Implementation of electronic signposting to interventions that prevent cancer: A realist review

Uptake of evidence-based interventions that prevent cancer is very low. Electronic signposting using digital messages sent via electronic healthcare systems is increasingly utilised to improve service reach and uptake. However, theory for optimising the implementation of electronic signposting 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. 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 electronic signposting 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 novel programme theory. Thirty studies were included, 26 of which were conducted in the United States. 57 individual context-mechanism-outcome configurations were identified. For patients, memorable messages using wording tailored to patient characteristics, and use of a popular communication channel (e.g., SMS text) improved ‘buy-in’ and usability. For providers, a good fit with organisational priorities, workflow, and establishing compatibility with existing technical systems was important. Increasing optimism of technology and ensuring electronic signposting did not risk existing patient-provider relationships were also key to success. To reduce cancer and cancer disparities, policymakers and providers need to implement electronic signposting in ways that promote ‘buy-in’, ensure perceived usability, and nurture positive attitudes towards technology. The field would benefit from further qualitative insight, health economic analysis, exploration of equity and long-term outcomes, and research in non-USA contexts. Protocol registration: PROSPERO [CRD42024586907].