Table 5.

How barriers and facilitators affect the adoption and scaling of RPMTSs

Nr	Main categories	Sub-categories (potential barriers and facilitators)	How sub-categories affect adoption and scaling of RPMTS interventions	Secondary source used
1	Stakeholders’ interests
	Conflicting and dynamic interests of and relationships between stakeholders are sure to have a significant impact on the adoption and scaling of RPMTSs. The extent to which RPMTS designers and developers are able tomanagethese conflicts and power relations may have a bearing on adoption and scaling thereof.	Healthcare organizations	Pursued visons, missions, strategies, funding structures and profit motives determine organizational structures and priorities. This may in turn lead to resistance or commitment to a particular RPMTS intervention.	[5, 22]
		Clinicians	How a new RPMTS intervention will affect existing workflows, work dynamics and job security will lead to support or resistance by clinicians and other healthcare practitioners.	[5]
		Patients or potential patients	Incentives such as being able to save on money and/or time while enjoying improved quality of care and better access to healthcare services may promote adoption and/or scaling.	[4, 5]
		Health technology companies	The visons, missions, strategies and profit motives will affect how RPMTS interventions are designed and deployed (intellectual property, policies and regulations) thereby positively or negatively affecting adoption and scaling.	[22]
		Governments	Government’s political priorities, policies and regulations may significantly promote or stifle an RPMTS’s development and potential for adoption and scaling.	[5, 22]
		Others (investors, NGOs, etc...)	Interests of other institutions such as NGOs, professional associations and lobby groups expressed in their missions and goals may promote or hinder the development, adoption and scaling of certain RPMTS interventions.	[22]
2	Contextual understanding
	The deeper the understanding that RPMTS designers and developers have of thecontextwithin which their planned intervention will be deployed, the more likely the intervention is to be suitable for adoption and scaling.	Community’s socio-economic factors	A community’s economic status and general social realities (income levels, social cohesion, financial resources...) can impact the potential for adoption and scaling of an RPMTS.	[4, 5, 22]
		Socio-cultural, values and beliefs	Cultural beliefs and values espoused by a given target community may lead to resistance or acceptance of an RPMTS’s intervention.	[4, 5, 22]
		Political priorities	Prevailing political views and priorities may enhance or hinder the development, adoption and scaling of RPMTS interventions.	[22]
		Health standards, policies and guidelines	Existing health policies, standards and guidelines may allow and encourage or obstruct the development, adoption and scaling of RPMTS interventions.	[4, 5, 22]
		General attitude towards technology	A community’s general interest in and experience in technology use (such as the use of smart phones and related apps) may be indicative of its propensity to adopt or not adopt RPMTS interventions.	[4, 5]
		Levels of education and technology skills	General levels of education has a bearing on the ability of a community to grasp the benefits of RPMTS’s use and to therefore take advantage of available learning and training opportunities around RPMTS interventions.	[4, 5, 22]
3	Existing local ICT infrastructure
	Prior to the planning and designing of an RPMTS intervention, adequate ICT infrastructure (appropriate network coverage, device penetration, data costs and reliability thereof) must exist to support its deployment and subsequent scaling.	ICTs’ accessibility, availability and sustainability	A community’s accessibility to an ICT infrastructure with long-term financial sustainability (costs of data, apps and devices) may have a significant impact on RPMTS’s adoption and scaling.	[4, 5, 22]
		Connectivity and reliability	The reliability and stability of established ICT connections for the purpose of healthcare services increase the community’s trust and confidence in RPMTS’s interventions and their potential to effectively complement or replace face to face service.	[4, 5]
		Potential for stakeholder collaboration	The ability of stakeholders to collaborate within and across industries to achieve health goals (e.g. ICT providers’ willingness to reduce data costs used for health purposes) may significantly improve the adoption and scaling of RPMTS interventions	[5, 22]
		Adequate technical support	The availability of adequate technical support increases the sustainability, continued adoption and scaling of RPMTS interventions. New users may adopt a new RPMTS intervention because of the availability of reliable, adequate support.	[4, 5]
		Network capacity and device penetration	The prevalence of mobile devices (smart phones) and network capacity in the target area may limit the potential for scaling and further adoption of a given RPMTS intervention.	[5, 22]
4	Design approach
	When the design of an RPMTS intervention iscentred onits targeted users, their needs and lifestyles, they will be more inclined to adopt it. Furthermore, if they are engaged in shaping itfrom its inception, they may feel a sense of ownership, which may positively influence their attitude toward its adoption and scaling.	Interoperability and compatibility	The extent to which new RPMTS interventions seamlessly fit into, interface and work with and within existing healthcare systems has a significant impact their adoption and scaling.	[4, 5, 22]
		Patient-centred design	The extent to which RPMTS interventions are designed to meet the needs of and provide tangible benefits to patients and potential patients significantly increases the chances of adoption and scaling of RPMTS’s interventions.	[4, 5]
		Functionality and adaptability	The inclusion of features and functionalities which are in light with the needs of intended users as well as the potential for customizing above features to a broad range of user groups would foster increased adoption and scaling of RPMTS interventions.	[4, 5, 22]
		Integration in clinical workflows	Integration of RPMTS interventions into clinical workflows and EPR, EMR and EHR improves access to and quality of healthcare services and may lead to their increased adoption and scaling.	[4, 5]
		Collaboration across the healthcare domain	Coordination of health services and collaboration between healthcare professionals helps to align often conflicting interests and may promote improved adoption and scaling of RPMTS interventions especially among clinicians.	[5, 22]
		User engagement	Involvement of users in development and planning of RPMTS interventions allows planners to become better acquainted with their requirements and to become aware of their potential resistance to adoptions and scaling of RPMTS interventions.	[4, 5]
		Simulation and validation (triability)	Opportunities to learn about and try RPMTS interventions without strings attached may increase the trustworthiness of specific RPMTS interventions and hence increase adoption and scaling.	[5]
		Fit between technology, users and organization	The extent to which RPMTS interventions are aligned with healthcare organizations’ goals and missions and helps users achieve their objectives (e.g. cost-effective, quality care) may determine their adoption and scaling.	[5]
		Data privacy and security	Privacy and security issues and concerns related to an RPMTS intervention may limit or even prevent its adoption and scaling altogether as potential users are not prepared to compromise their privacy.	[4, 5, 22]
5	Triggers for use and adoption
	Interventions ought to provideuse triggering opportunitiesto potential users to try or start using a particular RPMTS intervention. The greater the number of people in the targeted community able to come across and access these opportunities, the more likely an RPMTS intervention is to be adopted and scaled.	Number of targeted diseases	The diversity of health conditions addressed by an RPMTS intervention broadens opportunities for its uses (or usefulness). Furthermore, it may be the case that the greater the number of its users, the lower its costs per a user (economies of scale).	[4]
		Awareness and promotion	The extent to which new RPMTS interventions are promoted can shape attitudes and perceptions of potential users and trigger subsequent adoption and scaling of these systems and tools.	[5, 22]
		Trustworthiness and quality	The quality and trust that potential users perceive and experience from an RPMTS intervention may be a key trigger for its subsequent use, adoption and scaling.	[4, 5]
		Ease of use and automation	The ease of use and level of automation of RPMTS interventions can encourage users to start using them and eventually lead to their adoption and scaling.	[4, 5]
		Mobility and flexibility	Mobility and flexibility offers convenience to potential users and may help trigger the adoption of RPMTS intervention and lead to their subsequent scaling.	[4, 5]
		Training (clinician and users)	Opportunities for training on new RPMTS interventions often triggers adoption and may lead to subsequent scaling of these interventions.	[4, 5]
		Promotion of self-management	Promotion of self-management empowers clinicians and patients and increases their sense of ownership of an intervention, leading to adoption and subsequent scaling.	[5, 22]
		Accessibility to the general public	All things being equal, a more easily accessible RPMTS intervention is more likely to be used than one the public struggles to access or one which only a small number of people can access.	[4, 5]
		Perception and short feedback times	If users perceive RPMTS interventions as proving them with quick feedback than traditional channels, they are more likely to try them and adopt their use. Potential for scaling is also increased.	[4, 5, 22]
		Ability to complement or replace visits to clinics	Users who feel that RPMTS interventions complement or can replace face-to face interventions will be motivated to use them when accessing healthcare services.	[4, 5]
6	Post-deployment assessment factors
	Interventions are expected to be able to convincingly demonstrate (a-priori) evidence of how they will be able to meet certainkey performance indicators aftertheir implementation in order to attract adequate support and funding which may in turn have a bearing on their subsequent adoption and scaling.	Reduced healthcare costs	If stakeholders and users believe that the use of RPMTS leads to reduced healthcare costs, they are more likely to promoted its adoption and scaling.	[4, 5, 22]
		Return on investment (funding)	Funders expect some form of return on their funds and the extent to which an RPMTS intervention can demonstrates its sustainable benefits in this regard, the more likely that the necessary funds will be made available to design them for adoption and scaling.	[5, 22]
		Better quality of care	Planned RPMTS Interventions able to demonstrate evidence of improved quality of care after their deployment are more likely to improve their chances of receiving adequate funding and subsequent adoption and scaling.	[5, 22]
		Reduced rates of hospitalization	RPMTS Interventions capable of demonstrating reduced rates of hospitalization are not only more likely to attract adequate funding but also likely to be adopted and scaled	[4]
		Community wellbeing	RPMTS interventions which emphasize the relationship between healthcare providers and the community they serve to promote overall community’s wellbeing are likely to be adopted and scaled.	[22]
		Reduced waiting times and overcrowding	Patients and potential patients are likely to adopt RPMTS interventions which reduce their waiting time and clinicians may promote those the reduce overcrowding at their health facility.	[4, 5, 22]
		Improved access to healthcare services	RPMTS interventions demonstrating evidence of improved access to healthcare services (without increasing the care burden on traditional healthcare systems) after their implementation are more likely to be funded, adopted and scaled.	[4, 5]