Determinants of Early-stage User Involvement (EUI) in User Need Identification for Health Apps: An Exploratory Study

Promising digital health innovations, such as health apps, often fail to improve healthcare outcomes: approximately 80% of health apps are considered unreliable and 53% of them are reportedly uninstalled within 30 days of being downloaded, limiting their adoption and ability to deliver intended impact. Research shows that low user adherence — a primary barrier to successful adoption — is linked to insufficient perceived value, which stems from a mismatch between the app’s usefulness envisaged by developers and that experienced by users (patients, caregivers, and clinicians). This mismatch is largely attributed to developers’ insufficient understanding of users’ multifaceted needs (e.g. physical, psychological, and social) and contextual complexities. To address this issue, research acknowledges the benefits of involving users upstream during need identification in the fuzzy front-end (FFE) of the innovation process. However, academic literature characterising such early-stage user involvement (EUI) is sparse, highly fragmented, and unspecific regarding factors that facilitate, inhibit, and shape this involvement, as well as how these factors vary by organisational context, pointing to the need for empirical investigation into this area. This thesis addresses this gap by providing an initial response to the overarching research question: What influences the implementation of EUI in pre-design need identification in health app development? To do so, it has examined the determinants (enablers, barriers, and contextual factors) influencing EUI in the FFE of health app development in start-ups and multinational corporations (MNCs) and illustrated how organisational context influences EUI implementation. Guided by a relativist–interpretivist philosophy and a user-centred design (UCD) conceptual lens, this study used a sequential exploratory mixed-methods design. Phase 1 comprised semi-structured interviews across 28 industry case instances (17 start-ups; 11 MNCs). Abductive analysis helped integrate thematic coding with comparisons within and across organisational contexts to identify EUI determinants (25 in start-ups; 33 in MNCs), dimensions, and dimensional relationships and conceptualise initial EUI implementation frameworks. Phase 2 — a scoring survey administered to a purposively selected respondent group (Phase 1 interviewees) — informed the refinement of the initial EUI conceptual frameworks for start-ups and MNCs. The findings indicate that while EUI is practiced in both organisational settings, it can be enabled, constrained, and shaped by overlapping and distinct determinants. The study contributes to the academic literature at the intersection of innovation management in the fuzzy front-end, user involvement, and digital health intervention development in three ways. Firstly, it addresses the identified research gap by illuminating EUI determinants in the FFE and by elucidating how organisational context shapes EUI implementation. Secondly, the proposed EUI implementation frameworks augment established DHI development frameworks (e.g. CeHRes roadmap) by conceptualising EUI as a preliminary phase that can inform pre-design need identification and provide an initial response to recurrent calls in the literature for clearer guidance on effectively involving users in the health app development process. Thirdly, the results extend open innovation and UCD theory in the health app development context to better account for the interplay between user-centred considerations, organisational structures, and organisation-user tensions in healthcare’s complex and stringently regulated environment. The study also contributes to practice by providing innovation practitioners with an evidence-based starting point for key considerations as well as implications for integrating EUI into the early phases of digital health innovation to better identify user needs which can help improve the relevance and inclusivity of these solutions.

Name dc:type.qualificationname

Doctor of Philosophy (PhD)

Level dc:type.qualificationlevel

Doctoral

Grantor dc:publisher.institution

University of Cambridge

Year dc:date.issued

2025

Author dc:creator

• Sarkar, Devmalya

Advisor dc:contributor.advisor

• Minshall, Tim

• innovation management
• fuzzy front-end
• user involvement
• digital health
• user-centred design

Licence

• https://www.repository.cam.ac.uk/bitstreams/6cea0c33-da44-4f50-97df-46b51fa3c2dd/download
• http://purl.org/NET/rdflicense/allrightsreserved

Language dc:language

eng

DOI dc:identifier.doi

https://doi.org/10.17863/CAM.124841

OAI identifier oai:identifier

oai:www.repository.cam.ac.uk:1810/395290