8 (25.8) |
|
≥65 | 47 (6.5) | 10 (8.7) | 3 (9.7) |
|
||||
|
White | 510 (70.4) | 78 (67.8) | 21 (67.7) |
|
Black or African American | 63 (8.7) | 10 (8.7) | 6 (19.4) |
|
Asian | 60 (8.3) | 8 (6.9) | 0 (0) |
|
Native Hawaiian or other Pacific |
4 (0.6) | 1 (0.9) | 1 (3.2) |
|
American Indian or Alaska Native | 17 (2.4) | 18 (15.7) | 1 (3.2) |
|
N/Aa, other, or prefer not to say | 70 (9.7) | 2 (1.7) | 2 (6.5) |
|
||||
|
West | 214 (29.6) | 43 (37.4) | 14 (45.2) |
|
Midwest | 139 (19.2) | 21 (18.3) | 5 (16.1) |
|
Southwest | 12 (1.7) | 2 (1.7) | 1 (3.2) |
|
Northeast | 197 (27.2) | 32 (27.8) | 4 (12.9) |
|
Southeast | 162 (22.4) | 17 (14.8) | 7 (22.6) |
aN/A: not applicable.
Intrinsic influences
Extrinsic influences
Considering the quality
Assessing personal capacity
Patient-familiar
Patient-distant
Public-familiar
Public-distant
To enhance research reliability and validity, the research team used a constant comparison method to refine coding [
The survey contained 3 sections. The first section contained questions about the participants’ prior engagement with the smart HT for influenza. The second section contained questions about the impact of the COVID-19 pandemic on participants’ future engagement and enablement decisions associated with smart HT for influenza. Finally, the third section contained questions about participants’ potential engagement, enablement, empowerment, and activation decisions associated with smart HT for COVID-19. The survey did not ask participants to provide demographic information, given institutional review board cautions in asking demographics to preserve the anonymous nature of the survey (thus, we were unable to perform an analysis of demographic and categorical data).
Insights from semistructured interviews informed the survey questions, which were developed to validate and further explore factors affecting decision points associated with engagement and enablement, as well as choices resulting from empowerment and activation. Further exploration of factors was conducted because of the emergence of the COVID-19 pandemic. The research team included additional questions related to engagement, empowerment, and enablement associated with smart HT for COVID-19. The survey questions used ordinal and categorical response options. For ordinal questions, the research team used a 5-item Likert scale for responses ranging from strongly agree to strongly disagree. The Likert scale is an efficient and reliable technique for examining individual attitudes and perceptions [
Participants from phase 2 (trial of flu@home) were recruited to complete the survey (
The anonymous survey was administered using Qualtrics Survey Platform software [
Survey data were analyzed using descriptive statistics (mode, as well as response distribution counts and percentages), as appropriate for Likert scales [
The study design was approved by the University of Washington Institutional Review Board (STUDY00007627).
We aligned the general structure of our results with the Smart HT–Empowered Activation Model (
The acquisition of motivation involved both intrinsic and extrinsic influences. We identified intrinsic influences covering specific states (eg, mental distress) and traits (eg, personal agency) of the users. In addition, the identified extrinsic influences covered specific characteristics of smart HT (eg, convenience) and environmental conditions (eg, public health crisis).
Factors affecting engagement. Smart HT: smartphone-supported home testing.
Intrinsic influences include personal agency, awareness and understanding of viral infection (influenza; COVID-19), mental distress, and illness symptoms.
This technology appealed to interview participants who proactively managed their health, as well as individuals who self-identified as having poor health behaviors. Therefore, although we recognize that this may play a role in the decision process for some, there was no general consensus that
Regarding when health consumers might be motivated to perform a smart HT, survey responses indicated (
I should keep some of the kits at home on an ongoing basis so that anytime I feel I have this fever, sneezing, runny nose and all those symptoms.
Moreover, interview participants also indicated that mitigating
And I think that it would be more convenient because sometimes you just don’t feel well and feel like leaving the house. It’d be nice because I feel like you might be able to find out results sooner than if you wait to go to the doctor...I feel like there’s less pressure when you’re at home, and you’re more relaxed...I shouldn’t say pressure, but less stress. There’s always some, at least for me, levels of extra stress going to the doctor just in general. Getting out of the house and sitting in the waiting room, and being back there, and just kind of like nervous and stuff, waiting to see what the doctor’s going say.
We further delved into this issue in the survey. Although testing at home when feeling ill may mitigate the stress of traveling and waiting to see a provider to perform a diagnostic test, a concern about the future of home testing is that test results indicating a serious health condition (such as COVID-19) delivered without provider support could cause mental distress. According to our survey results, 74.1% (192/259) of the survey respondents indicated that they would find testing positive (ie, learning that they contracted the COVID-19 illness) in the at-home context (smart HT) no more distressing than learning of their diagnosis in other health care settings (
Extrinsic influences include convenience, public health crises, and security and privacy. Participants overwhelmingly shared that
Just the idea of being able to do home-based checking interests me. It sounds like it has promise to me. And I think that a lot of people might use something like that rather than going through the grief of trying to get a doctor’s appointment, which is hard to do here.
Furthermore, survey respondents indicated that a
Interview participants also identified the
The interview data revealed various factors leading to participants’ enablement facilitated by smart HT. We categorized these factors into two groups: (1) considering the quality of smart HT and (2) assessing personality capacity to use smart HT (
Factors affecting enablement. Smart HT: smartphone-supported home testing.
Regarding the
Interviewees also considered the
Participants also shared that they would like future iterations of flu@home to include more health information, such as explaining “how contagious the flu is,” and recommendations for managing the illness. For example, one of the participants described the following:
I think one of the biggest things we do that we shouldn’t do in this day and age is just trying to take something [medication] to suppress the symptoms and then head right back to work or other things. I think having some statistics or data about the dangers of taking the flu out of the house...would be really helpful.
In evaluating the
The interview participants generally indicated that they felt capable of completing the smart HT test. Specifically, participants indicated that they felt enabled to complete the test with the digital guidance provided in the flu@home app, thus, informing their belief that they completed the swabbing procedures as instructed in the app and that they felt capable of completing the smart HT again in the future.
Moreover, the
I feel like I would do it at home because there’s no other people around. They wouldn’t just see me stick something, the little test tube up my nose, or whatever. Can’t even think of what it’s called.
In the case of smart HT, empowerment and activation involve 2 sequential points. The first factor was the intention to perform the test. The second was the intention to act on confirmation of influenza results from completing the smart HT test.
We found evidence that the study population was empowered to use smart HT to test for viruses. Approximately 81.5% (207/254) of the participants who completed the survey indicated that they would prefer to test for viruses at home rather than a test conducted by a health care provider (
Survey responses showed that many people were willing to test for COVID-19 regularly, every 14 days (97/260, 37.3%), or monthly (93/260, 35.8%) to ensure that they were healthy and could interact with others (
Moreover, there were indications that an empowerment and activation process could have spillover effects on other possibilities. During the interviews, participants also mentioned various other (not necessarily viral) health conditions that they would be interested in using smart HT in the future: common cold, dementia, bronchitis, cancer, diabetes, pneumonia, sinus infections, hepatitis, and many others.
The findings indicate that individuals consider actions related to all four themes regarding acting on positive smart HT results:(1) patient-familiar, (2) patient-distant, (3) public-familiar, and (4) public-distant.
In looking holistically at multilevel choices resulting from empowerment and activation, some interview participants gravitated toward
To assess whether participants’ attitudes toward telemedicine (virtual care) changed because of COVID-19, we asked them to reflect on their initial willingness to seek virtual care. Survey respondents indicated that they were equally willing to have a virtual care appointment (telemedicine) after testing positive for influenza and COVID-19. Approximately 93.9% (265/282) of the participants strongly or somewhat agreed that they would have been willing to have a virtual appointment if the flu@home results had returned positive. Similarly, 93.1% (242/260) of the participants somewhat or strongly agreed that they would have been willing to have a virtual appointment if their COVID-19 test results returned positive.
It is also noteworthy that interview participants reported that the responsibility of caring for young children influenced their test result response choices, with parents of young children sometimes opting for distance care for themselves but preferring in-person care for their children.
Regarding public considerations, interview participants indicated that they were receptive to contributing to the public health management of a viral outbreak (
Regarding the
Multilevel choices resulting from empowerment and activation. Smart HT: smartphone-supported home testing.
Self-manage: Reasons for self-management included assumptions that a provider would tell them to rest at home and take over-the-counter medication to manage their illness anyway and the cost of care (particularly for the uninsured). Motivations for moving from self-care included the perceived need for prescription medication.
Primary care provider in person: Participants indicating that they would seek an appointment with their provider frequently referenced an established, trusting relationship with their primary care provider: some referenced pre-existing conditions that could create health care complexities with influenza.
Urgent care: Rationale for urgent care as a form of provider engagement included reference to accessibility, namely, urgent care clinic during weekend or evening hours.
Hospital emergency room: Some participants indicated that they would seek care from the emergency room as their default option when unsure how to manage a health issue.
Virtual consultation: Virtual consultation was referenced as a means of convenient verification of diagnosis and a quick means to obtain treatment (ie, prescriptions).
Prevent spread to family: Although participants referenced both quarantining in and sanitizing their homes to prevent spread to family, they also shared practical challenges, particularly with quarantine.
Prevent spread to coworkers: Participants mentioned the preference to stay home when sick with influenza symptoms to prevent spread to coworkers and more distant relationships (eg, public transit commuters). There was also mention of practical challenges because of some work arrangements.
Share for research: Some participants felt that anonymously sharing self-test results could contribute to improved influenza vaccine development.
Share for public health: Participants were generally willing to share self-test results for surveillance if done anonymously. They also indicated that they would personally reference a local or neighborhood-level influenza map in making prevention choices.
Smart HT aspires to facilitate the success and impact of home-based diagnostic testing by coupling the diagnostic procedure with technological supports [
Essentially, we contribute to the existing knowledge by
Our findings highlight the complexity of digital health engagement. One of the most apparent elements of complexity is the number of factors that come into play during the empowered activation journey. For smart HT information technology developers, this indicates the importance of having a strategy to consider, leverage, and support various factors that lead to successfully performing the test and acting on test results, essentially, a journey map (as noted in design thinking [
Upon further reviewing our model through the lens of complexity, it is noteworthy that various factors involving the acquisition of motivation (engagement) can change over time. For example, regarding intrinsic factors, changing illness symptoms and awareness and understanding of RVIs can affect motivation to engage with smart HT. This timing element is something to consider, particularly in the role of technology in message engagement considerations. Public health crises, an extrinsic example, can influence an individual’s motivation to use smart HT. Smart HT technology features can help health consumers evaluate the safety and feasibility of testing at home versus seeking testing by other means during public health crises. This motivating factor begets developers and perhaps policy makers to promote the use of smart HT with demonstrated efficacy during a public health crisis.
Regarding intrinsic motivation, smart HT technology can provide information to enhance a user’s awareness and understanding of a specific respiratory illness. Providing this educational information also introduces some assessment regarding how much information is provided, when to provide the information, and whether information needs to be tailored to a particular user’s capabilities, base knowledge, or interest in the information. Additionally, it is important to note that some factors of engagement may be more important than others. For example, there were mixed findings regarding the importance of participants’ general health behaviors and attitudes. Some participants indicated that they generally practiced healthy behaviors, whereas others indicated the opposite. This factor may be subordinate to other factors (eg, personal agency and illness symptoms). The relative importance of these factors should be explored in future research.
Furthermore, regarding the acquisition of motivation (engagement), we found evidence that individuals did not anticipate feeling more distress when learning that they have an RVI at home using smart HT than when learning about their health status in a clinical setting. However, research indicates that diagnosing different health conditions such as cancer, dementia, and COVID-19 can evoke emotional distress [
The study shows that in the case of contagious diseases, multiple level factors need to be considered to have a robust smart HT. The acquisition of a higher level of power (empowerment and activation) involves decisions at multiple levels, which can have both personal and far-reaching impacts. For example, informed individuals may vary in their patient, familiar, distant, and public actions when testing positive for a viral infection. Ideally, this choice variance is because of an informed decision process and not because of missing information or misinformation. Therefore, a key role of smart HT during the acquisition of ability (enablement) stage is to prepare the individual performing the test for the multiple downstream choices resulting from enablement. In response, developers may want to embed quality information and various paths of action into the design and functions of smart HT to support an informed empowerment and activation decision-making process. The multiple choices presented to a patient upon receipt of their positive test results should be carefully considered when developers design smart HTs to reduce choice complexity. It is particularly important to ensure that patients are not overwhelmed with too many choices, as too many options can impair an individual’s subsequent self-control (and, therefore, personal agency) [
In addition to providing a better understanding of the affirmative path of the Smart HT–Empowered Activation Model, our work provides a foundation for future work to explore other paths through the model. For example, future empirical research could explore the relative importance of the identified factors or whether the factors would hold in the context of other forms of smart HT. Regarding the latter, participants did mention potential interest in various forms of smart HT for both acute and chronic conditions. Future research could explore and validate the factors of engagement, empowerment, and enablement (derived in this study) in other contexts mentioned by the participants.
As with most studies that include qualitative methods, the generalization of the results must be approached with some caution. Although the study included a diverse set of participants in terms of age and geography, it had some limitations. Most notably, our study population included only participants in the flu@home study. Attitudes toward home testing may differ among individuals who did not experience this specific smart HT or type of respiratory testing. In addition, this study was conducted early during the COVID-19 pandemic. COVID-19 home testing and self-swabbing availability and experiences during the pandemic might have implications for smart HT for influenza and other home-based diagnostic testing. Overall, we strongly encourage future research to consider our findings in other smart HT and HIT contexts.
Through our findings, we proposed and informed a Smart HT–Empowered Activation Model depicting an engagement, enablement, empowerment, and activation process for smart HT use. The resulting model underscores the need to understand and address the path to health consumer empowerment and activation for smart HT use, resulting in actions that provide maximum health benefits to individuals and society. Overall, this study provides a foundation for researchers and developers to explore and create successful engagement strategies to align with consumer digital health opportunities to promote prevention, self-care, and spread control of infectious viruses such as influenza.
Interview protocol.
Likert scale survey questions.
Evidence trace tables for analysis of interview data.
Survey results.
Digital Health Engagement Model
health information technology
influenza-like illness
research question
respiratory viral infection
smartphone-supported home testing
The Seattle Flu Study was funded by Gates Ventures. The funder was not involved in the design of the study and does not have any ownership over the management and conduct of the study, data, or rights to publish. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Seattle Flu Study Investigators.
None declared.