Mixed-methods assessment of engagement with a digital intervention: The Wrapped feasibility randomised controlled trial

Digital health behaviour change interventions can face the challenge of low participant engagement, which can limit intervention effectiveness. Mixed methods approaches to understanding engagement, which capture the online and offline behaviours of participants, as well as the cognitive and affective aspects of engagement, are infrequently reported. The aim of this study was to explore these aspects of engagement for a digital intervention (Wrapped) to enable its optimisation ahead of testing in a randomised controlled trial (RCT). Wrapped is a digital intervention that aims to increase correct and consistent condom use, thereby decreasing the incidence of sexually transmitted infections among young people aged 16–24 years. Analytics data and website user history data were combined with data from surveys and qualitative interviews. Together this data was examined to assess the behavioural, cognitive, and affective aspects of engagement with the intervention. Results showed that participants experienced few barriers during the registration process, but that the tailoring questions used to assign content to individual users may not have been working as intended. Pre-determined intervention goals were as follows: ordering Sample Pack 48 (60.8%), using Condom Ordering Service 37 (52.9%), ordering Condom Carrier 31 (49.2%), watching Condom Demo video 7 (10%), watching Discussing Condoms video 4 (6.8%), and watching Real Life video 9 (13.6%). Participants described their use and enjoyment of the products they ordered; notably the condom carrier was less well liked and used. Participants reported not engaging with the video components, either because they were unaware that they existed or because they expected to find watching them to feel awkward. This study demonstrates that taking a mixed-methods approach to studying engagement provides a more complete understanding of where and how digital interventions need to be optimised than using single methods in isolation; this in turn is likely to lead to more effective interventions. Trial registration: ISRCTN Registry ISRCTN17478654.Author summary: For a digital health behaviour change intervention to be effective, participants must engage with the intervention. Unfortunately, low engagement is a challenge for many digital interventions. Few studies combine quantitative and qualitative data to capture the behavioural (both online and offline), cognitive, and affective aspects of engagement. The aim of the present study was to explore how a digital intervention (Wrapped) was used and to further understand the engagement experience to provide insights to guide future intervention optimisation. Wrapped is a digital intervention for 16–24 year olds that aims to increase correct and consistent condom use, thereby decreasing sexually transmitted infections (STIs). Analytics data and website user history data were combined with data from surveys and qualitative interviews. Results indicated that participants experienced few barriers in registering for the intervention or in ordering free products (e.g., a condom sample pack and carrier); participants also reported that they used and enjoyed the products that they received. Most participants did not engage with the video content, either because they expected to find watching them awkward or because they did not know they existed. Mixed-methods research better supports researchers to make decisions about the optimisation of digital interventions than using single methods alone.