Factors Influencing the Initiation and Continued Engagement of Digital Mental Health Tools Among Adults: Theory of Planned Behavior-Informed Systematic Review

Clinical Snapshot

Key Findings

• Effect Size: Not applicable (qualitative synthesis)

• Primary Outcome: Engagement with DMHTs jointly determined by user beliefs and design/access conditions

• Nnt Or Sensitivity: Bidirectional effects identified where same features could facilitate or hinder engagement depending on context

Clinical Application

High feasibility with emphasis on equity-focused implementation addressing cost, connectivity, and cultural barriers Highly relevant to Australian digital health initiatives, aligns with national digital mental health strategy and equity priorities Adults seeking digital mental health support across diverse backgrounds

Abstract

BACKGROUND: Digital mental health tools (DMHTs) offer scalable support, but engagement varies. Understanding the shapes of initiation and ongoing use is essential for effective design and implementation. OBJECTIVE: This study aims to synthesize determinants of adults' initiation and engagement with DMHTs, organized through two lenses: (1) psychological factors aligned with the theory of planned behavior (TPB) and (2) design and access features. METHODS: A systematic search of 9 databases (June 2025) identified qualitative and mixed methods primary studies reporting end-users' experiences with DMHTs. Studies were screened and reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal used quality assessment with diverse studies (QuADS). Data were synthesized using a framework-guided thematic approach, mapping findings to TPB constructs and complementary design and access domains. RESULTS: A total of 22 studies met inclusion criteria. Findings clustered into 2 interdependent domains. TPB constructs explained how beliefs, social expectations, and perceived control shaped decisions to start and persist with DMHTs. Design and access features frequently acted through these same pathways, especially by altering perceived behavioral control (PBC), with cost, connectivity, device constraints, and time flexibility affecting feasibility, with content design and privacy shaping perceived value and trust. Perceived fit (goals, cultural or linguistic relevance, and routine alignment) consistently influenced both initiation and continuation. Several features operated bidirectionally; depending on context, the same feature could facilitate or hinder engagement. CONCLUSIONS: Engagement with DMHTs is jointly determined by users' beliefs and the design and access conditions within which tools are offered. Implementation should pursue a dual strategy, strengthening willingness to seek support (addressing attitudes, norms, and perceived control) while engineering low-effort, trustworthy, and context-appropriate experiences. Priorities include equity-focused policies (data costs, devices, and connectivity), transparent data practices, co-design with diverse communities, and consistent, theory-informed outcome measures.

References

1. 1.Cheng, N., Lam, M. K., Grove, C., & Wachowicz, M. (2026). Factors influencing the initiation and continued engagement of digital mental health tools among adults: Theory of planned behavior-informed systematic review. JMIR Mental Health, 13(1), e88731. https://doi.org/10.2196/88731