Implementation of Electronic Signposting to Interventions that Prevent Cancer: A Realist Review

Background: Uptake of evidence-based interventions that prevent cancer is very low. Electronic signposting (eSignposting) using digital messages sent via electronic healthcare systems is increasingly utilised to improve service reach and uptake. However, synthesized knowledge of how best to implement eSignposting to cancer prevention interventions is lacking. We sought to generate a novel programme theory to illuminate what type of electronic signposting works, for whom and in what circumstances. Methods: A realist review, informed by Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES I), was conducted. Medline, EMBASE, CINAHL, Scopus, PsycINFO, ERIC and AMED databases, and grey literature were searched. Studies that contributed information on context and mechanisms of action for eSignposting to cancer prevention interventions for adults in any healthcare setting were included. Studies were assessed for quality based on relevance, richness and rigour. Realist synthesis and input from stakeholders, including patients, was used to aid development of our programme theory. Results: Thirty studies were included and 57 individual context-mechanism-outcome configurations identified. Findings demonstrate that eSignposting can enhance reach and uptake of cancer prevention interventions. eSignposting worked through multiple pathways and was highly context specific. For patients, memorable messages using wording closely tailored to patient characteristics, and use of a popular communication channel (e.g. short message service [SMS] text) improved ‘buy-in’ and usability. For providers, ‘buy-in’ was linked to a good fit with organisational priorities and finances. Establishing compatibility with existing technical systems improved provider usability. Increasing optimism of technology, and ensuring eSignposting messages did not risk existing patient-provider relationships were also key to implementation success. Conclusions: We developed a novel programme theory for the implementation of eSignposting to cancer prevention interventions. Implementation requires careful tailoring to patients and healthcare settings and the inclusion of a broad range of patients and professionals in intervention design. For both patients and providers, promoting ‘buy-in’, ensuring perceived usability, and nurturing positive attitudes towards technology, were key to implementation success. To effectively reduce cancer and cancer disparities, policymakers and healthcare providers need to implement electronic signposting in ways that increase equality-centred patient benefit.