• Review article
  • Open access
  • Published: 22 January 2020

Mapping research in student engagement and educational technology in higher education: a systematic evidence map

  • Melissa Bond   ORCID: orcid.org/0000-0002-8267-031X 1 ,
  • Katja Buntins 2 ,
  • Svenja Bedenlier 1 ,
  • Olaf Zawacki-Richter 1 &
  • Michael Kerres 2  

International Journal of Educational Technology in Higher Education volume  17 , Article number:  2 ( 2020 ) Cite this article

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Digital technology has become a central aspect of higher education, inherently affecting all aspects of the student experience. It has also been linked to an increase in behavioural, affective and cognitive student engagement, the facilitation of which is a central concern of educators. In order to delineate the complex nexus of technology and student engagement, this article systematically maps research from 243 studies published between 2007 and 2016. Research within the corpus was predominantly undertaken within the United States and the United Kingdom, with only limited research undertaken in the Global South, and largely focused on the fields of Arts & Humanities, Education, and Natural Sciences, Mathematics & Statistics. Studies most often used quantitative methods, followed by mixed methods, with little qualitative research methods employed. Few studies provided a definition of student engagement, and less than half were guided by a theoretical framework. The courses investigated used blended learning and text-based tools (e.g. discussion forums) most often, with undergraduate students as the primary target group. Stemming from the use of educational technology, behavioural engagement was by far the most often identified dimension, followed by affective and cognitive engagement. This mapping article provides the grounds for further exploration into discipline-specific use of technology to foster student engagement.

Introduction

Over the past decade, the conceptualisation and measurement of ‘student engagement’ has received increasing attention from researchers, practitioners, and policy makers alike. Seminal works such as Astin’s ( 1999 ) theory of involvement, Fredricks, Blumenfeld, and Paris’s ( 2004 ) conceptualisation of the three dimensions of student engagement (behavioural, emotional, cognitive), and sociocultural theories of engagement such as Kahu ( 2013 ) and Kahu and Nelson ( 2018 ), have done much to shape and refine our understanding of this complex phenomenon. However, criticism about the strength and depth of student engagement theorising remains e.g. (Boekaerts, 2016 ; Kahn, 2014 ; Zepke, 2018 ), the quality of which has had a direct impact on the rigour of subsequent research (Lawson & Lawson, 2013 ; Trowler, 2010 ), prompting calls for further synthesis (Azevedo, 2015 ; Eccles, 2016 ).

In parallel to this increased attention on student engagement, digital technology has become a central aspect of higher education, inherently affecting all aspects of the student experience (Barak, 2018 ; Henderson, Selwyn, & Aston, 2017 ; Selwyn, 2016 ). International recognition of the importance of ICT skills and digital literacy has been growing, alongside mounting recognition of its importance for active citizenship (Choi, Glassman, & Cristol, 2017 ; OECD, 2015a ; Redecker, 2017 ), and the development of interdisciplinary and collaborative skills (Barak & Levenberg, 2016 ; Oliver, & de St Jorre, Trina, 2018 ). Using technology has the potential to make teaching and learning processes more intensive (Kerres, 2013 ), improve student self-regulation and self-efficacy (Alioon & Delialioğlu, 2017 ; Bouta, Retalis, & Paraskeva, 2012 ), increase participation and involvement in courses as well as the wider university community (Junco, 2012 ; Salaber, 2014 ), and predict increased student engagement (Chen, Lambert, & Guidry, 2010 ; Rashid & Asghar, 2016 ). There is, however, no guarantee of active student engagement as a result of using technology (Kirkwood, 2009 ), with Tamim, Bernard, Borokhovski, Abrami, and Schmid’s ( 2011 ) second-order meta-analysis finding only a small to moderate impact on student achievement across 40 years. Rather, careful planning, sound pedagogy and appropriate tools are vital (Englund, Olofsson, & Price, 2017 ; Koehler & Mishra, 2005 ; Popenici, 2013 ), as “technology can amplify great teaching, but great technology cannot replace poor teaching” (OECD, 2015b ), p. 4.

Due to the nature of its complexity, educational technology research has struggled to find a common definition and terminology with which to talk about student engagement, which has resulted in inconsistency across the field. For example, whilst 77% of articles reviewed by Henrie, Halverson, and Graham ( 2015 ) operationalised engagement from a behavioural perspective, most of the articles did not have a clearly defined statement of engagement, which is no longer considered acceptable in student engagement research (Appleton, Christenson, & Furlong, 2008 ; Christenson, Reschly, & Wylie, 2012 ). Linked to this, educational technology research has, however, lacked theoretical guidance (Al-Sakkaf, Omar, & Ahmad, 2019 ; Hew, Lan, Tang, Jia, & Lo, 2019 ; Lundin, Bergviken Rensfeldt, Hillman, Lantz-Andersson, & Peterson, 2018 ). A review of 44 random articles published in 2014 in the journals Educational Technology Research & Development and Computers & Education, for example, revealed that more than half had no guiding conceptual or theoretical framework (Antonenko, 2015 ), and only 13 out of 62 studies in a systematic review of flipped learning in engineering education reported theoretical grounding (Karabulut-Ilgu, Jaramillo Cherrez, & Jahren, 2018 ). Therefore, calls have been made for a greater understanding of the role that educational technology plays in affecting student engagement, in order to strengthen teaching practice and lead to improved outcomes for students (Castañeda & Selwyn, 2018 ; Krause & Coates, 2008 ; Nelson Laird & Kuh, 2005 ).

A reflection upon prior research that has been undertaken in the field is a necessary first step to engage in meaningful discussion on how to foster student engagement in the digital age. In support of this aim, this article provides a synthesis of student engagement theory research, and systematically maps empirical higher education research between 2007 and 2016 on student engagement in educational technology. Synthesising the vast body of literature on student engagement (for previous literature and systematic reviews, see Additional file  1 ), this article develops “a tentative theory” in the hopes of “plot[ting] the conceptual landscape…[and chart] possible routes to explore it” (Antonenko, 2015 , pp. 57–67) for researchers, practitioners, learning designers, administrators and policy makers. It then discusses student engagement against the background of educational technology research, exploring prior literature and systematic reviews that have been undertaken. The systematic review search method is then outlined, followed by the presentation and discussion of findings.

Literature review

What is student engagement.

Student engagement has been linked to improved achievement, persistence and retention (Finn, 2006 ; Kuh, Cruce, Shoup, Kinzie, & Gonyea, 2008 ), with disengagement having a profound effect on student learning outcomes and cognitive development (Ma, Han, Yang, & Cheng, 2015 ), and being a predictor of student dropout in both secondary school and higher education (Finn & Zimmer, 2012 ). Student engagement is a multifaceted and complex construct (Appleton et al., 2008 ; Ben-Eliyahu, Moore, Dorph, & Schunn, 2018 ), which some have called a ‘meta-construct’ (e.g. Fredricks et al., 2004 ; Kahu, 2013 ), and likened to blind men describing an elephant (Baron & Corbin, 2012 ; Eccles, 2016 ). There is ongoing disagreement about whether there are three components e.g., (Eccles, 2016 )—affective/emotional, cognitive and behavioural—or whether there are four, with the recent suggested addition of agentic engagement (Reeve, 2012 ; Reeve & Tseng, 2011 ) and social engagement (Fredricks, Filsecker, & Lawson, 2016 ). There has also been confusion as to whether the terms ‘engagement’ and ‘motivation’ can and should be used interchangeably (Reschly & Christenson, 2012 ), especially when used by policy makers and institutions (Eccles & Wang, 2012 ). However, the prevalent understanding across the literature is that motivation is an antecedent to engagement; it is the intent and unobservable force that energises behaviour (Lim, 2004 ; Reeve, 2012 ; Reschly & Christenson, 2012 ), whereas student engagement is energy and effort in action; an observable manifestation (Appleton et al., 2008 ; Eccles & Wang, 2012 ; Kuh, 2009 ; Skinner & Pitzer, 2012 ), evidenced through a range of indicators.

Whilst it is widely accepted that no one definition exists that will satisfy all stakeholders (Solomonides, 2013 ), and no one project can be expected to possibly examine every sub-construct of student engagement (Kahu, 2013 ), it is important for each research project to begin with a clear definition of their own understanding (Boekaerts, 2016 ). Therefore, in this project, student engagement is defined as follows:

Student engagement is the energy and effort that students employ within their learning community, observable via any number of behavioural, cognitive or affective indicators across a continuum. It is shaped by a range of structural and internal influences, including the complex interplay of relationships, learning activities and the learning environment. The more students are engaged and empowered within their learning community, the more likely they are to channel that energy back into their learning, leading to a range of short and long term outcomes, that can likewise further fuel engagement.

Dimensions and indicators of student engagement

There are three widely accepted dimensions of student engagement; affective, cognitive and behavioural. Within each component there are several indicators of engagement (see Additional file  2 ), as well as disengagement (see Additional file 2 ), which is now seen as a separate and distinct construct to engagement. It should be stated, however, that whilst these have been drawn from a range of literature, this is not a finite list, and it is recognised that students might experience these indicators on a continuum at varying times (Coates, 2007 ; Payne, 2017 ), depending on their valence (positive or negative) and activation (high or low) (Pekrun & Linnenbrink-Garcia, 2012 ). There has also been disagreement in terms of which dimension the indicators align with. For example, Järvelä, Järvenoja, Malmberg, Isohätälä, and Sobocinski ( 2016 ) argue that ‘interaction’ extends beyond behavioural engagement, covering both cognitive and/or emotional dimensions, as it involves collaboration between students, and Lawson and Lawson ( 2013 ) believe that ‘effort’ and ‘persistence’ are cognitive rather than behavioural constructs, as they “represent cognitive dispositions toward activity rather than an activity unto itself” (p. 465), which is represented in the table through the indicator ‘stay on task/focus’ (see Additional file 2 ). Further consideration of these disagreements represent an area for future research, however, as they are beyond the scope of this paper.

Student engagement within educational technology research

The potential that educational technology has to improve student engagement, has long been recognised (Norris & Coutas, 2014 ), however it is not merely a case of technology plus students equals engagement. Without careful planning and sound pedagogy, technology can promote disengagement and impede rather than help learning (Howard, Ma, & Yang, 2016 ; Popenici, 2013 ). Whilst still a young area, most of the research undertaken to gain insight into this, has been focused on undergraduate students e.g., (Henrie et al., 2015 ; Webb, Clough, O’Reilly, Wilmott, & Witham, 2017 ), with Chen et al. ( 2010 ) finding a positive relationship between the use of technology and student engagement, particularly earlier in university study. Research has also been predominantly STEM and medicine focused (e.g., Li, van der Spek, Feijs, Wang, & Hu, 2017 ; Nikou & Economides, 2018 ), with at least five literature or systematic reviews published in the last 5 years focused on medicine, and nursing in particular (see Additional file  3 ). This indicates that further synthesis is needed of research in other disciplines, such as Arts & Humanities and Education, as well as further investigation into whether research continues to focus on undergraduate students.

The five most researched technologies in Henrie et al.’s ( 2015 ) review were online discussion boards, general websites, learning management systems (LMS), general campus software and videos, as opposed to Schindler, Burkholder, Morad, and Marsh’s ( 2017 ) literature review, which concentrated on social networking sites (Facebook and Twitter), digital games, wikis, web-conferencing software and blogs. Schindler et al. found that most of these technologies had a positive impact on multiple indicators of student engagement across the three dimensions of engagement, with digital games, web-conferencing software and Facebook the most effective. However, it must be noted that they only considered seven indicators of student engagement, which could be extended by considering further indicators of student engagement. Other reviews that have found at least a small positive impact on student engagement include those focused on audience response systems (Hunsu, Adesope, & Bayly, 2016 ; Kay & LeSage, 2009 ), mobile learning (Kaliisa & Picard, 2017 ), and social media (Cheston, Flickinger, & Chisolm, 2013 ). Specific indicators of engagement that increased as a result of technology include interest and enjoyment (Li et al., 2017 ), improved confidence (Smith & Lambert, 2014 ) and attitudes (Nikou & Economides, 2018 ), as well as enhanced relationships with peers and teachers e.g., (Alrasheedi, Capretz, & Raza, 2015 ; Atmacasoy & Aksu, 2018 ).

Literature and systematic reviews focused on student engagement and technology do not always include information on where studies have been conducted. Out of 27 identified reviews (see Additional file 3 ), only 14 report the countries included, and two of these were explicitly focused on a specific region or country, namely Africa and Turkey. Most of the research has been conducted in the USA, followed by the UK, Taiwan, Australia and China. Table  1 depicts the three countries from which most studies originated from in the respective reviews, and highlights a clear lack of research conducted within mainland Europe, South America and Africa. Whilst this could be due to the choice of databases in which the literature was searched for, this nevertheless highlights a substantial gap in the literature, and to that end, it will be interesting to see whether this review is able to substantiate or contradict these trends.

Research into student engagement and educational technology has predominantly used a quantitative methodology (see Additional file 3 ), with 11 literature and systematic reviews reporting that surveys, particularly self-report Likert-scale, are the most used source of measurement (e.g. Henrie et al., 2015 ). Reviews that have included research using a range of methodologies, have found a limited number of studies employing qualitative methods (e.g. Connolly, Boyle, MacArthur, Hainey, & Boyle, 2012 ; Kay & LeSage, 2009 ; Lundin et al., 2018 ). This has led to a call for further qualitative research to be undertaken, exploring student engagement and technology, as well as more rigorous research designs e.g., (Li et al., 2017 ; Nikou & Economides, 2018 ), including sampling strategies, data collection, and in experimental studies in particular (Cheston et al., 2013 ; Connolly et al., 2012 ). However, not all reviews included information on methodologies used. Crook ( 2019 ), in his recent editorial in the British Journal of Educational Technology , stated that research methodology is a “neglected topic” (p. 487) within educational technology research, and stressed its importance in order to conduct studies delving deeper into phenomena (e.g. longitudinal studies).

Therefore, this article presents an initial “evidence map” (Miake-Lye, Hempel, Shanman, & Shekelle, 2016 ), p. 19 of systematically identified literature on student engagement and educational technology within higher education, undertaken through a systematic review, in order to address the issues raised by prior research, and to identify research gaps. These issues include the disparity between field of study and study levels researched, the geographical distribution of studies, the methodologies used, and the theoretical fuzziness surrounding student engagement. This article, however, is intended to provide an initial overview of the systematic review method employed, as well as an overview of the overall corpus. Further synthesis of possible correlations between student engagement and disengagement indicators with the co-occurrence of technology tools, will be undertaken within field of study specific articles (e.g., Bedenlier, 2020b ; Bedenlier 2020a ), allowing more meaningful guidance on applying the findings in practice.

The following research questions guide this enquiry:

How do the studies in the sample ground student engagement and align with theory?

Which indicators of cognitive, behavioural and affective engagement were identified in studies where educational technology was used? Which indicators of student disengagement?

What are the learning scenarios, modes of delivery and educational technology tools employed in the studies?

Overview of the study

With the intent to systematically map empirical research on student engagement and educational technology in higher education, we conducted a systematic review. A systematic review is an explicitly and systematically conducted literature review, that answers a specific question through applying a replicable search strategy, with studies then included or excluded, based on explicit criteria (Gough, Oliver, & Thomas, 2012 ). Studies included for review are then coded and synthesised into findings that shine light on gaps, contradictions or inconsistencies in the literature, as well as providing guidance on applying findings in practice. This contribution maps the research corpus of 243 studies that were identified through a systematic search and ensuing random parameter-based sampling.

Search strategy and selection procedure

The initial inclusion criteria for the systematic review were peer-reviewed articles in the English language, empirically reporting on students and student engagement in higher education, and making use of educational technology. The search was limited to records between 1995 and 2016, chosen due to the implementation of the first Virtual Learning Environments and Learning Management Systems within higher education see (Bond, 2018 ). Articles were limited to those published in peer-reviewed journals, due to the rigorous process under which they are published, and their trustworthiness in academia (Nicholas et al., 2015 ), although concerns within the scientific community with the peer-review process are acknowledged e.g. (Smith, 2006 ).

Discussion arose on how to approach the “hard-to-detect” (O’Mara-Eves et al., 2014 , p. 51) concept of student engagement in regards to sensitivity versus precision (Brunton, Stansfield, & Thomas, 2012 ), particularly in light of engagement being Henrie et al.’s ( 2015 ) most important search term. The decision was made that the concept ‘student engagement’ would be identified from titles and abstracts at a later stage, during the screening process. In this way, it was assumed that articles would be included, which indeed are concerned with student engagement, but which use different terms to describe the concept. Given the nature of student engagement as a meta-construct e.g. (Appleton et al., 2008 ; Christenson et al., 2012 ; Kahu, 2013 ) and by limiting the search to only articles including the term engagement , important research on other elements of student engagement might be missed. Hence, we opted for recall over precision. According to Gough et al. ( 2012 ), p. 13 “electronic searching is imprecise and captures many studies that employ the same terms without sharing the same focus”, or would lead to disregarding studies that analyse the construct but use different terms to describe it.

With this in mind, the search strategy to identify relevant studies was developed iteratively with support from the University Research Librarian. As outlined in O’Mara-Eves et al. ( 2014 ) as a standard approach, we used reviewer knowledge—in this case strongly supported through not only reviewer knowledge but certified expertise—and previous literature (e.g. Henrie et al., 2015 ; Kahu, 2013 ) to elicit concepts with potential importance under the topics student engagement, higher education and educational technology . The final search string (see Fig.  1 ) encompasses clusters of different educational technologies that were searched for separately in order to avoid an overly long search string. It was decided not to include any brand names, e.g. Facebook, Twitter, Moodle etc. because it was again reasoned that in scientific publication, the broader term would be used (e.g. social media). The final search string was slightly adapted, e.g. the format required for truncations or wildcards, according to the settings of each database being used Footnote 1 .

figure 1

Final search terms used in the systematic review

Four databases (ERIC, Web of Science, Scopus and PsycINFO) were searched in July 2017 and three researchers and a student assistant screened abstracts and titles of the retrieved references between August and November 2017, using EPPI Reviewer 4.0. An initial 77,508 references were retrieved, and with the elimination of duplicate records, 53,768 references remained (see Fig.  2 ). A first cursory screening of records revealed that older research was more concerned with technologies that are now considered outdated (e.g. overhead projectors, floppy disks). Therefore, we opted to adjust the period to include research published between 2007 and 2016, labeled as a phase of research and practice, entitled ‘online learning in the digital age’ (Bond, 2018 ). Whilst we initially opted for recall over precision, the decision was then made to search for specific facets of the student engagement construct (e.g. deep learning, interest and persistence) within EPPI-Reviewer, in order to further refine the corpus. These adaptations led to a remaining 18,068 records.

figure 2

Systematic review PRISMA flow chart (slightly modified after Brunton et al., 2012 , p. 86; Moher, Liberati, Tetzlaff, & Altman, 2009 ), p. 8

Four researchers screened the first 150 titles and abstracts, in order to iteratively establish a joint understanding of the inclusion criteria. The remaining references were distributed equally amongst the screening team, which resulted in the inclusion of 4152 potentially relevant articles. Given the large number of articles for screening on full text, whilst facing restrained time as a condition in project-based and funded work, it was decided that a sample of articles would be drawn from this corpus for further analysis. With the intention to draw a sample that estimates the population parameters with a predetermined error range, we used methods of sample size estimation in the social sciences (Kupper & Hafner, 1989 ). To do so, the R Package MBESS (Kelley, Lai, Lai, & Suggests, 2018 ) was used. Accepting a 5% error range, a percentage of a half and an alpha of 5%, 349 articles were sampled, with this sample being then stratified by publishing year, as student engagement has become much more prevalent (Zepke, 2018 ) and educational technology has become more differentiated within the last decade (Bond, 2018 ). Two researchers screened the first 100 articles on full text, reaching an agreement of 88% on inclusion/exclusion. The researchers then discussed the discrepancies and came to an agreement on the remaining 12%. It was decided that further comparison screening was needed, to increase the level of reliability. After screening the sample on full text, 232 articles remained for data extraction, which contained 243 studies.

Data extraction process

In order to extract the article data, an extensive coding system was developed, including codes to extract information on the set-up and execution of the study (e.g. methodology, study sample) as well as information on the learning scenario, the mode of delivery and educational technology used. Learning scenarios included broader pedagogies, such as social collaborative learning and self-determined learning, but also specific pedagogies such as flipped learning, given the increasing number of studies and interest in these approaches (e.g., Lundin et al., 2018 ). Specific examples of student engagement and/or disengagement were coded under cognitive, affective or behavioural (dis)engagement. The facets of student (dis)engagement were identified based on the literature review undertaken (see Additional file 2 ), and applied in this detailed manner to not only capture the overarching dimensions of the concept, but rather their diverse sub-meanings. New indicators also emerged during the coding process, which had not initially been identified from the literature review, including ‘confidence’ and ‘assuming responsibility’. The 243 studies were coded with this extensive code set and any disagreements that occurred between the coders were reconciled. Footnote 2

As a plethora of over 50 individual educational technology applications and tools were identified in the 243 studies, in line with results found in other large-scale systematic reviews (e.g., Lai & Bower, 2019 ), concerns were raised over how the research team could meaningfully analyse and report the results. The decision was therefore made to employ Bower’s ( 2016 ) typology of learning technologies (see Additional file  4 ), in order to channel the tools into groups that share the same characteristics or “structure of information” (Bower, 2016 ), p. 773. Whilst it is acknowledged that some of the technology could be classified into more than one type within the typology, e.g. wikis can be used in individual composition, for collaborative tasks, or for knowledge organisation and sharing, “the type of learning that results from the use of the tool is dependent on the task and the way people engage with it rather than the technology itself” therefore “the typology is presented as descriptions of what each type of tool enables and example use cases rather than prescriptions of any particular pedagogical value system” (Bower, 2016 ), p. 774. For further elaboration on each category, please see Bower ( 2015 ).

Study characteristics

Geographical characteristics.

The systematic mapping reveals that the 243 studies were set in 33 different countries, whilst seven studies investigated settings in an international context, and three studies did not indicate their country setting. In 2% of the studies, the country was allocated based on the author country of origin, if the two authors came from the same country. The top five countries account for 158 studies (see Fig.  3 ), with 35.4% ( n  = 86) studies conducted in the United States (US), 10.7% ( n  = 26) in the United Kingdom (UK), 7.8% ( n  = 19) in Australia, 7.4% ( n  = 18) in Taiwan, and 3.7% ( n  = 9) in China. Across the corpus, studies from countries employing English as the official or one of the official languages total up to 59.7% of the entire sample, followed by East Asian countries that in total account for 18.8% of the sample. With the exception of the UK, European countries are largely absent from the sample, only 7.3% of the articles originate from this region, with countries such as France, Belgium, Italy or Portugal having no studies and countries such as Germany or the Netherlands having one respectively. Thus, with eight articles, Spain is the most prolific European country outside of the UK. The geographical distribution of study settings also clearly shows an almost complete absence of studies undertaken within African contexts, with five studies from South Africa and one from Tunisia. Studies from South-East Asia, the Middle East, and South America are likewise low in number this review. Whilst the global picture evokes an imbalance, this might be partially due to our search and sampling strategy, having focused on English language journals, indexed in four primarily Western-focused databases.

figure 3

Percentage deviation from the average relative frequencies of the different data collection formats per country (≥ 3 articles). Note. NS = not stated; AUS = Australia; CAN = Canada; CHN = China; HKG = Hong Kong; inter = international; IRI = Iran; JAP = Japan; MYS = Malaysia; SGP = Singapore; ZAF = South Africa; KOR = South Korea; ESP = Spain; SWE = Sweden; TWN = Taiwan; TUR = Turkey; GBR = United Kingdom; USA = United States of America

Methodological characteristics

Within this literature corpus, 103 studies (42%) employed quantitative methods, 84 (35%) mixed methods, and 56 (23%) qualitative. Relating these numbers back to the contributing countries, different preferences for and frequencies of methods used become apparent (see Fig. 3 ). As a general tendency, mixed methods and qualitative research occurs more often in Western countries, whereas quantitative research is the preferred method in East Asian countries. For example, studies originating from Australia employ mixed methods research 28% more often than the average, whereas Singapore is far below average in mixed methods research, with 34.5% less than the other countries in the sample. In Taiwan, on the other hand, mixed methods studies are being conducted 23.5% below average and qualitative research 6.4% less often than average. However, quantitative research occurs more often than in other countries, with 29.8% above average.

Amongst the qualitative studies, qualitative content analysis ( n  = 30) was the most frequently used analysis approach, followed by thematic analysis ( n  = 21) and grounded theory ( n  = 12). However, a lot of times ( n  = 37) the exact analysis approach was not reported, could not be allocated to a specific classification ( n  = 22), or no method of analysis was identifiable ( n  = 11). Within studies using quantitative methods, mean comparison was used in 100 studies, frequency data was collected and analysed in 83 studies, and in 40 studies regression models were used. Furthermore, looking at the correlation between the different analysis approaches, only one significant correlation can be identified, this being between mean comparison and frequency data (−.246). Besides that, correlations are small, for example, in only 14% of the studies both mean comparisons and regressions models are employed.

Study population characteristics

Research in the corpus focused on universities as the prime institution type ( n  = 191, 79%), followed by 24 (10%) non-specified institution types, and colleges ( n  = 21, 8.2%) (see Fig.  4 ). Five studies (2%) included institutions classified as ‘other’, and two studies (0.8%) included both college and university students. The most frequently studied student population was undergraduate students (60%, n  = 146), as opposed to 33 studies (14%) focused on postgraduate students (see Fig.  6 ). A combination of undergraduate and postgraduate students were the subject of interest in 23 studies (9%), with 41 studies (17%) not specifying the level of study of research participants.

figure 4

Relative frequencies of study field in dependence of countries with ≥3 articles. Note. Country abbreviations are as per Figure 4. A&H = Arts & Humanities; BA&L = Business, Administration and Law; EDU = Education; EM&C = Engineering, Manufacturing & Construction; H&W = Health & Welfare; ICT = Information & Communication Technologies; ID = interdisciplinary; NS,M&S = Natural Science, Mathematics & Statistics; NS = Not specified; SoS = Social Sciences, Journalism & Information

Based on the UNESCO (2015) ISCED classification, eight broad study fields are covered in the sample, with Arts & Humanities (42 studies), Education (42 studies), and Natural Sciences, Mathematics & Statistics (37) being the top three study fields, followed by Health & Welfare (30 studies), Social Sciences, Journalism & Information (22), Business, Administration & Law (19 studies), Information & Communication Technologies (13), Engineering, Manufacturing & Construction (11), and another 26 studies of interdisciplinary character. One study did not specify a field of study.

An expectancy value was calculated, according to which, the distribution of studies per discipline should occur per country. The actual deviation from this value then showed that several Asian countries are home to more articles in the field of Arts & Humanities than was expected: Japan with 3.3 articles more, China with 5.4 and Taiwan with 5.9. Furthermore, internationally located research also shows 2.3 more interdisciplinary studies than expected, whereas studies on Social Sciences occur more often than expected in the UK (5.7 more articles) and Australia (3.3 articles) but less often than expected across all other countries. Interestingly, the USA have 9.9 studies less in Arts & Humanities than was expected but 5.6 articles more than expected in Natural Science.

Question One: How do the studies in the sample ground student engagement and align with theory?

Defining student engagement.

It is striking that almost all of the studies ( n  = 225, 93%) in this corpus lack a definition of student engagement, with only 18 (7%) articles attempting to define the concept. However, this is not too surprising, as the search strategy was set up with the assumption that researchers investigating student engagement (dimensions and indicators) would not necessarily label them as student engagement. When developing their definitions, authors in these 18 studies referenced 22 different sources, with the work of Kuh and colleagues e.g., (Hu & Kuh, 2002 ; Kuh, 2001 ; Kuh et al., 2006 ), as well as Astin ( 1984 ), the only authors referred to more than once. The most popular definition of student engagement within these studies was that of active participation and involvement in learning and university life e.g., (Bolden & Nahachewsky, 2015 ; bFukuzawa & Boyd, 2016 ), which was also found by Joksimović et al. ( 2018 ) in their review of MOOC research. Interaction, especially between peers and with faculty, was the next most prevalent definition e.g., (Andrew, Ewens, & Maslin-Prothero, 2015 ; Bigatel & Williams, 2015 ). Time and effort was given as a definition in four studies (Gleason, 2012 ; Hatzipanagos & Code, 2016 ; Price, Richardson, & Jelfs, 2007 ; Sun & Rueda, 2012 ), with expending physical and psychological energy (Ivala & Gachago, 2012 ) another definition. This variance in definitions and sources reflects the ongoing complexity of the construct (Zepke, 2018 ), and serves to reinforce the need for a clearer understanding across the field (Schindler et al., 2017 ).

Theoretical underpinnings

Reflecting findings from other systematic and literature reviews on the topic (Abdool, Nirula, Bonato, Rajji, & Silver, 2017 ; Hunsu et al., 2016 ; Kaliisa & Picard, 2017 ; Lundin et al., 2018 ), 59% ( n  = 100) of studies did not employ a theoretical model in their research. Of the 41% ( n  = 100) that did, 18 studies drew on social constructivism, followed by the Community of Inquiry model ( n  = 8), Sociocultural Learning Theory ( n  = 5), and Community of Practice models ( n  = 4). These findings also reflect the state of the field in general (Al-Sakkaf et al., 2019 ; Bond, 2019b ; Hennessy, Girvan, Mavrikis, Price, & Winters, 2018 ).

Another interesting finding of this research is that whilst 144 studies (59%) provided research questions, 99 studies (41%) did not. Although it is recognised that not all studies have research questions (Bryman, 2007 ), or only develop them throughout the research process, such as with grounded theory (Glaser & Strauss, 1967 ), a surprising number of quantitative studies (36%, n  = 37) did not have research questions. This is a reflection on the lack of theoretical guidance, as 30 of these 37 studies also did not draw on a theoretical or conceptual framework.

Question 2: which indicators of cognitive, behavioural and affective engagement were identified in studies where educational technology was used? Which indicators of student disengagement?

Student engagement indicators.

Within the corpus, the behavioural engagement dimension was documented in some form in 209 studies (86%), whereas the dimension of affective engagement was reported in 163 studies (67%) and the cognitive dimension in only 136 (56%) studies. However, the ten most often identified student engagement indicators across the studies overall (see Table  2 ) were evenly distributed over all three dimensions (see Table  3 ). The indicators participation/interaction/involvement , achievement and positive interactions with peers and teachers each appear in at least 100 studies, which is almost double the amount of the next most frequent student engagement indicator.

Across the 243 studies in the corpus, 117 (48%) showed all three dimensions of affective, cognitive and behavioural student engagement e.g., (Szabo & Schwartz, 2011 ), including six studies that used established student engagement questionnaires, such as the NSSE (e.g., Delialioglu, 2012 ), or self-developed addressing these three dimensions. Another 54 studies (22%) displayed at least two student engagement dimensions e.g., (Hatzipanagos & Code, 2016 ), including six questionnaire studies. Studies exhibiting one student engagement dimension only, was reported in 71 studies (29%) e.g., (Vural, 2013 ).

Student disengagement indicators

Indicators of student disengagement (see Table  4 ) were identified considerably less often across the corpus, which could be explained by the purpose of the studies being to primarily address/measure positive engagement, but on the other hand this could potentially be due to a form of self-selected or publication bias, due to less frequently reporting and/or publishing studies with negative results. The three disengagement indicators that were most often indicated were frustration ( n  = 33, 14%) e.g., (Ikpeze, 2007 ), opposition/rejection ( n  = 20, 8%) e.g., (Smidt, Bunk, McGrory, Li, & Gatenby, 2014 ) and disappointment e.g., (Granberg, 2010 ) , as well as other affective disengagement ( n  = 18, 7% each).

Technology tool typology and engagement/disengagement indicators

Across the 243 studies, a plethora of over 50 individual educational technology tools were employed. The top five most frequently researched tools were LMS ( n  = 89), discussion forums ( n  = 80), videos ( n  = 44), recorded lectures ( n  = 25), and chat ( n  = 24). Following a slightly modified version of Bower’s ( 2016 ) educational tools typology, 17 broad categories of tools were identified (see Additional file 4 for classification, and 3.2 for further information). The frequency with which tools from the respective groups employed in studies varied considerably (see Additional file 4 ), with the top five categories being text-based tools ( n  = 138), followed by knowledge organisation & sharing tools ( n  = 104), multimodal production tools ( n  = 89), assessment tools ( n  = 65) and website creation tools ( n  = 29).

Figure  5 shows what percentage of each engagement dimension (e.g., affective engagement or cognitive disengagement) was fostered through each specific technology type. Given the results in 4.2.1 on student engagement, it was somewhat unsurprising to see the prevalence of text-based tools , knowledge organisation & sharing tools, and multimodal production tools having the highest proportion of affective, behavioural and cognitive engagement. For example, affective engagement was identified in 163 studies, with 63% of these studies using text-based tools (e.g., Bulu & Yildirim, 2008 ) , and cognitive engagement identified in 136 studies, with 47% of those using knowledge organisation & sharing tools e.g., (Shonfeld & Ronen, 2015 ). However, further analysis of studies employing discussion forums (a text-based tool ) revealed that, whilst the top affective and behavioural engagement indicators were found in almost two-thirds of studies (see Additional file  5 ), there was a substantial gap between that and the next most prevalent engagement indicator, with the exact pattern (and indicators) emerging for wikis. This represents an area for future research.

figure 5

Engagement and disengagement by tool typology. Note. TBT = text-based tools; MPT = multimodal production tools; WCT = website creation tools; KO&S = knowledge organisation and sharing tools; DAT = data analysis tools; DST = digital storytelling tools; AT = assessment tools; SNT = social networking tools; SCT = synchronous collaboration tools; ML = mobile learning; VW = virtual worlds; LS = learning software; OL = online learning; A&H = Arts & Humanities; BA&L = Business, Administration and Law; EDU = Education; EM&C = Engineering, Manufacturing & Construction; H&W = Health & Welfare; ICT = Information & Communication Technologies; ID = interdisciplinary; NS,M&S = Natural Science, Mathematics & Statistics; NS = Not specified; SoS = Social Sciences, Journalism & Information

Interestingly, studies using website creation tools reported more disengagement than engagement indicators across all three domains (see Fig.  5 ), with studies using assessment tools and social networking tools also reporting increased instances of disengagement across two domains (affective and cognitive, and behavioural and cognitive respectively). 23 of the studies (79%) using website creation tools , used blogs, with students showing, for example, disinterest in topics chosen e.g., (Sullivan & Longnecker, 2014 ), anxiety over their lack of blogging knowledge and skills e.g., (Mansouri & Piki, 2016 ), and continued avoidance of using blogs in some cases, despite introductory training e.g., (Keiller & Inglis-Jassiem, 2015 ). In studies where assessment tools were used, students found timed assessment stressful, particularly when trying to complete complex mathematical solutions e.g., (Gupta, 2009 ), as well as quizzes given at the end of lectures, with some students preferring take-up time of content first e.g., (DePaolo & Wilkinson, 2014 ). Disengagement in studies where social networking tools were used, indicated that some students found it difficult to express themselves in short posts e.g., (Cook & Bissonnette, 2016 ), that conversations lacked authenticity e.g., (Arnold & Paulus, 2010 ), and that some did not want to mix personal and academic spaces e.g., (Ivala & Gachago, 2012 ).

Question 3: What are the learning scenarios, modes of delivery and educational technology tools employed in the studies?

Learning scenarios.

With 58.4% across the sample, social-collaborative learning (SCL) was the scenario most often employed ( n  = 142), followed by 43.2% of studies investigating self-directed learning (SDL) ( n  = 105) and 5.8% of studies using game-based learning (GBL) ( n  = 14) (see Fig. 6 ). Studies coded as SCL included those exploring social learning (Bandura, 1971 ) and social constructivist approaches (Vygotsky, 1978 ). Personal learning environments (PLE) were found for 2.9% of studies, 1.3% studies used other scenarios ( n  = 3), whereas another 13.2% did not provide specification of their learning scenarios ( n  = 32). It is noteworthy that in 45% of possible cases for employing SDL scenarios, SCL was also used. Other learning scenarios were also used mostly in combination with SCL and SDL. Given the rising number of higher education studies exploring flipped learning (Lundin et al., 2018 ), studies exploring the approach were also specifically coded (3%, n  = 7).

figure 6

Co-occurrence of learning scenarios across the sample ( n  = 243). Note. SDL = self-directed learning; SCL = social collaborative learning; GBL = game-based learning; PLE = personal learning environments; other = other learning scenario

Modes of delivery

In 84% of studies ( n  = 204), a single mode of delivery was used, with blended learning the most researched (109 studies), followed by distance education (72 studies), and face-to-face instruction (55 studies). Of the remaining 39 studies, 12 did not indicate their mode of delivery, whilst the other 27 studies combined or compared modes of delivery, e.g. comparing face to face courses to blended learning, such as the study on using iPads in undergraduate nursing education by Davies ( 2014 ).

Educational technology tools investigated

Most studies in this corpus (55%) used technology asynchronously, with 12% of studies researching synchronous tools, and 18% of studies using both asynchronous and synchronous. When exploring the use of tools, the results are not surprising, with a heavy reliance on asynchronous technology. However, when looking at tool usage with studies in face-to-face contexts, the number of synchronous tools (31%) is almost as many as the number of asynchronous tools (41%), and surprisingly low within studies in distance education (7%).

Tool categories were used in combination, with text-based tools most often used in combination with other technology types (see Fig.  7 ). For example, in 60% of all possible cases using multimodal production tools, in 69% of all possible synchronous production tool cases, in 72% of all possible knowledge, organisation & sharing tool cases , and a striking 89% of all possible learning software cases and 100% of all possible MOOC cases. On the contrary, text-based tools were never used in combination with games or data analysis tools . However, studies using gaming tools were used in 67% of possible assessment tool cases as well. Assessment tools, however, constitute somewhat of a special case when studies using website creation tools are concerned, with only 7% of possible cases having employed assessment tools .

figure 7

Co-occurrence of tools across the sample ( n  = 243). Note. TBT = text-based tools; MPT = multimodal production tools; WCT = website creation tools; KO&S = knowledge organisation and sharing tools; DAT = data analysis tools; DST = digital storytelling tools; AT = assessment tools; SNT = social networking tools; SCT = synchronous collaboration tools; ML = mobile learning; VW = virtual worlds; LS = learning software; OL = online learning

In order to gain further understanding into how educational technology was used, we examined how often a combination of two variables should occur in the sample and how often it actually occurs, with deviations described as either ‘more than’ or ‘less than’ the expected value. This provides further insight into potential gaps in the literature, which can inform future research. For example, an analysis of educational technology tool usage amongst study populations (see Fig.  8 ) reveals that 5.0 more studies than expected looked at knowledge organisation & sharing for graduate students, but 5.0 studies less than expected investigated assessment tools for this group. By contrast, 5 studies more than expected researched assessment tools for unspecified study levels, and 4.3 studies less than expected employed knowledge organisation & sharing for undergraduate students.

figure 8

Relative frequency of educational technology tools used according to study level Note. Abbreviations are explained in Fig. 7

Educational technology tools were also used differently from the expected pattern within various fields of study (see Fig.  9 ), most obviously for the cases of the top five tools. However, also for virtual worlds, found in 5.8 studies more in Health & Welfare than expected, and learning software, used in 6.4 studies more in Arts & Humanities than expected. In all other disciplines, learning software was used less often than assumed. Text-based tools were used more often than expected in fields of study that are already text-intensive, including Arts & Humanities, Education, Business, Administration & Law as well as Social Sciences - but less often than thought in fields such as Engineering, Health & Welfare, and Natural Sciences, Mathematics & Statistics. Multimodal production tools were used more often only in Health & Welfare, ICT and Natural Sciences, and less often than assumed across all other disciplines. Assessment tools deviated most clearly, with 11.9 studies more in Natural Sciences, Mathematics & Statistics than assumed, but with 5.2 studies less in both Education and Arts & Humanities.

figure 9

Relative frequency of educational technology tools used according to field of study. Note. TBT = text-based tools; MPT = multimodal production tools; WCT = website creation tools; KO&S = knowledge organisation and sharing tools; DAT = data analysis tools; DST = digital storytelling tools; AT = assessment tools; SNT = social networking tools; SCT = synchronous collaboration tools; ML = mobile learning; VW = virtual worlds; LS = learning software; OL = online learning

In regards to mode of delivery and educational technology tools used, it is interesting to see that from the five top tools, except for assessment tools , all tools were used in face-to-face instruction less often than expected (see Fig.  10 ); from 1.6 studies less for website creation tools to 14.5 studies less for knowledge organisation & sharing tools . Assessment tools , however, were used in 3.3 studies more than expected - but less often than assumed (although moderately) in blended learning and distance education formats. Text-based tools, multimodal production tools and knowledge organisation & sharing tools were employed more often than expected in blended and distance learning, especially obvious in 13.1 studies more on t ext-based tools and 8.2 studies on knowledge organisation & sharing tools in distance education. Contrary to what one would perhaps expect, social networking tools were used in 4.2 studies less than expected for this mode of delivery.

figure 10

Relative frequency of educational technology tools used according mode of delivery. Note. Tool abbreviations as per Figure 10. BL = Blended learning; DE = Distance education; F2F = Face-to-face; NS = Not stated

The findings of this study confirm those of previous research, with the most prolific countries being the US, UK, Australia, Taiwan and China. This is rather representative of the field, with an analysis of instructional design and technology research from 2007 to 2017 listing the most productive countries as the US, Taiwan, UK, Australia and Turkey (Bodily, Leary, & West, 2019 ). Likewise, an analysis of 40 years of research in Computers & Education (CAE) found that the US, UK and Taiwan accounted for 49.9% of all publications (Bond, 2018 ). By contrast, a lack of African research was apparent in this review, which is also evident in educational technology research in top tier peer-reviewed journals, with only 4% of articles published in the British Journal of Educational Technology ( BJET ) in the past decade (Bond, 2019b ) and 2% of articles in the Australasian Journal of Educational Technology (AJET) (Bond, 2018 ) hailing from Africa. Similar results were also found in previous literature and systematic reviews (see Table 1 ), which again raises questions of literature search and inclusion strategies, which will be further discussed in the limitations section.

Whilst other reviews of educational technology and student engagement have found studies to be largely STEM focused (Boyle et al., 2016 ; Li et al., 2017 ; Lundin et al., 2018 ; Nikou & Economides, 2018 ), this corpus features a more balanced scope of research, with the fields of Arts & Humanities (42 studies, 17.3%) and Education (42 studies, 17.3%) constituting roughly one third of all studies in the corpus - and Natural Sciences, Mathematics & Statistics, nevertheless, assuming rank 3 with 38 studies (15.6%). Beyond these three fields, further research is needed within underrepresented fields of study, in order to gain more comprehensive insights into the usage of educational technology tools (Kay & LeSage, 2009 ; Nikou & Economides, 2018 ).

Results of the systematic map further confirm the focus that prior educational technology research has placed on undergraduate students as the target group and participants in technology-enhanced learning settings e.g. (Cheston et al., 2013 ; Henrie et al., 2015 ). With the overwhelming number of 146 studies researching undergraduate students—compared to 33 studies on graduate students and 23 studies investigating both study levels—this also indicates that further investigation into the graduate student experience is needed. Furthermore, the fact that 41 studies do not report on the study level of their participants is an interesting albeit problematic fact, as implications might not easily be drawn for application to one’s own specific teaching context if the target group under investigation is not clearly denominated. A more precise reporting of participants’ details, as well as specification of the study context (country, institution, study level to name a few) is needed to transfer and apply study results to practice—being then able to take into account why some interventions succeed and others do not.

In line with other studies e.g. (Henrie et al., 2015 ), this review has also demonstrated that student engagement remains an under-theorised concept, that is often only considered fragmentally in research. Whilst studies in this review have often focused on isolated aspects of student engagement, their results are nevertheless interesting and valuable. However, it is important to relate these individual facets to the larger framework of student engagement, by considering how these aspects are connected and linked to each other. This is especially helpful to integrate research findings into practice, given that student engagement and disengagement are rarely one-dimensional; it is not enough to focus only on one aspect of engagement, but also to look at aspects that are adjacent to it (Pekrun & Linnenbrink-Garcia, 2012 ). It is also vital, therefore, that researchers develop and refine an understanding of student engagement, and make this explicit in their research (Appleton et al., 2008 ; Christenson et al., 2012 ).

Reflective of current conversations in the field of educational technology (Bond, 2019b ; Castañeda & Selwyn, 2018 ; Hew et al., 2019 ), as well as other reviews (Abdool et al., 2017 ; Hunsu et al., 2016 ; Kaliisa & Picard, 2017 ; Lundin et al., 2018 ), a substantial number of studies in this corpus did not have any theoretical underpinnings. Kaliisa and Picard ( 2017 ) argue that, without theory, research can result in disorganised accounts and issues with interpreting data, with research effectively “sit[ting] in a void if it’s not theoretically connected” (Kara, 2017 ), p. 56. Therefore, framing research in educational technology with a stronger theoretical basis, can assist with locating the “field’s disciplinary alignment” (Crook, 2019 ), p. 486 and further drive conversations forward.

The application of methods in this corpus was interesting in two ways. First, it is noticeable that quantitative studies are prevalent across the 243 articles in the sample. The number of studies employing qualitative research methods in the sample was comparatively low (56 studies as opposed to 84 mixed method studies and 103 quantitative studies). This is also reflected in the educational technology field at large, with a review of articles published in BJET and Educational Technology Research & Development (ETR&D) from 2002 to 2014 revealing that 40% of articles used quantitative methods, 26% qualitative and 13% mixed (Baydas, Kucuk, Yilmaz, Aydemir, & Goktas, 2015 ), and likewise a review of educational technology research from Turkey 1990–2011 revealed that 53% of articles used quantitative methods, 22% qualitative and 10% mixed methods (Kucuk, Aydemir, Yildirim, Arpacik, & Goktas, 2013 ). Quantitative studies primarily show that an intervention has worked or not when applied to e.g. a group of students in a certain setting as done in the study on using mobile apps on student performance in engineering education by Jou, Lin, and Tsai ( 2016 ), however, not all student engagement indicators can actually be measured in this way. The lower numbers of affective and cognitive engagement found in the studies in the corpus, reflect a wider call to the field to increase research on these two domains (Henrie et al., 2015 ; Joksimović et al., 2018 ; O’Flaherty & Phillips, 2015 ; Schindler et al., 2017 ). Whilst it is arguably more difficult to measure these two than behavioural engagement, the use of more rigorous and accurate surveys could be one possibility, as they can “capture unobservable aspects” (Henrie et al., 2015 ), p. 45 such as student feelings and information about the cognitive strategies they employ (Finn & Zimmer, 2012 ). However, they are often lengthy and onerous, or subject to the limitations of self-selection.

Whereas low numbers of qualitative studies researching student engagement and educational technology were previously identified in other student engagement and technology reviews (Connolly et al., 2012 ; Kay & LeSage, 2009 ; Lundin et al., 2018 ), it is studies like that by Lopera Medina ( 2014 ) in this sample, which reveal how people perceive this educational experience and the actual how of the process. Therefore, more qualitative and ethnographic measures should also be employed, such as student observations with thick descriptions, which can help shed light on the complexity of teaching and learning environments (Fredricks et al., 2004 ; Heflin, Shewmaker, & Nguyen, 2017 ). Conducting observations can be costly, however, both in time and money, so this is suggested in combination with computerised learning analytic data, which can provide measurable, objective and timely insight into how certain manifestations of engagement change over time (Henrie et al., 2015 ; Ma et al., 2015 ).

Whereas other results of this review have confirmed previous results in the field, the technology tools that were used in the studies and considered in their relation to student engagement in this corpus deviate. Whilst Henrie et al. ( 2015 ) found that the most frequently researched tools were discussion forums, general websites, LMS, general campus software and videos, the studies here focused predominantly on LMS, discussion forums, videos, recorded lectures and chat. Furthermore, whilst Schindler et al. ( 2017 ) found that digital games, web-conferencing software and Facebook were the most effective tools at enhancing student engagement, this review found that it was rather text-based tools , knowledge organisation & sharing , and multimodal production tools .

Limitations

During the execution of this systematic review, we tried to adhere to the method as rigorously as possible. However, several challenges were also encountered - some of which are addressed and discussed in another publication (Bedenlier, 2020b ) - resulting in limitations to this study. Four large, general educational research databases were searched, which are international in scope. However, by applying the criterion of articles published in English, research published on this topic in languages other than English was not included in this review. The same applies to research documented in, for example, grey literature, book chapters or monographs, or even articles from journals that are not indexed in the four databases searched. Another limitation is that only research published within the period 2007–2016 was investigated. Whilst we are cognisant of this being a restriction, we also think that the technological advances and the implications to be drawn from this time-frame relate more meaningfully to the current situation, than would have been the case for technologies used in the 1990s see (Bond, 2019b ). The sampling strategy also most likely accounts for the low number of studies from certain countries, e.g. in South America and Africa.

Studies included in this review represent various academic fields, and they also vary in the rigour with which they were conducted. Harden and Gough ( 2012 ) stress that the appraisal of quality and relevance of studies “ensure[s] that only the most appropriate, trustworthy and relevant studies are used to develop the conclusions of the review” (p. 154), we have included the criterion of being a peer reviewed contribution as a formal inclusion criterion from the beginning. In doing so, we reason that studies met a baseline of quality as applicable to published research in a specific field - otherwise they would not have been accepted for publication by the respective community. Finally, whilst the studies were diligently read and coded, and disagreements also discussed and reconciled, the human flaw of having overlooked or misinterpreted information provided in the individual articles cannot fully be excluded.

Finally, the results presented here provide an initial window into the overall body of research identified during the search, and further research is being undertaken to provide deeper insight into discipline specific use of technology and resulting student engagement using subsets of this sample (Bedenlier, 2020a ; Bond, M., Bedenlier, S., Buntins, K., Kerres, M., & Zawacki-Richter, O.: Facilitating student engagement through educational technology: A systematic review in the field of education, forthcoming).

Recommendations for future work and implications for practice

Whilst the evidence map presented in this article has confirmed previous research on the nexus of educational technology and student engagement, it has also elucidated a number of areas that further research is invited to address. Although these findings are similar to that of previous reviews, in order to more fully and comprehensively understand student engagement as a multi-faceted construct, it is not enough to focus only on indicators of engagement that can easily be measured, but rather the more complex endeavour of uncovering and investigating those indicators that reside below the surface. This also includes the careful alignment of theory and methodological design, in order to both adequately analyse the phenomenon under investigation, as well as contributing to the soundly executed body of research within the field of educational technology. Further research is invited in particular into how educational technology affects cognitive and affective engagement, whilst considering how this fits within the broader sociocultural framework of engagement (Bond, 2019a ). Further research is also invited into how educational technology affects student engagement within fields of study beyond Arts & Humanities, Education and Natural Sciences, Mathematics & Statistics, as well as within graduate level courses. The use of more qualitative research methods is particularly encouraged.

The findings of this review suggest that research gaps exist with particular combinations of tools, study levels and modes of delivery. With respect to study level, the use of assessment tools with graduate students, as well as knowledge organisation & sharing tools with undergraduate students, are topics researched far less than expected. The use of text-based tools in Engineering, Health & Welfare and Natural Sciences, Mathematics & Statistics, as well as the use of multimodal production tools outside of these disciplines, are also areas for future research, as is the use of assessment tools in the fields of Education and Arts & Humanities in particular.

With 109 studies in this systematic review using a blended learning design, this is a confirmation of the argument that online distance education and traditional face-to-face education are becoming increasingly more integrated with one another. Whilst this indicates that a lot of educators have made the move from face-to-face teaching to technology-enhanced learning, this also makes a case for the need for further professional development, in order to apply these tools effectively within their own teaching contexts, with this review indicating that further research is needed in particlar into the use of social networking tools in online/distance education. The question also needs to be asked, not only why the number of published studies are low within certain countries and regions, but also to enquire into the nature of why that is the case. This entails questioning the conditions under which research is being conducted, potentially criticising publication policies of major, Western-based journals, but also ultimately to reflect on one’s search strategy and research assumptions as a Western educator-researcher.

Based on the findings of this review, educators within higher education institutions are encouraged to use text-based tools , knowledge, organisation and sharing tools , and multimodal production tools in particular and, whilst any technology can lead to disengagement if not employed effectively, to be mindful that website creation tools (blogs and ePortfolios), social networking tools and assessment tools have been found to be more disengaging than engaging in this review. Therefore, educators are encouraged to ensure that students receive sufficient and ongoing training for any new technology used, including those that might appear straightforward, e.g. blogs, and that they may require extra writing support. Ensure that discussion/blog topics are interesting, that they allow student agency, and they are authentic to students, including the use of social media. Social networking tools that augment student professional learning networks are particularly useful. Educators should also be aware, however, that some students do not want to mix their academic and personal lives, and so the decision to use certain social platforms could be decided together with students.

Availability of data and materials

All data will be made publicly available, as part of the funding requirements, via https://www.researchgate.net/project/Facilitating-student-engagement-with-digital-media-in-higher-education-ActiveLeaRn .

The detailed search strategy, including the modified search strings according to the individual databases, can be retrieved from https://www.researchgate.net/project/Facilitating-student-engagement-with-digital-media-in-higher-education-ActiveLeaRn

The full code set can be retrieved from the review protocol at https://www.researchgate.net/project/Facilitating-student-engagement-with-digital-media-in-higher-education-ActiveLeaRn .

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This research resulted from the ActiveLearn project, funded by the Bundesministerium für Bildung und Forschung (BMBF-German Ministry of Education and Research) [grant number 16DHL1007].

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All authors contributed to the design and conceptualisation of the systematic review. MB, KB and SB conducted the systematic review search and data extraction. MB undertook the literature review on student engagement and educational technology, co-wrote the method, results, discussion and conclusion section. KB designed and executed the sampling strategy and produced all of the graphs and tables, as well as assisted with the formulation of the article. SB co-wrote the method, results, discussion and conclusion sections, and proof read the introduction and literature review sections. All authors read and approved the final manuscript.

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Literature reviews (LR) and systematic reviews (SR) on student engagement

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Indicators of engagement and disengagement

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Literature reviews (LR) and systematic reviews (SR) on student engagement and technology in higher education (HE)

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Educational technology tool typology based on Bower ( 2016 ) and Educational technology tools used

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Text-based tool examples by engagement domain

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Bond, M., Buntins, K., Bedenlier, S. et al. Mapping research in student engagement and educational technology in higher education: a systematic evidence map. Int J Educ Technol High Educ 17 , 2 (2020). https://doi.org/10.1186/s41239-019-0176-8

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Rapid advances in technology during the last few decades have provided a multitude of new options for teaching and learning. Although technology is being widely adopted in education, there is a shortage of research on the effects that this technology might have on student learning, and why those effects occur. We conducted a comprehensive review of the literature on various uses of digital technology in educational settings, and the effects of that technology on students’ objective learning outcomes. We interpret these effects within the context of empirical research on effective principles of learning, and the extent to which the affordances of technology permit opportunities for increased engagement with the material, retrieval practice, and spacing. Results revealed that technology is neither beneficial nor harmful for learning when used primarily as a means of presenting information (e.g., information viewed on a computer screen vs. on paper), but can be beneficial when it involves unique affordances that leverage effective learning principles. We discues these findings in light of the ever-increasing availability of technology in education, and the importance of evidence-guided criteria in decisions about adoption and implementation.

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education and technology research paper

Even with the same instructor across all conditions, there is a possibility that some instructor-related factors could change across conditions or across time (e.g., instructors could improve their teaching effectiveness from one term to the next, or have difficulty implementing a new technology). Notwithstanding these possibilities, instructor-related factors that could influence student learning are likely to be greater when there are different instructors across the conditions (e.g., bringing differences in teaching style, personality, grading practices, or experience), such that the potential influence of these factors was minimized by ensuring that the same instructor taught all students.

In these studies it cannot be determined whether the immediacy of the feedback per se was responsible for the learning gains. Some studies have directly explored the timing of feedback and have found that feedback can be more beneficial for learning some types of materials—particularly those involving non-overlapping materials—when it is delayed rather than provided immediately (Carpenter and Vul 2011 ; Corral et al. in press ). In the studies reviewed here, however, the answer to any one item (such as a math problem or grammatical rule) could have informed students’ answers to subsequent problems of the same type. Beyond the timing of feedback per se, therefore, the immediacy of the correct answers could have changed the way that students approached subsequent questions of the same type, increasing the likelihood that they would apply the correct answer.

A third group was included that used 3-D printers but did not receive the same type of lecture-based guidance from the instructor. Due to the difference in instructional procedures, this “experiential learning” group is not included in the comparisons.

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Yeung, K.L., Carpenter, S.K. & Corral, D. A Comprehensive Review of Educational Technology on Objective Learning Outcomes in Academic Contexts. Educ Psychol Rev 33 , 1583–1630 (2021). https://doi.org/10.1007/s10648-020-09592-4

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How technology is reinventing education

Stanford Graduate School of Education Dean Dan Schwartz and other education scholars weigh in on what's next for some of the technology trends taking center stage in the classroom.

education and technology research paper

Image credit: Claire Scully

New advances in technology are upending education, from the recent debut of new artificial intelligence (AI) chatbots like ChatGPT to the growing accessibility of virtual-reality tools that expand the boundaries of the classroom. For educators, at the heart of it all is the hope that every learner gets an equal chance to develop the skills they need to succeed. But that promise is not without its pitfalls.

“Technology is a game-changer for education – it offers the prospect of universal access to high-quality learning experiences, and it creates fundamentally new ways of teaching,” said Dan Schwartz, dean of Stanford Graduate School of Education (GSE), who is also a professor of educational technology at the GSE and faculty director of the Stanford Accelerator for Learning . “But there are a lot of ways we teach that aren’t great, and a big fear with AI in particular is that we just get more efficient at teaching badly. This is a moment to pay attention, to do things differently.”

For K-12 schools, this year also marks the end of the Elementary and Secondary School Emergency Relief (ESSER) funding program, which has provided pandemic recovery funds that many districts used to invest in educational software and systems. With these funds running out in September 2024, schools are trying to determine their best use of technology as they face the prospect of diminishing resources.

Here, Schwartz and other Stanford education scholars weigh in on some of the technology trends taking center stage in the classroom this year.

AI in the classroom

In 2023, the big story in technology and education was generative AI, following the introduction of ChatGPT and other chatbots that produce text seemingly written by a human in response to a question or prompt. Educators immediately worried that students would use the chatbot to cheat by trying to pass its writing off as their own. As schools move to adopt policies around students’ use of the tool, many are also beginning to explore potential opportunities – for example, to generate reading assignments or coach students during the writing process.

AI can also help automate tasks like grading and lesson planning, freeing teachers to do the human work that drew them into the profession in the first place, said Victor Lee, an associate professor at the GSE and faculty lead for the AI + Education initiative at the Stanford Accelerator for Learning. “I’m heartened to see some movement toward creating AI tools that make teachers’ lives better – not to replace them, but to give them the time to do the work that only teachers are able to do,” he said. “I hope to see more on that front.”

He also emphasized the need to teach students now to begin questioning and critiquing the development and use of AI. “AI is not going away,” said Lee, who is also director of CRAFT (Classroom-Ready Resources about AI for Teaching), which provides free resources to help teach AI literacy to high school students across subject areas. “We need to teach students how to understand and think critically about this technology.”

Immersive environments

The use of immersive technologies like augmented reality, virtual reality, and mixed reality is also expected to surge in the classroom, especially as new high-profile devices integrating these realities hit the marketplace in 2024.

The educational possibilities now go beyond putting on a headset and experiencing life in a distant location. With new technologies, students can create their own local interactive 360-degree scenarios, using just a cell phone or inexpensive camera and simple online tools.

“This is an area that’s really going to explode over the next couple of years,” said Kristen Pilner Blair, director of research for the Digital Learning initiative at the Stanford Accelerator for Learning, which runs a program exploring the use of virtual field trips to promote learning. “Students can learn about the effects of climate change, say, by virtually experiencing the impact on a particular environment. But they can also become creators, documenting and sharing immersive media that shows the effects where they live.”

Integrating AI into virtual simulations could also soon take the experience to another level, Schwartz said. “If your VR experience brings me to a redwood tree, you could have a window pop up that allows me to ask questions about the tree, and AI can deliver the answers.”

Gamification

Another trend expected to intensify this year is the gamification of learning activities, often featuring dynamic videos with interactive elements to engage and hold students’ attention.

“Gamification is a good motivator, because one key aspect is reward, which is very powerful,” said Schwartz. The downside? Rewards are specific to the activity at hand, which may not extend to learning more generally. “If I get rewarded for doing math in a space-age video game, it doesn’t mean I’m going to be motivated to do math anywhere else.”

Gamification sometimes tries to make “chocolate-covered broccoli,” Schwartz said, by adding art and rewards to make speeded response tasks involving single-answer, factual questions more fun. He hopes to see more creative play patterns that give students points for rethinking an approach or adapting their strategy, rather than only rewarding them for quickly producing a correct response.

Data-gathering and analysis

The growing use of technology in schools is producing massive amounts of data on students’ activities in the classroom and online. “We’re now able to capture moment-to-moment data, every keystroke a kid makes,” said Schwartz – data that can reveal areas of struggle and different learning opportunities, from solving a math problem to approaching a writing assignment.

But outside of research settings, he said, that type of granular data – now owned by tech companies – is more likely used to refine the design of the software than to provide teachers with actionable information.

The promise of personalized learning is being able to generate content aligned with students’ interests and skill levels, and making lessons more accessible for multilingual learners and students with disabilities. Realizing that promise requires that educators can make sense of the data that’s being collected, said Schwartz – and while advances in AI are making it easier to identify patterns and findings, the data also needs to be in a system and form educators can access and analyze for decision-making. Developing a usable infrastructure for that data, Schwartz said, is an important next step.

With the accumulation of student data comes privacy concerns: How is the data being collected? Are there regulations or guidelines around its use in decision-making? What steps are being taken to prevent unauthorized access? In 2023 K-12 schools experienced a rise in cyberattacks, underscoring the need to implement strong systems to safeguard student data.

Technology is “requiring people to check their assumptions about education,” said Schwartz, noting that AI in particular is very efficient at replicating biases and automating the way things have been done in the past, including poor models of instruction. “But it’s also opening up new possibilities for students producing material, and for being able to identify children who are not average so we can customize toward them. It’s an opportunity to think of entirely new ways of teaching – this is the path I hope to see.”

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How technology is reinventing education.

Image credit: Claire Scully

New advances in technology are upending education, from the recent debut of new artificial intelligence (AI) chatbots like ChatGPT to the growing accessibility of virtual-reality tools that expand the boundaries of the classroom. For educators, at the heart of it all is the hope that every learner gets an equal chance to develop the skills they need to succeed. But that promise is not without its pitfalls.

“Technology is a game-changer for education – it offers the prospect of universal access to high-quality learning experiences, and it creates fundamentally new ways of teaching,” said Dan Schwartz, dean of  Stanford Graduate School of Education  (GSE), who is also a professor of educational technology at the GSE and faculty director of the  Stanford Accelerator for Learning . “But there are a lot of ways we teach that aren’t great, and a big fear with AI in particular is that we just get more efficient at teaching badly. This is a moment to pay attention, to do things differently.”

For K-12 schools, this year also marks the end of the Elementary and Secondary School Emergency Relief (ESSER) funding program, which has provided pandemic recovery funds that many districts used to invest in educational software and systems. With these funds running out in September 2024, schools are trying to determine their best use of technology as they face the prospect of diminishing resources.

Here, Schwartz and other Stanford education scholars weigh in on some of the technology trends taking center stage in the classroom this year.

AI in the classroom

In 2023, the big story in technology and education was generative AI, following the introduction of ChatGPT and other chatbots that produce text seemingly written by a human in response to a question or prompt. Educators immediately  worried  that students would use the chatbot to cheat by trying to pass its writing off as their own. As schools move to adopt policies around students’ use of the tool, many are also beginning to explore potential opportunities – for example, to generate reading assignments or  coach  students during the writing process.

AI can also help automate tasks like grading and lesson planning, freeing teachers to do the human work that drew them into the profession in the first place, said Victor Lee, an associate professor at the GSE and faculty lead for the AI + Education initiative at the Stanford Accelerator for Learning. “I’m heartened to see some movement toward creating AI tools that make teachers’ lives better – not to replace them, but to give them the time to do the work that only teachers are able to do,” he said. “I hope to see more on that front.”

He also emphasized the need to teach students now to begin questioning and critiquing the development and use of AI. “AI is not going away,” said Lee, who is also director of  CRAFT  (Classroom-Ready Resources about AI for Teaching), which provides free resources to help teach AI literacy to high school students across subject areas. “We need to teach students how to understand and think critically about this technology.”

Immersive environments

The use of immersive technologies like augmented reality, virtual reality, and mixed reality is also expected to surge in the classroom, especially as new high-profile devices integrating these realities hit the marketplace in 2024.

The educational possibilities now go beyond putting on a headset and experiencing life in a distant location. With new technologies, students can create their own local interactive 360-degree scenarios, using just a cell phone or inexpensive camera and simple online tools.

“This is an area that’s really going to explode over the next couple of years,” said Kristen Pilner Blair, director of research for the Digital Learning initiative at the Stanford Accelerator for Learning, which runs a program exploring the use of virtual field trips to promote learning. “Students can learn about the effects of climate change, say, by virtually experiencing the impact on a particular environment. But they can also become creators, documenting and sharing immersive media that shows the effects where they live.”

Integrating AI into virtual simulations could also soon take the experience to another level, Schwartz said. “If your VR experience brings me to a redwood tree, you could have a window pop up that allows me to ask questions about the tree, and AI can deliver the answers.”

Gamification

Another trend expected to intensify this year is the gamification of learning activities, often featuring dynamic videos with interactive elements to engage and hold students’ attention.

“Gamification is a good motivator, because one key aspect is reward, which is very powerful,” said Schwartz. The downside? Rewards are specific to the activity at hand, which may not extend to learning more generally. “If I get rewarded for doing math in a space-age video game, it doesn’t mean I’m going to be motivated to do math anywhere else.”

Gamification sometimes tries to make “chocolate-covered broccoli,” Schwartz said, by adding art and rewards to make speeded response tasks involving single-answer, factual questions more fun. He hopes to see more creative play patterns that give students points for rethinking an approach or adapting their strategy, rather than only rewarding them for quickly producing a correct response.

Data-gathering and analysis

The growing use of technology in schools is producing massive amounts of data on students’ activities in the classroom and online. “We’re now able to capture moment-to-moment data, every keystroke a kid makes,” said Schwartz – data that can reveal areas of struggle and different learning opportunities, from solving a math problem to approaching a writing assignment.

But outside of research settings, he said, that type of granular data – now owned by tech companies – is more likely used to refine the design of the software than to provide teachers with actionable information.

The promise of personalized learning is being able to generate content aligned with students’ interests and skill levels, and making lessons more accessible for multilingual learners and students with disabilities. Realizing that promise requires that educators can make sense of the data that’s being collected, said Schwartz – and while advances in AI are making it easier to identify patterns and findings, the data also needs to be in a system and form educators can access and analyze for decision-making. Developing a usable infrastructure for that data, Schwartz said, is an important next step.

With the accumulation of student data comes privacy concerns: How is the data being collected? Are there regulations or guidelines around its use in decision-making? What steps are being taken to prevent unauthorized access? In 2023 K-12 schools experienced a rise in cyberattacks, underscoring the need to implement strong systems to safeguard student data.

Technology is “requiring people to check their assumptions about education,” said Schwartz, noting that AI in particular is very efficient at replicating biases and automating the way things have been done in the past, including poor models of instruction. “But it’s also opening up new possibilities for students producing material, and for being able to identify children who are not average so we can customize toward them. It’s an opportunity to think of entirely new ways of teaching – this is the path I hope to see.”

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Impacts of digital technologies on education and factors influencing schools' digital capacity and transformation: A literature review

Stella timotheou.

1 CYENS Center of Excellence & Cyprus University of Technology (Cyprus Interaction Lab), Cyprus, CYENS Center of Excellence & Cyprus University of Technology, Nicosia-Limassol, Cyprus

Ourania Miliou

Yiannis dimitriadis.

2 Universidad de Valladolid (UVA), Spain, Valladolid, Spain

Sara Villagrá Sobrino

Nikoleta giannoutsou, romina cachia.

3 JRC - Joint Research Centre of the European Commission, Seville, Spain

Alejandra Martínez Monés

Andri ioannou, associated data.

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Digital technologies have brought changes to the nature and scope of education and led education systems worldwide to adopt strategies and policies for ICT integration. The latter brought about issues regarding the quality of teaching and learning with ICTs, especially concerning the understanding, adaptation, and design of the education systems in accordance with current technological trends. These issues were emphasized during the recent COVID-19 pandemic that accelerated the use of digital technologies in education, generating questions regarding digitalization in schools. Specifically, many schools demonstrated a lack of experience and low digital capacity, which resulted in widening gaps, inequalities, and learning losses. Such results have engendered the need for schools to learn and build upon the experience to enhance their digital capacity and preparedness, increase their digitalization levels, and achieve a successful digital transformation. Given that the integration of digital technologies is a complex and continuous process that impacts different actors within the school ecosystem, there is a need to show how these impacts are interconnected and identify the factors that can encourage an effective and efficient change in the school environments. For this purpose, we conducted a non-systematic literature review. The results of the literature review were organized thematically based on the evidence presented about the impact of digital technology on education and the factors that affect the schools’ digital capacity and digital transformation. The findings suggest that ICT integration in schools impacts more than just students’ performance; it affects several other school-related aspects and stakeholders, too. Furthermore, various factors affect the impact of digital technologies on education. These factors are interconnected and play a vital role in the digital transformation process. The study results shed light on how ICTs can positively contribute to the digital transformation of schools and which factors should be considered for schools to achieve effective and efficient change.

Introduction

Digital technologies have brought changes to the nature and scope of education. Versatile and disruptive technological innovations, such as smart devices, the Internet of Things (IoT), artificial intelligence (AI), augmented reality (AR) and virtual reality (VR), blockchain, and software applications have opened up new opportunities for advancing teaching and learning (Gaol & Prasolova-Førland, 2021 ; OECD, 2021 ). Hence, in recent years, education systems worldwide have increased their investment in the integration of information and communication technology (ICT) (Fernández-Gutiérrez et al., 2020 ; Lawrence & Tar, 2018 ) and prioritized their educational agendas to adapt strategies or policies around ICT integration (European Commission, 2019 ). The latter brought about issues regarding the quality of teaching and learning with ICTs (Bates, 2015 ), especially concerning the understanding, adaptation, and design of education systems in accordance with current technological trends (Balyer & Öz, 2018 ). Studies have shown that despite the investment made in the integration of technology in schools, the results have not been promising, and the intended outcomes have not yet been achieved (Delgado et al., 2015 ; Lawrence & Tar, 2018 ). These issues were exacerbated during the COVID-19 pandemic, which forced teaching across education levels to move online (Daniel, 2020 ). Online teaching accelerated the use of digital technologies generating questions regarding the process, the nature, the extent, and the effectiveness of digitalization in schools (Cachia et al., 2021 ; König et al., 2020 ). Specifically, many schools demonstrated a lack of experience and low digital capacity, which resulted in widening gaps, inequalities, and learning losses (Blaskó et al., 2021 ; Di Pietro et al, 2020 ). Such results have engendered the need for schools to learn and build upon the experience in order to enhance their digital capacity (European Commission, 2020 ) and increase their digitalization levels (Costa et al., 2021 ). Digitalization offers possibilities for fundamental improvement in schools (OECD, 2021 ; Rott & Marouane, 2018 ) and touches many aspects of a school’s development (Delcker & Ifenthaler, 2021 ) . However, it is a complex process that requires large-scale transformative changes beyond the technical aspects of technology and infrastructure (Pettersson, 2021 ). Namely, digitalization refers to “ a series of deep and coordinated culture, workforce, and technology shifts and operating models ” (Brooks & McCormack, 2020 , p. 3) that brings cultural, organizational, and operational change through the integration of digital technologies (JISC, 2020 ). A successful digital transformation requires that schools increase their digital capacity levels, establishing the necessary “ culture, policies, infrastructure as well as digital competence of students and staff to support the effective integration of technology in teaching and learning practices ” (Costa et al, 2021 , p.163).

Given that the integration of digital technologies is a complex and continuous process that impacts different actors within the school ecosystem (Eng, 2005 ), there is a need to show how the different elements of the impact are interconnected and to identify the factors that can encourage an effective and efficient change in the school environment. To address the issues outlined above, we formulated the following research questions:

a) What is the impact of digital technologies on education?

b) Which factors might affect a school’s digital capacity and transformation?

In the present investigation, we conducted a non-systematic literature review of publications pertaining to the impact of digital technologies on education and the factors that affect a school’s digital capacity and transformation. The results of the literature review were organized thematically based on the evidence presented about the impact of digital technology on education and the factors which affect the schools’ digital capacity and digital transformation.

Methodology

The non-systematic literature review presented herein covers the main theories and research published over the past 17 years on the topic. It is based on meta-analyses and review papers found in scholarly, peer-reviewed content databases and other key studies and reports related to the concepts studied (e.g., digitalization, digital capacity) from professional and international bodies (e.g., the OECD). We searched the Scopus database, which indexes various online journals in the education sector with an international scope, to collect peer-reviewed academic papers. Furthermore, we used an all-inclusive Google Scholar search to include relevant key terms or to include studies found in the reference list of the peer-reviewed papers, and other key studies and reports related to the concepts studied by professional and international bodies. Lastly, we gathered sources from the Publications Office of the European Union ( https://op.europa.eu/en/home ); namely, documents that refer to policies related to digital transformation in education.

Regarding search terms, we first searched resources on the impact of digital technologies on education by performing the following search queries: “impact” OR “effects” AND “digital technologies” AND “education”, “impact” OR “effects” AND “ICT” AND “education”. We further refined our results by adding the terms “meta-analysis” and “review” or by adjusting the search options based on the features of each database to avoid collecting individual studies that would provide limited contributions to a particular domain. We relied on meta-analyses and review studies as these consider the findings of multiple studies to offer a more comprehensive view of the research in a given area (Schuele & Justice, 2006 ). Specifically, meta-analysis studies provided quantitative evidence based on statistically verifiable results regarding the impact of educational interventions that integrate digital technologies in school classrooms (Higgins et al., 2012 ; Tolani-Brown et al., 2011 ).

However, quantitative data does not offer explanations for the challenges or difficulties experienced during ICT integration in learning and teaching (Tolani-Brown et al., 2011 ). To fill this gap, we analyzed literature reviews and gathered in-depth qualitative evidence of the benefits and implications of technology integration in schools. In the analysis presented herein, we also included policy documents and reports from professional and international bodies and governmental reports, which offered useful explanations of the key concepts of this study and provided recent evidence on digital capacity and transformation in education along with policy recommendations. The inclusion and exclusion criteria that were considered in this study are presented in Table ​ Table1 1 .

Inclusion and exclusion criteria for the selection of resources on the impact of digital technologies on education

To ensure a reliable extraction of information from each study and assist the research synthesis we selected the study characteristics of interest (impact) and constructed coding forms. First, an overview of the synthesis was provided by the principal investigator who described the processes of coding, data entry, and data management. The coders followed the same set of instructions but worked independently. To ensure a common understanding of the process between coders, a sample of ten studies was tested. The results were compared, and the discrepancies were identified and resolved. Additionally, to ensure an efficient coding process, all coders participated in group meetings to discuss additions, deletions, and modifications (Stock, 1994 ). Due to the methodological diversity of the studied documents we began to synthesize the literature review findings based on similar study designs. Specifically, most of the meta-analysis studies were grouped in one category due to the quantitative nature of the measured impact. These studies tended to refer to student achievement (Hattie et al., 2014 ). Then, we organized the themes of the qualitative studies in several impact categories. Lastly, we synthesized both review and meta-analysis data across the categories. In order to establish a collective understanding of the concept of impact, we referred to a previous impact study by Balanskat ( 2009 ) which investigated the impact of technology in primary schools. In this context, the impact had a more specific ICT-related meaning and was described as “ a significant influence or effect of ICT on the measured or perceived quality of (parts of) education ” (Balanskat, 2009 , p. 9). In the study presented herein, the main impacts are in relation to learning and learners, teaching, and teachers, as well as other key stakeholders who are directly or indirectly connected to the school unit.

The study’s results identified multiple dimensions of the impact of digital technologies on students’ knowledge, skills, and attitudes; on equality, inclusion, and social integration; on teachers’ professional and teaching practices; and on other school-related aspects and stakeholders. The data analysis indicated various factors that might affect the schools’ digital capacity and transformation, such as digital competencies, the teachers’ personal characteristics and professional development, as well as the school’s leadership and management, administration, infrastructure, etc. The impacts and factors found in the literature review are presented below.

Impacts of digital technologies on students’ knowledge, skills, attitudes, and emotions

The impact of ICT use on students’ knowledge, skills, and attitudes has been investigated early in the literature. Eng ( 2005 ) found a small positive effect between ICT use and students' learning. Specifically, the author reported that access to computer-assisted instruction (CAI) programs in simulation or tutorial modes—used to supplement rather than substitute instruction – could enhance student learning. The author reported studies showing that teachers acknowledged the benefits of ICT on pupils with special educational needs; however, the impact of ICT on students' attainment was unclear. Balanskat et al. ( 2006 ) found a statistically significant positive association between ICT use and higher student achievement in primary and secondary education. The authors also reported improvements in the performance of low-achieving pupils. The use of ICT resulted in further positive gains for students, namely increased attention, engagement, motivation, communication and process skills, teamwork, and gains related to their behaviour towards learning. Evidence from qualitative studies showed that teachers, students, and parents recognized the positive impact of ICT on students' learning regardless of their competence level (strong/weak students). Punie et al. ( 2006 ) documented studies that showed positive results of ICT-based learning for supporting low-achieving pupils and young people with complex lives outside the education system. Liao et al. ( 2007 ) reported moderate positive effects of computer application instruction (CAI, computer simulations, and web-based learning) over traditional instruction on primary school student's achievement. Similarly, Tamim et al. ( 2011 ) reported small to moderate positive effects between the use of computer technology (CAI, ICT, simulations, computer-based instruction, digital and hypermedia) and student achievement in formal face-to-face classrooms compared to classrooms that did not use technology. Jewitt et al., ( 2011 ) found that the use of learning platforms (LPs) (virtual learning environments, management information systems, communication technologies, and information- and resource-sharing technologies) in schools allowed primary and secondary students to access a wider variety of quality learning resources, engage in independent and personalized learning, and conduct self- and peer-review; LPs also provide opportunities for teacher assessment and feedback. Similar findings were reported by Fu ( 2013 ), who documented a list of benefits and opportunities of ICT use. According to the author, the use of ICTs helps students access digital information and course content effectively and efficiently, supports student-centered and self-directed learning, as well as the development of a creative learning environment where more opportunities for critical thinking skills are offered, and promotes collaborative learning in a distance-learning environment. Higgins et al. ( 2012 ) found consistent but small positive associations between the use of technology and learning outcomes of school-age learners (5–18-year-olds) in studies linking the provision and use of technology with attainment. Additionally, Chauhan ( 2017 ) reported a medium positive effect of technology on the learning effectiveness of primary school students compared to students who followed traditional learning instruction.

The rise of mobile technologies and hardware devices instigated investigations into their impact on teaching and learning. Sung et al. ( 2016 ) reported a moderate effect on students' performance from the use of mobile devices in the classroom compared to the use of desktop computers or the non-use of mobile devices. Schmid et al. ( 2014 ) reported medium–low to low positive effects of technology integration (e.g., CAI, ICTs) in the classroom on students' achievement and attitude compared to not using technology or using technology to varying degrees. Tamim et al. ( 2015 ) found a low statistically significant effect of the use of tablets and other smart devices in educational contexts on students' achievement outcomes. The authors suggested that tablets offered additional advantages to students; namely, they reported improvements in students’ notetaking, organizational and communication skills, and creativity. Zheng et al. ( 2016 ) reported a small positive effect of one-to-one laptop programs on students’ academic achievement across subject areas. Additional reported benefits included student-centered, individualized, and project-based learning enhanced learner engagement and enthusiasm. Additionally, the authors found that students using one-to-one laptop programs tended to use technology more frequently than in non-laptop classrooms, and as a result, they developed a range of skills (e.g., information skills, media skills, technology skills, organizational skills). Haßler et al. ( 2016 ) found that most interventions that included the use of tablets across the curriculum reported positive learning outcomes. However, from 23 studies, five reported no differences, and two reported a negative effect on students' learning outcomes. Similar results were indicated by Kalati and Kim ( 2022 ) who investigated the effect of touchscreen technologies on young students’ learning. Specifically, from 53 studies, 34 advocated positive effects of touchscreen devices on children’s learning, 17 obtained mixed findings and two studies reported negative effects.

More recently, approaches that refer to the impact of gamification with the use of digital technologies on teaching and learning were also explored. A review by Pan et al. ( 2022 ) that examined the role of learning games in fostering mathematics education in K-12 settings, reported that gameplay improved students’ performance. Integration of digital games in teaching was also found as a promising pedagogical practice in STEM education that could lead to increased learning gains (Martinez et al., 2022 ; Wang et al., 2022 ). However, although Talan et al. ( 2020 ) reported a medium effect of the use of educational games (both digital and non-digital) on academic achievement, the effect of non-digital games was higher.

Over the last two years, the effects of more advanced technologies on teaching and learning were also investigated. Garzón and Acevedo ( 2019 ) found that AR applications had a medium effect on students' learning outcomes compared to traditional lectures. Similarly, Garzón et al. ( 2020 ) showed that AR had a medium impact on students' learning gains. VR applications integrated into various subjects were also found to have a moderate effect on students’ learning compared to control conditions (traditional classes, e.g., lectures, textbooks, and multimedia use, e.g., images, videos, animation, CAI) (Chen et al., 2022b ). Villena-Taranilla et al. ( 2022 ) noted the moderate effect of VR technologies on students’ learning when these were applied in STEM disciplines. In the same meta-analysis, Villena-Taranilla et al. ( 2022 ) highlighted the role of immersive VR, since its effect on students’ learning was greater (at a high level) across educational levels (K-6) compared to semi-immersive and non-immersive integrations. In another meta-analysis study, the effect size of the immersive VR was small and significantly differentiated across educational levels (Coban et al., 2022 ). The impact of AI on education was investigated by Su and Yang ( 2022 ) and Su et al. ( 2022 ), who showed that this technology significantly improved students’ understanding of AI computer science and machine learning concepts.

It is worth noting that the vast majority of studies referred to learning gains in specific subjects. Specifically, several studies examined the impact of digital technologies on students’ literacy skills and reported positive effects on language learning (Balanskat et al., 2006 ; Grgurović et al., 2013 ; Friedel et al., 2013 ; Zheng et al., 2016 ; Chen et al., 2022b ; Savva et al., 2022 ). Also, several studies documented positive effects on specific language learning areas, namely foreign language learning (Kao, 2014 ), writing (Higgins et al., 2012 ; Wen & Walters, 2022 ; Zheng et al., 2016 ), as well as reading and comprehension (Cheung & Slavin, 2011 ; Liao et al., 2007 ; Schwabe et al., 2022 ). ICTs were also found to have a positive impact on students' performance in STEM (science, technology, engineering, and mathematics) disciplines (Arztmann et al., 2022 ; Bado, 2022 ; Villena-Taranilla et al., 2022 ; Wang et al., 2022 ). Specifically, a number of studies reported positive impacts on students’ achievement in mathematics (Balanskat et al., 2006 ; Hillmayr et al., 2020 ; Li & Ma, 2010 ; Pan et al., 2022 ; Ran et al., 2022 ; Verschaffel et al., 2019 ; Zheng et al., 2016 ). Furthermore, studies documented positive effects of ICTs on science learning (Balanskat et al., 2006 ; Liao et al., 2007 ; Zheng et al., 2016 ; Hillmayr et al., 2020 ; Kalemkuş & Kalemkuş, 2022 ; Lei et al., 2022a ). Çelik ( 2022 ) also noted that computer simulations can help students understand learning concepts related to science. Furthermore, some studies documented that the use of ICTs had a positive impact on students’ achievement in other subjects, such as geography, history, music, and arts (Chauhan, 2017 ; Condie & Munro, 2007 ), and design and technology (Balanskat et al., 2006 ).

More specific positive learning gains were reported in a number of skills, e.g., problem-solving skills and pattern exploration skills (Higgins et al., 2012 ), metacognitive learning outcomes (Verschaffel et al., 2019 ), literacy skills, computational thinking skills, emotion control skills, and collaborative inquiry skills (Lu et al., 2022 ; Su & Yang, 2022 ; Su et al., 2022 ). Additionally, several investigations have reported benefits from the use of ICT on students’ creativity (Fielding & Murcia, 2022 ; Liu et al., 2022 ; Quah & Ng, 2022 ). Lastly, digital technologies were also found to be beneficial for enhancing students’ lifelong learning skills (Haleem et al., 2022 ).

Apart from gaining knowledge and skills, studies also reported improvement in motivation and interest in mathematics (Higgins et. al., 2019 ; Fadda et al., 2022 ) and increased positive achievement emotions towards several subjects during interventions using educational games (Lei et al., 2022a ). Chen et al. ( 2022a ) also reported a small but positive effect of digital health approaches in bullying and cyberbullying interventions with K-12 students, demonstrating that technology-based approaches can help reduce bullying and related consequences by providing emotional support, empowerment, and change of attitude. In their meta-review study, Su et al. ( 2022 ) also documented that AI technologies effectively strengthened students’ attitudes towards learning. In another meta-analysis, Arztmann et al. ( 2022 ) reported positive effects of digital games on motivation and behaviour towards STEM subjects.

Impacts of digital technologies on equality, inclusion and social integration

Although most of the reviewed studies focused on the impact of ICTs on students’ knowledge, skills, and attitudes, reports were also made on other aspects in the school context, such as equality, inclusion, and social integration. Condie and Munro ( 2007 ) documented research interventions investigating how ICT can support pupils with additional or special educational needs. While those interventions were relatively small scale and mostly based on qualitative data, their findings indicated that the use of ICTs enabled the development of communication, participation, and self-esteem. A recent meta-analysis (Baragash et al., 2022 ) with 119 participants with different disabilities, reported a significant overall effect size of AR on their functional skills acquisition. Koh’s meta-analysis ( 2022 ) also revealed that students with intellectual and developmental disabilities improved their competence and performance when they used digital games in the lessons.

Istenic Starcic and Bagon ( 2014 ) found that the role of ICT in inclusion and the design of pedagogical and technological interventions was not sufficiently explored in educational interventions with people with special needs; however, some benefits of ICT use were found in students’ social integration. The issue of gender and technology use was mentioned in a small number of studies. Zheng et al. ( 2016 ) reported a statistically significant positive interaction between one-to-one laptop programs and gender. Specifically, the results showed that girls and boys alike benefitted from the laptop program, but the effect on girls’ achievement was smaller than that on boys’. Along the same lines, Arztmann et al. ( 2022 ) reported no difference in the impact of game-based learning between boys and girls, arguing that boys and girls equally benefited from game-based interventions in STEM domains. However, results from a systematic review by Cussó-Calabuig et al. ( 2018 ) found limited and low-quality evidence on the effects of intensive use of computers on gender differences in computer anxiety, self-efficacy, and self-confidence. Based on their view, intensive use of computers can reduce gender differences in some areas and not in others, depending on contextual and implementation factors.

Impacts of digital technologies on teachers’ professional and teaching practices

Various research studies have explored the impact of ICT on teachers’ instructional practices and student assessment. Friedel et al. ( 2013 ) found that the use of mobile devices by students enabled teachers to successfully deliver content (e.g., mobile serious games), provide scaffolding, and facilitate synchronous collaborative learning. The integration of digital games in teaching and learning activities also gave teachers the opportunity to study and apply various pedagogical practices (Bado, 2022 ). Specifically, Bado ( 2022 ) found that teachers who implemented instructional activities in three stages (pre-game, game, and post-game) maximized students’ learning outcomes and engagement. For instance, during the pre-game stage, teachers focused on lectures and gameplay training, at the game stage teachers provided scaffolding on content, addressed technical issues, and managed the classroom activities. During the post-game stage, teachers organized activities for debriefing to ensure that the gameplay had indeed enhanced students’ learning outcomes.

Furthermore, ICT can increase efficiency in lesson planning and preparation by offering possibilities for a more collaborative approach among teachers. The sharing of curriculum plans and the analysis of students’ data led to clearer target settings and improvements in reporting to parents (Balanskat et al., 2006 ).

Additionally, the use and application of digital technologies in teaching and learning were found to enhance teachers’ digital competence. Balanskat et al. ( 2006 ) documented studies that revealed that the use of digital technologies in education had a positive effect on teachers’ basic ICT skills. The greatest impact was found on teachers with enough experience in integrating ICTs in their teaching and/or who had recently participated in development courses for the pedagogical use of technologies in teaching. Punie et al. ( 2006 ) reported that the provision of fully equipped multimedia portable computers and the development of online teacher communities had positive impacts on teachers’ confidence and competence in the use of ICTs.

Moreover, online assessment via ICTs benefits instruction. In particular, online assessments support the digitalization of students’ work and related logistics, allow teachers to gather immediate feedback and readjust to new objectives, and support the improvement of the technical quality of tests by providing more accurate results. Additionally, the capabilities of ICTs (e.g., interactive media, simulations) create new potential methods of testing specific skills, such as problem-solving and problem-processing skills, meta-cognitive skills, creativity and communication skills, and the ability to work productively in groups (Punie et al., 2006 ).

Impacts of digital technologies on other school-related aspects and stakeholders

There is evidence that the effective use of ICTs and the data transmission offered by broadband connections help improve administration (Balanskat et al., 2006 ). Specifically, ICTs have been found to provide better management systems to schools that have data gathering procedures in place. Condie and Munro ( 2007 ) reported impacts from the use of ICTs in schools in the following areas: attendance monitoring, assessment records, reporting to parents, financial management, creation of repositories for learning resources, and sharing of information amongst staff. Such data can be used strategically for self-evaluation and monitoring purposes which in turn can result in school improvements. Additionally, they reported that online access to other people with similar roles helped to reduce headteachers’ isolation by offering them opportunities to share insights into the use of ICT in learning and teaching and how it could be used to support school improvement. Furthermore, ICTs provided more efficient and successful examination management procedures, namely less time-consuming reporting processes compared to paper-based examinations and smooth communications between schools and examination authorities through electronic data exchange (Punie et al., 2006 ).

Zheng et al. ( 2016 ) reported that the use of ICTs improved home-school relationships. Additionally, Escueta et al. ( 2017 ) reported several ICT programs that had improved the flow of information from the school to parents. Particularly, they documented that the use of ICTs (learning management systems, emails, dedicated websites, mobile phones) allowed for personalized and customized information exchange between schools and parents, such as attendance records, upcoming class assignments, school events, and students’ grades, which generated positive results on students’ learning outcomes and attainment. Such information exchange between schools and families prompted parents to encourage their children to put more effort into their schoolwork.

The above findings suggest that the impact of ICT integration in schools goes beyond students’ performance in school subjects. Specifically, it affects a number of school-related aspects, such as equality and social integration, professional and teaching practices, and diverse stakeholders. In Table ​ Table2, 2 , we summarize the different impacts of digital technologies on school stakeholders based on the literature review, while in Table ​ Table3 3 we organized the tools/platforms and practices/policies addressed in the meta-analyses, literature reviews, EU reports, and international bodies included in the manuscript.

The impact of digital technologies on schools’ stakeholders based on the literature review

Tools/platforms and practices/policies addressed in the meta-analyses, literature reviews, EU reports, and international bodies included in the manuscript

Additionally, based on the results of the literature review, there are many types of digital technologies with different affordances (see, for example, studies on VR vs Immersive VR), which evolve over time (e.g. starting from CAIs in 2005 to Augmented and Virtual reality 2020). Furthermore, these technologies are linked to different pedagogies and policy initiatives, which are critical factors in the study of impact. Table ​ Table3 3 summarizes the different tools and practices that have been used to examine the impact of digital technologies on education since 2005 based on the review results.

Factors that affect the integration of digital technologies

Although the analysis of the literature review demonstrated different impacts of the use of digital technology on education, several authors highlighted the importance of various factors, besides the technology itself, that affect this impact. For example, Liao et al. ( 2007 ) suggested that future studies should carefully investigate which factors contribute to positive outcomes by clarifying the exact relationship between computer applications and learning. Additionally, Haßler et al., ( 2016 ) suggested that the neutral findings regarding the impact of tablets on students learning outcomes in some of the studies included in their review should encourage educators, school leaders, and school officials to further investigate the potential of such devices in teaching and learning. Several other researchers suggested that a number of variables play a significant role in the impact of ICTs on students’ learning that could be attributed to the school context, teaching practices and professional development, the curriculum, and learners’ characteristics (Underwood, 2009 ; Tamim et al., 2011 ; Higgins et al., 2012 ; Archer et al., 2014 ; Sung et al., 2016 ; Haßler et al., 2016 ; Chauhan, 2017 ; Lee et al., 2020 ; Tang et al., 2022 ).

Digital competencies

One of the most common challenges reported in studies that utilized digital tools in the classroom was the lack of students’ skills on how to use them. Fu ( 2013 ) found that students’ lack of technical skills is a barrier to the effective use of ICT in the classroom. Tamim et al. ( 2015 ) reported that students faced challenges when using tablets and smart mobile devices, associated with the technical issues or expertise needed for their use and the distracting nature of the devices and highlighted the need for teachers’ professional development. Higgins et al. ( 2012 ) reported that skills training about the use of digital technologies is essential for learners to fully exploit the benefits of instruction.

Delgado et al. ( 2015 ), meanwhile, reported studies that showed a strong positive association between teachers’ computer skills and students’ use of computers. Teachers’ lack of ICT skills and familiarization with technologies can become a constraint to the effective use of technology in the classroom (Balanskat et al., 2006 ; Delgado et al., 2015 ).

It is worth noting that the way teachers are introduced to ICTs affects the impact of digital technologies on education. Previous studies have shown that teachers may avoid using digital technologies due to limited digital skills (Balanskat, 2006 ), or they prefer applying “safe” technologies, namely technologies that their own teachers used and with which they are familiar (Condie & Munro, 2007 ). In this regard, the provision of digital skills training and exposure to new digital tools might encourage teachers to apply various technologies in their lessons (Condie & Munro, 2007 ). Apart from digital competence, technical support in the school setting has also been shown to affect teachers’ use of technology in their classrooms (Delgado et al., 2015 ). Ferrari et al. ( 2011 ) found that while teachers’ use of ICT is high, 75% stated that they needed more institutional support and a shift in the mindset of educational actors to achieve more innovative teaching practices. The provision of support can reduce time and effort as well as cognitive constraints, which could cause limited ICT integration in the school lessons by teachers (Escueta et al., 2017 ).

Teachers’ personal characteristics, training approaches, and professional development

Teachers’ personal characteristics and professional development affect the impact of digital technologies on education. Specifically, Cheok and Wong ( 2015 ) found that teachers’ personal characteristics (e.g., anxiety, self-efficacy) are associated with their satisfaction and engagement with technology. Bingimlas ( 2009 ) reported that lack of confidence, resistance to change, and negative attitudes in using new technologies in teaching are significant determinants of teachers’ levels of engagement in ICT. The same author reported that the provision of technical support, motivation support (e.g., awards, sufficient time for planning), and training on how technologies can benefit teaching and learning can eliminate the above barriers to ICT integration. Archer et al. ( 2014 ) found that comfort levels in using technology are an important predictor of technology integration and argued that it is essential to provide teachers with appropriate training and ongoing support until they are comfortable with using ICTs in the classroom. Hillmayr et al. ( 2020 ) documented that training teachers on ICT had an important effecton students’ learning.

According to Balanskat et al. ( 2006 ), the impact of ICTs on students’ learning is highly dependent on the teachers’ capacity to efficiently exploit their application for pedagogical purposes. Results obtained from the Teaching and Learning International Survey (TALIS) (OECD, 2021 ) revealed that although schools are open to innovative practices and have the capacity to adopt them, only 39% of teachers in the European Union reported that they are well or very well prepared to use digital technologies for teaching. Li and Ma ( 2010 ) and Hardman ( 2019 ) showed that the positive effect of technology on students’ achievement depends on the pedagogical practices used by teachers. Schmid et al. ( 2014 ) reported that learning was best supported when students were engaged in active, meaningful activities with the use of technological tools that provided cognitive support. Tamim et al. ( 2015 ) compared two different pedagogical uses of tablets and found a significant moderate effect when the devices were used in a student-centered context and approach rather than within teacher-led environments. Similarly, Garzón and Acevedo ( 2019 ) and Garzón et al. ( 2020 ) reported that the positive results from the integration of AR applications could be attributed to the existence of different variables which could influence AR interventions (e.g., pedagogical approach, learning environment, and duration of the intervention). Additionally, Garzón et al. ( 2020 ) suggested that the pedagogical resources that teachers used to complement their lectures and the pedagogical approaches they applied were crucial to the effective integration of AR on students’ learning gains. Garzón and Acevedo ( 2019 ) also emphasized that the success of a technology-enhanced intervention is based on both the technology per se and its characteristics and on the pedagogical strategies teachers choose to implement. For instance, their results indicated that the collaborative learning approach had the highest impact on students’ learning gains among other approaches (e.g., inquiry-based learning, situated learning, or project-based learning). Ran et al. ( 2022 ) also found that the use of technology to design collaborative and communicative environments showed the largest moderator effects among the other approaches.

Hattie ( 2008 ) reported that the effective use of computers is associated with training teachers in using computers as a teaching and learning tool. Zheng et al. ( 2016 ) noted that in addition to the strategies teachers adopt in teaching, ongoing professional development is also vital in ensuring the success of technology implementation programs. Sung et al. ( 2016 ) found that research on the use of mobile devices to support learning tends to report that the insufficient preparation of teachers is a major obstacle in implementing effective mobile learning programs in schools. Friedel et al. ( 2013 ) found that providing training and support to teachers increased the positive impact of the interventions on students’ learning gains. Trucano ( 2005 ) argued that positive impacts occur when digital technologies are used to enhance teachers’ existing pedagogical philosophies. Higgins et al. ( 2012 ) found that the types of technologies used and how they are used could also affect students’ learning. The authors suggested that training and professional development of teachers that focuses on the effective pedagogical use of technology to support teaching and learning is an important component of successful instructional approaches (Higgins et al., 2012 ). Archer et al. ( 2014 ) found that studies that reported ICT interventions during which teachers received training and support had moderate positive effects on students’ learning outcomes, which were significantly higher than studies where little or no detail about training and support was mentioned. Fu ( 2013 ) reported that the lack of teachers’ knowledge and skills on the technical and instructional aspects of ICT use in the classroom, in-service training, pedagogy support, technical and financial support, as well as the lack of teachers’ motivation and encouragement to integrate ICT on their teaching were significant barriers to the integration of ICT in education.

School leadership and management

Management and leadership are important cornerstones in the digital transformation process (Pihir et al., 2018 ). Zheng et al. ( 2016 ) documented leadership among the factors positively affecting the successful implementation of technology integration in schools. Strong leadership, strategic planning, and systematic integration of digital technologies are prerequisites for the digital transformation of education systems (Ređep, 2021 ). Management and leadership play a significant role in formulating policies that are translated into practice and ensure that developments in ICT become embedded into the life of the school and in the experiences of staff and pupils (Condie & Munro, 2007 ). Policy support and leadership must include the provision of an overall vision for the use of digital technologies in education, guidance for students and parents, logistical support, as well as teacher training (Conrads et al., 2017 ). Unless there is a commitment throughout the school, with accountability for progress at key points, it is unlikely for ICT integration to be sustained or become part of the culture (Condie & Munro, 2007 ). To achieve this, principals need to adopt and promote a whole-institution strategy and build a strong mutual support system that enables the school’s technological maturity (European Commission, 2019 ). In this context, school culture plays an essential role in shaping the mindsets and beliefs of school actors towards successful technology integration. Condie and Munro ( 2007 ) emphasized the importance of the principal’s enthusiasm and work as a source of inspiration for the school staff and the students to cultivate a culture of innovation and establish sustainable digital change. Specifically, school leaders need to create conditions in which the school staff is empowered to experiment and take risks with technology (Elkordy & Lovinelli, 2020 ).

In order for leaders to achieve the above, it is important to develop capacities for learning and leading, advocating professional learning, and creating support systems and structures (European Commission, 2019 ). Digital technology integration in education systems can be challenging and leadership needs guidance to achieve it. Such guidance can be introduced through the adoption of new methods and techniques in strategic planning for the integration of digital technologies (Ređep, 2021 ). Even though the role of leaders is vital, the relevant training offered to them has so far been inadequate. Specifically, only a third of the education systems in Europe have put in place national strategies that explicitly refer to the training of school principals (European Commission, 2019 , p. 16).

Connectivity, infrastructure, and government and other support

The effective integration of digital technologies across levels of education presupposes the development of infrastructure, the provision of digital content, and the selection of proper resources (Voogt et al., 2013 ). Particularly, a high-quality broadband connection in the school increases the quality and quantity of educational activities. There is evidence that ICT increases and formalizes cooperative planning between teachers and cooperation with managers, which in turn has a positive impact on teaching practices (Balanskat et al., 2006 ). Additionally, ICT resources, including software and hardware, increase the likelihood of teachers integrating technology into the curriculum to enhance their teaching practices (Delgado et al., 2015 ). For example, Zheng et al. ( 2016 ) found that the use of one-on-one laptop programs resulted in positive changes in teaching and learning, which would not have been accomplished without the infrastructure and technical support provided to teachers. Delgado et al. ( 2015 ) reported that limited access to technology (insufficient computers, peripherals, and software) and lack of technical support are important barriers to ICT integration. Access to infrastructure refers not only to the availability of technology in a school but also to the provision of a proper amount and the right types of technology in locations where teachers and students can use them. Effective technical support is a central element of the whole-school strategy for ICT (Underwood, 2009 ). Bingimlas ( 2009 ) reported that lack of technical support in the classroom and whole-school resources (e.g., failing to connect to the Internet, printers not printing, malfunctioning computers, and working on old computers) are significant barriers that discourage the use of ICT by teachers. Moreover, poor quality and inadequate hardware maintenance, and unsuitable educational software may discourage teachers from using ICTs (Balanskat et al., 2006 ; Bingimlas, 2009 ).

Government support can also impact the integration of ICTs in teaching. Specifically, Balanskat et al. ( 2006 ) reported that government interventions and training programs increased teachers’ enthusiasm and positive attitudes towards ICT and led to the routine use of embedded ICT.

Lastly, another important factor affecting digital transformation is the development and quality assurance of digital learning resources. Such resources can be support textbooks and related materials or resources that focus on specific subjects or parts of the curriculum. Policies on the provision of digital learning resources are essential for schools and can be achieved through various actions. For example, some countries are financing web portals that become repositories, enabling teachers to share resources or create their own. Additionally, they may offer e-learning opportunities or other services linked to digital education. In other cases, specific agencies of projects have also been set up to develop digital resources (Eurydice, 2019 ).

Administration and digital data management

The digital transformation of schools involves organizational improvements at the level of internal workflows, communication between the different stakeholders, and potential for collaboration. Vuorikari et al. ( 2020 ) presented evidence that digital technologies supported the automation of administrative practices in schools and reduced the administration’s workload. There is evidence that digital data affects the production of knowledge about schools and has the power to transform how schooling takes place. Specifically, Sellar ( 2015 ) reported that data infrastructure in education is developing due to the demand for “ information about student outcomes, teacher quality, school performance, and adult skills, associated with policy efforts to increase human capital and productivity practices ” (p. 771). In this regard, practices, such as datafication which refers to the “ translation of information about all kinds of things and processes into quantified formats” have become essential for decision-making based on accountability reports about the school’s quality. The data could be turned into deep insights about education or training incorporating ICTs. For example, measuring students’ online engagement with the learning material and drawing meaningful conclusions can allow teachers to improve their educational interventions (Vuorikari et al., 2020 ).

Students’ socioeconomic background and family support

Research show that the active engagement of parents in the school and their support for the school’s work can make a difference to their children’s attitudes towards learning and, as a result, their achievement (Hattie, 2008 ). In recent years, digital technologies have been used for more effective communication between school and family (Escueta et al., 2017 ). The European Commission ( 2020 ) presented data from a Eurostat survey regarding the use of computers by students during the pandemic. The data showed that younger pupils needed additional support and guidance from parents and the challenges were greater for families in which parents had lower levels of education and little to no digital skills.

In this regard, the socio-economic background of the learners and their socio-cultural environment also affect educational achievements (Punie et al., 2006 ). Trucano documented that the use of computers at home positively influenced students’ confidence and resulted in more frequent use at school, compared to students who had no home access (Trucano, 2005 ). In this sense, the socio-economic background affects the access to computers at home (OECD, 2015 ) which in turn influences the experience of ICT, an important factor for school achievement (Punie et al., 2006 ; Underwood, 2009 ). Furthermore, parents from different socio-economic backgrounds may have different abilities and availability to support their children in their learning process (Di Pietro et al., 2020 ).

Schools’ socioeconomic context and emergency situations

The socio-economic context of the school is closely related to a school’s digital transformation. For example, schools in disadvantaged, rural, or deprived areas are likely to lack the digital capacity and infrastructure required to adapt to the use of digital technologies during emergency periods, such as the COVID-19 pandemic (Di Pietro et al., 2020 ). Data collected from school principals confirmed that in several countries, there is a rural/urban divide in connectivity (OECD, 2015 ).

Emergency periods also affect the digitalization of schools. The COVID-19 pandemic led to the closure of schools and forced them to seek appropriate and connective ways to keep working on the curriculum (Di Pietro et al., 2020 ). The sudden large-scale shift to distance and online teaching and learning also presented challenges around quality and equity in education, such as the risk of increased inequalities in learning, digital, and social, as well as teachers facing difficulties coping with this demanding situation (European Commission, 2020 ).

Looking at the findings of the above studies, we can conclude that the impact of digital technologies on education is influenced by various actors and touches many aspects of the school ecosystem. Figure  1 summarizes the factors affecting the digital technologies’ impact on school stakeholders based on the findings from the literature review.

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Factors that affect the impact of ICTs on education

The findings revealed that the use of digital technologies in education affects a variety of actors within a school’s ecosystem. First, we observed that as technologies evolve, so does the interest of the research community to apply them to school settings. Figure  2 summarizes the trends identified in current research around the impact of digital technologies on schools’ digital capacity and transformation as found in the present study. Starting as early as 2005, when computers, simulations, and interactive boards were the most commonly applied tools in school interventions (e.g., Eng, 2005 ; Liao et al., 2007 ; Moran et al., 2008 ; Tamim et al., 2011 ), moving towards the use of learning platforms (Jewitt et al., 2011 ), then to the use of mobile devices and digital games (e.g., Tamim et al., 2015 ; Sung et al., 2016 ; Talan et al., 2020 ), as well as e-books (e.g., Savva et al., 2022 ), to the more recent advanced technologies, such as AR and VR applications (e.g., Garzón & Acevedo, 2019 ; Garzón et al., 2020 ; Kalemkuş & Kalemkuş, 2022 ), or robotics and AI (e.g., Su & Yang, 2022 ; Su et al., 2022 ). As this evolution shows, digital technologies are a concept in flux with different affordances and characteristics. Additionally, from an instructional perspective, there has been a growing interest in different modes and models of content delivery such as online, blended, and hybrid modes (e.g., Cheok & Wong, 2015 ; Kazu & Yalçin, 2022 ; Ulum, 2022 ). This is an indication that the value of technologies to support teaching and learning as well as other school-related practices is increasingly recognized by the research and school community. The impact results from the literature review indicate that ICT integration on students’ learning outcomes has effects that are small (Coban et al., 2022 ; Eng, 2005 ; Higgins et al., 2012 ; Schmid et al., 2014 ; Tamim et al., 2015 ; Zheng et al., 2016 ) to moderate (Garzón & Acevedo, 2019 ; Garzón et al., 2020 ; Liao et al., 2007 ; Sung et al., 2016 ; Talan et al., 2020 ; Wen & Walters, 2022 ). That said, a number of recent studies have reported high effect sizes (e.g., Kazu & Yalçin, 2022 ).

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Current work and trends in the study of the impact of digital technologies on schools’ digital capacity

Based on these findings, several authors have suggested that the impact of technology on education depends on several variables and not on the technology per se (Tamim et al., 2011 ; Higgins et al., 2012 ; Archer et al., 2014 ; Sung et al., 2016 ; Haßler et al., 2016 ; Chauhan, 2017 ; Lee et al., 2020 ; Lei et al., 2022a ). While the impact of ICTs on student achievement has been thoroughly investigated by researchers, other aspects related to school life that are also affected by ICTs, such as equality, inclusion, and social integration have received less attention. Further analysis of the literature review has revealed a greater investment in ICT interventions to support learning and teaching in the core subjects of literacy and STEM disciplines, especially mathematics, and science. These were the most common subjects studied in the reviewed papers often drawing on national testing results, while studies that investigated other subject areas, such as social studies, were limited (Chauhan, 2017 ; Condie & Munro, 2007 ). As such, research is still lacking impact studies that focus on the effects of ICTs on a range of curriculum subjects.

The qualitative research provided additional information about the impact of digital technologies on education, documenting positive effects and giving more details about implications, recommendations, and future research directions. Specifically, the findings regarding the role of ICTs in supporting learning highlight the importance of teachers’ instructional practice and the learning context in the use of technologies and consequently their impact on instruction (Çelik, 2022 ; Schmid et al., 2014 ; Tamim et al., 2015 ). The review also provided useful insights regarding the various factors that affect the impact of digital technologies on education. These factors are interconnected and play a vital role in the transformation process. Specifically, these factors include a) digital competencies; b) teachers’ personal characteristics and professional development; c) school leadership and management; d) connectivity, infrastructure, and government support; e) administration and data management practices; f) students’ socio-economic background and family support and g) the socioeconomic context of the school and emergency situations. It is worth noting that we observed factors that affect the integration of ICTs in education but may also be affected by it. For example, the frequent use of ICTs and the use of laptops by students for instructional purposes positively affect the development of digital competencies (Zheng et al., 2016 ) and at the same time, the digital competencies affect the use of ICTs (Fu, 2013 ; Higgins et al., 2012 ). As a result, the impact of digital technologies should be explored more as an enabler of desirable and new practices and not merely as a catalyst that improves the output of the education process i.e. namely student attainment.

Conclusions

Digital technologies offer immense potential for fundamental improvement in schools. However, investment in ICT infrastructure and professional development to improve school education are yet to provide fruitful results. Digital transformation is a complex process that requires large-scale transformative changes that presuppose digital capacity and preparedness. To achieve such changes, all actors within the school’s ecosystem need to share a common vision regarding the integration of ICTs in education and work towards achieving this goal. Our literature review, which synthesized quantitative and qualitative data from a list of meta-analyses and review studies, provided useful insights into the impact of ICTs on different school stakeholders and showed that the impact of digital technologies touches upon many different aspects of school life, which are often overlooked when the focus is on student achievement as the final output of education. Furthermore, the concept of digital technologies is a concept in flux as technologies are not only different among them calling for different uses in the educational practice but they also change through time. Additionally, we opened a forum for discussion regarding the factors that affect a school’s digital capacity and transformation. We hope that our study will inform policy, practice, and research and result in a paradigm shift towards more holistic approaches in impact and assessment studies.

Study limitations and future directions

We presented a review of the study of digital technologies' impact on education and factors influencing schools’ digital capacity and transformation. The study results were based on a non-systematic literature review grounded on the acquisition of documentation in specific databases. Future studies should investigate more databases to corroborate and enhance our results. Moreover, search queries could be enhanced with key terms that could provide additional insights about the integration of ICTs in education, such as “policies and strategies for ICT integration in education”. Also, the study drew information from meta-analyses and literature reviews to acquire evidence about the effects of ICT integration in schools. Such evidence was mostly based on the general conclusions of the studies. It is worth mentioning that, we located individual studies which showed different, such as negative or neutral results. Thus, further insights are needed about the impact of ICTs on education and the factors influencing the impact. Furthermore, the nature of the studies included in meta-analyses and reviews is different as they are based on different research methodologies and data gathering processes. For instance, in a meta-analysis, the impact among the studies investigated is measured in a particular way, depending on policy or research targets (e.g., results from national examinations, pre-/post-tests). Meanwhile, in literature reviews, qualitative studies offer additional insights and detail based on self-reports and research opinions on several different aspects and stakeholders who could affect and be affected by ICT integration. As a result, it was challenging to draw causal relationships between so many interrelating variables.

Despite the challenges mentioned above, this study envisaged examining school units as ecosystems that consist of several actors by bringing together several variables from different research epistemologies to provide an understanding of the integration of ICTs. However, the use of other tools and methodologies and models for evaluation of the impact of digital technologies on education could give more detailed data and more accurate results. For instance, self-reflection tools, like SELFIE—developed on the DigCompOrg framework- (Kampylis et al., 2015 ; Bocconi & Lightfoot, 2021 ) can help capture a school’s digital capacity and better assess the impact of ICTs on education. Furthermore, the development of a theory of change could be a good approach for documenting the impact of digital technologies on education. Specifically, theories of change are models used for the evaluation of interventions and their impact; they are developed to describe how interventions will work and give the desired outcomes (Mayne, 2015 ). Theory of change as a methodological approach has also been used by researchers to develop models for evaluation in the field of education (e.g., Aromatario et al., 2019 ; Chapman & Sammons, 2013 ; De Silva et al., 2014 ).

We also propose that future studies aim at similar investigations by applying more holistic approaches for impact assessment that can provide in-depth data about the impact of digital technologies on education. For instance, future studies could focus on different research questions about the technologies that are used during the interventions or the way the implementation takes place (e.g., What methodologies are used for documenting impact? How are experimental studies implemented? How can teachers be taken into account and trained on the technology and its functions? What are the elements of an appropriate and successful implementation? How is the whole intervention designed? On which learning theories is the technology implementation based?).

Future research could also focus on assessing the impact of digital technologies on various other subjects since there is a scarcity of research related to particular subjects, such as geography, history, arts, music, and design and technology. More research should also be done about the impact of ICTs on skills, emotions, and attitudes, and on equality, inclusion, social interaction, and special needs education. There is also a need for more research about the impact of ICTs on administration, management, digitalization, and home-school relationships. Additionally, although new forms of teaching and learning with the use of ICTs (e.g., blended, hybrid, and online learning) have initiated several investigations in mainstream classrooms, only a few studies have measured their impact on students’ learning. Additionally, our review did not document any study about the impact of flipped classrooms on K-12 education. Regarding teaching and learning approaches, it is worth noting that studies referred to STEM or STEAM did not investigate the impact of STEM/STEAM as an interdisciplinary approach to learning but only investigated the impact of ICTs on learning in each domain as a separate subject (science, technology, engineering, arts, mathematics). Hence, we propose future research to also investigate the impact of the STEM/STEAM approach on education. The impact of emerging technologies on education, such as AR, VR, robotics, and AI has also been investigated recently, but more work needs to be done.

Finally, we propose that future studies could focus on the way in which specific factors, e.g., infrastructure and government support, school leadership and management, students’ and teachers’ digital competencies, approaches teachers utilize in the teaching and learning (e.g., blended, online and hybrid learning, flipped classrooms, STEM/STEAM approach, project-based learning, inquiry-based learning), affect the impact of digital technologies on education. We hope that future studies will give detailed insights into the concept of schools’ digital transformation through further investigation of impacts and factors which influence digital capacity and transformation based on the results and the recommendations of the present study.

Acknowledgements

This project has received funding under Grant Agreement No Ref Ares (2021) 339036 7483039 as well as funding from the European Union’s Horizon 2020 Research and Innovation Program under Grant Agreement No 739578 and the Government of the Republic of Cyprus through the Deputy Ministry of Research, Innovation and Digital Policy. The UVa co-authors would like also to acknowledge funding from the European Regional Development Fund and the National Research Agency of the Spanish Ministry of Science and Innovation, under project grant PID2020-112584RB-C32.

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Title: quantum education in the frontier city of kharkiv.

Abstract: This article provides the description of current training processes and structure of education in quantum physics at the Education and Research Institute "School of Physics and Technology" (SPT) of V.N. Karazin Kharkiv National University, Ukraine. Crucial feature of quantum education at the SPT is the involvement of scientists and experts from national and international research centers who are actively working in the field. By taking example of particular quantum courses, we outline the main challenges in the educational process during the large-scale military aggression and the ways the lecturers, scientific employees, and students manage to overcome them. We also overview the recently emerged initiatives oriented on sustaining and development of quantum education in Kharkiv, as well as the international events with a broader impact. History of the School and its main achievements are provided in brief.

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This paper is in the following e-collection/theme issue:

Published on 22.2.2024 in Vol 26 (2024)

Living Lab Data of Patient Needs and Expectations for eHealth-Based Cardiac Rehabilitation in Germany and Spain From the TIMELY Study: Cross-Sectional Analysis

Authors of this article:

Author Orcid Image

Original Paper

  • Boris Schmitz 1, 2 , PhD   ; 
  • Svenja Wirtz 1, 2 , MSc   ; 
  • Manuela Sestayo-Fernández 3 , BSc   ; 
  • Hendrik Schäfer 1, 2 , MSc   ; 
  • Emma R Douma 4 , MSc   ; 
  • Marta Alonso Vazquez 3 , MSc   ; 
  • Violeta González-Salvado 5 , MD   ; 
  • Mirela Habibovic 4 , PhD   ; 
  • Dimitris Gatsios 6 , PhD   ; 
  • Willem Johan Kop 4 , PhD   ; 
  • Carlos Peña-Gil 5 , MD   ; 
  • Frank Mooren 1, 2 , MD  

1 Department of Rehabilitation Sciences, Faculty of Health, University of Witten/Herdecke, Witten, Germany

2 Center for Medical Rehabilitation, DRV Clinic Königsfeld, Ennepetal, Germany

3 Health Research Institute of Santiago de Compostela, Santiago de Compostela, Spain

4 Center of Research on Psychological Disorders and Somatic Diseases, Tilburg University, Tilburg, Netherlands

5 Cardiology and Coronary Care Department, IDIS, CIBER CV, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain

6 Capemed, Ioannina, Greece

Corresponding Author:

Boris Schmitz, PhD

Department of Rehabilitation Sciences

Faculty of Health

University of Witten/Herdecke

Alfred-Herrhausen-Straße 50

Witten, 58455

Phone: 49 23339888 ext 156

Email: [email protected]

Background: The use of eHealth technology in cardiac rehabilitation (CR) is a promising approach to enhance patient outcomes since adherence to healthy lifestyles and risk factor management during phase III CR maintenance is often poorly supported. However, patients’ needs and expectations have not been extensively analyzed to inform the design of such eHealth solutions.

Objective: The goal of this study was to provide a detailed patient perspective on the most important functionalities to include in an eHealth solution to assist them in phase III CR maintenance.

Methods: A guided survey as part of a Living Lab approach was conducted in Germany (n=49) and Spain (n=30) involving women (16/79, 20%) and men (63/79, 80%) with coronary artery disease (mean age 57 years, SD 9 years) participating in a structured center-based CR program. The survey covered patients’ perceived importance of different CR components in general, current usage of technology/technical devices, and helpfulness of the potential features of eHealth in CR. Questionnaires were used to identify personality traits (psychological flexibility, optimism/pessimism, positive/negative affect), potentially predisposing patients to acceptance of an app/monitoring devices.

Results: All the patients in this study owned a smartphone, while 30%-40% used smartwatches and fitness trackers. Patients expressed the need for an eHealth platform that is user-friendly, personalized, and easily accessible, and 71% (56/79) of the patients believed that technology could help them to maintain health goals after CR. Among the offered components, support for regular physical exercise, including updated schedules and progress documentation, was rated the highest. In addition, patients rated the availability of information on diagnosis, current medication, test results, and risk scores as (very) useful. Of note, for each item, except smoking cessation, 35%-50% of the patients indicated a high need for support to achieve their long-term health goals, suggesting the need for individualized care. No major differences were detected between Spanish and German patients (all P >.05) and only younger age ( P =.03) but not sex, education level, or personality traits (all P >.05) were associated with the acceptance of eHealth components.

Conclusions: The patient perspectives collected in this study indicate high acceptance of personalized user-friendly eHealth platforms with remote monitoring to improve adherence to healthy lifestyles among patients with coronary artery disease during phase III CR maintenance. The identified patient needs comprise support in physical exercise, including regular updates on personalized training recommendations. Availability of diagnoses, laboratory results, and medications, as part of a mobile electronic health record were also rated as very useful.

Trial Registration: ClinicalTrials.gov NCT05461729; https://clinicaltrials.gov/study/NCT05461729

Introduction

The application of eHealth technology in cardiac rehabilitation (CR) is being increasingly adopted to enhance patient outcomes. eHealth, which involves the use of digital health technologies, has the potential to facilitate CR programs to offer better, more efficient, and cost-effective care. CR is a crucial aspect of the recovery process after a cardiac event, aiming to reduce the risk of future events and improve the quality of life of patients [ 1 , 2 ]. The European Society of Cardiology defines CR as a multifactorial intervention with core components in patient assessment, physical activity, diet/nutritional counselling, risk factor control, patient education, psychosocial management, vocational advice, and lifestyle behavior change, including patients’ adherence and self-management [ 3 ]. The CR process is typically divided into 3 stages. During phase I, patients discuss their cardiovascular risk factors and health situation in the acute clinic after a coronary intervention or surgery with their treating physician or a CR nurse. This brief phase lasts only a few days and aims to get patients moving as soon as possible, encouraging mild levels of physical activity [ 4 ]. Phase II, the reconditioning phase, occurs at inpatient or outpatient CR centers or even in the home environment with various levels of support. This multidisciplinary phase includes education on risk factors, supervised exercise training, and psychological support, with the goal of improving patients’ exercise capacity, functional mobility, and self-management skills [ 5 ]. In phase III, also referred to as the maintenance phase, patients continue their care in a community or home-based setting. Phase III is the longest and least structured phase of CR, aiming at lifelong self-care with continuous risk factor management and regular physical activity to maintain the achievements made during phase II [ 4 , 6 ]. However, adherence to a healthy lifestyle, including regular physical activity and risk factor management, during phase III maintenance is challenging and often poorly supported [ 7 , 8 ]. The main reasons for suboptimal adherence to phase III CR include patient-related factors (eg, motivation) and unsustainable costs for lifelong patient support in addition to usual care by general practitioners or cardiologists [ 9 , 10 ]. In addition, patient barriers such as time and travel burden may add to lower adherence and uptake of maintenance programs.

Information and communication technology in the form of eHealth applications has undergone recent developments by targeting reduction of possible barriers of initiation and continued engagement in CR [ 11 ]. The advantages of eHealth include less time investment and constraints due to the absence of travel, option of continuous monitoring, and possibility for patients to manage their disease independently [ 12 , 13 ]. The use of eHealth technologies allows for personalization and tailoring of CR programs to individual needs, leading to higher effectiveness and improved outcomes for patients. Furthermore, eHealth applications allow for different CR aspects to be targeted independently or in a combined and synergistic manner and may have positive effects on physical activity, medication adherence, mood states, anxiety, and depression in cardiac patients [ 14 ]. However, there is no uniform eHealth platform available combining all aspects of CR for patients with cardiovascular disease over the continuum of care, including phase III maintenance. Although challenging on a technological level, user acceptance and applicability in day-to-day setting are key for implementation and success of such a solution. In addition, factors such as technological skills, trustworthiness, and overall individual attitude toward eHealth need to be considered [ 15 - 17 ].

Based on this background, the goal of this study was to provide a detailed description of the patient perspective on the most important aspects to be included in an eHealth solution to assist phase III CR maintenance. This report is part of the multistakeholder project TIMELY, which aims at developing a personalized eHealth platform to assist patients over the continuum of the disease according to recent coronary artery disease (CAD) guidelines [ 18 ]. TIMELY employs artificial intelligence–powered CR components in a patient app connected with a patient management platform and decision support tools for case managers and clinicians. Additionally, artificial intelligence–powered conversational agents (chatbots) will be provided to engage in motivational conversations with patients based on behavior change techniques with the goal of optimizing program and exercise adherence. The development of the TIMELY eHealth solution is guided by a Living Lab approach that allows researchers to co-design innovations such as TIMELY with patients in a real-life context to increase acceptance [ 19 ]. Multiple feedback loops are included at pivotal developing stages, incorporating patients and clinicians in a modified Delphi approach [ 20 , 21 ]. Within the TIMELY prospective study, patients are equipped with different devices as part of the envisioned solution, including a long-term 3-channel electrocardiogram (ECG) patch, a hemodynamic monitor for blood pressure measurement and pulse wave analysis, and a wrist-worn activity tracker. This report describes patients’ needs and expectations for eHealth-based CR collected within the TIMELY Living Lab in CR centers from Germany and Spain.

Approach and Participants

To characterize patients’ needs and expectations for an eHealth-based phase III CR maintenance system, a guided survey was conducted at medical rehabilitation centers Clinic Königsfeld, Germany, and University Hospital of Santiago de Compostela, Spain, between July 2021 and March 2022, aiming at a representative sample of ~80 participants. Patients were asked to participate during their inpatient (Germany) or outpatient (Spain) CR program, and participants were recruited consecutively without further selection. Patients diagnosed with CAD were eligible while participating in a structured center-based CR program.

Ethics Approval

This study complied with the Helsinki Declaration “Ethical Principles for Medical Research Involving Human Subjects” and was approved by the ethics committee of University Witten/Herdecke (115/2020) and Servizo Galego de Saúde (2021/190). All participants gave their written informed consent before participating in this study. This study is part of the TIMELY observational trial (ClinicalTrials.gov: NCT05461729), which aims to characterize the progress of patients with CAD during phase II and phase III CR.

Patients’ Characteristics

Patients’ anthropometric and clinical data, including severity of CAD, type of intervention, and comorbidities (rated using the D’Hoore comorbidity index [ 22 ]) were extracted from electronic health records by clinical personnel. Patients’ highest level of education was documented and specified by country. Hauptschule and Educación primaria were defined as primary, Realschule and Educación secundaria obligatoria or vocational training as secondary, and Abitur or Bachillerato as tertiary education in Germany (DE) and Spain (ES), respectively. A university degree was classified as the highest educational category. For comparability and due to differing educational systems in Germany and Spain, the level of education was categorized as “lower/equal to high school” (first two levels) or “higher than high school” (all other higher levels).

Interview-Based Survey

This survey was developed with experts from a clinical and theoretical perspective by using the Delphi method until consensus was reached. The survey (20 items) was composed of 3 parts: (1) importance of different CR components in general, (2) digital literacy and current usage of technology/technical devices, and (3) helpfulness of the potential features of eHealth in CR ( Multimedia Appendix 1 ). Closed questions were used with a list of provided answers rated on a 5-point Likert scale (1=unimportant/not useful; 5=very important/very useful). A filter question was used, which optionally exempted participants who indicated that they would never use an eHealth platform linked to devices. These participants were asked for their reasons for refusing to use an eHealth platform. The survey was pretested with selected patients in Clinic Königsfeld, and adaptations for wordings were made, where necessary. The final version of the survey was translated to German (SW and BS) and Spanish (MSF and MA) by at least 2 researchers for each translation. The survey was conducted by researchers of the local rehabilitation center. Questions were read to the patients, and further explanation was provided if needed. Investigators documented the answers by using a paper-pencil version or an electronic version of the survey ( Multimedia Appendix 1 ).

Questionnaires

In a subset of 40 German patients with CAD, questionnaires were used to identify personal traits potentially predisposing patients for acceptance of an app or monitoring devices to document the progress of CR (ie, questions Q12 and Q13 of the survey). Psychological flexibility was assessed using the Acceptance and Action Questionnaire version 2 (AAQ-2) [ 23 ], and the Revised Life Orientation Test (LOT-R) [ 24 ] was used to identify patients’ optimism/pessimism. The Type D scale for social inhibition (DS-14) [ 25 ] was used to assess negative affectivity, social inhibition, and type D personality. In addition, the Positive and Negative Affect Schedule (PANAS) was applied [ 26 ].

Statistical Analysis

Statistical analyses were performed using the open access program Jamovi (version 2.2.2, The Jamovi project) and SPSS (version 29, IBM Corp). Data are presented as mean and standard deviation, median and range for the Likert rating scales, or n (%) as indicated. Normality was tested using Shapiro-Wilks test. Between group differences were tested using independent 2-sided t -test or analysis of variance. Nonparametric tests were used to investigate group differences in Likert scale data (Mann Whitney U and Kruskal Wallis test). The associations of sex, age, education level as well as different psychological constructs with openness to using eHealth were analyzed between groups (general willingness [yes/maybe] and patients not willing to use eHealth [no]) by using chi-square test or Mann Whitney U test as indicated. To analyze the combined predictive values of multiple patients’ characteristics on eHealth acceptance, we used multivariate linear regression and naïve Bayes classification. The statistical significance level was set at P <.05.

Seventy-nine patients participated in the guided survey (Germany, n=49; Spain, n=30; 16/79, 20% females). The mean age (in years) of the patients was 57 (SD 7; range 37-79) ( Table 1 ). In Germany, our sample population was comparable in terms of sex and age to patients with CAD in general (registry data) [ 27 ] and to patients with CAD undergoing CR in particular (mean 54.9, SD 7.0 years, in-house data). Further comparison of the study sample to German patients with CAD undergoing CR showed considerable similarity also in terms of ST-elevation myocardial infarction/non–ST-elevation myocardial infarction (~75%), number of affected vessels (1 vessel disease, ~30%-40%), and performed intervention (bypass, ~20%; all in-house data). For Spain, our study sample was comparable to patients with CAD undergoing CR in terms of age (~61 years), ST-elevation myocardial infarction/non–ST-elevation myocardial infarction (~85%), number of affected vessels (1 vessel disease, ~60%), and performed intervention (bypass, ~5%; all in-house data, region Galicia). Overall, in terms of the education level, 87% (69/79) of the participants were ≤high school and 13% (10/79) were >high school ( Table 1 ). Comparisons between countries suggested good comparability even though the age (in years) of the Spanish participants (mean 62, SD 10) was higher than that of the German participants (mean 56, SD 6; P <.001), which was associated with a significantly higher burden of comorbidities (median ES 2.3, IQR 1-8; median DE 1.6, IQR 0-7; P =.03). The percentage of former smokers among patients with CAD in Germany was significantly higher than that in Spain (27/49, 55% vs 7/30, 24%; P <.001). Overall, 30% (24/79) of the included participants were active smokers. Of the 79 participants, >85% (67/79) indicated that they (highly) appreciated being involved in the planning of a future eHealth solution.

a P values were calculated using independent 2-sided t test (nonnormally distributed data were analyzed by Mann Whitney U test) and analysis of variance (nonnormally distributed variables were analyzed by Kruskal-Wallis rank sum test).

b P <.05 for within-group comparison.

c Comorbidity index was calculated according to the modified D’Hoore comorbidity index.

d Primary education is known as Hauptschule in Germany (DE) and educación primaria in Spain (ES).

e Secondary education is known as Realschule in Germany (DE) and educación secundaria obligatoria or vocational training in Spain (ES).

f Tertiary education is known as Abitur in Germany and Bachillerato in Spain.

Digital Literacy and Current Usage of Technology

For the assessment of the use of technology among patients and their associated digital literacy, participants were asked what devices they owned, for which purpose the devices were used, and how experienced they were with health/fitness apps. All patients owned a smartphone, while a significantly lower proportion of Spanish patients owned a tablet (ES: 11/30, 37%; DE: 34/49, 69%; P =.005) ( Figure 1 ). The majority of patients also owned a notebook or PC (ES: 18/30, 60%; DE: 25/30, 84%). Smartwatches (ES: 10/30, 33%; DE: 16/49, 33%) and fitness trackers (ES: 9/30, 30%; DE: 21/49, 43%) were used by a significant proportion of the participants with no differences between centers. Although smartphone, tablet, and notebook/PC were predominantly used for communication and information by the patients, a difference for smartwatch/fitness trackers was recorded in that up to 40% (12/30) of the Spanish patients used those devices also for entertainment. This was only reported by 6% (3/49) of the German patients ( P =.06). Instead, 50% (25/49) of the German patients used wearables and associated apps for documentation (including physical activity), which was only reported by 20% (6/30) of the Spanish patients ( P >.05). In terms of experience with automatic blood pressure monitors, 62% (49/79) of the patients reported their level of experience as “experienced” to “very experienced,” and 29% (23/79) and 13% (10/79) reported this level of experience for fitness trackers and health apps, respectively ( Multimedia Appendix 1 ). Of note, more than 40% (32/79) of the patients reported at least some experience with health or fitness apps.

education and technology research paper

Rating of CR Components

To assess how patients rated the importance of different CR components for disease management, we recorded their feedback on separate aspects of CR (using 5-point rating scales). Patients’ overall rating of the importance of CR components along the continuum of care for risk reduction was very high, including regular physical exercise (median 5, IQR 3-5), healthy diet (median 5, IQR 3-5), stress management (median 5, IQR 1-5), smoking cessation (median 5, IQR 1-5), optimal medication (median 5, IQR 3-5), motivation for lifestyle changes (median 5, IQR 3-5), and overall risk factor management (median 5, IQR 2-5), with no significant difference between the 2 centers. Patients also rated their individual need for support during phase III CR maintenance in the beforementioned areas, revealing large interindividual differences with all items ranging from 1 to 5. In general, patients expressed a high need for support for regular physical exercise (median 4, range 1-5), less need for support for smoking cessation (median 1, range 1-5; only active smokers were asked), and less support for healthy diet (median 3, range 1-5), stress management (median 3, range 1-5), medication (median 3, range 1-5), motivation for lifestyle changes (median 3, range 1-5), and risk factor management (median 3, range 1-5). Of note, for each item except from smoking cessation, 35%-50% of the patients indicated a high need for support (≥4) to achieve their long-term health goals, suggesting a need for individualized care. The subgroup of patients expressing low perceived smoking cessation support needs was analyzed further to investigate if it includes patients with high-risk phenotypes. However, this analysis did not suggest an elevated risk for these patients, as age, sex, BMI, disease severity (bypass performed [yes/no]), and comorbidity index were similar to those of the group of smokers indicating need for smoking cessation support.

Rating of eHealth Components to Assist in Phase III CR Maintenance

Overall, 71% (56/79) of the patients reported that they considered technology, including mobile apps, to be helpful in maintaining health goals after phase II CR. To investigate the specific needs and expectations for an eHealth system to assist in phase III CR maintenance, we asked patients about the features that would be the most helpful for reaching their individual health goals if they were free to choose from a predefined set of options. The presented features were selected by the TIMELY investigators involving cardiologists, rehabilitation experts, behavioral change experts, sports scientists, and by considering recent literature on eHealth in CR [ 6 ]. Selected features were grouped into 3 categories for the presentation of results, including exercise-related features, clinical/medical components, and motivational/other features ( Figure 2 ) and were analyzed for differences between nationality, age groups, and men versus women. No significant differences between nationalities were detected for exercise-related features or medical-related entities. In the domain of other CR components, overall progression documentation was significantly rated as more useful/more needed by German patients (median 5, range 1-5) than by Spanish patients (median 4, range 1-5; P <.001). German patients also rated “individual feedback of a real person” more useful than Spanish patients (median 5, range 1-5 vs median 4, range 3-5; P =.005, respectively). With respect to motivational features, Spanish patients rated the possibility to “share progress with friends and family” as more useful than German patients (median 4, range 1-5 vs median 2, range 1-5]; P =.02, respectively). When asked about the preferred frequency for motivational messages, only 5% of the patients answered “several times a day.” Approximately 27% (21/79) preferred to receive messages once a day, 26% (20/79) every other day, and 9% (7/79) did not want to receive messages. Approximately 32% (25/79) indicated that they would prefer a flexible schedule for messages. Of note, no differences in preference for any suggested features were detected between women and men or among age groups. However, the score for most items ranged from 1 to 5, highlighting that perceived usefulness of potential eHealth features differs substantially between individuals.

education and technology research paper

Factors Associated With Acceptance of eHealth in CR Maintenance

To investigate the factors associated with the acceptance of eHealth, we used questionnaires to analyze factors such as sex, age, clinical data, educational as well as psychological factors. Questionnaires involved LOT-R for optimism/pessimism, AAQ-2 for psychological flexibility, DS-14 for social inhibition, and PANAS for positive/negative affectivity. Education level was not associated with the acceptance of eHealth components ( Table 2 ). No differences were observed with regard to acceptance between women and men, but younger age was significantly associated with more acceptance of monitoring devices ( P =.03), while only a tendency was seen for willingness to use a mobile app ( P =.11). Of note, only 6% (3/49) of the patients who accepted eHealth indicated they would likely not use eHealth components because of privacy concerns, and 8% (4/49) of the patients did not like the idea of being monitored. Although multivariate linear regression analysis did not identify a combination of factors associated with eHealth acceptance, naïve Bayes classification suggested that eHealth acceptance may potentially be predicted based on younger age, a lower AAQ-2 score indicating psychological flexibility, and the index event (having experienced myocardial infarction). Willingness to use a mobile app was predicted with an overall accuracy of 97.9% (using age and AAQ-2), and the acceptance of monitoring devices was predicted with an overall accuracy of 91.7% (using age, AAQ-2, and myocardial infarction). However, validation in an independent data set was not performed.

a Data are given as n (%) and median and range. Patients were asked if they would use a mobile app for their cardiac rehabilitation maintenance support and if they would use monitoring devices (eg, blood pressure monitor, electrocardiogram, activity tracker) during maintenance. Options provided were yes/maybe or no. Between-group comparison was performed using chi-square test or Mann-Whitney U test.

b Three missing. Only German patients (n=40) were involved.

c LOT-R: Revised Life Orientation Test; 2 dimensions; range 0-12 (higher = larger optimism/pessimism).

d AAQ-2: Acceptance and Action Questionnaire version 2; range 7-49 (higher = greater psychological inflexibility).

e DS-14: Type D scale for social inhibition; 2 dimensions; range 0-28 (higher = larger negative affectivity/social inhibition).

f PANAS: Positive and Negative Affect Schedule; 2 dimensions; range 0-10 (higher = larger affect).

Principal Findings

This study aimed to define patients’ needs and expectations for eHealth-based CR to assist them during the lifelong maintenance phase. A Living Lab approach was used for German and Spanish patients with CAD to characterize their use of technology, their preferences and rating of importance for different components of a future eHealth solution for CR maintenance, as well as their general willingness to use eHealth. In brief, our main findings are (1) patients with CAD appreciated being involved in the planning of a future eHealth system, and they had sufficient levels of digital literacy, (2) patients rated the importance of CR components along the continuum of care for risk reduction as very high, (3) 71% (56/79) of the patients expected that technology could help them to maintain health goals after center-based CR, and (4) a large intraindividual heterogeneity was detected in terms of reported needs and perceived usefulness for different eHealth components.

CAD is a chronic disease, necessitating innovative approaches for effective management and support over the lifelong maintenance phase after successful intervention and rehabilitation [ 1 - 3 ]. In recent years, telemedicine and eHealth solutions have emerged as promising tools for improving the care of patients with CAD [ 6 ]. In this regard, eHealth has already been shown to be an effective alternative to phase II CR, and a recent meta-analysis suggested that telehealth-based phase II CR may be even superior to center-based programs at least for enhancing physical activity levels [ 28 - 30 ]. In addition, eHealth may have the potential to involve a large number of patients since it may also be an option for patients who cannot or do not want to attend a center-based CR. In terms of cost efficiency, Frederix et al [ 30 ] estimated that a 6-month internet-based program consisting of exercise training with telemonitoring support, text messages, and web service can be cost-efficient for up to 2 years after the end of the intervention [ 30 ]. However, the development of eHealth solutions tailored for patients with CAD requires a dynamic and patient-centered approach since low user acceptance is one of the largest barriers for success of these solutions. The European Society of Cardiology e-Cardiology Working Group reported that digital health developments are often technically driven and not based on the needs and expectations of patients, thereby calling for cocreation with patient involvement in the design [ 15 ]. The European Society of Cardiology position paper strongly emphasized that patient-related barriers and user characteristics may hinder the large-scale deployment of eHealth services. Thus, the TIMELY project includes a Living Lab as means to involve patients and patient organizations, and our analyses reflect part of this patient-centered approach.

Per definition, Living Labs represent open innovation ecosystems to cocreate, assess, and refine innovative (technical) solutions [ 19 ]. To achieve a user-centric design, Living Labs prioritize the engagement of patients together with health care professionals to ensure that the resulting applications align with the needs, preferences, and challenges faced by the specific needs of a patient group. It is however important to place Living Labs in authentic settings, as implemented in this study, where patients with CAD undergoing center-based phase II CR are involved. These patients had received comprehensive information on the etiology and treatment of their disease as well as lifestyle factors that modify CAD. The majority of the involved patients indicated that they liked the approach and appreciated being involved in the conception and development of an eHealth solution to assist them during the maintenance phase even though some indicated that too much effort might keep them from using such a solution. In terms of predictors of eHealth use, previous research on sociodemographic factors among US adult internet users suggested that patients with lower education levels had lower odds of using certain features, including web-based tracking of personal health information, using a website to support physical activity, or downloading health information to a mobile device [ 31 ]. That study also indicated that being female was a predictor of eHealth use across health care and user-generated content, while age influenced health information–seeking [ 31 ]. In comparison, our data also suggest that younger age was associated with the indicated acceptance of technology, but women were as likely as men to accept eHealth for managing their disease, and the education level was not identified as a predictor. These findings might be based on the fact that smartphones, device hardware, and mobile apps are rapidly advancing, and daily exposure lowers the barriers for patients to use technology [ 32 ]. Although our study was performed among a selected group of patients with CAD participating in a prospective study, it is interesting to compare our cohort also in terms of the necessary hardware availability, that is, smartphone ownership in this patient group in general. Between 2019 and 2020, a large cross-sectional study among cardiac inpatients in Australia reported a high frequency of smartphone ownership (85%-89%) among patients aged 50-69 years and lower ownership (~60%) in patients aged 70-79 years [ 33 ]. In our sample (mean age 57 years, SD 9 years), every patient owned a smartphone and one-third also used activity trackers/smartwatches, which might also be explained by the differences between countries (Australia vs Germany/Spain). Percentage of technology ownership as well as usage and expectations for eHealth were not different between Germany and Spain, even though the Spanish population was significantly older ( P =.001) and clinical characteristics differed to some extent. Further, CR in Spain is based on outpatient care, which, while equally effective in terms of reaching the main CR outcomes, could have affected the estimated need for eHealth in this population. Of the analyzed psychological factors, only psychological flexibility showed some predictive value for eHealth acceptance. This result partly contradicts previous findings among older (>60 years) residents of Hong Kong, wherein optimism was significantly related to perceived eHealth usefulness [ 34 ]. To what extent these differences are caused by differences in age or cultural background warrant further investigations.

State-of-the-art digital health care programs face numerous technical and interoperability hurdles that make implementation difficult. This includes transmitting physiological measurements from ECGs and blood pressure monitors as well as data from activity trackers and other wearables to a centralized platform. Respective solutions rely on wireless networks; different hardware, software, and algorithms for capturing and processing data; as well as connected dashboards. Challenges include system reliability, data quality, interoperability, and overall, the highest level of data security. We have not asked the involved patients about their opinions on system availability and stability, as these aspects as well as data security and privacy need to meet the highest standards as conditio sine qua non when providing eHealth to patients. However, information regarding these aspects needs to be provided to patients in sufficient detail, since privacy-related concerns represent considerable barriers [ 15 , 35 ]. These technical requirements and interdependencies result in high costs for any eHealth solution targeting to improve patients’ self-care. Foreseen functionalities should thus not only be based on current guidelines but should be aligned with patient needs and expectations. This study shows that patients with CAD expected considerable merit in the documentation and availability of their diagnosis, laboratory results, and current medication—all details that would be part of an electronic health record. Patients also showed interest in their overall risk score, which TIMELY will base on a biomarker score to predict the 10-year mortality risk [ 36 , 37 ]. The majority of patients rated the usefulness of blood pressure and ECG monitors as high or very high. Functionalities related to support daily physical activities and physical exercise were perceived as (very) useful, with most patients indicating a high need for progress documentation and regular updates on personalized training recommendations. This observation is relevant since commercial activity trackers have been reported to significantly increase the daily step count and aerobic capacity in patients undergoing CR [ 38 , 39 ], and a considerable number of patients were already relying on commercial solutions, which, however, do not always provide the necessary level of data protection and have not been tested sufficiently in patient populations. Functionalities related to other important parts of CR, including smoking cessation, stress management, advice on heart-healthy eating, as well as self-education, were perceived as less useful or rated neutral, likely depending on the individual perceived needs of the patients. This aspect was pronounced for smoking cessation, which was perceived as an important part of CR, but 50% of the smokers indicated that they did not want support with this health-related aspect.

Limitations

Although reporting on 2 samples of participants undergoing CR from Germany and Spain with cultural and socioeconomic differences is a strength of this study, this report may be affected by the potential study selection bias since patients participating in scientific research studies differ in terms of motivational aspects. However, our sample population did not differ with respect to the sociodemographic characteristics of the samples of patients with CAD undergoing CR who were analyzed in previous reports [ 22 ]. It should be noted that health literacy, a central factor in eHealth usage and a pivotal determinant of health in general, is a complex construct and was not assessed in all dimensions in our study population. The results of naïve Bayes classification should be interpreted with care since validation in an independent data set was not performed. The timepoint and situation of this survey may also have affected the results since patients may answer differently when asked in their home environment or with greater time interval after an acute event. Focus groups may allow for more and detailed information on the reasoning underlying the reported answers to this guided survey, and the results of focus groups within TIMELY will be reported elsewhere.

This survey involving patients undergoing CR in Germany and Spain revealed that eHealth for CR maintenance should emphasize on support for regular physical activity and physical exercise, including patient feedback on achievements and renewal of training recommendations. Devices for physiological measurements, including blood pressure and ECG monitors, were considered useful, and most patients expressed a need for the documentation of diagnosis, medication, and laboratory results in terms of an electronic health record. In general, the patients who took part in this project showed a sufficient level of digital literacy and current usage of technology to make good use of even more advanced eHealth solutions. Although only minor differences were observed among Spanish and German patients as well as between female and male patients and educational status did not appear to be a contributing factor, it is crucial to note substantial variability in patients’ individual needs and expectations. Consequently, eHealth solutions should prioritize personalization to enhance user acceptance. Next steps of the TIMELY Living Lab will involve analyses of details on the implementation of the individual CR functionalities and feedback on the mobile app design.

Acknowledgments

We thank all the patients involved in this study for participating and appreciate the help of our colleagues in answering the Delphi questions to develop the survey used in this project. BS, FM, MH, CP-G, and WJK received funding from the European Commission within the H2020 framework (project TIMELY, grant agreement number 101017424).

Data Availability

The data generated during this study are available from the corresponding author upon reasonable request.

Authors' Contributions

BS, SW, and FM designed this study. SW, MSF, HS, MAV, and VG-S performed the survey and collected the data. SW, MSF, and BS analyzed the data. BS, WJK, and MH interpreted the results. BS, SW, and ERD wrote the manuscript. FM, WJK, MH, CP-G, and DG provided important intellectual content. All authors contributed to the revision of the manuscript and approved the final version of the manuscript.

Conflicts of Interest

BS is the Associate Editor of JMIR Rehabilitation and Assistive Technologies . The other authors declare no conflicts of interest.

Details of the survey.

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Abbreviations

Edited by T de Azevedo Cardoso, S He; submitted 26.10.23; peer-reviewed by J Su, D Liu, P Dilaveris; comments to author 20.12.23; revised version received 28.12.23; accepted 30.01.24; published 22.02.24.

©Boris Schmitz, Svenja Wirtz, Manuela Sestayo-Fernández, Hendrik Schäfer, Emma R Douma, Marta Alonso Vazquez, Violeta González-Salvado, Mirela Habibovic, Dimitris Gatsios, Willem Johan Kop, Carlos Peña-Gil, Frank Mooren. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 22.02.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

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