research paper digital books

November 1, 2013

12 min read

The Reading Brain in the Digital Age: Why Paper Still Beats Screens

E-readers and tablets are becoming more popular as such technologies improve, but reading on paper still has its advantages

By Ferris Jabr

One of the most provocative viral YouTube videos in the past two years begins mundanely enough: a one-year-old girl plays with an iPad, sweeping her fingers across its touch screen and shuffling groups of icons. In following scenes, she appears to pinch, swipe and prod the pages of paper magazines as though they, too, are screens. Melodramatically, the video replays these gestures in close-up.

For the girl's father, the video— A Magazine Is an iPad That Does Not Work —is evidence of a generational transition. In an accompanying description, he writes, “Magazines are now useless and impossible to understand, for digital natives”—that is, for people who have been interacting with digital technologies from a very early age, surrounded not only by paper books and magazines but also by smartphones, Kindles and iPads.

Whether or not his daughter truly expected the magazines to behave like an iPad, the video brings into focus a question that is relevant to far more than the youngest among us: How exactly does the technology we use to read change the way we read?

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Since at least the 1980s researchers in psychology, computer engineering, and library and information science have published more than 100 studies exploring differences in how people read on paper and on screens. Before 1992 most experiments concluded that people read stories and articles on screens more slowly and remember less about them. As the resolution of screens on all kinds of devices sharpened, however, a more mixed set of findings began to emerge. Recent surveys suggest that although most people still prefer paper—especially when they need to concentrate for a long time—attitudes are changing as tablets and e-reading technology improve and as reading digital texts for facts and fun becomes more common. In the U.S., e-books currently make up more than 20 percent of all books sold to the general public.

Despite all the increasingly user-friendly and popular technology, most studies published since the early 1990s confirm earlier conclusions: paper still has advantages over screens as a reading medium. Together laboratory experiments, polls and consumer reports indicate that digital devices prevent people from efficiently navigating long texts, which may subtly inhibit reading comprehension. Compared with paper, screens may also drain more of our mental resources while we are reading and make it a little harder to remember what we read when we are done. Whether they realize it or not, people often approach computers and tablets with a state of mind less conducive to learning than the one they bring to paper. And e-readers fail to re-create certain tactile experiences of reading on paper, the absence of which some find unsettling.

“There is physicality in reading,” says cognitive scientist Maryanne Wolf of Tufts University, “maybe even more than we want to think about as we lurch into digital reading—as we move forward perhaps with too little reflection. I would like to preserve the absolute best of older forms but know when to use the new.”

Textual Landscapes Understanding how reading on paper differs from reading on screens requires some explanation of how the human brain interprets written language. Although letters and words are symbols representing sounds and ideas, the brain also regards them as physical objects. As Wolf explains in her 2007 book Proust and the Squid , we are not born with brain circuits dedicated to reading, because we did not invent writing until relatively recently in our evolutionary history, around the fourth millennium b.c. So in childhood, the brain improvises a brand-new circuit for reading by weaving together various ribbons of neural tissue devoted to other abilities, such as speaking, motor coordination and vision.

Some of these repurposed brain regions specialize in object recognition: they help us instantly distinguish an apple from an orange, for example, based on their distinct features, yet classify both as fruit. Similarly, when we learn to read and write, we begin to recognize letters by their particular arrangements of lines, curves and hollow spaces—a tactile learning process that requires both our eyes and hands. In recent research by Karin James of Indiana University Bloomington, the reading circuits of five-year-old children crackled with activity when they practiced writing letters by hand but not when they typed letters on a keyboard. And when people read cursive writing or intricate characters such as Japanese kanji , the brain literally goes through the motions of writing, even if the hands are empty.

Beyond treating individual letters as physical objects, the human brain may also perceive a text in its entirety as a kind of physical landscape. When we read, we construct a mental representation of the text. The exact nature of such representations remains unclear, but some researchers think they are similar to the mental maps we create of terrain—such as mountains and trails—and of indoor physical spaces, such as apartments and offices. Both anecdotally and in published studies, people report that when trying to locate a particular passage in a book, they often remember where in the text it appeared. Much as we might recall that we passed the red farmhouse near the start of a hiking trail before we started climbing uphill through the forest, we remember that we read about Mr. Darcy rebuffing Elizabeth Bennett at a dance on the bottom left corner of the left-hand page in one of the earlier chapters of Jane Austen's Pride and Prejudice .

In most cases, paper books have more obvious topography than on-screen text. An open paper book presents a reader with two clearly defined domains—the left- and right-hand pages—and a total of eight corners with which to orient oneself. You can focus on a single page of a paper book without losing awareness of the whole text. You can even feel the thickness of the pages you have read in one hand and the pages you have yet to read in the other. Turning the pages of a paper book is like leaving one footprint after another on a trail—there is a rhythm to it and a visible record of how far one has traveled. All these features not only make the text in a paper book easily navigable, they also make it easier to form a coherent mental map of that text.

In contrast, most digital devices interfere with intuitive navigation of a text and inhibit people from mapping the journey in their mind. A reader of digital text might scroll through a seamless stream of words, tap forward one page at a time or use the search function to immediately locate a particular phrase—but it is difficult to see any one passage in the context of the entire text. As an analogy, imagine if Google Maps allowed people to navigate street by individual street, as well as to teleport to any specific address, but prevented them from zooming out to see a neighborhood, state or country. Likewise, glancing at a progress bar gives a far more vague sense of place than feeling the weight of read and unread pages. And although e-readers and tablets replicate pagination, the displayed pages are ephemeral. Once read, those pages vanish. Instead of hiking the trail yourself, you watch the trees, rocks and moss pass by in flashes, with no tangible trace of what came before and no easy way to see what lies ahead.

“The implicit feel of where you are in a physical book turns out to be more important than we realized,” says Abigail J. Sellen of Microsoft Research Cambridge in England, who co-authored the 2001 book The Myth of the Paperless Office . “Only when you get an e-book do you start to miss it. I don't think e-book manufacturers have thought enough about how you might visualize where you are in a book.”

Exhaustive Reading At least a few studies suggest that screens sometimes impair comprehension precisely because they distort people's sense of place in a text. In a January 2013 study by Anne Mangen of the University of Stavanger in Norway and her colleagues, 72 10th grade students studied one narrative and one expository text. Half the students read on paper, and half read PDF files on computers. Afterward, students completed reading comprehension tests, during which they had access to the texts. Students who read the texts on computers performed a little worse, most likely because they had to scroll or click through the PDFs one section at a time, whereas students reading on paper held the entire texts in their hands and quickly switched between different pages. “The ease with which you can find out the beginning, end, and everything in between and the constant connection to your path, your progress in the text, might be some way of making it less taxing cognitively,” Mangen says. “You have more free capacity for comprehension.”

Other researchers agree that screen-based reading can dull comprehension because it is more mentally taxing and even physically tiring than reading on paper. E-ink reflects ambient light just like the ink on a paper book, but computer screens, smartphones and tablets shine light directly on people's faces. Today's LCDs are certainly gentler on eyes than their predecessor, cathode-ray tube (CRT) screens, but prolonged reading on glossy, self-illuminated screens can cause eyestrain, headaches and blurred vision. In an experiment by Erik Wästlund, then at Karlstad University in Sweden, people who took a reading comprehension test on a computer scored lower and reported higher levels of stress and tiredness than people who completed it on paper.

In a related set of Wästlund's experiments, 82 volunteers completed the same reading comprehension test on computers, either as a paginated document or as a continuous piece of text. Afterward, researchers assessed the students' attention and working memory—a collection of mental talents allowing people to temporarily store and manipulate information in their mind. Volunteers had to quickly close a series of pop-up windows, for example, or remember digits that flashed on a screen. Like many cognitive abilities, working memory is a finite resource that diminishes with exertion.

Although people in both groups performed equally well, those who had to scroll through the unbroken text did worse on the attention and working memory tests. Wästlund thinks that scrolling—which requires readers to consciously focus on both the text and how they are moving it—drains more mental resources than turning or clicking a page, which are simpler and more automatic gestures. The more attention is diverted to moving through a text, the less is available for understanding it. A 2004 study conducted at the University of Central Florida reached similar conclusions.

An emerging collection of studies emphasizes that in addition to screens possibly leeching more attention than paper, people do not always bring as much mental effort to screens in the first place. Based on a detailed 2005 survey of 113 people in northern California, Ziming Liu of San Jose State University concluded that those reading on screens take a lot of shortcuts—they spend more time browsing, scanning and hunting for keywords compared with people reading on paper and are more likely to read a document once and only once.

When reading on screens, individuals seem less inclined to engage in what psychologists call metacognitive learning regulation—setting specific goals, rereading difficult sections and checking how much one has understood along the way. In a 2011 experiment at the Technion–Israel Institute of Technology, college students took multiple-choice exams about expository texts either on computers or on paper. Researchers limited half the volunteers to a meager seven minutes of study time; the other half could review the text for as long as they liked. When under pressure to read quickly, students using computers and paper performed equally well. When managing their own study time, however, volunteers using paper scored about 10 percentage points higher. Presumably, students using paper approached the exam with a more studious attitude than their screen-reading peers and more effectively directed their attention and working memory.

Even when studies find few differences in reading comprehension between screens and paper, screen readers may not remember a text as thoroughly in the long run. In a 2003 study Kate Garland, then at the University of Leicester in England, and her team asked 50 British college students to read documents from an introductory economics course either on a computer monitor or in a spiral-bound booklet. After 20 minutes of reading, Garland and her colleagues quizzed the students. Participants scored equally well regardless of the medium but differed in how they remembered the information.

Psychologists distinguish between remembering something—a relatively weak form of memory in which someone recalls a piece of information, along with contextual details, such as where and when one learned it—and knowing something: a stronger form of memory defined as certainty that something is true. While taking the quiz, Garland's volunteers marked both their answer and whether they “remembered” or “knew” the answer. Students who had read study material on a screen relied much more on remembering than on knowing, whereas students who read on paper depended equally on the two forms of memory. Garland and her colleagues think that students who read on paper learned the study material more thoroughly more quickly; they did not have to spend a lot of time searching their mind for information from the text—they often just knew the answers.

Perhaps any discrepancies in reading comprehension between paper and screens will shrink as people's attitudes continue to change. Maybe the star of A Magazine Is an iPad That Does Not Work will grow up without the subtle bias against screens that seems to lurk among older generations. The latest research suggests, however, that substituting screens for paper at an early age has disadvantages that we should not write off so easily. A 2012 study at the Joan Ganz Cooney Center in New York City recruited 32 pairs of parents and three- to six-year-old children. Kids remembered more details from stories they read on paper than ones they read in e-books enhanced with interactive animations, videos and games. These bells and whistles deflected attention away from the narrative toward the device itself. In a follow-up survey of 1,226 parents, the majority reported that they and their children prefer print books over e-books when reading together.

Nearly identical results followed two studies, described this past September in Mind, Brain, and Education , by Julia Parrish-Morris, now at the University of Pennsylvania, and her colleagues. When reading paper books to their three- and five-year-old children, parents helpfully related the story to their child's life. But when reading a then popular electric console book with sound effects, parents frequently had to interrupt their usual “dialogic reading” to stop the child from fiddling with buttons and losing track of the narrative. Such distractions ultimately prevented the three-year-olds from understanding even the gist of the stories, but all the children followed the stories in paper books just fine.

Such preliminary research on early readers underscores a quality of paper that may be its greatest strength as a reading medium: its modesty. Admittedly, digital texts offer clear advantages in many different situations. When one is researching under deadline, the convenience of quickly accessing hundreds of keyword-searchable online documents vastly outweighs the benefits in comprehension and retention that come with dutifully locating and rifling through paper books one at a time in a library. And for people with poor vision, adjustable font size and the sharp contrast of an LCD screen are godsends. Yet paper, unlike screens, rarely calls attention to itself or shifts focus away from the text. Because of its simplicity, paper is “a still point, an anchor for the consciousness,” as William Powers writes in his 2006 essay “Hamlet's Blackberry: Why Paper Is Eternal.” People consistently report that when they really want to focus on a text, they read it on paper. In a 2011 survey of graduate students at National Taiwan University, the majority reported browsing a few paragraphs of an item online before printing out the whole text for more in-depth reading. And in a 2003 survey at the National Autonomous University of Mexico, nearly 80 percent of 687 students preferred to read text on paper rather than on a screen to “understand it with clarity.”

Beyond pragmatic considerations, the way we feel about a paper book or an e-reader—and the way it feels in our hands—also determines whether we buy a best-selling book in hardcover at a local bookstore or download it from Amazon. Surveys and consumer reports suggest that the sensory aspects of reading on paper matter to people more than one might assume: the feel of paper and ink; the option to smooth or fold a page with one's fingers; the distinctive sound a page makes when turned. So far digital texts have not satisfyingly replicated such sensations. Paper books also have an immediately discernible size, shape and weight. We might refer to a hardcover edition of Leo Tolstoy's War and Peace as a “hefty tome” or to a paperback of Joseph Conrad's Heart of Darkness as a “slim volume.” In contrast, although a digital text has a length that may be represented with a scroll or progress bar, it has no obvious shape or thickness. An e-reader always weighs the same, regardless of whether you are reading Marcel Proust's magnum opus or one of Ernest Hemingway's short stories. Some researchers have found that these discrepancies create enough so-called haptic dissonance to dissuade some people from using e-readers.

To amend this sensory incongruity, many designers have worked hard to make the e-reader or tablet experience as close to reading on paper as possible. E-ink resembles typical chemical ink, and the simple layout of the Kindle's screen looks remarkably like a page in a paper book. Likewise, Apple's iBooks app attempts to simulate somewhat realistic page turning. So far such gestures have been more aesthetic than pragmatic. E-books still prevent people from quickly scanning ahead on a whim or easily flipping to a previous chapter when a sentence surfaces a memory of something they read earlier.

Some digital innovators are not confining themselves to imitations of paper books. Instead they are evolving screen-based reading into something else entirely. Scrolling may not be the ideal way to navigate a text as long and dense as Herman Melville's Moby Dick , but the New York Times , the Washington Post , ESPN and other media outlets have created beautiful, highly visual articles that could not appear in print because they blend text with movies and embedded sound clips and depend entirely on scrolling to create a cinematic experience. Robin Sloan has pioneered the tap essay, which relies on physical interaction to set the pace and tone, unveiling new words, sentences and images only when someone taps a phone or a tablet's touch screen. And some writers are pairing up with computer programmers to produce ever more sophisticated interactive fiction and nonfiction in which one's choices determine what one reads, hears and sees next.

When it comes to intensively reading long pieces of unembellished text, paper and ink may still have the advantage. But plain text is not the only way to read.

Ferris Jabr is a contributing writer for Scientific American . He has also written for the New York Times Magazine , the New Yorker and Outside .

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A Meta-Analysis of the Effect of Paper Versus Digital Reading on Reading Comprehension in Health Professional Education

Guillaume fontaine.

a Université de Montréal, Faculty of Nursing, Montréal, Canada

b Montreal Heart Institute, Research Center, Montréal, Canada

Ivry Zagury-Orly

c Université de Montréal, Faculty of Medicine, Montréal, Canada

Marc-André Maheu-Cadotte

d Université de Montréal Hospital Center, Research Center, Montréal, Canada

Alexandra Lapierre

e Hôpital du Sacré-Cœur de Montréal, Research Center, Montréal, Canada

Nicolas Thibodeau-Jarry

Simon de denus.

f Université de Montréal, Faculty of Pharmacy, Montréal, Canada

Marie Lordkipanidzé

Patrice dupont.

g Université de Montréal, Health Sciences Library, Montréal, Canada

Patrick Lavoie

Objective. Despite a rise in the use of digital education in health professional education (HPE), little is known about the comparative effectiveness of paper-based reading and its digital alternative on reading comprehension. The objectives of this study were to identify, appraise, and synthesize the evidence regarding the effect of how media is read on reading comprehension in the context of HPE.

Methods. Observational, quasi-experimental, and experimental studies published before April 16, 2021, were included if they compared the effectiveness of paper-based vs digital-based reading on reading comprehension among HPE students, trainees, and residents. Random-effects meta-analyses were performed using standardized mean differences.

Results. From a pool of 2,208 references, we identified and included 10 controlled studies that had collectively enrolled 817 participants. Meta-analyses revealed a slight but nonsignificant advantage to students reading paper-based HPE texts rather than digital text (standardized mean difference, -0.08; 95% CI -0.28 to 0.12). Subgroup analyses revealed that students reading HPE-related texts had better reading comprehension when reading text on paper rather than digitally (SMD =  -0.36; 95% CI -0.69 to -0.03). Heterogeneity was low in all analyses. The quality of evidence was low because of risks of bias across studies.

Summary. Current evidence suggests little to no difference in students’ comprehension when reading HPE texts on paper vs digitally. However, we observed effects favoring reading paper-based texts when texts relevant to the students’ professional discipline were considered. Rigorous studies are needed to confirm this finding and to evaluate new means of boosting reading comprehension among students in HPE programs.

INTRODUCTION

Digital education has become ubiquitous in health professional education (HPE). 1 - 3 It can be defined as “the act of teaching and learning by means of digital technologies.” 1 Digital education encompasses various teaching and learning approaches, ranging from the simple transformation of text from paper-based to digital formats (eg, portable document format) to the interactive use of sophisticated digital technologies. 1 A majority of health professional students and practitioners report using a digital device in their studies or routine clinical practice. 4 , 5 Despite the rise of digital education, little is known about the comparative effectiveness of reading media, ie, paper-based reading vs its digital alternative, on reading comprehension in HPE. 6 , 7

Reading comprehension is a complex process that involves the ability to recall, understand, integrate, and evaluate text, and depends on several factors, including the reader (eg, vocabulary, degree of familiarity with the text), the reading content (eg, degree of complexity), and the reading media (see Table 1 for definitions). 8 , 9 Reviews investigating the impact of reading media on reading comprehension have yielded inconsistent results but tend to favor paper-based reading for comprehension and retention of information. 9 - 14 Proposed explanations for lower digital-based reading results include readers’ variable experience with technology, overconfidence in comprehension, and more superficial reading when using technology. 15 , 16 Furthermore, the physical presence of a paper text may facilitate reading comprehension and learning. 17

Definitions of Key Terms Used in a Review and Meta-Analysis of the Effect of Paper vs Digital Reading in Health Professional Education

Previous reviews have not examined the impact of reading media in the context of HPE, an exercise that is of both clinical, disciplinary, and cross-disciplinary interest. From a clinical standpoint, reading comprehension is essential to acquire the knowledge base for effective clinical decision-making that is required for the provision of safe, quality care. 18 , 19 Health professional education often follows a similar, cross-disciplinary learning framework: a pre-clinical phase characterized by basic science education and a clinical phase integrating prior knowledge and applying it to cases in a clinical context. In all health professions, learners are driven by clinical considerations and a patient-centered perspective influencing their collection and processing of information and consequent decision-making. Examining reading comprehension in the context of HPE may eventually allow drawing inferences between reading comprehension and clinical outcomes.

From a disciplinary standpoint, tenets of disciplinary literacy suggest that the cognitive requirements for reading are intertwined with the specialized knowledge of those who produce and communicate knowledge within each discipline. 20 This is in opposition to the view that reading builds on a generic set of skills and strategies, regardless of the discipline. 21 While the effect of text genre on reading comprehension was considered in previous reviews, they did not examine whether the topic of the text was related to students’ discipline. 9 , 10 Providing students with texts relevant to their discipline may aid their reading comprehension by building on prior knowledge and disciplinary habits of mind (eg, ways of thinking, reasoning, and critiquing). 1 A key learning principle is relevancy; thus, students who deem a text less relevant could have a less meaningful learning experience. 22 Thus, we believe differentiating between texts that are HPE-related and those that are not is fundamental.

Finally, from a cross-disciplinary standpoint, we believe that examining reading comprehension in HPE specifically also provides important insights for other fields of study. The current review will provide a new framework for examining reading comprehension in specific populations, a variable not explicitly controlled for in previous systematic reviews. This is important not only for providing meaningful material to learners, but also in terms of systematic review methodology as a way of reducing potential population and intervention heterogeneity. Thus, this systematic review and meta-analysis builds on previous evidence by considering studies in which the effectiveness of reading media on reading comprehension was evaluated in the context of HPE, examining the effect of text topics (HPE-related or non-HPE-related topics) considering students’ professional discipline, and including studies with graduate students. Our objective was to identify, appraise, and describe studies comparing the effectiveness of paper-based versus digital-based reading on reading comprehension among students, trainees, and residents in HPE.

This systematic review and meta-analysis was conducted following the Joanna Briggs Institute guidelines. 23 This paper is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and the PRISMA-S guidelines for reporting literature searches. 24 , 25 The protocol has been published and registered in the International Prospective Register of Systematic Reviews on April 28, 2020 (PROSPERO; CRD42020154519). 26 , 27

This review considered observational, quasi-experimental, and experimental studies published in any language that compared the effectiveness of paper-based vs digital-based reading on reading comprehension. We defined reading comprehension as the immediate recall or understanding of the textual content among HPE students, trainees, and residents. We excluded studies conducted with individuals with reading difficulties, cognitive impairments, and related disorders. Paper-based reading was defined as reading text printed on paper (eg, books, articles). Digital reading was defined as “reading text on digital screens, including computers, tablets, mobile phones, and e-readers.” 10 Studies examining media that included videos, animations, hyperlinks, web navigation, gamification, and adaptivity were excluded because these features could confound the results. 10

The search strategy was designed to focus on three concepts: students, trainees, and residents participating in HPE (population); reading media (intervention); and reading comprehension (outcome). The search strategies for all databases are presented in Appendix 2. We performed searches in six databases (CINAHL via EbscoHost, EMBASE via OVID, ERIC via ProQuest, Medline via OVID, PsychInfo via EbscoHost, and Web of Science) on April 16 and 17, 2020.

Identified citations were uploaded in the Covidence software (Veritas Health Innovation, Melbourne, Australia; www.covidence.org ). Duplicates were removed using Covidence. Two independent authors screened studies and reviewed full texts. Disagreements were resolved through discussion.

We worked independently and in duplicate to assess study quality using the Medical Education Research Study Quality Instrument (MERSQI). 28 We also assessed risks of bias independently using the Effective Practice and Organization of Care (EPOC) risk of bias criteria. 29 Risks of bias refer to methodological elements that could affect the internal validity of study results.

We used Covidence to perform data extraction independently and in duplicate. We extracted data at four levels: study level, participant level, intervention level, and outcome level. Data items extracted are specified in the published protocol. 26 In addition, we have added variables related to the context of intervention implementation, including the degree of distraction (low, medium, or high) and presence of supervision (yes, no). We considered the degree of distraction: low, when reading and assessment of reading comprehension had been conducted in a supervised setting without evident mention of potential distractors; medium, when these had been conducted in a supervised setting with possible distractors (eg, multiple testing stations); and high, when these had been conducted in an unsupervised setting (eg, home) with an uncontrollable and unspecified degree of distraction.

The characteristics of studies and interventions were synthesized in a table. We undertook random-effects meta-analyses in Review Manager (RevMan) software, version 5.3 (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark, 2014) to compare the effects of paper vs digital reading on reading comprehension in HPE. Data were analyzed using standardized mean differences (SMDs) with 95% confidence intervals (CIs). Heterogeneity was assessed by examining the characteristics of the studies and using the I 2 statistic. Three subgroup analyses were carried out to investigate the impact of moderators on statistical heterogeneity: HPE-related texts; reading time frame, presence of supervision. The risk of reporting bias was assessed qualitatively based on the country of study conduct, the year of study publication, and the statistical significance of study results.

We worked independently to assess the quality of evidence, or our confidence, in the pooled SMDs. We used the Grading of Recommendations Assessment, Development and Evaluation web-based software (GRADEpro, 2015, McMaster University and Evidence Prime, Inc, https://gradepro.org ). We considered five factors for assessing the quality of evidence (risk of bias, indirectness of evidence, unexplained heterogeneity or inconsistency of results, imprecision of the results, probability of reporting bias).

From a pool of 2,208 potentially relevant articles, we found 10 quantitative, controlled studies comparing the effects of paper and digital reading on reading comprehension in HPE. Eight studies were included in the meta-analysis because they provided enough data to calculate SMD ( Figure 1 ).

Flow Diagram of Article Screening and Selection

Selected characteristics of the studies included are summarized in Table 2 . Nine studies were randomized controlled trials and one was a non-randomized controlled trial. Participants were undergraduate psychology students (n = 5), 6 , 7 , 30 - 32 undergraduate dental students (n = 2), 33 graduate medical students (n = 2), 34 , 35 and graduate optometry students (n = 1), all of which were considered to be students in HPE. 36 - 39 Studies involving graduate students, including medical and optometry students, accounted for three of the 10 studies included. The median sample size was 70 participants. All included studies were deemed of moderate quality according to the MERSQI; scores ranged from 10.5 to 12.5 out of 18 possible points.

Characteristics of Included Studies

Key characteristics of paper-based and digital-based reading media are summarized in Table 2 . Reading topics varied greatly, ranging from oral histology to microeconomics. Whereas all studies included health professional students, the topic of texts was related to HPE in four studies, non-related to HPE in five studies, and not specified in one study. We observed significant variations regarding text length. The reading time was unlimited in five studies, limited to five to 25 minutes in four studies, and not specified in one study. In a majority of studies, students’ reading was supervised in a controlled setting (n = 7), which meant that there was a low or medium potential for distraction. In the three remaining studies, students read at home and were not supervised, suggesting a high potential for distraction.

All studies were judged to be at high risk of bias. The risk of selection bias was high or unclear in all studies, as was the risk of bias related to imbalances between groups in characteristics of participants at baseline. The risk of bias related to imbalances between groups in outcome measurements at baseline were high or unclear in eight studies. 6 , 7 , 30 - 32 , 34 - 36 Six studies had a high or unclear risk of attrition bias. 6 , 30 - 32 , 34 , 35 Six studies had a high or unclear risk of performance bias. 6 , 7 , 32 , 34 - 36 Six studies had a high or unclear risk of contamination bias. 6 , 30 , 32 , 34 - 36 Finally, the risk of reporting bias was low in all but one study. 34

Two studies could not be pooled in the meta-analysis because of missing data. 30 , 34 The pooled effect size across eight studies revealed a negligible and nonsignificant advantage of paper- over digital-based reading media for reading comprehension (SMD = −0.08; 95% CI −0.28 to 0.12; p  = .43; Figure 2 ). Heterogeneity was low (I 2  = 21%).

Forest Plot of Effect Sizes in Relation to Reading Comprehension

In a cluster-randomized trial with medical students, Matthes, Herzig, Muller, Stosch 34 observed that a digital basic pharmacology e-book had a small, nonsignificant advantage over a similar paper book on final scores from a written multiple-choice examination (SMD = 0.27; p  = .08). Similarly, in a study on introductory psychology students, Taylor 30 noted no differences in reading comprehension between students who used digital texts and those who used paper texts (the effect size and the p value were non-reported and could not be calculated based on the data presented).

We conducted three subgroup analyses: studies in which students read texts on topics related to HPE vs non-related to HPE; studies in which reading time was unlimited vs limited; and studies in which reading was supervised vs unsupervised. We observed a modest, significant difference ( p  = .04) in favor of paper-based reading for HPE-related texts (SMD = −0.36; 95% CI −0.69 to −0.03; I 2  = 0%) compared to non-HPE related texts (SMD = −0.08; 95% CI −0.17 to 0.24; I 2  = 0%). We found no significant difference ( p  = .59) between paper and digital reading regarding reading time. We observed a modest, significant difference ( p  = .02) in favor of paper-based reading in unsupervised settings (SMD = −0.57; 95% CI −1.06 to −0.08; I 2  = 0%) compared to supervised settings (SMD = 0; 95% CI −0.19 to 0.18; I 2  = 0%). However, the two studies meta-analyzed for unsupervised settings were drawn from the same paper. The quality of the evidence regarding the effect of reading media on reading comprehension was deemed low because of the high risks of bias across studies. However, inconsistency, indirectness, and imprecision were deemed not serious.

This is the first systematic review and meta-analysis to compare the effect of paper-based and digital-based reading HPE media on students’ reading comprehension. We identified 10 studies published since 2001. The pooled effect size across eight studies revealed a negligible, nonsignificant advantage of paper-based over digital-based reading media for reading comprehension. Despite the small number of studies, a subgroup analysis revealed a modest significant increase in reading comprehension when students read paper copies of HPE texts compared to digital copies of the same texts. Risk of bias was generally high across studies, and the quality of evidence was low.

The negligible, nonsignificant advantage of paper-based reading found in this review is similar to the results of previous reviews. 9 , 10 , 14 These reviews found a small, significant advantage of paper-based reading over digital-based reading. 9 , 10 , 14 Our results also revealed marked variability regarding the characteristics of texts used to assess reading comprehension in HPE. Less than half of studies involved texts on topics related to students’ discipline (eg, oral histology, optometry), whereas the rest used texts on non-related topics (eg, short fiction, microeconomics). Prior research has highlighted the importance of text characteristics, including topic and relevance, 1 when assessing reading comprehension. The significant difference in favor of paper-based reading for HPE-related texts echoes these previous findings; it suggests increased effects of reading media when considering texts relevant to students’ discipline.

Our findings reveal that unsupervised, uncontrolled environments led to a small but significant difference in favor of paper-based reading, when compared to supervised, controlled environments. This finding should be interpreted with caution: only two studies were unsupervised, both published by the same authors in a single article. That said, this finding may be explained by the fact that in unsupervised settings learners using digital devices may be more easily distracted by social media, digital notifications, or web browsing to name a few. This could explain why paper-based media appears to favor reading comprehension in unsupervised settings where learners are less exposed to such distractions. Research suggests that students regularly fall prey to distractions when using digital devices. Over a quarter of students self-report in-class, off-task distractions, and an estimated 50% of students’ laptop time is spent on tasks unrelated to their studies. 40 - 42 Interestingly, the impact of digital-based reading is more negative for easy-to-read material than for hard-to read texts. 43

Concerns for the distraction potential of digital devices such as smartphones or laptops may be minimized using e-readers, whose sole function is to enable reading. In our review, only one study focused on reading comprehension with e-readers 7 , as compared to computer- and paper-based media and no difference was found. However, that study was conducted in a low distraction, supervised setting. Another study with fifth grade students compared reading on e-readers and paper and found no significant differences in students’ attitudes, motivation or reading comprehension. 44 Additional studies must be conducted before the impact of e-readers on reading comprehension can be appropriately assessed. These studies should directly compare electronic devices with a potential for distractions (eg, laptops, computers, smartphones) to e-readers that limit such distractions. Besides the degree of distraction, future studies should be explicit about the tasks that students are asked to perform and the restraints that are in place when using the digital device.

More studies on the effect of reading media on reading comprehension in HPE are needed using rigorous study designs (eg, randomized trials, non-inferiority trials, factorial trials), interventions, and outcome measures. Indeed, given the high risk of bias of the published literature, future studies should be conducted as per the most recent standards for trials (eg, Consolidated Standards of Reporting Trials [CONSORT]). 45 Findings from properly designed RCTs, if consistent with our findings, may confirm that digital media is not inferior to paper-based media in terms of its impact on reading comprehension in HPE, a finding that could have significant implications for reading efficiency. Indeed, students reading computer passages read significantly faster than students who read on paper. 36 Discrepancies in reading speed may impact the time efficiency that is central to future health care professionals’ practice.

Because of the various known advantages of digital media, namely, ease of access, organization, and eco-friendliness, the time-saving benefit of digital-based reading needs to be investigated. Educators and researchers need to consider that digital-based reading is only one educational component of modern e-learning programs, which may provide benefits for HPE that would not be possible through static, paper-based learning. For example, some e-learning programs include adaptivity features to personalize learning content through the consideration of each learner’s knowledge. This can increase learning efficiency, reduce superfluous cognitive load, and support learner engagement. 46 , 47

However, in a commentary by Fjortoft and colleagues, 48 the authors cautioned against pharmacy students’ overreliance on technology and the possible impact it could have on their long-term memory, suggesting a concurrent association with a decreased passing rate for the national board examinations in recent years. Although many variables can explain such a decreasing trend, this review provides preliminary insight as to whether the reading media should be considered as part of curricular planning.

This systematic review and meta-analysis has various strengths and limitations. In terms of strengths, the protocol was prospectively registered and published, which enhances the transparency of the research process. Moreover, the search strategy was developed over several months with an experienced librarian to ensure specificity, sensibility, and replicability. Regarding limitations, outcome measures varied across studies. To address this variation, we conducted meta-analyses using SMD to standardize the results of studies to a uniform scale before pooling them. Furthermore, although we had initially planned to assess the effect of reading media on skill development and clinical behavior, the absence of such data in the studies included prevented us from doing so.

This review did not find any significant differences between digital and paper-based reading except when the topic of the text and its relevance to students’ professional discipline was considered, in which case paper-based reading yielded a modest advantage over digital media. This review highlights the need for robust randomized trials in HPE using HPE-related texts to strengthen the quality and validity of the current evidence.

ACKNOWLEDGMENTS

This work was supported by the Cercle du Doyen, Faculty of Pharmacy, Université de Montréal, Canada.

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Reading in the digital era.

• Lutz Koepnick Lutz Koepnick Department of German, Russian and East European Studies, Vanderbilt University
• https://doi.org/10.1093/acrefore/9780190201098.013.2
• Published online: 31 August 2016

Digital reading has been an object of fervent scholarly and public debates since the mid-1990s. Often digital reading has been associated solely with what may happen between readers and screens, and in dominant approaches digital reading devices have been seen as producing radically different readers than printed books produce.

Far from merely reducing digital reading to a mere matter of what e-books might do to the attention spans of individual readers, however, contemporary critiques emphasize how digital computing affects and is being affected by neurological, sensory, kinetic, and apparatical processes. The future of reading has too many different aspects to be discussed by scholars of one discipline or field of study alone. Digital reading is as much a matter for neurologists as for literary scholars, for engineers as much as ergonomicians, for psychologists, physiologists, media historians, art critics, critical theorists, and many others. Scholars of literature will need to consult many fields to elaborate a future poetics of digital reading and examine how literary texts in all their different forms are and will be met by 21st-century readers.

• digital culture
• electronic literature
• screen studies
• digital humanities

Libraries are filled with volumes chronicling the history of the book and discussing how different social, political, and technological frameworks have produced, and have been produced by, different cultures of reading. Digital archives and databases abound with electronic essays and analyses addressing the impact of digital culture on people’s modes of processing the written word. Various national and international research projects are on their way to produce empirical data and reliable sociological, psychological, and neurological knowledge of how the advent of e-readers such as Amazon’s Kindle or the iPad affect individual reading patterns and attentional economies, while scholars in newer fields such as game studies ask whether the story of the printed book has simply come to an end or needs to be incorporated into disciplines such as media studies or ludology. 1 The principal ambition of this essay is to map theoretical positions that think through different modes of reading in the present digital age. The article sketches out a number of paradigmatic perspectives that frame possible approaches to studying reading in the first place. The account presented here, therefore, will not do justice to the richness of writing on reading that has developed in various scholarly communities and cultures in recent decades. The primary point is simply to outline a number of key perspectives and theoretical questions that have driven or continue to drive current thinking about reading and digital textuality as primarily formulated by North American critics, who have proven to be of exemplary value to navigating the field in general.

The Spirit of Departure in the 1990s

The widespread arrival of Internet-based communication and information technologies in the early 1990s coincided with fervent scholarly debates about a so-called visual turn in contemporary culture and the humanities. While Internet browsers such as Mosaic translated digital data into navigable surfaces on-screen and email programs began to open new popular avenues for electronic messaging, theorists of culture pointed toward tectonic shifts in the landscapes of self-expression, information, meaning, knowledge, and pleasure: from words to images, from reading to seeing. 2 The surfeit of mediated images energized scholarly work in fields such as art history, anthropology, cultural studies, film studies, philosophy, and psychology. At the same time, however, this raised considerable fears about the future of reading and writing, the rise of digital technologies often considered as the end of the Gutenberg galaxy, and the condition for the possibility of focused, critical reading and competent writing. 3

As numerous theorists and critics during the 1990s began to ponder the pictorial turns of contemporary culture, a different set of scholars mapped the emergence of new forms and genres of electronic literature, produced since the 1980s with the help of personal computers and distributed through the emerging World Wide Web to interested readers in the 1990s. 4 Though the objects of their study—hypertext fiction and computer-generated poetry—remained at the fringes of the established canons of literary analysis, the new faces of writing in the age of digital culture were often enthusiastically greeted as a culmination of poststructuralist and deconstructivist interventions. Mostly created with the help of the then popular Storyspace software, pathbreaking work such as Michael Joyce’s afternoon ( 1987 ), Stuart Moulthrop’s Victory Garden ( 1991 ), and Shelley Jackson’s Patchwork Girl ( 1995 ), according to this perspective, exemplified what critics such as Roland Barthes, Jacques Derrida, Michel Foucault, and Paul de Man onward had theorized from the mid-1960s as the fundamental instabilities of all writing and reading. HTML’s hyperlinks exploded both the spatial and temporal boundaries of individual texts; they at once highlighted the extent to which any textual practice echoes the existence of other texts and questioned the category of the autonomous work and its closure as a central unit of traditional literary analysis and hermeneutical meaning-making. The malleability of digital material online and onscreen also emphasized the active role of the reader in the production of what may count as a text in the first place. Digital culture, it was argued, would finalize the death of the author that French critical theory had foretold in various ways in the decades preceding the arrival of personal computing. While some feared the end of reading and writing altogether, others thus embraced and celebrated digital and networked communication as the birth of a new reader: one emancipated from the authority of the text, one speculatively engaging the open-ended play of signifiers, one no longer bound to texts as fixed containers of meaning and intentionality. In her 1997 book, Hamlet on the Holodeck: The Future of Narrative in Cyberspace , Janet H. Murray expressed this spirit of rupture and departure perhaps most forcefully when calling on her readers to “imagine a future digital medium, shaped by the hacker’s spirit and the enduring power of the imagination and worthy of the rapture our children are bringing to it.” 5

Transitions in the 2000s

The new millennium certainly bore witness to the development of digital media and mediums unfathomed even in the most technophilic visions of the 1990s. Digital devices not only penetrated every fissure of the everyday; they also had an impact on structures of perception, knowledge, and pleasure far beyond the presence of what initially was seen as digital culture’s principal interface: the static computer screen and its representation of hyperlinked text elements. With the dramatic rise of locational and handheld media, the growing ubiquity of digitally powered interfaces, the success story of touchscreens coming in all shapes and sizes, and the ever more potent presence of wearable and haptic media, the primary association of the digital with the seemingly transparent “window” of a fixed computer screen no longer met the realities of the early new century. 6 Unlike the critics of the 1990s, who celebrated the digital as a radical departure from the physical strictures of the body and the recalcitrant burdens of materiality, 21st-century scholarship increasingly came to reckon with the fact that digital media owned bodies as well and were embedded in and helped produce embedded matter. 7 Far from solely producing disembodied onlookers of abstract data on-screen, digital new media could just as well serve as engines of embodiment, recalibrating the relationship between mind and matter and thereby reorganizing the realm of the sensible. For example, as stressed in particular by the work of scholars and artists at the SpecLab at the University of Virginia, digital media could do much more than simply serve as cold and abstract handlers of data. Understood as a medium whose materiality mattered, the computer, in the words of Johanna Drucker, here was employed to “create aesthetic provocations—visual, verbal, textual results that were surprising and unpredictable” 8 and precisely thus helped (re)articulate the embodied subjectivity of its users.

And yet instead of following such expansions of the horizon of discussion, scholarly and public writing about the location of digital reading in the new millennium has primarily come to focus on the question of screen reading, on how individual readers, when facing the display of text on devices such as Kindles, iPads, and NOOKS as they were introduced after 2007 , are able to hold on to reading practices shaped by print-based materials or find themselves forced to develop new habits and strategies of appropriation. 9 In the wake of media theorists such as Friedrich Kittler, one tendency has been to hold technological innovations directly responsible for changes in cultural practice, that is to say, to deny possible differences between technical hardware and cultural software and consider new media platforms as being in full control over what users might want to and can do with them. A sketch of this argument, of how screens produce different readers than printed text, and of how different hardware configuration result in different cognitive, physiological, and sensory operations, has typically looked like this:

Although we might at first think of the pages of a book as a window to the world generated by the text, as a transparent frame effectively transporting us into a different and imaginary time and place, such metaphors largely fail to address how books have historically managed to grasp a reader’s mind and attention. A book’s page can be a self-effacing looking glass onto a different order of things, but much depends on the reader and the context. Readers may find themselves fully immersed in what the letters on paper communicate to them, but at the same time they experience the physical turning of the page, the quality of the paper, or the material properties of the cover as something that deeply contributes to how they hold on to the book and allow it to move them forward in time. A book’s physical properties matter to the act of reading. They play a considerable role in seizing our attention and inviting us to enter a curious space of temporal negotiation; a space in which our own sense of time, a book’s story time, and the time it might take to physically read its letters and sentences in their prearranged order meet and take hold of each other. Books invite us to get lost, to lose ourselves within their pages, precisely because they provide something steady and permanent, something we can touch as much as it can touch upon us. By contrast, the “window and frame” metaphor is much more appropriate to describe reading text on a screen than in a printed book. Screens and reading software encourage us to scroll down, zoom in and out, travel across, and scan and skip text similar to the way in which viewers might use a window to peruse distant realities at their own will. Unlike the printed word, digital text has no real existence or permanence. Digital text allows vast possibilities of nonlinear appropriation, whether we use search functions, follow embedded hyperlinks, or in fact start to reassemble its form or order with the help of different software functions. Digital reading, then, is closer to roaming. It empowers readers to meet a text on their own temporal terms and immerse themselves in their own ability to manipulate what appears in front of them rather than in the world represented by the words. Existing in some strange nowhere land, text on screen not only asks us to find or plot a way, but find or plot our way to define what we want to count as text in the first place.

There is no doubt considerable value in argumentative sketches like this. Media technologies structure, define, and reflect cultural practices, and there is ample evidence—scientific and anecdotal—that readers approach and consume e-books quite differently than printed material. And yet such arguments rarely do justice to the complexities of digital reading in the 21st century, not least because they measure digital reading against the normative bedrock of print reading, whereas the true challenge might be to understand digital reading as an expansion and reformulation of what might count as reading to begin with.

Digital Manichaeism

It has become commonplace to say that no aspect of literary culture today is free of digital mediation, whether it concerns the production, the distribution, the advertising, the delivery, the reception, the analysis, or the preservation of written material even in its most traditional form. Moreover, though many fault digital writing and reading for promoting a decline in textual competence, it has also become clear that the spread of new media and personal computational devices since the 1990s did not kill writing, or that the late 20th century’s turn toward the visual eliminated the mental resources necessary for productive acts of reading. The first decades of the 21st century will certainly not be remembered for a dearth of writing and reading; on the contrary, the production and consumption of written language today clearly trumps that of any other age, with email defining new standards for the speed of mediated exchange, with social media blurring what previous eras considered the lines between the intimate and the public, and with text messaging serving as a virtual lifeline for the communicative needs and self-expressive energies of an entire generation. Reading in the digital era is alive and well. It may simply exist in new places, rely on technological platforms other than the printed page, and involve structures of attention that fundamentally differ from the ones that characterized the history of reading during the preceding decades, and even centuries.

And yet even though the digital can be found in all kinds of forms, locations, and practices of textuality today, most public debates about the future of reading reduce the status of reading in the digital age to the question of screen and e-book reading. 10 In these debates, e-book reading is often feared to usher readers into a state of utter dematerialization, producing highly distracted and multitasking subjects no longer able to enjoy either the deep absorption or the attentive criticality of previous generations. 11 As displayed on tablets or cell phone screens, the objects of reading are often seen to lose any sense of integrity, that is, the kind of authority they may require to incite curiosity, prolonged attention, critical engagement, and aesthetic pleasure. Instead, screen reading is perceived to foster reading habits that value narcissistic self-management and uncommitted window-shopping over deep engagement, identification, and learning. Moreover, as practiced with the assistance of paperless e-books, digital reading continues to be seen as a cultural practice that threatens the fabrics of memory and tradition, the fleetingness of pixels and code undermining the materiality of the archive, the preservation and storage of cultural treasures, and the physical infrastructures necessary to retain and revisit important texts.

Similar to historical debates about the cultural impact of virtual reality in the 1990s, the majority of conversations about the transformation of reading in the age of the digital today remain deeply Manichean in nature. While presumed technophobes continue to battle with apparent technophiles and utter enthusiasm clashes with profound skepticism, participants in these debates often feel pressed to assume positions as if the only options were either to go fully digital with electronic devices or to stay entirely analog with the help of print-based books. Though certainly no technophobe hostile to the transformation of reading under the aegis of the digital, Naomi S. Baron perhaps expresses the array of lingering suspicions best when at the end of her Words on Screen: The Fate of Reading in a Digital World she passes the ball of judgment to the reader without really questioning the presumed binary of digital and nondigital reading:

Today’s digital technologies place no limits on text length or complexity. Richardson’s complete Clarissa is available as an eBook from Amazon, keeping company with Kindle Singles. You can read Aristotle on your mobile phone if you choose, and no one is stopping you from rereading Pride and Prejudice on your tablet as many times as you please. The real question is whether the affordances of reading onscreen lead us to a new normal. One in which length and complexity and annotation and memory and rereading and especially concentration are proving more challenging than when reading in hardcopy. One in which we are willing to say that if the new technology doesn’t encourage these approaches to reading, maybe these approaches aren’t so valuable after all. Is this the new normal we want? In case not, the ball is in your court. 12

Four scholarly positions on digital reading entail more than what may happen between e-book screens and users, each of them recognizing readers of digital text as more than mere effects of hardware configurations. Though all of these positions accord specificity to the concept and practice of digital reading, at the same time, they move beyond the binary of pixel and print, screen and page. One example of digital writing and reading indicates the need to think of the digital as dynamic, not simply displacing older practices of reading but recalibrating the very notion of what it might mean to read and thus transcending the Manichaeism that continues to inform mainstream approaches to the question of digital reading.

Digital Reading and Cognitive Remodeling

Curiously never published in any e-book format, N. Katherine Hayles’s 2008 Electronic Literature: New Horizons for the Literary 13 remains one of the most seminal explorations of literary changes in the era of the digital. Primarily meant to map new forms of creative writing and formal experimentation under the sign of computational culture, Hayles’s book offers an important window on what processes of digital mediation might do to acts of reading. Contrary to the agendas of many fellow literary critics and media theorists, her effort is to understand new media as complex negotiations of technological innovations, social infrastructures, and cultural practices, rather than to present media—deterministically, as it were—as authoritative structures fully controlling what users might want and can do with them. “Many scholars in the humanities,” Hayles argues, “think of the digital computer as an inflexible brute force machine, useful for calculating but limited by its mechanical nature to the simplest kind of operations. This is both true and false—true in that everything computable must be reduced to binary code to be executed, but false in the belief that this inevitably limits the computer to simple mechanical tasks with no possibility for creativity, originality, or anything remotely like cognition.” 14 In order to overcome common assumptions about human-computer interactions, Hayles’s analysis focuses on experimental literary texts that use computational devices such as cellular automata and codelet functions that bootstrap digital and analog processes. Her interest is in literary works that rely on dynamic hierarchies between digital computer and user, namely, multitiered systems of reciprocity that rely on various feedback and feed-forward loops and are designed to allow the computer’s algorithmic and the user’s cognitive operations to continuously inform and mutually determine each other.

Rather than thinking of the computer as a machine producing and processing data and the human brain as an organ generating interpretations and meanings, Hayles considers the neurological and the computational as mutually implicated, one interpreting and enhancing the other in such a way that—in Edward Fredkin’s formulation—“the meaning of information is given by the process that interprets it.” 15 What Hayles calls intermediation, that is, the process by which certain emergent patterns or operational structures of one medium are captured, represented, and further developed by another, is also seen at the heart of electronic literature. Discussing the work of authors such as Michael Joyce, Maria Mencia, and particularly Judd Morrissey , Hayles argues that electronic literature has the unique ability at once to perform and allegorize, to represent and re-represent the intermediation of machine and user intelligence, of code and cognition, of information and knowledge. Electronic literature, she concludes, evokes this ability whenever its texts perform

actions that bind together author and program, player and computer, into a complex system characterized by intermediating dynamics. The computer’s performance builds high-level responses out of low-level processes that interpret binary code. These performances elicit emergent complexity in the player, whose cognitions likewise build up from the low-level processes interpreting sensory and perceptual input to high-level thoughts that possess much more powerful and flexible cognitive powers than the computer does, but that nevertheless are bound together with the computer’s subcognitive processes through intermediating dynamics. 16

To read in the age of digital computing, then, is to engage in complexity-generating processes of intermediation. Rather than crunching human subjectivity, intelligence, and expressivity with their soulless abstractions, computers have the capability to train readers to read with categorically different forms of self-reflection. The effect of computational processes, as they permeate all aspects of literary production and consumption today, is to empower new types of readers uniquely able to explore the feedbacks loops and mutual interpretations of human and machine cognition. It redefines reading as a cultural practice that reimagines literary works as open-ended games to be played, as challenging dynamics that augment cognitive and interpretive processes and define language and code, consciousness and program as reciprocal agents. To read in the area of the digital is not simply to consume text on screen but to participate in an exciting drama of adaptive coevolution. It is to invite the human reader to investigate the operations of his or her own consciousness and cognition, and to allow machinic intelligence to learn from and in turn impact the workings of neural processes. Instead of dumbing down the cultural practice of reading, digital textuality offers readers sites to understand themselves better, remake their cognitive capabilities, and—in a word—become smarter.

Digital Reading and the Senses

If Hayles’s concept of intermediation is meant to stress how digital reading can at once explore, reveal, and allegorize the reciprocal cognitive advances of algorithmic machines and human brains, a second strain of thought has sought, from a more phenomenological perspective, to highlight the extent to which digital reading may expand the body’s sensory, tactile, and kinesthetic interactions with its environments. Hayles herself has certainly contributed to this line of thinking as well, ultimately trying to fold cognitive and somatic, neurological and phenomenological arguments into one conceptual dynamic. But the strongest advocate for this argument has been Mark B. Hansen, arguing in books such as Bodies in Code: Interfaces with New Media ( 2006 ) and New Philosophy for New Media ( 2004 ) that digital technologies have a unique potential to foster and complicate processes of embodiment. 17 Rather than usher users into an age of bleak abstraction and sense-less intellectualism, what makes new media new in Hansen’s perspective is their unique ability to recalibrate the body’s sense of place, its extension into the world, and its self-perception as a moving entity amid other things in motion.

Hansen’s point of departure is the dual assumption (1) that human bodies, long before the arrival of digital tools, always already operated as media, constantly developing models and schemata of how to relate sensorily to their environment, and (2) that digital technologies and code, though often seen as mechanisms of virtualization and cerebral weightlessness, own bodies and material existence as well and hence are as much part of the physical world as the bodies of their users. Rather than inhabiting radically different ontological universes, then, technologies and bodies share common ground: the former cannot exist in the world without a physical base; the latter cannot do without certain technics and technologies of mediation to relate to the world. Due to their advanced way of interacting with and responding to a user’s input, Hansen argues, digital technologies assume a privileged position to “lend support to a phenomenological account of embodiment and expose the technical element that has always inhabited and mediated our embodied coupling with the world.” 18 With installations such as Text Rain ( 1999 ) by Romy Achituv and Camille Utterback in mind, Hansen concludes that computational culture produces readers for whom performative acts of reading reveal the technological substructure and sensory technics of the human organism as much as the ineluctable, albeit often denied, physicality of digital code. To read in the age of the digital is to link bodies and machines in such a way that both can map their material specificities onto each other and co-develop the physical, physiological, and psychological underpinnings of mediation. To read digitally is to explore and reposition the body’s relation to the world and to probe different structures and technics of embodiment.

Perhaps less philosophical and complex, yet also more specific and tangible, versions of Hansen’s intervention can be found in the accounts of scholars such as Roberto Simanowski emphasizing the kinesthetic dimensions of digital reading without necessarily insisting on the material coevolution of code, technology, and the human organism. 19 Due to the platforms, devices, and interfaces that circulate it, digital literature in 2016 mostly entails that textuality is consumed on the move. Digital text makes and marks our built environment through ubiquitous screens and wraparound news tickers, ambient monitors, and handheld displays such as smartphone screens and portable tablets. Literary texts are thus not merely consumed in mid-stride and with different degrees of attention; they also rely on the reader’s own sense of motion, a text’s shapes and meanings animating as much as being animated by a user’s kinetic energies. Moreover, as the work of media artists and digital “writers” such as Achituv and Utterback, Julius Popp, and Noah Wardrip-Fruin indicates, digital literature reckons with a user’s interaction and feedback, stress textual surfaces over hermeneutic depth, and valorize audience experience and the performativity of reception over an author’s modes of self-expression. Most of all, however, it anticipates and puts to work readers whose sense of motility—their often unpredictable movements, contingent pathways of interaction, and individualized durational commitments—is critical for unlocking the full potential of particular works. A reader’s movement through space, his or her kinetic engagement, is thus constitutive for the construction of meaning of digital textuality. Because the digital has unmoored texts from their former sites and invites readers to be with, produce, and consume text in ever-changing places, to read digitally is to use the body and its motions as an active element in the making of what might count as text in the first place. 20

Rather than providing avenues into sensory abstraction, then, digital reading unfolds in likeness to the way in which viewers navigate the environments of screen-based installation art, probing ever different angles and routes to engage with a particular work, or of gamers who traverse the virtual landscapes of a videogame, using sensory stimuli and input to steer a path through worlds characterized by real rules and fictional setups. 21 It calls for literary critics willing to suspend former models of hermeneutic analysis and close reading and instead consider reading as an architectural practice, an activity in space relating different movements, trajectories, and temporalities, a form of spatial practice ceaselessly negotiating the relation of words, ambient environments, and bodies (in motion).

Digital Reading as Finger and Multimodal Reading

A third approach to digital reading can be found in efforts to retrace the concept’s etymological past and see it as something familiar to human readers with a much longer history than the recent arrival of modern-day computing devices. The word digital derives from the Latin digitus , meaning the finger or toe, that is, corporeal extremities that have the ability to point at, touch, identify, and manipulate worldly matter in a controlled fashion. 22 The digitus is an organ of intentional recognition and deliberate separation. It sets apart what is continuous for the purpose of better orientation; it renders calculable and fragments what may be contiguous into manageable units. The digitus is at the origin, not simply of our ability and desire to count, but of the measurability of the world and the reign of modern instrumental reason. It is for this reason that the finger has always had a troubled relationship to the aesthetic. To be sure, Michelangelo’s Creation of Adam in the Sistine Chapel or Steven Spielberg’s E. T. the Extra-Terrestrial ( 1982 ) celebrate the finger as a direct conduit to the divine and transcendental, as the self-effacing portal to touch on and be touched by spiritual forces. But much more influential is the image of the isolated finger as a mere tool that debases aesthetic creativity and experience, that fragments coherence and fluidity, that brings death to what should showcase abundant life. One may only think of late 19th-century writers resisting the coming of typewriters, being fearful that the hammering of individual keys would drain the power of the poetic imagination. Or think of the children in the opening of Fritz Lang’s M as they use their fingers to count each other out and thus anticipate their own future as objects of a mass murderer’s urge to kill. An advocate of what is discrete and therefore computable, the finger—the digitus—often seems to lack what artistic creation and experience has been understood to be about. It aspires to count and control rather than synthesize. It hopes to point at and identify something as something rather than open the door toward the incommensurable. It wants to arrest objects in time and space instead of liquefying hardened forms of subjectivity and probing the habitual mechanisms of perception.

And yet to associate the digitus solely with a logic of willful classification and goal-oriented action, dispute its aesthetic potentiality, and then in turn project such assumptions onto the scenes of contemporary digital culture so as to rebuke it as the downfall of true art and aesthetic experience falls short of the historical richness of “finger” reading. Consider, for instance, the fact that Braille, developed in the early 19th century as a tactile writing system to allow the blind, or those with limited vision, to read all kinds of texts, relied and continues to rely on the capacity of individual or multiple fingers to recognize embossed code and translate it into meanings. 23 Designed in the wake of the upsurge of individual reading around 1800 and of widespread concerns about reading’s effects on the bourgeois subject’s soul (in particular those of female readers), Braille’s code tried to bring literary masterpieces to blind readers and hence to situate the reader’s finger as a dependable portal or interface to the aesthetic and its imaginary elsewheres and elsewhens. It is therefore no coincidence that Braille code plays a central function in digital touchscreen projects such as the iPad novella Pry , developed by the art collective Tender Claws in 2014 .

Rather than seeing the etymological history of the digital and its association with both the tactile and the measurable as a burden on reading in the age of the digital, scholars have come to recognize it as an important reminder that, first, the history of reading is not simply a history of visual and hence silent, solitary, essentially spiritualized reading as cultivated by poets, image makers, and pedagogues since the Renaissance, and, second, digital reading at heart is multimodal reading, engaging multiple sensory channels and platforms as interfaces to access extant textualities. Contrary to its theorists of the 1990s, digital writing and electronic textuality in the new millennium do much more than simply put to work the decentering force of hyperlinks. Instead, text has come to aggregate or combine different modalities of communication: it often relies on written language as much as on still or moving images, on sound and music, on embedded graphs and charts, on the combination of certain elements with relative stability and others that may refresh and hence change with varying frequencies. Moreover, given the ever expanding functionality of positioning systems and locational mapping, what scholars may call text encountered via the screens of mobile gadgets increasingly responds to the movements and geographical positions of the reader. What this all means is that reading text and literature today is by no means a merely visual exercise of decoding written language. Electronic literature at once presupposes and trains readers able and eager to competently follow the train of fictional narratives across different media platforms and multiple channels of information. It situates the poetic not simply in the visual gestalt of written letters and lines, but in how these may interact with fleeting images and atmospheric sound bites. To be a reader of electronic literature is to be touched by literary or poetic objects, not simply because they enter the reader’s soul through the eye, its proverbial window, but because the reader will literally touch on these texts and in so doing affect their existence in the world. As indicated by the etymological origins of the word “digital,” then, digital reading engages multiple sensory channels and modes of input, including the sense of touch, to embrace multimodal streams of information as unstable objects of knowledge, imaginary travel, pleasure, and meaning.

Reading, Writing, and Being Read

Though certainly known at early junctures of cultural developments and media history as well (think for instance of the readers of highly ornamented medieval and early modern folios), multimodal writing and reading today are largely energized by how digital hard- and software platforms support the convergence of different channels of information. Because the 0s and 1s of digital code are agnostic to what kind of files, documents, or computational objects are to be encoded with them, the digital breaks down ontological boundaries between images, sounds, and words, enabling the principal possibility of converting or transposing one into the other, and aggregates or fuses all into the unity of one document. To read digitally is to be an adept navigator of contemporary convergence culture, 24 the way in which stationary or mobile computing devices today—in Jay Bolter and Richard Grusin’s words 25 —easily remediate former media technologies such as the printed book, the record and tape player, the photographic image, and the cinematographic camera and projector, and combine their respective logics for the sake of making and disseminating new hybrid media objects.

No account of reading in the age of digital computing is therefore complete without addressing how computational convergence culture destabilizes former boundaries between processes of production and consumption, writing and reading. What earlier generations of theorists applauded as the death of the author, and what caused many a critic of 20th-century modernism to understand readers, listeners, or viewers as co-participants in the creation of aesthetic objects, has become commonplace under the sign of 21st century convergence culture and it rise of the so-called prosumer. Digital prosumers see no principal difference in receiving and remaking or down- and uploading, between accessing, recalibrating, and making accessible digital data. They understand the instability of digital objects as the baseline of cultural practice and creativity, and they symbolize the cultural conditions under which former distinctions between (and hierarchies of) makers and theorists, between creative and analytical processes, between originals, copies, remakes, samples, and mash-ups increasingly lose their former clarity and validity. In her 2014 book, Reading Writing Interfaces: From the Digital to the Bookbound , 26 Lori Emerson has suggested the term “readingwriting” to conceptualize the impact of digital feedback loops and prosumer practices under fully networked computational conditions. While also meant to advocate experimental practices that could probe and denaturalize the ideological transparency of contemporary interfaces of reading and writing—the masking of underlying templates in the name of user-friendliness—Emerson’s concept is helpful to underscore the fact that in our computational culture of ongoing remediation, convergence, and 24/7 networking, no act of reading can be considered as being independent from processes of writing, whether intentional or not, and that every act of writing is enmeshed in various reading processes, whether carried out by instant readers on other screens or by machines as they translate—read—a writer’s input into code, transmittable information, or measurable data.

Emerson’s concept of readingwriting reminds us of the fact that computational culture has come to promote everyday forms of reading—of machine reading—that have no real equivalent in the era of book print. Any attempt to develop a viable concept of digital reading must address how digital computers might carry out considerable reading efforts for human readers while also reading each other in ceaseless feedback loops of data processing. 27 While computers may struggle with offering hermeneutical complexity or deconstructive textual finesse, digital soft- and hardware operations perform certain acts of reading at all times, with and without a reader’s awareness. 28 Search engines such as Google read billions of web pages with the help of constantly refined search algorithms; they rank pages according to the number of other pages that link up to them and display this metric interpretation of available data whenever users request and read their advice. Amazon reads its customers’ search and purchase history when suggesting future readings to them and whetting their appetites for similar products. Web browsers read markup language such as HTML in order to convert code and embed digital objects into user-friendly representations. Network servers and routers constantly read incoming blocks of data to reverse the Internet’s primary mode of transmitting data, the process of packet switching. No single email comes to its reader in one piece solely along one route: with a single email broken into separate bits of information and sent along a multiplicity of different network paths to ensure the speed and robustness of communication, email readers unwittingly rely on a computer’s ability to interpret invisible headers and read metadata to receive even the most trivial email as one coherent message on-screen.

What all these examples illustrate is the fact that in the world of digital media platforms and networked information flows, the blurring of stable boundaries between reading and writing coincides with a radical increase in the number of possible agents of reading. Rather than silence words with images, digital convergence culture has drastically expanded existing practices, sites, technologies, and subjects of reading. As perhaps most poignantly investigated in installation work such as John Cayle and Daniel Howe’s How It Is in Common Tongues ( 2012 ), machines not only read like they have never done before, they read our own reading and process information thus gained for the production of new text, code, and data, whether we are meant to read them or not.

To read in the age of the digital, then, always also means to be read. To study the topologies, histories, and practices of reading in the age of networked computing is to consider and include processes often highly technical in nature and far beyond the expertise for which literary scholars and critics are traditionally known. Though often seen as soulless mechanisms draining the spirit from the humanities, machine reading today is too prevalent and too central to any act of reading to be ignored by those who profess to study the role and meaning of reading in society. And, as Emerson persuasively claims, whatever scholars in our age of digital networking and multimodal computation want to understand as the concept of literature needs to reckon with how reading today is not simply embedded in processes of writing but involves the feedback loops of machine reading, of being read by automatized algorithms and distant apparatuses, at all possible times:

Now that we are all constantly connected to networks, driven by invisible, formidable algorithms, the role of the writer and the nature of writing itself is being significantly transformed. Media poetics is fast becoming a practice not just of experimenting with the limits and the possibilities of writing interfaces but rather of readingwriting —the practice of writing through the network, which as it tracks, indexes, and algorithmizes every click and every bit of text we enter into the network is itself constantly reading our writing and writing our reading. This strange blurring of and even feedback loop between reading and writing signals a definitive shift in the nature and the definition of literature. 29

Rethinking Reading

Far from reducing digital reading to a mere matter of what e-books might do to the attention spans of individual readers, these various contemporary critiques emphasize how digital computing affects and is being affected by neurological, sensory, kinetic, and apparatical processes. These bootstrap readers and computational devices in sometimes symmetrical, at other times asymmetrical feedback loops. As it turns out, reading in the digital age is not always as radically new and different as many critics claim, whether with fear or praise. It may, for instance, tap into practices to which readers of medieval folios or 19th-century Braille code were already well accustomed. And yet it is difficulty to resist the thesis not only that reading in the digital age is qualitatively different from what it used to be during the Gutenberg era of print culture, but that the advent and proliferation of computational technologies indeed call for readjustments of what scholars and critics might want to understand as text, literature, interpretation, and reading in the first place. Instead of seeing digital reading as a fall from the grace of traditional reading practices, or—conversely—a revolutionary foray into a posthumanistic paradise, the positions discussed here all indicate that the true challenge is in understanding digital reading as an expansion of previous models of reading, one that invites us to recognize the historicity of all concepts of reading and in so doing inevitably makes us see even the past in a new light.

In closing, I wish to profile a work—Julius Popp’s bit.fall —that encapsulates all the different aspects in paradigmatic form, envisioning a reader for whom reading in the digital age might entail cognitive, sensory, and kinesthetic adventures as much as it may mean to be drawn into complex processes of machine reading, of being read. Installed in various locations—museums, art galleries, public spaces—ever since it first exhibition in 2006 , bit.fall consists of hundreds of water nozzles mounted along a metal construction several meters above a capture basin. 30 Magnetic vents allow each nozzle to emit individual water drops in a measured and controlled fashion, thus not simply producing a technological recreation of a waterfall but mimicking in highly ephemeral form the operations of both a computer screen and an inkjet printer and their respective abilities to represent data with the help of discrete units of information. Each of Popp’s nozzles is connected to and controlled by a central computer, which scans the websites of select news organizations in real time for their use of statistically relevant keywords and then issues the command to “print” these words using the water contraption. Seemingly endless cascades of words thus fall with high frequency from the metal beam into the capture basin. Just as we are able to identify one of the buzzwords of the day, we will see the concept disappear again, briefly replaced by yet another one. The text offered to the eye of the reader is highly fragmented and heterogeneous, and yet—or precisely because of this—it communicates the conflicts, obsessions, and dramas of our accelerated present effectively. Bit.fall invites the viewer to read its texts from all possible angles and sides, to walk around the installation and probe different bodily relationships to the words on display, to look through the cascade of falling water as much as to stretch out one’s hand to read its words haptically or even, on hot days, to step straight through the gush of drops to cool down.

By using water drops as a medium of presentation and representation, Popp stresses not only the fleeting and amorphous character of our age of global networking and instantaneous connectivity but also the ontology of flow, instability, and openness often seen at the very heart of the digital. To write, here, means to empower machines to read other machines, yet precisely in so doing also to wrest brief moments of legibility, reference, and meaning from the contemporary noise of information overload. Yet to read is to engage in a continual effort to identify traces of writing in the first place and to explore possible connections between isolated text fragments. At first, Popp’s human readers might be reminded of The Matrix and the image of downward streaming code in the film’s opening sequence as it offers a prelude to what turns out to be the digital backbone of a postapocalyptic world of pure simulation. Popp’s bit.fall , however, remains distant to how most works of science fiction— The Matrix included—indulge in images of calamitous futures. As he at once visualizes and rubs against the ceaseless streaming of data and information in digital culture, Popp encourages the viewer of his installation to read in a new, and yet not entirely unfamiliar, key. On one level, bit.fall allegorizes and puts to work what Hayles calls intermediation. The work reveals the extent not only to which the meaning of information today requires processes that interpret them, but to which in the era of digital reading algorithms and human cognition may affect each other. While rapid neurological operations try to keep pace with the machinic production of text, computational mechanisms process and break down for us the unmanageability of human data and interpretation in a fully connected world. On a second level, Popp reckons with and (re)trains readers eager to engage with text haptically. Like Hansen’s subjects of digital culture, Popp’s readers, as they stretch their hands into the waterfall (or at least toy with the idea of doing so), seek to read words with their skin rather than their eyes. Yet in contrast to the prisoner of Franz Kafka’s story “In the Penal Colony,” Popp’s readers do not experience such forms of bodily reading as an administering of physical torture and death but as an exhilarating way of rendering the abstraction of today’s information flows more concrete and precisely thereby as a territorializing extension of the boundaries of one’s own body. Third, Popp’s installation challenges dominant traditions of reading that consider it at its best when engaged in as a silent, immobile, private, isolated, and absorbed activity. To read bit.fall is always also to read moving text on the move; to probe different viewing angles and distances; to watch the sight of falling text and watch others watching it; to allow the rhythmic sounds of falling water to energize one’s own sense of pace and movement. It is to understand how the reduced materiality of the digital has the power to produce readers who—like the viewers of installation art in general—embrace physical movement as a medium to engage with and in fact call forth text. Fourth, and finally, Popp’s bit.fall illustrates nothing less than the intricacies of what Emerson calls the rise of readingwriting in digital culture. Popp’s water drops document machinic processes of reading as much as they write words right in front of another reader’s eye. Popp’s visitors read the writing of the apparatus, as much as their physical movements and forms of ambient attention rewrite what becomes visible briefly before the machine’s text disappears for good.

Rather than seeing expanded practices of reading in the digital age as the downfall of concentrated reading, Julius Popp’s installation presents it as way of mapping the complexities of digital culture itself. And instead of seeing digital reading as the joyful rise of the nonrepresentational and post-human, bit.fall sets up a space in which readers can learn how to read with and against the ever growing culture of machine reading, how to critically negotiate the shifting landscapes of code and cognition, information and interpretation, algorithms and bodily movements. Neither is all lost, nor all won, when readers engage with Popp’s choreography of falling words. What bit.fall reminds us of is the fact that the future of reading has too many different aspects to be discussed by scholars of one discipline or field of study alone. Digital reading is as much a matter for neurologists as for literary scholars, for engineers as much as ergonomicians, for psychologists, physiologists, media historians, art critics, critical theorists, and many others. Scholars of literature will need to consult many fields to elaborate a future poetics of digital reading and examine how literary texts in all their different forms are and will be met by 21st-century readers.

Further Reading

• Aarseth, Espen J. Cybertext: Perspectives on Ergodic Literature . Baltimore: Johns Hopkins University Press, 1997.
• Baron, Naomi S. Words Onscreen: The Fate of Reading in a Digital World . New York: Oxford University Press, 2015.
• Bolter, Jay D. Writing Space: Computers, Hypertext, and the Remediation of Print . 2d ed. Mahwah, NJ: Lawrence Erlbaum Associates, 2001.
• Bolter, Jay , and Richard Grusin . Remediation: Understanding New Media . Cambridge, MA: MIT Press, 1999.
• Burdick, Anne , et al. Digital_Humanities . Cambridge, MA: MIT Press, 2012.
• Drucker, Johanna . SpecLab: Digital Aesthetics and Projects in Speculative Computing. Chicago: University of Chicago Press, 2009.
• Eckmann, Sabine , and Lutz Koepnick . [Grid <>Matrix] . Saint Louis: Mildred Lane Kemper Art Museum, 2006.
• Emerson, Lori . Reading Writing Interfaces: From the Digital to the Bookbound . Minneapolis: University of Minnesota Press, 2014.
• Friedberg, Anne . The Virtual Window: From Alberti to Microsoft . Cambridge, MA: MIT Press, 2006.
• Fuller, Matthew . Software Studies: A Lexicon . Cambridge, MA: MIT Press, 2008.
• Galey, Alan . “The Enkindling Reciter: E-books in the Bibliographical Imagination.” Book History 15 (2012): 210–247.
• Gitelman, Lisa . Paper Knowledge: Toward a Media History of Documents . Durham, NC: Duke University Press, 2014.
• Han, Byung-Chul . Im Schwarm: Ansichten des Digitalen . Berlin: Matthes & Seitz, 2013.
• Hansen, Mark B. New Philosophy for New Media . Cambridge, MA: MIT Press, 2004.
• Hansen, Mark B. Bodies in Code: Interfaces with New Media . New York: Routledge, 2006.
• Hayles, N. Katherine . Writing Machines . Cambridge, MA: MIT Press, 2002.
• Hayles, N. Katherine . My Mother Was a Computer: Digital Subjects and Literary Texts. Chicago: University of Chicago Press, 2005.
• Hayles, N. Katherine . Electronic Literature: New Horizons for the Literary. Notre Dame, IN: University of Notre Dame Press, 2008.
• Hayles, N. Katherine , and Jessica Pressman , Comparative Textual Media: Transforming the Humanities in the Postprint Era . Minneapolis: University of Minnesota Press, 2009.
• Jenkins, Henry . Convergence Culture: Where Old and New Media Collide . New York: NYU Press, 2008.
• Joyce, Michael . “ Notes toward an Unwritten Non-Linear Electronic Text .” Postmodern Culture 2.1 (September 1991).
• Juul, Jesper . Half-Real: Video Games between Real Rules and Fictional Worlds . Cambridge, MA: MIT Press, 2011.
• Kirschenbaum, Matthew . Mechanisms: New Media and the Forensic Imagination . Cambridge, MA: MIT Press, 2008.
• Kirschenbaum, Matthew . “ The .txtual Condition: Digital Humanities, Born-Digital Archives, and the Future Literary .” Digital Humanities Quarterly 7.1 (2013).
• Kirschenbaum, Matthew . Track Changes: A Literary History of Word Processing . Cambridge, MA: Harvard University Press, 2016.
• Kirschenbaum, Matthew , and Sarah Werner , “Digital Scholarship and Digital Studies: The State of the Discipline.” Book History 17 (2014): 406–458.
• Koepnick, Lutz . “Can Computers Read?” In Distant Readings: Topologies of German Culture in the Long Nineteenth Century. Edited by Matt Erlin and Lynne Tatlock , 333–346. Rochester, NY: Camden House, 2014.
• Landow, George P. Hypertext: The Convergence of Contemporary Critical Theory and Technology . Baltimore: Johns Hopkins University Press, 1991.
• Manguel, Alberto . A History of Reading . Rev. ed. New York: Viking, 2014.
• Manovich, Lev . The Language of New Media. Cambridge, MA: MIT Press, 2001.
• McGann, Jerome . The Textual Condition . Princeton, NJ: Princeton University Press, 1991.
• McGann, Jerome . Radiant Textuality: Literature after the World Wide Web . New York: Palgrave, 2004.
• McGann, Jerome . New Republic of Letters: Humanities Scholarship in an Age of Digital Reproduction . Cambridge, MA: Harvard University Press, 2014
• Mondloch, Kate . Screens: Viewing Media Installation Art . Minneapolis: University of Minnesota Press, 2010.
• Moretti, Franco . Distant Reading . London: Verso, 2013.
• Murray, Janet H. Hamlet on the Holodeck: The Future of Narrative in Cyberspace. New York: MIT Press, 1998.
• National Endowment for the Arts . Reading at Risk . Research Division Report no. 46. Washington, DC: National Endowment for the Arts, 2004.
• National Endowment for the Arts . To Read or Not to Read: A Question of National Consequence . Research Report no. 47. Washington, DC: National Endowment for the Arts, 2007.
• Piper, Andrew . Book Was There: Reading in Electronic Times . Chicago: University of Chicago Press, 2013.
• Pressman, Jessica . Digital Modernism: Making it New in the New Media. Oxford: Oxford University Press, 2014.
• Raley, Rita . Tactical Media . Minneapolis: University of Minnesota Press, 2009.
• Ramsay, Stephen . Reading Machines: Toward and Algorithmic Criticism . Urbana: University of Illinois Press, 2011.
• Ricardo, Francisco J. Literary Art in Digital Performance . London: Continuum, 2009.
• Simanowski, Roberto . Digital Art and Meaning: Reading Kinetic Poetry, Text Machines, Mapping Art, and Interactive Installations . Minneapolis: University of Minnesota Press, 2011.
• Striphas, Ted . The Late Age of Print: Everyday Book Culture from Consumerism to Control . New York: Columbia University Press, 2009.
• Wardrip-Fruin, Noah . Expressive Processing: Digital Fictions, Computer Games, and Software Studies . Cambridge, MA: MIT Press, 2009.
• Werner, Sarah . “ Where Material Book Culture Meets Digital Humanities .” Journal of Digital Humanities 1.3 (2012).

1. For an informative overview of current scholarship on digital textuality, see Matthew Kirschenbaum and Sarah Werner , “Digital Scholarship and Digital Studies: The State of the Discipline,” Book History 17 (2014): 406–458 .

2. W. J. T. Mitchell , Picture Theory (Chicago: University of Chicago Press, 1994) ; and Mitchell , “Showing Seeing: A Critique of Visual Culture,” Journal of Visual Culture 1.2 (2002): 165–181 .

3. These debates, in the North American context, found perhaps their most dramatic expression over time in two widely discussed reports issued by the National Endowment for the Arts in 2004 and 2007, respectively: Reading at Risk and To Read or Not to Read: A Question of National Consequence .

4. See, for instance, Janet H. Murray , Hamlet on the Holodeck: The Future of Narrative in Cyberspace (New York: Free Press, 1997) ; Espen J. Aarseth , Cybertext: Perspectives on Ergodic Literature (Baltimore: Johns Hopkins University Press, 1997) ; and Michael Joyce , “ Notes toward an Unwritten Non-Linear Electronic Text ,” Postmodern Culture 2.1 (September 1991) .

5. Murray, Hamlet on the Holodeck , 10.

6. For important mappings of the newness of new media in the new millennium, see among many other works, Lev Manovich , The Language of New Media (Cambridge, MA: MIT Press, 2001) ; Anne Friedberg , The Virtual Window: From Alberti to Microsoft (Cambridge, MA: MIT Press, 2006) ; and Rita Raley , Tactical Media (Minneapolis: University of Minnesota Press, 2009) .

7. Important works exploring the relationship of new media and issues of embodiment include Vivian Sobchack , Carnal Thoughts: Embodiment and Moving Image Culture (Berkeley: University of California Press, 2004) ; Laura U. Marks , Touch: Sensuous Theory and Multisensory Media (Minneapolis: University of Minnesota Press, 2002) ; Mark B. N. Hansen , New Philosophy for New Media (Cambridge, MA: MIT Press, 2004) ; Hansen , Bodies in Code: Interfaces with Digital Media (New York: Routledge, 2006) ; Caroline A. Jones , ed., Sensorium: Embodied Experience, Technology, and Contemporary Art (Cambridge, MA: MIT Press, 2006) ; Anna Munster , Materializing New Media: Embodiment in Information Aesthetics (Hanover, NH: Dartmouth College Press, 2006) ; and Bernadette Wegenstein , Getting Under the Skin: Body and Media Theory (Cambridge, MA: MIT Press, 2006) .

8. Johanna Drucker , SpecLab: Digital Aesthetics and Projects in Speculative Computing (Chicago: University of Chicago Press, 2009), 19 .

9. For an insightful reading, see Alan Galey , “The Enkindling Reciter: E-books in the Bibliographical Imagination,” Book History 15 (2012): 210–247 .

10. A good overview of the fault lines of these debates can be found in Andrew Piper , Book Was There: Reading in Electronic Times (Chicago: University of Chicago Press, 2013) .

11. Detailed research done under the umbrella of the European Cooperation in Science and Technology across different European settings certainly provides a much more nuanced picture than what concerned pedagogues and pundits often articulate in the public sphere. See: “ Evolution of Reading in the Age of digiti#sation (E-READ) ” and “ Reading in Europe: Contemporary Issues in Historical and Comparative Perspectives .”

12. Naomi S. Baron , Words Onscreen: The Fate of Reading in a Digital World (New York: Oxford University Press, 2015), 235 .

13. Katherine Hayles , Electronic Literature: New Horizons for the Literary (Notre Dame, IN: University of Notre Dame Press, 2008) . See also, of course, Hayles ’s pathbreaking My Mother Was a Computer: Digital Subjects and Literary Texts (Chicago: University of Chicago Press, 2005) .

14. Hayles, Electronic Literature , 44.

15. Quoted in Hayles, Electronic Literature , 52.

16. Hayles, Electronic Literature , 56.

17. Mark B. Hansen , Bodies in Code: Interfaces with New Media (New York: Routledge, 2006) ; and Hansen , New Philosophy for New Media (Cambridge, MA: MIT Press, 2004) .

18. Hansen, Bodies in Code , 26.

19. Roberto Simanowski , Digital Art and Meaning: Reading Kinetic Poetry, Text Machines, Mapping Art, and Interactive Installations (Minneapolis: University of Minnesota Press, 2011) .

20. Rita Raley ’s work has been important to explore many of these aspects. See her Tactical Media (Minneapolis: University of Minnesota Press, 2009) , but also Raley , “TXTual Practice,” in Comparative Textual Media , ed. N. Katherine Hayles and Jessica Pressman (Minneapolis: University of Minnesota Press, 2013), 5–32 ; and Raley , “Walk This Way: Mobile Narrative as Composed Experience,” in Beyond the Screen: Transformations of Literary Structures, Interfaces and Genres , ed. Jörgen Schäfer and Peter Gendolla (Bielefeld, Germany: Transcript Verlag/Transaction, 2010), 299–316 .

21. Kate Mondloch , Screens: Viewing Media Installation Art (Minneapolis: University of Minnesota Press, 2010) ; and Jesper Juul , Half-Real: Video Games between Real Rules and Fictional Worlds (Cambridge, MA: MIT Press, 2011) .

22. Byung-Chul Han , Im Schwarm: Ansichten des Digitalen (Berlin: Matthes & Seitz, 2013) ; and Lutz Koepnick, “Digitus: Bausteine einer Poetik digitalen Lesens,” forthcoming.

23. See Evelyn J. Rex et al., Foundations of Braille Literacy (New York: AFB Press, 1994) .

24. Henry Jenkins , Convergence Culture: Where Old and New Media Collide (New York: NYU Press, 2008) .

25. Jay Bolter and Richard Grusin , Remediation: Understanding New Media (Cambridge, MA: MIT Press, 1999) .

26. Lori Emerson , Reading Writing Interfaces: From the Digital to the Bookbound (Minneapolis: University of Minnesota Press, 2014) .

27. This is not the place to address the question how developments in the digital humanities, by employing computing resources to perform big data analysis and so-called distant reading, add categorically new methods to scholarly reading practices or simply recast with new tools older strategies of empirical research and sociological analysis. For overviews, see Franco Moretti , Distant Reading (London: Verso, 2013) . See also, among many other works, Anne Burdick et al., Digital_Humanities (Cambridge, MA: MIT Press, 2012) ; Jerome McGann , New Republic of Letters: Humanities Scholarship in an Age of Digital Reproduction (Cambridge, MA: Harvard University Press, 2014) ; and Sarah Werner , “ Where Material Book Culture Meets Digital Humanities ,” Journal of Digital Humanities 1.3 (2012) .

28. For an extended version of this argument, see Lutz Koepnick , “Can Computers Read?” Distant Readings: Topologies of German Culture in the Long Nineteenth Century , ed. Matt Erlin and Lynne Tatlock (Rochester, NY: Camden House, 2014), 333–346 .

29. Emerson, Reading Writing Interfaces , Kindle edition.

30. For more extended discussions of Popp’s installation, see Sabine Eckmann , “Take I,” in [Grid <>Matrix] , by Sabine Eckmann and Lutz Koepnick (Saint Louis: Mildred Lane Kemper Art Museum, 2006), 26–30 ; and Lutz Koepnick , “Abenteuerliche Reisen? Walter Benjamin im Zeitalter neuer Medien,” Text+Kritik 31–32 (February 2009): 130–133 .

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BRIEF RESEARCH REPORT article

Discussion of students' e-book reading intention with the integration of theory of planned behavior and technology acceptance model.

• Business School, Guilin University of Technology, Guilin, China

The emergence of e-books with the characteristics of easy access and reading any time anywhere is a subject of debate in academia. Topics include the use of e-books in libraries, their use in support teaching, new possibilities for reading activities, potential uses for library archives, and the motivation and intention of e-book users. Students at Guilin University of Technology participated in a survey. Of the 300 copies of the questionnaire distributed, 263 valid copies were returned, a retrieval rate of 88%. The research results show that (1) Usability and reading need are the key factors in e-book usage. Usability refers to convenient keyword searches, portability, and any time reading. E-books are considered to make searching and reading large amounts of data easier. (2) E-books are not restricted to time and space so that the overall reading quantity is increasing. Readers become accustomed to reading e-books, and the quality of their digital reading is gradually enhanced. (3) Students should complete e-book use courses offered by libraries to enhance their familiarity with e-books and their use of e-book software, thereby enhancing postgraduate student readers' e-book information literacy. The results of the research prompt suggestions to enhance the promotion of reading and e-book information to encourage student readers' e-book reading intention.

Introduction

In the rapidly developing information era, the value of e-books gradually became apparent. The portability of e-books has been an attraction ever since their first appearance. In the field of library and information science, e-books were much discussed. Some argued that e-books should not only be used in the library but should also enhance the services that libraries provide and should be used to support teaching. Susantini et al. (2021) mentioned that it was remarked that e-books can be a new approach to reading and can change how and when people use libraries. As digital publishing expanded, libraries began to acquire significant amounts of digital products allowing users to search digital documents in a convenient and suitable manner. Almost not a country or region in the world could escape from the pandemic of Novel Coronavirus (COVID-19). The pandemic results in major changes in human life to change life and learning styles. Mass or national school closure is preceded in many countries or regions this year in order to reduce the spread of COVID-19 ( Viner et al., 2020 ). To cope with the pandemic, the approach of “Learning never stops” allows students continuing the learning with the minimal impact. Nevertheless, in face of the menacing pandemic, most teachers passively adopt distance courses without advance warning or enough time for preparing courses ( Almekhlafi, 2021 ). Although distance education presents various advantages and is limited to time and location ( Karakoç Öztürk, 2021 ), the practice of distance education is the maximal transformation. A lot of countries in the world, and even schools, temporarily practice or promote distance education. It would have the frontline teachers and students face some problems or difficulties. Current academic discussions on temporary promotion of distance learning are limited, while the use of e-books is inevitable for the promotion of distance education. The rise in digital publishing led to a situation where there are more e-books than printed books ( Erkayhan and Ulke, 2017 ). This fact is challenging for libraries, especially university libraries, where a gradual transition occurred from paper-based collections to digital resources. Users of university libraries tend to have specific needs, and building a suitable collection can be difficult. Although libraries have started to value the development of their digital collections, they lack information on readers' acceptance, requirements, usage time, and reading habits. They are unsure if readers will change their reading habits and their requirements for printed books after e-books have been introduced into libraries. This is an area worthy of discussion when libraries are compiling their collections. Therefore, the integration of the Theory of Planned Behavior (TPB) and the Technology Acceptance Model (TAM) was used in this research to investigate students' reading intention toward e-books. Understanding how readers use the collections in the libraries and assessing how their expectations are being met might improve students' reading literacy of printed books and e-books. New insights could help to promote students' reading services.

Literature Review

Digital reading behavior.

In their survey of digital reading behavior, Huang and Chang (2019) found that frequent e-book reading locations included rooms at home, especially the living room, offices, schools, and on transport to work. In different situations, the most common types of e-book reading were: “business and finance,” “literature and fiction,” “tourism and sport,” “lifestyle and hobbies,” and “fashion and entertainment.” While at home, readers mainly read e-books on tablets, and they use smartphones while commuting. Regarding reading habits, 60% of respondents read 1–4 e-books a month, and about 50% of respondents read e-books for an average of 16–30 min each time. In the survey, more than 70% of the respondents were satisfied with their e-book reading experience. Leong et al. (2019) discovered that most readers read e-books on tablets, read at home, and read every week and that reading methods depend on the type of books. In terms of the effect of e-books on readers, readers' knowledge of e-books was related to the reading experience. Readers favored the convenience of e-books, but they were used to reading paper books. Ease of use of software and hardware and readers' reading habits were the key factors in reading intention. Reading e-books changed reading habits, such as searching for books, type of reading material, time spent reading, note-taking habits, frequency of repeated reading, and book sharing behavior. Readers' problems with e-books included installation, searching, and reading, with searching as the biggest problem. Readers' needs for e-books resulted in bigger collections and longer recommendation book lists. The need arose for reading software to improve searching and personalization.

Application of Model

Kaushik and Rahman (2017) revealed that the use of the TAM to predict users' behavioral intention in using new technologies and their real-use behavior was supported by a significant body of empirical research. However, two factors, the social factor and the controlling factor, which were proven to significantly affect users' real-use behavior with new technologies, were not included in the model. These two factors were the key variables in the TPB. Wei et al. (2017) integrated the TAM and the TPB, including a subjective norm and perceived behavioral control in the TAM, proposing a combined TAM and TPB (C-TAM-TPB), and they conducted empirical research on students' use behavior of computing resource centers.

The empirical results of the study by Lee and Cranage (2018) revealed that the C-TAM-TPB, integrating the TAM and the TPB, presented a high level of fit in explaining users' use behavior with new technologies. Moreover, the group analysis of users with different use experiences revealed that C-TAM-TPB presented a good fit for users with or without experience. Therefore, in this study, TPB and TAM are integrated to discuss students' e-book reading intention.

Research Hypothesis

Lee (2017) stated that Davis included the belief—attitude—intention—behavior relation in the theory of reasoned action in the TAM and particularly emphasized the importance of “perceived usefulness” and “perceived ease of use.” Davis considered that information technology with higher ease of use in situations with comparable tasks could assist an individual in completing more tasks in the same time, further enhancing individual work performance. In this case, the perceived ease of use could reinforce the perceived usefulness to the individual of information technology. Stouthuysen et al. (2018) mentioned that Davis also considered that users might have a negative attitude toward specific information technology but would still be willing to use the technology when its use is perceived to enhance personal work performance. Ko (2017) indicated that perceived usefulness could indirectly affect the use intention of information technology through attitude and could directly affect the behavioral intention of users. Furthermore, in addition to perceived usefulness and perceived ease of use as major factors in the attitudes of users toward information technology, attitudes would further affect the behavioral intention of users, thereby determining the acceptance and use behavior of information technology.

The following hypotheses are therefore established in this study.

H1: Perceived ease of use presents positive and direct effects on perceived usefulness.

H2: Perceived ease of use shows positive and direct effects on attitude.

H3: Perceived usefulness reveals positive and direct effects on attitude.

H4: Perceived usefulness shows positive and direct effects on behavioral intention.

H5: Attitude shows positive and direct effects on behavioral intention.

H6: Subjective norm reveals positive and direct effects on behavioral intention.

H7: Perceived behavioral control shows positive and direct effects on behavioral intention.

H8: Perceived behavioral control presents positive and direct effects on behavior.

H9: Behavioral intention reveals positive and direct effects on behavior.

Methodology

Conceptual structure.

The integration of the TAM and the TPB is used to construct the model in this study, as shown in Figure 1 .

Figure 1 . Conceptual structure.

Research Subject and Analysis Method

Five hundred copies of a questionnaire were distributed to university students in Guilin, China. A total of 433 valid copies were returned, a retrieval rate of 87%. AMOS software was used as the data analysis tool to evaluate students' e-book reading intention.

Confirmatory Factor Analysis (CFA) results show that convergent validity in the observation model could observe the suggested reliability value of individual observed variables, construct reliability (CR), and average variances extracted (AVE), where the reliability of individual observed variables is suggested as higher than 0.5. The factor loadings of various observed variables in this study are higher than the suggested value. A CR value of higher than 0.6 is preferable, but some researchers suggest that it should be higher than 0.5. The estimation result of the model shows that the CR is higher than 0.5. The average variance extracted should be higher than 0.5. The average variance extracted of dimensions in this study is higher than 0.5, conforming to the suggested value.

The estimation results of the structural equation are shown in Table 1 . First, the suggested standards for X 2 /df, RMSEA, GFI, AGFI, RMR, and NFI are ≦ 5, ≦ 0.08, ≧ 0.9, ≧ 0.9, ≦ 0.05, and ≧ 0.9, respectively. The values in this study appear as X 2 /df = 3.134 ≦ 5, RMSEA = 0.034 ≦ 0.08, GFI = 0.968 ≧ 0.9, AGFI = 0.925 ≧ 0.9, RMR = 0.03 ≦ 0.05, and NFI = 0.942 ≧ 0.9, revealing good overall fit. As a result, the estimation results of the structural equation ( Table 1 ) show that all parameters achieve the significant standards ( p < 0.05).

Table 1 . Structural equations model result.

From the above estimation results of the structural equations, the following seven research hypotheses in this study are supported: H1: Perceived ease of use presents positive and direct effects on perceived usefulness; H2: Perceived ease of use shows positive and direct effects on attitude; H3: Perceived usefulness reveals positive and direct effects on attitude; H4: Perceived usefulness shows positive and direct effects on behavioral intention; H5: Attitude shows positive and direct effects on behavioral intention; H6: Subjective norm reveals positive and direct effects on behavioral intention; and H7: Perceived behavioral control shows positive and direct effects on behavioral intention.

Most e-books are free and easy to access. Therefore, students tend to read quickly and to immediately reject unsuitable e-books and to search for the next one. In the reading process of acquisition and searching, e-books usually show an abstract on the interface indicating the content and facilitating the elimination of unsuitable books or articles. Printed books do not often show abstracts, and the content is only indicated by the cover. Students appear to have a higher acceptance of e-books and to have definite reading goals, thereby increasing reading frequency. Furthermore, students generally appreciate the convenience of keyword searches of e-books, discovering new reading strategies involving integration and explanation. Students tend to read printed books for comprehension and to use keywords to directly search for solutions in e-books. It seems that an increasing number of students are engaging in digital reading for academic purposes.

The research results reveal students' high demands for reading e-books. The convenience of not being restricted to time and space is popular among students when considering the importance of e-books. The results show that students are not familiar with e-book resources and how to use them, and that digital reading can be limited by software and hardware issues. In addition, note-taking can be challenging because of the unfamiliar interface. Therefore, students should participate actively in the e-book use education courses offered by libraries to increase their understanding of e-books and to improve their ability to use e-book reading software to enhance their e-book information literacy. Students encounter many difficulties in the digital reading experience, including the limitations of software and hardware, the challenges involved in underlining and making notes, and the unfriendly user interface. Students expressed the view that unstable software or hardware might hinder their e-book reading. E-book firms could improve the stability of software and hardware, thereby enhancing students' use satisfaction. It is therefore suggested that e-book firms should regularly survey readers' digital reading experiences and improve the e-book service to increase students' e-book use intention.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Ethics Statement

The present study was conducted in accordance with the recommendations of the Ethics Committee of the Guilin University of Technology, with written informed consent being obtained from all the participants. The research protocol was approved by the ethical committee of the Guilin University of Technology.

Author Contributions

Y-ZL performed the initial analyses and wrote the manuscript. Y-MX was responsible for the methodology, software, and validation. Y-YM and CL assisted in the data collection and data analysis. All authors revised and approved the submitted version of the manuscript.

This research was supported by the Guangxi Zhuang Autonomous Region: 100 Plan on the Introduction of High-level Overseas Talents for Colleges and Universities in Guangxi (YM 20181204).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The authors thank the reviewers for their valuable comments.

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Keywords: theory of planned behavior, technology acceptance model, e-book, reading intention, behavioral intention

Citation: Luo Y-Z, Xiao Y-M, Ma Y-Y and Li C (2021) Discussion of Students' E-book Reading Intention With the Integration of Theory of Planned Behavior and Technology Acceptance Model. Front. Psychol. 12:752188. doi: 10.3389/fpsyg.2021.752188

Received: 02 August 2021; Accepted: 25 August 2021; Published: 20 September 2021.

Reviewed by:

Copyright © 2021 Luo, Xiao, Ma and Li. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Chao Li, walking_lee@163.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Three-in-ten Americans now read e-books

Americans are spreading their book consumption across several formats. The share of adults who have read print books in the past 12 months still outpaces the share using other forms, but 30% now say they have read an e-book in that time frame.  

Overall, 75% of U.S. adults say they have read a book in the past 12 months in any format, whether completely or part way through, a figure that has remained largely unchanged since 2011, according to a Pew Research Center survey conducted from Jan. 25 to Feb. 8, 2021. Print books remain the most popular format for reading, with 65% of adults saying that they have read a print book in the past year.

While shares of print book readers and audiobook listeners remain mostly unchanged from a Center survey conducted in 2019, there has been an uptick in the share of Americans who report reading e-books, from 25% to 30%.

Pew Research Center has studied how Americans read books for years. For this analysis, we surveyed 1,502 U.S. adults from Jan. 25 to Feb. 8, 2021, by cellphone and landline phone. The survey was conducted by interviewers under the direction of Abt Associates and is weighted to be representative of the U.S. adult population by gender, race, ethnicity, education and other categories. Here are  the questions, responses and methodology used  for this analysis.

Americans read an average (mean) of roughly 14 books during the previous 12 months and the typical (median) American read five books in that period, according to the survey. These figures are identical to 2011 , when the Center first began conducting surveys of Americans’ book reading habits.  

Despite growth in certain digital formats, it remains the case that relatively few Americans only consume digital books (which include audiobooks and e-books) to the exclusion of print. Some 33% of Americans read in these digital formats and also read print books, while 32% say they read only print books. Just 9% of Americans say they only read books in digital formats and have not read any print books in the past 12 months.

Demographic differences in book reading in 2021 are similar to the patterns seen in past Center surveys . For example, adults who have a bachelor’s or advanced degree are more likely to be book readers than those who have only attended some college and those with a high school education or less, and adults ages 18 to 29 are more likely to read books than those 65 and older. At the same time, patterns of book consumption among a few groups changed since 2019. Some examples:

Adults with lower incomes – The share of adults with an annual household income of less than $30,000 who have listened to an audiobook has increased 8 percentage points since 2019 (22% vs. 14%).  

Urban adults – The share of American adults living in urban communities who say they have read a book in any format in the previous 12 months grew from 75% in 2019 to 81% now – an increase of 6 percentage points.

The table below covers how different groups reported their reading habits in the survey.

Note: Here are  the questions, responses and methodology used  for this analysis. This is an update of a post by Andrew Perrin originally published Sept. 1, 2016.

Michelle Faverio is a research analyst focusing on internet and technology research at Pew Research Center

Andrew Perrin is a former research analyst focusing on internet and technology at Pew Research Center

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Facts on foreign students in the u.s., book reading 2016, long-form reading shows signs of life in our mobile news world, slightly fewer americans are reading print books, new survey finds, most popular.

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Psychology: Research and Review

• Open access
• Published: 06 May 2022

Reading digital- versus print-easy texts: a study with university students who prefer digital sources

• Noemí Bresó-Grancha 1 ,
• María José Jorques-Infante 2 &
• Carmen Moret-Tatay   ORCID: orcid.org/0000-0002-2867-9399 2 , 3  

Psicologia: Reflexão e Crítica volume  35 , Article number:  10 ( 2022 ) Cite this article

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The transition from on-paper to on-screen reading seems to make it necessary to raise some considerations, as a greater attentional effort has been claimed for print texts than digital ones. Not surprisingly, most university students prefer this digital medium. This research aims to examine reading times by contextualizing this phenomenon into two processes: namely, word recognition and reading comprehension task on paper and on screen. Thus, two different tasks—counterbalanced into digital and print mediums—were carried out per each participant with a preference for a digital medium: a reading comprehension task (RCT) and a lexical decision task (LDT) after reading a specific story. Participants were slower reading print texts and no statistically significant differences were found in RCT accuracy. This result suggests that the task required more cognitive resources under the print medium for those with a worse comprehension performance in reading, and a more conservative pattern in digital RCT for those with a better performance.

Introduction

Reading has different effects on the brain, is considered as an activity that can reduce stress (Corazon et al., 2010 ), improves people’s memories (Peng et al., 2018 ), and enhances empathic skills (Gabay, Dundas, Plaut, & Behrmann, 2017 ; Kuzmičová, Mangen, Støle, & Begnum, 2017 ; Mangen, 2016 ), among others. This process has also been linked to longer life spans (Chang, Wu, & Hsiung, 2020 ; Peng et al., 2018 ), but, surprisingly for most, it is not innate. It must be learned through specific exercises for this purpose, usually in our childhood. In this way, networks of connections are developed through an architecture which is already used for recognizing visual patterns and understanding spoken language (Vogel et al., 2013 ). This architecture has been mainly addressed by studying response times (RTs) (Luce, 1986 ) and the specificity of reading-related regions through fMRI (Vogel et al., 2013 ).

When describing the reading process, an abstraction is developed in the fusiform gyrus that allows our brain to recognize strings of letters in milliseconds. This occurs even if stimuli are presented in different typographies, sizes, or even upper or lower cases, among others (Perea, Moret-Tatay, & Panadero, 2011 ). The changing nature and circumstances of reading, as digitization is growing, is a subject of debate that might influence our reading process. Literature has suggested a greater attentional effort for print texts than for digital texts (Mangen & Kuiken, 2014 ). While some studies stipulate higher reading comprehension on paper (Kim & Kim, 2013 ; Mangen, Walgermo, & Brønnick, 2013 ), others find no such differences between mediums (Porion, Aparicio, Megalakaki, Robert, & Baccino, 2016 ; Rockinson- Szapkiw, Courduff, Carter, & Bennett, 2013 ). These differences on results might be explained through the effect of modulating variables (Delgado, Vargas, Ackerman, & Salmerón, 2018 ) such as time constraints, genre or type of text, and temporal moment. Moreover, a piece of research (Mangen, Olivier, & Velay, 2019 ) stands out by assessing this variable in Kindle DX, as a digital medium, and print. Participants were assessed in their reconstruction of the story from both mediums. The authors concluded that kinesthetic feedback was less informative in a Kindle. Another study comparing print, e-reader, and a tablet computer by combining EEG and eye-tracking measures showed shorter mean fixation durations and lower EEG theta band voltage density in the digital medium for older participants (Kretzschmar et al., 2013 ). However, comprehension accuracy did not differ between mediums.

Comparisons in this front have also been addressed from fields such as ergonomics and perception (Benedetto, Drai-Zerbib, Pedrotti, Tissier, & Baccino, 2013 , 2014 ). It should be noted that the physical interaction that occurs while reading on paper or on screen is significantly different. Actions like turning a page or feeling the paper of a book produce a multisensory experience that increases the cognitive, affective, and emotional insertion in the subject matter (Jacobs, 2015 ; Kuzmičová et al., 2017 ; Mangen et al., 2019 ). In this context, a shallowing hypothesis is theorized, which tries to explain how recent media technologies might lead to a decline in reflective thought and an increase in superficial learning, as an immediate reward is expected (Annisette & Lafreniere, 2017 ). Given this change in pattern, could decoding be different from one medium to the other, being more superficial in digital, and thus affecting comprehension?

Classical authors such as Eldredge ( 1988 ) claimed that repeated exposure to frequently words in print mediums is likely to improve learners’ visual recognition of those words, which in turn is also likely to improve reading comprehension. Not surprisingly, this is an accepted strategy in fluency interventions (Brown et al., 2018 ). One of the main classical models on text comprehension defines this process as the result of the interaction of text features and readers' knowledge, involving variables such as propositional representation and readers' prior knowledge (Hsu, Clariana, Schloss, & Li, 2019 ; McNamara & Kintsch, 1996 ). In this way, familiarity with the medium is a variable of interest, and differences can be stipulated between samples that are more familiar with the digital versus print environment. On the other hand, considering the simple view of reading (Hoover & Gough, 1990 ) as one of the most influential approaches which has been developed to address early reading comprehension, reading must be addressed from a cognitive perspective. More precisely, this cognitive model of reading comprehension (RC) stipulates that RC is a consequence of the interaction between decoding and linguistic comprehension, where word recognition can be considered part of the decoding process (de Oliveira, da Silva, Dias, Seabra, & Macedo, 2014 ; Kirby & Savage, 2008 ).

According to the literature, the most commonly employed cognitive tasks involved in printed word identification have been lexical decision (LDT) and naming (Imbir et al., 2020 ; Katz et al., 2012 ; Navarro-Pardo, Navarro-Prados, Gamermann, & Moret-Tatay, 2013 ), bearing in mind that in both tasks RTs and accuracy are the main dependent variables. Moreover, one of the dependent variables that RC and lexical decision tasks have in common is the analysis of reaction time or response latency. Within this field, processing speed has been described as an indicator of reading performance in groups such as participants with dyslexia (Norton & Wolf, 2012 ), and is considered a reflection of brain architecture (Luce, 1986 ; Moret-Tatay, Gamermann, Navarro-Pardo, de Córdoba, & Castellá, 2018 ). Some studies seem to indicate that readers in digital media spend less time than in printed texts; however, their understanding may also be affected (Ackerman & Lauterman, 2012 ). Therefore, the literature has stipulated that readers may overestimate their understanding of digital texts.

According to the literature, a decline of long-form reading in higher education is diminishing (Baron & Mangen, 2021 ). In this way, university students seem to prefer, or more frequently used, digital sources than print ones for short times of reading (Terra, 2015 ). Differences between mediums, which were previously described, might be of interest for to be addressed, particularly for short texts. For this reason, this research aims to examine the differences between digital and print easy-texts reading in University students who prefer digital sources. We hypothesize that university students with a preference for digital texts have lower reading latency for simple digital texts than print ones. In addition, we expect, in this profile of participants, shorter lexical decision latencies in digital versus print easy-texts. If comprehension is not compromised in easy texts, previous literature might reflect a cost optimization, which becomes more controversial in long texts, as previous literature has shown. A RC and word recognition across mediums were selected for this research question. Moreover, if word recognition is considered directly linked to RC, it is expected a similar pattern for both processes in terms of speed processing. Lastly, a Bayesian approach was considered as an alternative strategy to support traditional analysis as described in prior literature (Nuzzo, 2014 ; Puga, Krzywinski, & Altman, 2015 ).

Materials and methods

Participants.

A sample of 40 university students (25 women and 15 men with an average age of 18.90 years and SD= 1.51), with no history or evidence of neurological or psychiatric disease, volunteered to participate. All participants were Spanish native speakers, without any neurological disorder reported and normal or corrected vision, and a preference for digital texts than print ones. All participants indicated a higher use of digital media than print, although specific usage was not quantified. They were randomly divided into two counterbalanced groups to perform the experiment tasks. In this way, one subgroup first performed the digital task and after that the print one, while the other way around was employed for the second subgroup. The tasks were carried out in accordance with the Declaration of Helsinki and approved by the University ethical committee. The ethical code is UCV/2020-2021/030. Participants gave written consent to participate in the study.

A total of two tasks were carried out per participant: a reading comprehension task (RCT) and a lexical decision task (LDT).

For the reading comprehension task, two stories published in previous literature (Perea, Panadero, Moret-Tatay, & Gómez, 2012 ) were selected with its correspondent reading comprehension questions. These two stories have been successfully employed with children and employed in a counterbalanced design as the one carried out in the original research. In other words, the participants were divided into two groups, one read one of the stories in digital and the other one in print, while conversely in the other group. In terms of presentation, the whole text was presented in a single screen or in a single piece of paper. One text has a total of 153 Spanish words and the second one 162, with the title “The Wind” and “The Snowman” (see Perea et al., 2012 ). Afterwards, participants had to write in a piece of paper the answer to five questions related to each text, which were the same questions employed in the original study.

The second part of the session was dedicated to carry out the LDT. The stimuli consisted of a set of 120 five-letter words in Spanish and 120 pseudowords. Words were divided into two lists (to enable the comparison between print and digital in a counterbalanced way) and matched in terms of frequency and orthographic neighbors, as in the original publication (Moret-Tatay & Perea, 2011 ) Footnote 1 . It should be noted that this material was also originally developed for children and published in previous research work, but it has been employed in other experiments with other Spanish groups that differ in age, such as university and senior students (Navarro-Pardo et al., 2013 ; Perea, Devis, Marcet, & Gomez, 2016 ). By using these materials employed in children and older adults, the reading of simple texts is to be examined. Moreover, current results might allow future comparisons in different age groups.

All stimuli were presented with a fixed text that was the same for the digital and printed versions, in lowercase 14 pt Times New Roman. The viewing distance was optional for the participants, who were free to approach the text as closely as they wished, but with a maximum distance of 30 cm. For ecological validity reasons, the chosen presentation of texts was carried out as follows: the digital texts were presented on the computer screen, while the printed ones were presented on a sheet of paper on the table.

As previous mentioned, participants had to perform a LDT and a RCT. Thus, two lists of words and two versions for each story, one for a digital and one for a print medium, were prepared and randomly counterbalanced across participants. Half of the participants were initially presented with one text and word list, (e.g., digital), and then the other text and word list (e.g., on paper). The participants were tested in a quiet room at the University structure in small groups. The presentation of the stimuli and recorded response times were controlled by computers through the Windows software DMDX (Forster and Forster, 2003 ).

The presentation of the stories was counterbalanced across digital and print media, as shown in Fig. 1 . It should be noted that for the RCT there was no maximum time in both print and digital mediums, the time employed for each participant was recorded. Participants were encouraged to employ the time they needed to properly read the text. They must press a key in the keyboard to indicate the starting and the same bottom to indicate the reading end in both mediums, similar than the LDT procedure. After the reading phase, they were asked to answer five questions out of time in a paper medium. Therefore, the dependent variables used were the unrestricted reading times (paper versus digital) and accuracy was measured.

RCT task. The task was counterbalanced in the order of presentation of reading material according to media type: digital or print (left versus right). Finally, written comprehension questions were asked in written form

For the LDT digital version, after pressing a starting bottom, a fixation point (+) was presented for 500 ms in the center of the screen. Then the target stimulus was presented until the participant’s response, with a maximum of 2500 ms. Participants were instructed to press a button (labeled “yes”) if the stimulus corresponded to an existing word in Spanish, and press another button (labeled “no”) if it did not. As depicted in Fig. 2 , for the paper-based adaptation of the TDL, randomized lists of words were generated on printed paper, and participants were challenged to cross out the words against the pseudo-words.

The classical LDT. The left-hand page is the paper adaptation for the LDT where participants crossed the words from pseudowords

In this case, participants had to press a button in DMDX to start and finish the task, and their timing was compared with the digital version. For the whole experiment, participants were instructed to respond as quickly as possible, maintaining a reasonable level of accuracy. The stimuli were randomly presented to each participant. Each session lasted about 20 minutes. Since reaction time might vary slightly between words and pseudo-words into each medium (due to obvious differences in media manipulation), only the accuracy between digital and print word recognition was taken as the dependent variable.

Data analysis

Sample size was estimated with G*Power software (Faul, Erdfelder, Lang, & Buchner, 2007 ). A non-parametric approach was carried out, as some assumptions, such as normality, were not accomplished on the RCT times and LDT accuracy of the participants. Correlation was used to examine how performance in RCT and word recognition were related to each other. Furthermore, a Bayesian inference was carried out using the Bayes factor notation (BF10), as a strategy that offers several benefits from frequentist statistics in terms of Interval confidence for parameters, as well as evidential trajectory in favor of H 1 over H 0 (Marsman & Wagenmakers, 2017 ). This approach also allows to quantify uncertainty about effect sizes more easily (Moret-Tatay, Wester, & Gamermann, 2020 ). It should be noted that that measure of interest, the RTs, can be non-normally distributed, so other approaches might be of interest to shed light on the barriers to reach assumptions such as data normality. In this way, the Bayes factor notation (BF10) was employed to support H 1 over H 0 where, according to medium theories, word recognition and reading times predict comprehension, and differences might appear depending on the format. Data analysis was performed by using JASP (Version 0.12.2) [Computer software].

Descriptive analyses on the variables of interest are depicted in Table 1 . It should be noted that reading time in the RCT was remarkably longer for on-paper reading than for on-screen reading. The same pattern was identified in reading comprehension and word recognition tasks. A test of normality (Shapiro-Wilks) was conducted on the variables under study. Statistically significant results (all p <.01) suggested that these variables were not normally distributed. For this reason, a non-parametric approach was carried out.

A Wilcoxon signed-ranks test indicated that reading time in a print medium was higher than in a digital one, and the rank-biserial correlation ( r ) between both measures was employed as a measure for effect size in this non-parametric approach: Z =− 5.05; p <.001; r =.91; 95% CI [.84, .96]. This difference was also statistically significant in LDT accuracy; however, the confidence interval did not support this difference: Z =− 3.84; p <.001; r = − .04; 95% CI [− .37, .30]. RCT accuracy also reached the statistical significance level: Z = − 1.16; p <.001; r = − .50; 95% CI [− .72, -.20]. Table 2 depicts the Spearman correlations across variables, showing a strong correlation between RCT accuracy of digital and print media (rho=0.608; p <0.01). Moreover, RCT time in digital media correlated with RCT accuracy in digital in a positive way (rho=0.39; p <0.05), but not in print media. RCT time in print inversely correlated with accuracy in both digital (rho= − 0.339; p <0.05) and print mediums (rho= − 0.263; p <0.01). Finally, digital LDT only correlated with RCT time (rho=0.334; p <0.05), while print LDT correlated with both print (rho=0.319; p <0.05) and digital reading time (rho=0.335; p <0.05).

A Bayesian paired procedure was also carried out across mediums. Figures 3 , 4 , and 5 illustrate the evidential trajectory in favor of H 1 over H 0 . It must be pointed out that the evidence for the alternative hypothesis is relatively stable for reading times and word recognition, thereby suggesting that the analysis is robust. However, the evidence in favor of H1 in RC is not anecdotical.

Bayes factor robustness check for differences between RCT time on screen and paper format

Bayes factor robustness check for differences between LDT accuracy on digital and paper support

Bayes factor robustness check for differences between RCT accuracy on digital and paper support

The digital proliferation has attracted the scientific community’s interest towards the reading process in the last decade (Clinton, 2019 ). A switch towards superficial from deep reading processes has been described in digital mediums (Mangen & Kuiken, 2014 ), also suggesting that those who often read in print texts are less likely to perform multiple tasks during reading than those who often read in digital screens. Not surprisingly, it has been claimed that this difference is related to encouraging divided attention in this last medium (Sanbonmatsu, Strayer, Medeiros-Ward, & Watson, 2013 ). Even if detrimental effects have been reported regarding digital texts, university students seem to prefer digital sources (Terra, 2015 ). Even if mixed results have been found in the literature on long texts, what are the differences between reading digital- versus print-easy texts in university students who prefer the digital medium? Do these differences influence individual word recognition or only general comprehension?

The current results show a longer reading time for printed texts compared to digital texts. From the Bayesian approach, it is interesting to note that the most robust variables on the differences between print and digital texts were RCT time and LDT accuracy, but not for RCT accuracy. A feasible explanation related to RCT time would be related to the fact that printed texts allow readers to see and feel the spatial extent and physical dimensions of the text. In this way, the number of stimuli in printed texts would be enlarged, ultimately providing a greater number of physical, tactile, and spatio-temporal cues for reading, even for easy texts. However, comprehension seems not to be affected under such a level of demand. This might also explain higher attentional levels. However, the current manipulation does not allow to claim this explanation, as attentional levels were not measured, but are of interest for future lines of research. What these results did attempt to measure was the level of comprehension, which although slightly higher in the printed format, it was not conclusive. This result could support that young people would adapt to this form of reading as opposed to the older adult groups described in previous literature with techniques such as EEG (Kretzschmar et al., 2013 ). However, although the results seem promising, replications with other age groups are necessary to establish such e-generation claim.

The second main aim of the study was to address the relationship between RC and LDT accuracy in both mediums under study. An inverse relationship is found between RCT time and accuracy for print. However, this pattern changes for digital texts. This could reflect a familiarization cost from one medium to another. On the other hand, the direct relationship between RCT accuracy and time in digital texts might reflect a more conservative pattern of response in this medium that is more familiar to participants. Finally, a relationship was found between RCT and LDT accuracy per each medium. RCT accuracy in digital was also related to LDT accuracy in print, but not inversely. This would mark differences in individual patterns, as marked in previous literature regarding how text is integrated between mediums (Latini, Bråten, & Salmerón, 2020 ). Nevertheless, it must be considered that the results were not direct, suggesting that more variables underlie this process. One variable of interest—and it was not controlled in the current study—is the motivation during the task. This is one of the main limitations of this study. Moreover, the task employed here could be very easy for university students. This material was employed to avoid any “floor effect” and allows future comparison with other age groups.

It should be noted that being faster in the reading task has been also linked to the search for immediate reward in previous literature (Ackerman & Lauterman, 2012 ; Delgado et al., 2018 ). If so, that might explain shorter RTs under the digital, which in this case, might not affect comprehension in an easier task as the one under study. Despite the well-known preference for digital texts, regardless of the task and the benefits offered by the medium (for example, portability and speed), there are certain controversies regarding them, particularly considering groups of readers with dyslexia, who showed a more effective and comprehensive reading in digital texts (Chen & Keong, 2017 ; Schneps, Thomson, Chen, Sonnert, & Pomplun, 2013 ), but in these cases, the difficulty of the text was not controlled.

Finally, we would like to highlight the extra value of an integrative strategy such as the Bayesian approach in this field (Moret-Tatay, Beneyto-Arrojo, Laborde-Bois, Martínez-Rubio, & Senent-Capuz, 2016 ; Nuzzo, 2014 ; Ruiz-Ruano, López-Puga, & Delgado-Morán, 2019 ), by offering additional evidence to support differences between digital and print materials. In this regard, the Bayesian correlation depicted not particularly strong H 1 in some cases. To sum up, the results of this study seem not to ensure the superiority of electronic texts over print ones in the prediction of reading time, as latency is not a single indicator, and as superficial pattern seems to be depicted even for easier texts.

Conclusions

The aim of this study was to examine the relationship between RCT accuracy, RCT time, and LDT accuracy in print and digital mediums in university students with a preference for digital texts. For this reason, two experiments were carried out into a counterbalanced order across digital and print environments. Results can be described as follows: (i) latencies for reading on digital texts were shorter in digital than print mediums; (ii) Word recognition and Comprehension were slightly higher for print than digital texts, but not conclusive (iii) Reading time on digital and print text strongly correlated to each other; (iv) A relationship regarding LDT accuracy in print and RCT accuracy in print and digital texts was found, but this is not the case with LDT accuracy in digital.

As in the original research by Moret-Tatay and Perea et al. ( 2011 ) the same 120 words from this research were employed, 60 were of high frequency (mean = 146.7 per million, range = 30.9–675.6) and 60 low frequency (mean = 10.2 per million, range = 0.7–23.2). Moreover, and as previously mentioned, the same two lists of stimuli than in the original research were employed, with 60 words and 60 nonwords being randomly assigned to List 1 and the other 60 words and 60 nonwords being assigned to List 2. In this way, those participants who were initially were presented with List 1 in Block 1, the second block would be List 2 and vice versa.

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Acknowledgements

We would like to thank all participants involved in this study, and Professor Gracia Prats Arolas for their support on participants’ recruitment and comments, as well as the Universidad Católica de Valencia San Vicente Mártir for the support and funding.

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María José Jorques-Infante & Carmen Moret-Tatay

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Conceptualization: N.B.-G. and C. M.-T.; methodology and formal analysis: C.M.-T.; data curation: N.B.-G., M-J.I., and C.M.-T.; writing—review and editing: N.B.-G., M.J.-I., and C.M.-T. The authors read and approved the final manuscript.

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Bresó-Grancha, N., Jorques-Infante, M.J. & Moret-Tatay, C. Reading digital- versus print-easy texts: a study with university students who prefer digital sources. Psicol. Refl. Crít. 35 , 10 (2022). https://doi.org/10.1186/s41155-022-00212-4

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Paper books linked to stronger readers in an international study

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There’s a lot to like about digital books. They’re lighter in the backpack and often cheaper than paper books. But a new international report suggests that physical books may be important to raising children who become strong readers.

An Organization for Economic Cooperation and Development (OECD) study across approximately 30 countries found that teens who said they most often read paper books scored considerably higher on a 2018 reading test taken by 15-year-olds compared to teens who said they rarely or never read books. Even among students of similar socioeconomic backgrounds, those who read books in a paper format scored a whopping 49 points higher on the Program for International Student Assessment, known as PISA. That’s equal to almost 2.5 years of learning. By comparison, students who tended to read books more often on digital devices scored only 15 points higher than students who rarely read  – a difference of less than a year’s worth of learning.

In other words, all reading is good, but reading on paper is linked to vastly superior achievement outcomes.

It's impossible to say from this study whether paper books are the main reason why students become better readers. It could be that stronger readers prefer paper and they would be reading just as well if they were forced to read on screens. Dozens of previous studies have found a comprehension advantage for reading on paper versus screens . But these studies are usually conducted in a laboratory setting where people take comprehension tests immediately after reading a passage in different formats.  This report is suggesting the possibility that there are longer term cumulative benefits for students who regularly read books in a paper format.

It’s noteworthy that the 2018 PISA reading test was a computer-based assessment in the vast majority of countries. Paper book readers are correctly answering more questions about what they have read on screens than digital readers!

Strong readers who had higher scores on the PISA reading test also read on screens at home, but they tended to use their devices to gather information, such as reading the news or browsing the internet for school work. When these strong readers wanted to read a book, they opted to read in paper format or balance their reading time between paper and digital devices.

Every three years, when 600,000 students around the world take the PISA test, they fill out surveys about their families and their reading habits. Researchers at the OECD compared these survey responses with test scores and noticed intriguing relationships between books in the home, a preference for reading on paper and reading achievement. The report, “ Does the digital world open up an increasing divide in access to print books? ” was published on July 12, 2022.

In the United States, 31 percent of 15-year-olds said they never or rarely read books, compared with 35 percent worldwide. Meanwhile, 35 percent of American students said they primarily read paper books, almost matching the international average of 36 percent. Another 16 percent of Americans said they read books more often on screens and 18 percent responded that they read books equally on both paper and screens.

Digital books have become extremely popular among students in some regions of Asia, but students who read books on paper still outperformed even in cultures where digital reading is commonplace. More than 40 percent of students in Hong Kong, Indonesia, Malaysia, Taiwan and Thailand reported reading books more often on digital devices. Yet in Hong Kong, Malaysia and Taiwan, students who read books mostly on paper or read in both formats scored higher than those who primarily read digital books. Both Thailand and Indonesia were exceptions; digital readers did better. Hong Kong and Taiwan are two of the highest performing education systems in the world and even after adjusting for students’ socioeconomic status, the advantage for paper reading remained pronounced.

Teens around the world are rapidly turning away from reading, according to OECD surveys. Fifteen-year-olds are reading less for leisure and fewer fiction books. The number of students who consider reading a “waste of time” jumped by more than 5 percentage points. Simultaneously, reading performance around the world, which had been slowly improving up until 2012, declined between 2012 and 2018.  Across OECD countries that participated in both assessments, reading performance fell back to what it had been in 2006.

OECD researchers wonder if the presence of physical books at home still matters in the digital age. In the student surveys, students were told that each meter of shelving typically holds 40 books and were asked to estimate the number of books in their homes. Both rich and poor students alike reported fewer books in the home over the past 18 years, but the book gap between the two remained persistently large with wealthier students living amid twice as many books as poorer students.

The influence of books at home is a bit of a chicken-egg riddle. The OECD found that students who had more books at home reported that they enjoyed reading more. Logically, students who are surrounded by physical books may feel more encouraged by their families and inspired to read. But it could be that students who enjoy reading receive lots of books as presents or bring more books home from the library. It’s also possible that both are true simultaneously in a virtuous two-way spiral: more books at home inspire kids to read and voracious readers buy more books.

OECD researchers are most worried about poorer students. Low-income students made huge strides in access to digital technology well before the pandemic. Ninety-four percent of students from low-income families across 26 developed nations had access to the internet at home in 2018, up from 75 percent in 2009. “While disadvantaged students are catching up in terms of access to digital resources, their access to cultural capital like paper books at home has diminished,” the OECD report noted.

As one gap closes, another one opens.

This story about digital readers was written by Jill Barshay and produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for the Hechinger newsletter.

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“Unparalleled research quality”: An interview with Tanya Laplante, Head of Product Platforms

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• April 24 th 2024

As part of our Publishing 101 blog series, we are interviewing “hidden” figures at Oxford University Press: colleagues who our authors would not typically work with but who make a crucial contribution to the success of their books.

Tanya explains how, as research behaviours have changed, we use digital platforms to ensure that our authors’ books reach readers worldwide.

What is your role at OUP?

I am Head of Product Platforms in the Academic Division of Oxford University Press. I oversee the strategic development for the platforms, such as Oxford Academic, that host our book and journal products and services.

What is the difference between the product and editorial departments at OUP?

While editorial focuses on individual works like books and journals, product is responsible for the overall success and health of OUP’s digital portfolio. Many departments contribute to our digital products and oversee various aspects of product creation and maintenance that are central to success: editorial, sales, marketing, data strategy, content operations, royalties, etc. Product’s role is to ensure that all of those aspects are working together in as seamless a way as possible to deliver high-quality, author-driven products to the people that read our content, namely researchers.

How did Oxford Academic become our home for academic books?

Research behaviours have changed over the past two decades, as we have steadily seen sales shift away from print towards online. Oxford Academic allows us to better connect the online version of our books into a wider aggregated library of content that is easily found on search engines like Google, which can dramatically enhance the reach and impact of our authors’ work. Digital dissemination allows us to put scholarship into the hands of researchers and learners worldwide who might never have access to a library print copy. 

Oxford Academic came out of a desire within the Press to create a single gateway into Academic’s content to streamline the research journeys of those searching for content in our books and journals. It launched with journals in 2017, with research books following in 2022. Digital-first publishing is a priority for OUP as it increases the discoverability and accessibility of our research, thereby magnifying its reach and impact for our authors.

What opportunities does Oxford Academic offer our authors?

Oxford Academic offers authors a modern, mobile-friendly, accessible, search engine optimized platform upon which to publish research. In practice, this means that it’s easier for researchers to find our authors’ work online. With journals and books on the same platform, reader journeys across the two formats are not only possible but can be informed by AI-driven recommendation widgets, so readers are recommended other relevant research.

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Our Insight Working Group is constantly reviewing reader behaviors to recommend development that will drive the use of our books and journals content and, consequently, the impact of authors’ research.

What do you enjoy most about your job?

I enjoy working across departments with various stakeholders to find innovative platform solutions for customers, readers, and authors. It can be a challenge to narrow down the areas of the platform that we should invest in. But I, and the stakeholders I work with, have developed a great deal of expertise that informs where investment is best placed. We want to invest in areas that will have the greatest impact for the greatest number of people that use platforms such as Oxford Academic, including authors, customers, and society partners.

How do you see the digital publishing landscape evolving over the next few years?

New publishing models (Open Access) and technological changes (AI) are both impacting scholarly publishing. With the expansion of Open Access and a changing funder landscape, OUP needs to demonstrate the value of what we, as a non-profit publisher, bring to the research ecosystem. We need to better educate funders, authors, and customers about the critical role we play in the publishing process: overseeing peer review, managing distribution, application of metadata, maximizing discoverability on digital platforms, and more.

In terms of AI and other technological changes, we need to optimize the benefits while minimizing the risks. We are entering a period of great change in digital publication, from review to submission to publication and discoverability. The quality of the research we publish on behalf of authors is unparalleled. We need to harness that quality and use AI as a way to enrich the user experience and increase discoverability of the content, while ensuring we are still driving users to a trusted version of record on OUP’s platforms.

In both of these spaces, we will also need to consider unique services and capabilities we can provide for key stakeholders in this space, including authors, customers, and society partners. What can OUP bring to the table to make their role in the publication process a more seamless one?

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Survey: Most people prefer reading paper books over digital books on tablets, phones

LONDON —  Digital books on tablets, smartphones, and devices like Amazon’s Kindle are certainly convenient, but according to a new survey most people still prefer a good old fashioned paper book. There’s just something satisfying about turning the page and holding a physical book in one’s hands, as over two-thirds of adults say they always opt for a real book over digital reading.

Put together by Oxfam , researcher polled 2,000 respondents in the United Kingdom regarding their thoughts on paper books versus digital books. Close to half (46%) enjoy physically turning pages and 42 percent prefer the feel of a physical book in their hands. One in four say they love the smell of paper books. Meanwhile, another 32 percent feel like they become much more immersed in the story while reading a paper book and 16 percent go for traditional books because they remind them of libraries.

The look and feel of books is still special

Interestingly, over a third of respondents (35%) enjoy buying paper books because that allows them to proudly display them on their bookshelf as a background during Zoom meetings.

All in all, only 16 percent of adults prefer digital books and a meager eight percent who favor audio books. On average, the survey finds most adults own 49 books and read for three hours per week.

“People prefer to read physical books because they offer something more tangible and grounded. There’s something that can feel more “permanent” about real books over digital for mats,” says Dr. Elena Touroni, a consultant psychologist and co-founder of The Chelsea Psychology Clinic, in a statement. “Reading offers us a for m of escapism. It provides us with a break from our everyday lives, and often also, an opportunity to learn something new and expand our minds.”

What’s old is new again

Over half the poll (58%) read to relax, while 46 percent usually read as a break from the real world. More than three in 10 like to read as a means of learning something new and 39 percent read to feel happier. Close to half (45%) have been reading more ever since COVID lockdowns began. Moving past the pandemic, 84 percent plan to take a few books with them on vacation this year.

Three-quarters say they’re considering donating books they’ve finished and 72 percent usually buy used books themselves. Moreover, this research suggests that books are the top item most adults are willing to buy used. Seventy-one percent say they buy used books because it is cheaper and 52 percent do it because it is better for the environment.

Nearly one in five (18%) just like the smell of used books, while another 18 percent like the texture of a second-hand book. Fifteen percent of respondents just love the idea that they might find a note or letter written inside a used book. Nearly one in two people (45%) like to ponder where their old books have been before landing in their hands.

Generally speaking, 49 percent of adults often buy second-hand items, with goods such as books, clothes, CDs, DVDs, and cars topping the list. Six in 10 adults believe buying used items is just as good as buying new.

The survey was conducted by OnePoll.

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Reading paper books leads to better text comprehension — but how?

Overall, research has found reading physical books more beneficial than reading e-books.

By Eva Terry

In December 2023, the University of Valencia published research showing that reading paper books results in six to eight times better comprehension than reading e-books. Over 450,000 people participated in the study.

Cristina Vargas and Ladislao Salmerón from the Educational Psychology department explained in a University of Valencia newsletter, “If a student spends 10 hours reading books on paper, their comprehension will probably be 6 to 8 times greater than if they read on digital devices for the same amount of time.”

While it may seem counterintuitive, researching online had “minimal associations with text comprehension.” The research also showed that text comprehension increases across all demographics with age.

Teenagers who read paper books are much more likely to have academic success compared to their peers who don’t, according to a study conducted by the Organization for Economic Cooperation and Development .

The study added that regardless of socioeconomic background, teenagers who “most often read paper books” scored nearly 50 points above non-readers on the PISA (international testing) across 30 countries. This higher score is equivalent to “almost 2.5 years of learning.”

Is it better to read paper books?

A study published in the Educational Research Review in 2018 found three reasons why comprehension is better when reading paper books.

1. Paper books provide a better time frame for comprehension

The study explained, “The paper-based reading advantage increased in time-constrained reading compared to self-paced reading.”

Reading for the purpose of comprehension comes in virtually any form: studying for exams, researching for work, looking for information on medical, mental or social issues, and more.

Paper books are better for this type of time-constrained comprehension, as they limit distractions and cognitive overload, offer tangibility and spatial awareness, and allow for pen-and-paper annotations.

The internet’s close proximity to reading e-books makes staying focused difficult. Notifications and pop-up ads pull the reader away from their reading. Even if these distractions are only temporary, their influence is harmful to text comprehension.

Harvard Business Review conducted a study on how much time the average American spends toggling between tabs and apps and how task-switching influences the brain and productivity. When measuring how long toggling took the average user, researchers found one switch took slightly over two seconds. They also found that “the average user in the dataset toggled between different apps and websites nearly 1,200 times each day.”

In one day, each participant spent roughly four hours simply switching tasks, and over the course of a year, HBR predicted this would be equivalent to five work weeks.

2. It’s harder to get distracted when you read a physical book

Paper books make it harder for websites to lure you in and distract you from the content your brain is working to comprehend.

Not only do e-books make the user more prone to task-switching, e-book reading itself is less thorough.

“Screen-based reading behavior is characterized by more time spent on browsing and scanning, keyword spotting, one-time reading, non-linear reading, and reading more selectively,” Ziming Liu, a professor of library and information science at San Jose University , explained.

3. Paper books make digesting informational texts easier

Text genre has a large impact on whether reading on paper or reading e-books influences comprehension.

The study compared comprehension levels of different genres depending on the reading mode. Participants had much higher comprehension of informational texts and informational texts with aspects of narrative than books strictly based on narration.

The study found no difference in comprehension for strictly narrative genres.

The physicality of a text helps the brain retain information: “The haptic feedback of a touch screen is different from a paper book, and the implications of such interactions warrant empirical investigations,” Anne Mangen, professor of reading science at the University of Stavanger, wrote in a 2016 study .

Being able to touch, flip through pages and mark the paper help the brain build mental representations of the text’s content.

An article published in Scientific American explained how the brain perceives words as a “tangible part of the physical world.” Reading requires several areas of the brain that deal with aural language, sight and motor coordination.

The brain perceives words as physical objects. Scans of the brain show that when someone processes a word, it activates mainly the visual areas of the brain, according to research published in “Discovering the Brain” by science writer Sandra Ackerman.

The Scientific American ’s research described reading paper books as similarly physical. A physical book orients the reader in two directions: backward and forward. It also allows the brain to build mental maps ranging from chronology to topography.

Educational psychologist Ernst Rothkopf explained, “Both scholarly evidence and anecdotal experience testify that when people try to locate a particular piece of information they have read, they often are able to recall where in the text it appeared, such as a limerick on the top of a right-hand page.”

Rethinking Institutional Repositories: Innovations in Management, Collections, and Inclusion

Posted in: Digital Commons , Homepage Features

As an R2: Doctoral University, Montclair State University publishes an abundance of books and research conducted by its many talented faculty and staff. To make their works available to those who may be interested in their topics, University Libraries houses an institutional repository consisting of these many works known as Digital Commons. Although Digital Commons launched publicly in April 2018, there was a need to measure awareness, and ease of use, among Montclair faculty and staff.

To find out, Research Services Librarian Darren Sweeper and Market Research Analyst (former Repository Coordinator and Research & Projects Specialist) Karen Ramsden conducted a study titled, Establishing and Promoting an Institutional Repository and Research Information Management System .

From their abstract, “The purpose of this paper is to share the experiences and to highlight lessons learned from the establishment of the institutional repository (IR) while collaborating in a state-wide initiative to showcase the scholarly output of New Jersey researchers.”

At the time of this study, Digital Commons had existed for about 3 – 4 years. While the number of views and downloads of each paper is tracked by the repository, it was unknown as to how well the existence of it has dispersed amongst faculty and staff on campus. They also wanted to learn what users already knew about the institutional repository and if they had an understanding of why it existed. To make this determination, the research consisted of conducting literature reviews , creating user personas , and completing qualitative in-depth interviews to learn from real users about their knowledge of, and experience with Digital Commons.

Being such a valuable set of research, they were invited to publish the study as a chapter in the book Rethinking Institutional Repositories: Innovations in Management, Collections, and Inclusion titled “I Don’t Have the Time or Really Understand What This Is! Examining Faculty’s Motivation to Use (or not) Montclair State University’s Institutional Repository”.

Want to learn more about their research and the results? Read their paper and more in University Libraries Digital Commons .

Ebook vs paper: which reading medium is better for the environment?

Ereader makers have taken steps to make digital reading greener, but how sustainable is it?

Blame it on the digital age or on the Covid lockdown years, but the way we read has changed. We’re increasingly consuming books digitally, with several of us adopting ereaders instead of buying printed books. This change in behavior could be considered better for the planet – after all, no trees are getting destroyed to make said books.

That’s not the only reason to read ebooks. Did you know that about 26% of worldwide waste is paper and paperboard? Clearly we’re not all recycling as much as we should be. UK-based waste management company Business Waste has some interesting stats on how much paper we throw away, and it doesn’t even take into account all the paperbacks and text books we might be discarding. Sure, paper decomposes, but that takes 2-6 weeks and the ink could be poisoning our soil and groundwater. 

On the other hand, manufacturing an electronic device arguably has a bigger carbon footprint. According to a New York Times report from 2010, a single ereader needs about 33 pounds of minerals and 79 gallons of water to make, and it has a limited lifespan.

Sustaining digital reading

Manufacturing processes may have changed since that report was published, and while I’m not saying they’re a sustainable process, there are some ereader makers trying to make a change.

Amazon ’s 2022 Kindle was the first to be made using up to 75% recycled plastic in its body and up to 90% recycled magnesium. Amazon adopted a similar stance with the Kindle Scribe a little later that same year, with the larger note-taking ereader built with 48% recycled plastic and 100% recycled aluminum.

Life without a Kindle is like life without a library nearby. Franz McLaren, Author (Home Lost)

Japanese-Canadian brand Kobo, however, is making ereading even more sustainable. The first tablet it released that used recycled materials was the Kobo Clara 2E – the E moniker indicating its eco-friendly origins. According to Kobo, its body was 80% recycled plastic, 10% of which was ocean bound. It was the same with the Kobo Elipsa 2E as well. The company’s 2024 ereaders take it even further – the Kobo Libra Colour , Clara Colour and Clara BW not only use recycled plastics (including ocean-bound waste) in their bodies, but the packaging is 100% recycled and all the words and images printed on the boxes are soy ink, which is biodegradable.

Like other electronic devices, ereaders also have a limited lifespan – on average, a Kindle or a Kobo will give you 6-8 years of use, but several can exceed 10 years of use. Kobo, however, is trying to extend the life of its devices, with the 2024 models possibly becoming the most repairable ereaders available today. The brand has partnered with iFixit to make repair kits and instructions available to potential customers, although this initiative hasn’t gotten off the ground yet – the Libra Colour, Clara Colour and Clara BW are still in pre-order as of this writing.

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I am yet to hear about other ereader brands, like Onyx and PocketBook, moving towards a greener future, but this is a good start, particularly from Kobo.

Kindle your (green) reading dreams

There hasn’t been much research done on which reading habit is more sustainable. There are a handful of studies, and a 2021 article published in the Journal of Library & Information Science Research tried to collate this information to determine whether ereading was more sustainable – the results were inconclusive. So, for the more environmentally conscious reader, which option do you choose?

Well, opting for one of the latest Kobo ereaders might be a good place to start and, despite some non-renewable materials being used to make it, a report from 2009 (via CNET ) suggested using an ereader might be the greener option. At the time it was estimated that around 168kg of carbon dioxide was produced over the lifespan of a single Kindle DX, which was the most popular e-ink device back then. 

Despite being a big number, it can offset about 1,074kg of CO2 produced if you were to buy just three print books each month over four years. Depending on how long the ereader lasted, it could compensate for up to 26,000kg of CO2 over its lifetime. Even if you aren’t a voracious reader, an ebook reader could still have a lower carbon footprint than paper books.

Until recently, I was an ebook sceptic, see; one of those people who harrumphs about the “physical pleasure of turning actual pages” and how ebook will “never replace the real thing”. Then I was given a Kindle as a present. That shut me up. Charlie Brooker, Writer & TV presenter

There are other reading habits you can develop that would make digital reading a greener option than buying paperbacks. For starters, borrowing ebooks and digital magazines from the library instead of buying new titles in print not only means there’s less paper being used, but you’re also saving money on buying new books – digital or otherwise. That’s a win-win.

In the US, you can use your Kindle to borrow from a library; elsewhere, Kobo is your best option, with OverDrive baked into every model. You will need to check with your local library if they have OverDrive support, or borrowing directly from a Kobo device is a no go. You can, however, use the Libby mobile app if your library supports that.

If you’re someone who prefers to buy rather than borrow, an ereader becomes the more eco-friendly option if you read upwards of five 360-page hardback titles a year or around nine paperbacks. If you don’t read as much, then purchasing second-hand printed books is the better alternative.

No matter what reading format you choose, the most important thing is to dispose of the books or the device thoughtfully.

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

Published on 24.4.2024 in Vol 26 (2024)

Behavior Change Approaches in Digital Technology–Based Physical Rehabilitation Interventions Following Stroke: Scoping Review

Authors of this article:

• Helen J Gooch, BSc   ; 
• Kathryn A Jarvis, PhD   ; 
• Rachel C Stockley, PhD  

Stroke Research Team, School of Nursing and Midwifery, University of Central Lancashire, Preston, United Kingdom

Corresponding Author:

Helen J Gooch, BSc

Stroke Research Team

School of Nursing and Midwifery

University of Central Lancashire

BB247 Brook Building

Victoria Street

Preston, PR1 2HE

United Kingdom

Phone: 44 1772894956

Email: [email protected]

Background: Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions.

Objective: This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT.

Methods: Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1).

Results: From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality.

Conclusions: Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation.

Introduction

Digital health technologies (DHTs) comprise apps, programs, or software used in the health and social care systems [ 1 ]. They are considered to have almost unlimited potential to transform health care interventions and delivery and empower people to take a greater role in their own care and well-being [ 2 , 3 ].

Stroke is one of the leading causes of acquired disability worldwide, with around 12 million people experiencing a stroke each year [ 4 ]. Rehabilitation is a complex, multifaceted process [ 5 ] that facilitates those with health conditions and disabilities to participate in and gain independence in meaningful life roles [ 6 ]. It is considered an essential aspect of health care provision following a stroke [ 7 ] as a means to address poststroke impairments, which can involve motor, sensory, and cognitive functions. Changes in the ability to move due to impairment of both movement and sensory function are commonly experienced by people following a stroke [ 8 ] and are addressed by physical rehabilitation comprising regular, intensive practice and repetition of movements and tasks [ 9 , 10 ]. Conventional physical rehabilitation often struggles to deliver the intensity required to optimize recovery [ 11 ], and over recent years, there has been significant interest in the use of DHTs, such as virtual reality (VR), telerehabilitation, robotics, and activity monitors [ 12 - 16 ], to enhance and increase the intensity of rehabilitation. DHTs can provide a whole intervention or be used as a component of a wider intervention; the term DHT-based intervention has been used within this review to refer to both situations.

For many people who survive a stroke, rehabilitation requires individuals to engage in regular and frequent rehabilitative activities to achieve improvements in function and realize their optimal recovery. This necessitates adjustments to an individual’s behavior [ 17 ] over a sustained period of time. Changing behavior is a complex process and is underpinned by a variety of different theories, models, and frameworks [ 18 ], such as social cognitive theory [ 19 ] or the behavior change wheel framework [ 20 ]. Individual activities within a complex intervention that are designed to change behavior can be separated into replicable active components widely referred to as behavior change techniques (BCTs) [ 21 ]. Historically, labels applied to BCTs have lacked consensus, resulting in uncertainty and difficulty in comparing interventions. This has been addressed in the behavior change technique taxonomy version 1 (BCTTv1) [ 22 ], a classification system of 93 distinct BCTs clustered into 16 groups, which is a well-recognized tool to provide consistency with BCT reporting in interventions. DHTs provide an emerging opportunity to support the behavior change required within physical stroke rehabilitation interventions through facilitators that are embedded within the technology itself that aim to form, alter, or reinforce behaviors [ 23 ]. Understanding of this area is limited, with most literature exploring the use of DHTs to support behavior change focused on specific health-related behaviors such as physical activity or healthy eating [ 24 ] rather than as a core component of a type of rehabilitation intervention. Motivation is acknowledged to play an integral role in behavior change [ 25 ], and it is often assumed that DHTs provide motivation to engage with rehabilitation [ 26 ]. However, for this assumption to be realized, the DHTs must be able to support and deliver interventions that facilitate the vital changes in behavior needed to promote prolonged and sustained engagement in stroke rehabilitative activities. Imperative to this is understanding the theories, models, and frameworks that underpin interventions and the BCTs (active components) within the interventions [ 27 - 29 ]. The theories, models, and frameworks alongside the BCTs will be referred to hereinafter as approaches. Within the context of DHT-based physical stroke rehabilitation interventions, approaches to behavior change warrant further investigation.

Aim and Objectives

This scoping review aimed to identify if and how behavior change approaches are incorporated within DHT-based physical stroke rehabilitation interventions. Specifically, it sought to:

• Establish if behavior change theories, models, and frameworks, or BCTs, are described when reporting on DHT-based interventions that have been developed or evaluated for use in poststroke physical rehabilitation.
• Identify if behavior change theories, models, or frameworks underpin the interventions and which of these are being used.
• Identify if the BCTTv1 is being used to report BCTs within interventions.
• Determine which BCTs (based on the BCTTv1) can be identified within the interventions.
• Explore whether the type of technology influences the techniques used to change behaviors.

Review Methodology

A scoping review was completed and reported following established guidelines [ 30 , 31 ] and the Preferred Reporting of Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR; Multimedia Appendix 1 ) [ 32 ]. The protocol was registered with the Open Science Framework [ 33 ].

Eligibility Criteria

Any published sources that reported a completed primary research study in which a behavior change approach could be identified within a DHT-based physical stroke rehabilitation intervention were included ( Multimedia Appendix 2 ). Physical rehabilitation comprised interventions that addressed an impairment, or sequela of impairment, of sensory function and pain, neuromusculoskeletal and movement-related functions, or voice and speech, as defined by the International Classification of Functioning, Disability, and Health [ 34 ]. Completed primary research included all types of studies, both quantitative and qualitative, and no minimum sample size or intervention length was set. The BCTTv1 [ 22 ] was used to support the identification of BCTs within the interventions.

Information Sources and Search Strategy

A systematic database search was conducted in Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews, CENTRAL Register of Controlled Trials, and AMED on March 21, 2023. The search was completed in collaboration with an information specialist who provided support with the development of the free text and thesaurus search terms, created the final search, adjusted the searches for the different databases, and ran the search. It consisted of 4 distinct search streams: behavior change, DHT, physical rehabilitation, and stroke, which were then combined ( Multimedia Appendix 3 ). Searches were restricted to the English language (due to review resources) and by date to search from 2001; the date restriction acknowledges the main time period of DHT growth [ 35 ], captures sources reported in systematic reviews of DHTs in stroke rehabilitation [ 12 - 16 ], and is reflected in other scoping literature exploring DHTs [ 24 ]. Additional sources were identified by hand searching, including scrutiny of the included source reference lists.

Selection of Sources of Evidence

The titles and abstracts of deduplicated sources from database searches and hand searches were independently screened by 2 reviewers, 1 of whom had completed the BCTTv1 web-based training package [ 36 ] to inform decisions made around the use of BCTs. Any conflicts were discussed, and if a consensus was not reached, the source was included for full-text screening. Attempts were made to locate a completed study publication from eligible conference abstracts, protocols, and trial registry entries. Full-text sources were screened independently by 2 reviewers, and disagreements were resolved by a third reviewer. Reasons for full-text exclusion were recorded. EndNote X9 software (Clarivate) and the Rayyan web tool software (Qatar Computing Research Institute) [ 37 ] were used to facilitate the source selection process.

Data Charting Process

A review-specific data charting tool was developed and initially piloted using 3 sources by 3 reviewers, and then further developed iteratively throughout the process [ 30 ]. Data charting was completed collectively by 2 reviewers. When several sources referred to a single study, these sources were grouped together for data charting, and if a source identified additional sources for further detail of the intervention (eg, a protocol or supplementary material), then this information was also used to support data charting.

The data charting tool was developed with reference to the Template for Intervention Description and Replication (TIDieR) checklist [ 27 ] and with a focus on the DHT-based intervention and behavior change approaches ( Multimedia Appendix 4 [ 14 , 38 - 40 ]). In the absence of a recognized predefined taxonomy for DHTs, the DHTs used in the sources were charted iteratively by the type of technology [ 41 ] from the information provided about the intervention. Over time, DHT categories emerged and were defined ( Multimedia Appendix 4 ). Discrete BCTs were identified from the intervention detail provided using the BCTTv1 [ 22 ] ( Multimedia Appendix 5 [ 42 ]). A pragmatic decision was made that the single reviewer who had completed the BCTTv1 web-based training package [ 36 ] would code the interventions to the BCTTv1. Any areas of uncertainty were discussed in detail among the review team.

Synthesis of Results

In accordance with the aims of a scoping review, formal assessments of methodological quality were not completed [ 30 , 31 ]. Findings were synthesized using descriptive statistics facilitated by SPSS Statistics 28.0.0.0 (IBM Corp) and Microsoft Excel (version 2208; Microsoft Corporation) and presented in text, table, and chart formats. The characteristics of the included sources, specifically participant numbers, age, and time since stroke, and intervention details, were summarized to provide contextual information for the review. Time since stroke was based on a published timeline framework [ 43 ], which describes the following phases: acute (1-7 days), early subacute (7 days to 3 months), late subacute (3-6 months), and chronic (greater than 6 months).

The behavior change theories, models, or frameworks underpinning the DHT-based interventions and sources where interventions had already been coded to the BCTTv1 were summarized. The use of individual BCTs, as coded by reviewers from intervention descriptions, was briefly summarized; however, the main focus of the BCT synthesis was completed by grouping the BCTs into the 16 BCTTv1 clusters, in order to provide an overview of their use across the sources and allow comparison with other reviews [ 44 , 45 ]. A cluster was only identified once per source, irrespective of the number of individual BCTs within that cluster. Relationships between BCTTv1 clusters and between DHT type and BCTTv1 clusters were descriptively explored. A relationship map was used to visually represent the strength of the connections between the BCTTv1 clusters, with a thicker line indicating that variables were more frequently reported together. No inferential statistical analysis was used.

From a total of 1973 sources screened, 357 full-text sources were assessed for eligibility, then after grouping sources that referred to a single study, 103 (5%) distinct sources were included in the review [ 46 - 148 ] ( Figure 1 ). Of the 245 sources excluded at full-text screening, 165 (67%) were excluded due to a lack of a behavior change approach.

Characteristics of Sources of Evidence

All sources of evidence were studies and will be referred to as such hereinafter. The number of studies in this field has rapidly increased over time ( Figure 2 ), from a single study in 2004 to 8 in 2022, with a peak of 15 in 2021. The majority (86/103, 83%) [ 47 - 51 , 53 - 56 , 58 , 59 , 61 , 63 - 68 , 71 - 86 , 89 - 95 , 97 - 105 , 107 , 109 , 111 , 112 , 114 , 115 , 117 - 126 , 128 - 136 , 138 - 148 ] were published in the past 10 years. Most studies took place in North America (41/103, 40%) [ 46 - 49 , 52 , 55 , 56 , 60 , 64 - 67 , 69 , 70 , 72 , 74 , 76 - 78 , 80 , 85 - 88 , 92 , 93 , 97 , 99 , 101 , 108 - 110 , 126 - 129 , 137 , 138 , 141 , 142 , 145 ] and Europe (35/103, 34%) [ 51 , 53 , 54 , 57 , 58 , 62 , 63 , 68 , 71 , 79 , 81 - 84 , 89 , 111 , 113 - 125 , 132 , 136 , 140 , 143 , 146 , 147 ], with the remainder in Asia (16/103, 16%) [ 50 , 59 , 61 , 91 , 94 , 95 , 98 , 100 , 102 - 104 , 107 , 135 , 139 , 144 , 148 ], Australasia (9/103, 9%) [ 75 , 96 , 105 , 106 , 112 , 130 , 131 , 133 , 134 ], Africa (1/103, 1%) [ 90 ], and a single multicontinental study (1/103, 1%) [ 73 ]. Almost half (45/103, 44%) the studies are reported as feasibility or pilot studies [ 49 , 56 , 58 , 64 , 66 , 68 , 69 , 72 - 74 , 76 , 77 , 79 , 82 - 84 , 89 , 90 , 92 , 93 , 95 , 97 , 100 - 104 , 106 , 108 , 114 , 116 , 117 , 119 , 122 , 124 - 126 , 131 , 134 , 136 , 138 , 139 , 141 , 143 , 147 ]. Other study designs included randomized controlled trials (20/103, 19%) [ 50 , 51 , 60 , 61 , 65 , 75 , 80 , 85 , 86 , 91 , 107 , 109 , 112 , 128 - 130 , 137 , 144 , 146 , 148 ], single session investigations (19/103, 18%) [ 47 , 52 , 57 , 59 , 71 , 78 , 87 , 88 , 98 , 110 , 115 , 118 , 120 , 123 , 127 , 132 , 133 , 135 , 142 ], nonrandomized experimental designs (13/103, 13%) [ 53 - 55 , 62 , 63 , 67 , 81 , 94 , 96 , 99 , 105 , 113 , 145 ], case studies (4/103, 4%) [ 46 , 48 , 70 , 140 ], and realist evaluations (2/103, 2%) [ 111 , 121 ].

Participants

There were a total of 2825 participants in the 103 included studies. Studies tended to be small, with a median of 16 participants and a range of 1-188. Only half (55/103, 53%) the studies [ 46 - 48 , 50 , 56 , 57 , 59 , 61 , 64 , 67 , 69 - 72 , 78 , 79 , 82 , 87 , 88 , 92 , 93 , 95 - 99 , 101 , 102 , 105 , 106 , 108 , 111 - 121 , 123 - 127 , 134 , 138 - 140 , 142 , 143 , 145 , 147 ] reported the minimum and maximum age of participants, which ranged from 17 to 99 years. Over three-quarters (83/103, 81%; 2508 participants) of studies reported the time since the onset of stroke. Of these 83 studies, 1 (1%; 48 participants) study [ 91 ] was conducted in the acute phase, 14 (17%; 504 participants) studies [ 60 , 61 , 68 , 74 , 79 , 92 , 100 , 102 , 109 , 114 , 133 , 144 , 146 , 148 ] were conducted in the early subacute phase, 11 (13%; 316 participants) studies [ 59 , 65 , 66 , 72 , 75 , 76 , 81 , 104 , 107 , 121 , 134 ] were conducted in the late subacute phase, and 57 (69%; 1640 participants) studies [ 46 , 48 , 49 , 51 , 53 , 54 , 57 , 63 , 64 , 67 , 69 , 70 , 73 , 78 , 80 , 82 , 84 , 85 , 88 , 89 , 93 - 99 , 101 , 103 , 105 , 106 , 108 , 111 - 113 , 117 - 120 , 122 - 125 , 127 - 131 , 136 - 142 , 145 , 147 ] were conducted in the chronic phase [ 43 ].

Study Intervention

An overview of study intervention characteristics is provided ( Table 1 ). Interventions were focused on upper limb rehabilitation in almost two-thirds (65/103, 63%) of the studies [ 46 - 49 , 51 , 54 - 59 , 62 - 65 , 68 , 71 , 72 , 74 , 75 , 77 - 81 , 85 - 88 , 92 , 95 , 96 , 99 , 101 - 103 , 105 - 108 , 110 , 112 , 113 , 116 - 118 , 121 , 123 - 125 , 127 , 128 , 132 , 133 , 135 - 137 , 139 - 142 , 144 - 147 ]. Nearly all interventions (96/103, 93%) [ 46 - 80 , 84 - 94 , 96 - 117 , 119 - 121 , 124 - 148 ] were delivered to individual participants, with over half (62/103, 60%) [ 46 - 50 , 53 - 58 , 60 , 61 , 64 - 70 , 72 , 74 - 77 , 79 , 80 , 82 - 86 , 89 , 90 , 93 , 94 , 96 , 97 , 99 , 101 , 105 , 111 , 112 , 116 , 117 , 119 - 122 , 126 , 129 - 131 , 134 , 136 , 138 , 139 , 141 , 143 - 145 , 147 ] delivered fully or partly in the participant’s homes. Two-thirds (70/103, 68%) of studies [ 46 - 50 , 52 - 54 , 57 , 60 , 62 , 63 , 65 - 74 , 76 - 84 , 86 - 93 , 98 , 100 , 102 , 104 , 108 , 109 , 112 - 115 , 117 , 118 , 120 , 122 - 125 , 129 - 131 , 135 - 138 , 140 - 142 , 144 - 146 , 148 ] included partial or full supervision of the intervention, with this predominately being provided face-to-face (48/70, 69%) [ 46 , 47 , 52 , 57 , 60 , 62 , 63 , 67 , 68 , 71 , 73 , 78 , 81 - 84 , 86 - 89 , 91 , 92 , 98 , 100 , 102 , 104 , 108 , 109 , 112 - 115 , 117 , 118 , 120 , 122 - 125 , 135 - 137 , 140 , 142 , 144 - 146 , 148 ]. Interventions lasted between a single session and 26 weeks.

Of the 103 studies, over half (n=57, 55%) of the studies [ 46 , 47 , 51 - 54 , 57 , 61 , 63 , 67 , 68 , 70 , 71 , 73 , 75 - 78 , 81 , 84 - 86 , 88 - 91 , 93 , 95 , 96 , 98 , 100 , 102 - 104 , 106 , 109 , 112 , 114 , 115 , 123 - 126 , 129 , 130 , 132 , 133 , 135 - 138 , 140 , 143 - 147 ] included 1 type of DHT, 30 (29%) studies [ 48 , 49 , 55 , 56 , 58 - 60 , 62 , 64 , 69 , 83 , 92 , 94 , 97 , 99 , 101 , 105 , 107 , 108 , 110 , 111 , 113 , 116 , 118 , 121 , 122 , 127 , 128 , 139 , 142 ] included 2 types, and 16 (16%) studies [ 50 , 65 , 66 , 72 , 74 , 79 , 80 , 82 , 87 , 117 , 119 , 120 , 131 , 134 , 141 , 148 ] included 3 types. VR was the most frequently used DHT (58/103, 56%) [ 46 - 49 , 51 - 53 , 57 , 59 , 62 , 63 , 65 , 66 , 69 , 71 , 72 , 74 , 77 , 78 , 80 , 81 , 84 - 89 , 92 , 95 , 96 , 98 , 102 - 104 , 106 , 112 , 113 , 115 , 117 - 120 , 123 - 128 , 132 , 135 - 137 , 140 , 142 , 143 , 146 - 148 ] followed by apps (31/103, 30%) [ 50 , 55 , 56 , 58 , 61 , 64 - 66 , 72 , 74 , 75 , 79 , 82 , 83 , 94 , 97 , 99 , 101 , 105 , 108 , 111 , 114 , 116 , 119 - 122 , 131 , 134 , 139 , 141 ]. Further information on intervention characteristics with detail on associated citations is available ( Multimedia Appendix 6 [ 46 - 148 ]).

a F2F: face-to-face.

b DHT: digital health technology.

c VR: virtual reality.

Behavior Change Theories, Models, and Frameworks

Most studies (93/103, 90%) [ 46 - 49 , 51 - 62 , 64 - 73 , 75 - 89 , 91 - 93 , 96 - 106 , 108 - 115 , 117 - 137 , 139 , 140 , 142 - 148 ] endeavored to link the intervention to behavior change; however, in the majority of these studies (75/93, 81%) [ 46 , 51 - 56 , 58 - 62 , 64 - 69 , 71 - 73 , 75 , 77 - 89 , 91 - 93 , 96 , 97 , 99 - 101 , 103 - 106 , 108 , 110 , 112 , 114 , 115 , 117 - 120 , 123 , 124 , 127 , 128 , 131 - 137 , 139 , 140 , 142 - 144 , 146 - 148 ], this explanation was centered on the reporting of the techniques perceived to change behaviors without direct reference to use of the BCTTv1 or on the reporting of a component of the intervention or the whole of the intervention as motivating. These explanations lack detail on how or why this influences behavior change. Examples of this included “the app also provided performance feedback, allowing the user to compare their current performance against their score from the previous session” (Bhattacharjya et al [ 56 ]) and “games motivate patients to engage in enjoyable play behavior” (Cramer et al [ 66 ]). A limited number of studies (18/103, 17%) [ 47 - 49 , 57 , 70 , 76 , 98 , 102 , 109 , 111 , 113 , 121 , 122 , 125 , 126 , 129 , 130 , 145 ] articulated 1 or more theories, models, or frameworks of behavior change. While it is acknowledged that the BCTTv1 is a taxonomy framework rather than a theoretical framework, for the purpose of this review, it has been included as a framework for behavior change. A total of 13 different theories, models, or frameworks were identified within these 18 studies, with social cognitive theory being the most frequently reported (6/18, 33%) [ 76 , 109 , 111 , 121 , 129 , 130 ], followed by the behavior change technique taxonomy (4/18, 22%) [ 48 , 49 , 122 , 129 ], game design theory (3/18, 17%) [ 47 , 57 , 125 ], operant conditioning (3/18, 17%) [ 47 , 98 , 121 ], and self-determination theory (3/18, 17%) [ 48 , 49 , 126 ]. Further information on behavior change theories, models, and frameworks, with details on associated citations, is available ( Multimedia Appendix 7 [ 47 - 49 , 57 , 70 , 76 , 98 , 102 , 109 , 111 , 113 , 121 , 122 , 125 , 126 , 129 , 130 , 145 ]).

Behavior Change Techniques

Despite 4 studies acknowledging the BCTTv1, explicit BCTTv1 codes were only reported in 2 studies (2/103, 2%) [ 48 , 122 ]. However, a third study (1/103, 1%) mapped the techniques used to change behavior directly to the transtheoretical model [ 145 ]. There was a median of 3 (range 1-14) individual BCTs coded per study, with a total of 383 BCTs across the 103 studies. The most frequently identified individual BCTs were feedback on behavior and nonspecific reward ( Multimedia Appendix 8 ).

There was also a median of 3 (range 1-8) BCTTv1 clusters per study, with a total of 288 clusters coded across the 103 studies. The most frequently used of the 16 possible clusters were feedback and monitoring (88/103, 85%) [ 46 - 60 , 62 - 69 , 71 - 74 , 76 , 78 - 80 , 82 - 92 , 94 - 106 , 108 - 113 , 116 , 117 , 119 - 129 , 134 - 146 , 148 ], reward and threat (56/103, 54%) [ 46 - 49 , 51 - 53 , 55 - 57 , 62 , 65 , 69 , 71 , 72 , 74 , 77 , 80 , 81 , 85 , 86 , 88 , 89 , 91 , 92 , 95 , 96 , 98 , 102 , 103 , 106 - 108 , 112 , 113 , 115 , 117 - 119 , 121 - 125 , 128 , 132 , 134 - 137 , 140 , 142 , 143 , 146 - 148 ], goals and planning (33/103, 32%) [ 49 , 58 , 60 , 65 - 68 , 70 , 72 , 74 , 76 , 79 , 80 , 82 , 83 , 90 , 91 , 93 , 94 , 97 , 100 , 109 , 111 , 112 , 121 , 122 , 126 , 129 , 130 , 134 , 138 , 141 , 145 ], and shaping knowledge (33/103, 32%) [ 46 , 48 , 50 , 53 - 56 , 58 , 60 , 61 , 64 - 72 , 74 , 75 , 86 , 94 , 97 , 101 - 103 , 108 , 111 , 113 , 114 , 120 , 129 - 131 , 139 - 141 ]. Other BCTTv1 clusters used were social support (24/103, 23%) [ 48 , 49 , 58 , 60 , 64 , 67 , 70 , 72 , 73 , 79 , 80 , 82 , 84 , 90 , 93 , 101 , 108 , 117 , 119 , 129 - 131 , 134 , 141 ], comparison of behavior (23/103, 22%) [ 46 , 50 , 53 , 54 , 60 , 61 , 64 - 66 , 74 , 75 , 81 , 86 , 101 , 104 , 111 , 114 , 118 , 122 , 123 , 125 , 131 , 139 ], associations (16/103, 15%) [ 58 , 60 , 65 , 66 , 68 , 75 , 80 , 83 , 87 , 90 , 110 , 120 , 131 , 133 , 139 , 144 ], repetition and substitution (6/103, 6%) [ 60 , 82 , 109 , 122 , 129 , 130 ], scheduled consequences (3/103, 3%) [ 47 , 80 , 88 ], natural consequences (2/103, 2%) [ 129 , 138 ], comparison of outcomes (2/103, 2%) [ 47 , 133 ], antecedents (1/103, 1%) [ 60 ], and self-belief (1/103, 1%) [ 70 ]. The clusters of regulation, identity, and covert learning were not identified. Within the context of the review, it was noted that the reward and threat cluster only included reward-based BCTs. A tabulated summary and graphical representation of the BCTTv1 clusters is available ( Multimedia Appendix 9 [ 46 - 148 ]).

The exploration of clusters that were reported together in an intervention ( Figure 3 ) identified the strongest relationship between the clusters of feedback and monitoring and reward and threat. Clear links were also identified between feedback and monitoring and 4 other clusters: goals and planning, shaping knowledge, social support, and comparison of behavior, and between the shaping knowledge and comparison of behavior clusters.

Behavior Change Techniques and Digital Health Technology

The feedback and monitoring cluster was reported most frequently for all types of DHT ( Figure 4 ), with the greatest proportion of this cluster in robotics (11/25, 44%) [ 59 , 62 , 87 , 92 , 110 , 113 , 117 , 127 , 128 , 142 , 148 ], VR (52/148, 35%) [ 46 - 49 , 51 - 53 , 57 , 59 , 62 , 63 , 65 , 66 , 69 , 71 , 72 , 74 , 78 , 80 , 84 - 89 , 92 , 95 , 96 , 98 , 102 - 104 , 106 , 112 , 113 , 117 , 119 , 120 , 123 - 135 - 137 , 140 , 142 , 143 , 146 , 148 ], and sensors (17/48, 35%) [ 50 , 55 , 56 , 87 , 94 , 99 , 101 , 105 , 108 , 110 , 111 , 116 , 119 - 121 , 134 , 141 ]. Robotics and VR also often used the reward and threat cluster (9/25, 36% [ 62 , 92 , 107 , 113 , 117 , 118 , 128 , 142 , 148 ] and 48/148, 32% [ 46 - 49 , 51 - 53 , 57 , 62 , 65 , 69 , 71 , 72 , 74 , 77 , 80 , 81 , 85 , 86 , 88 , 89 , 92 , 95 , 96 , 98 , 102 , 103 , 106 , 112 , 113 , 115 , 117 - 119 , 123 - 125 , 128 , 132 , 135 - 137 , 140 , 142 , 143 , 146 - 148 ], respectively), while the goals and planning cluster was a dominant second cluster in activity monitors (13/53, 25%) [ 67 , 68 , 76 , 79 , 80 , 82 , 91 , 100 , 109 , 122 , 129 , 138 , 145 ].

Summary of Evidence

This scoping review provides a comprehensive overview of approaches used to support changes in behavior in DHT-based physical stroke rehabilitation interventions. Research in this field is in its infancy, with the predominance of studies in this review being described as pilot or feasibility studies with limited participants.

Despite using comprehensive behavior change search terms, only a limited number (103/1973, 6%) of screened sources were included. Over two-thirds of full-text sources were excluded as they did not describe or refer to any behavior change theories, models, or frameworks or BCTs, suggesting that in general, explicit behavior change approaches are not reported as being integral to DHT-based physical stroke rehabilitation.

Only 18 (17%) of the 103 included studies articulated a theory, model, or framework to underpin the intervention, which aimed to change behavior, despite widely published recommendations about the importance of overt use of theory when developing, evaluating, and reporting interventions [ 27 , 29 ], including those related to behavior change [ 28 ]. The proportion of studies articulating a behavior change theory, model, or framework in this work is significantly lower than review findings in non-rehabilitation DHT-based interventions that have sought to influence specific behaviors such as physical activity or weight control [ 24 , 44 ]. These reviews have identified up to two-thirds of sources reporting a theory, model, or framework. However, our findings mirror the relative absence of behavior change theories, models, and frameworks in rehabilitation interventions more generally, irrespective of whether they use digital technology [ 149 ] or not [ 45 ], and it is widely recognized that the complex nature of rehabilitation often results in the essential characteristics of interventions being poorly defined [ 150 ]. Consistent with our findings in these other reviews, a variety of theories, models, and frameworks were found to underpin interventions, with social cognitive theory being the most frequently reported [ 24 , 44 , 45 , 149 ]. The explicit description of BCTs using the BCTTv1 within DHT-based physical stroke rehabilitation interventions is also poorly reported (2%), despite a significant proportion of the sources being dated after the publication of the BCTTv1 in 2013 [ 22 ]. This lack of acknowledgment of behavior change approaches impedes the accumulation of knowledge within this field.

It is important that both the underpinning theory and BCTs are reported so the mechanisms by which the BCTs elicit change can be better understood [ 21 ]. The general assumption that the motivational and captivating aspects of DHTs will promote prolonged and repeated engagement with rehabilitative activities, in particular in those DHTs that incorporate game design [ 151 ], risks suboptimal outcomes for patients and wasted investment of time and money if the mechanisms by which the DHT elicits change are not considered.

When exploring which BCT clusters featured within the reviewed DHT-based interventions, the findings relating to the commonly used clusters of feedback and monitoring, goals and planning, and shaping knowledge are consistent with findings from DHT-based interventions to change a specific behavior [ 44 ] and non-DHT–based rehabilitation [ 45 ]. However, a novel finding in our review was the frequent identification of the reward and threat cluster, although it was noted that all techniques related to reward and none to threat. A large number of studies in this review used VR technology, which frequently incorporates gamified tasks or gameplay. Reward is an integral part of game design theory alongside feedback [ 152 ], and so it is perhaps unsurprising that the feedback and monitoring, and reward and threat clusters dominated and an association between these 2 clusters was seen.

Limitations

Rehabilitation is a process that comprises multiple behaviors and so exploring approaches to change behavior within this context was complicated. There were challenges in searching and screening sources for inclusion as few studies explicitly reported approaches to change behavior, and there is a similarity in the vocabulary used within behavior change and other theoretical approaches (eg, “feedback,” which is used within motor learning). Similarly, only a very small proportion of studies explicitly reported BCTs within interventions. The lack of clear reporting of behavior change introduces the risk that sources may be omitted during both the searching and screening process highlighting the difficulty of comprehensively reviewing this field of work. An inclusive approach to screening reduced the risk of erroneously excluding sources, but it is perhaps inevitable that the sources included reflect those studies that have reported a behavior change approach rather than all studies that have used one.

This lack of clear BCT reporting also posed challenges for intervention coding. The use of the BCTTv1 aimed to ensure the review used a generalizable nomenclature to describe BCTs, and the 1 reviewer who had completed BCTTv1 training coded all the interventions. It is acknowledged that decisions made in the application of the BCTTv1 within the context of the review will have introduced some subjectivity in intervention coding, which will ultimately influence the review findings. Although the coding process could have been made more robust by having a second reviewer trained in the BCTTv1 also code the interventions, regular and extensive discussions between all members of the review team took place with the aim of ensuring consistency with the coding process. Clear documentation as to how the BCTTv1 was used within this review ( Multimedia Appendix 5 ) supports transparency as to the decisions made and the reproducibility of the review.

The absence of a recognized predefined taxonomy for DHTs posed a challenge when categorizing the DHT interventions, acknowledging that the distinction between the categories used to present the results is open to interpretation. A description of how the reviewers interpreted these categories is provided ( Multimedia Appendix 4 ).

Implications for Research

Future studies aimed at developing and evaluating DHT-based rehabilitation interventions, including those relating to physical stroke rehabilitation, need to ensure there is explicit recognition and reporting of the specific approaches used to change behavior, articulating both the theory on which the intervention is based and how the intervention plans to deliver the change in behavior using universally recognized terminology. This should be reported as part of a program theory and potential mechanisms of action, which are key parts of developing and evaluating complex interventions [ 29 ]. This detailed reporting would further support an understanding of how changes in behavior could be best enabled by DHT-based rehabilitation interventions and how this contributes to changes in patient outcomes. It would also enable further evaluation of the optimal behavioral components of interventions, enabling patients to use and clinicians to deliver the most effective DHT-based rehabilitative interventions. More generally, as the use of DHTs expands, there is an urgent need for some form of taxonomy to categorize and clearly define the different types of DHTs to facilitate consistent reporting, replication, and comparison of DHT-based interventions.

This novel and original review is the first to explore if and how approaches to change behavior are incorporated within DHT-based physical stroke rehabilitation. It demonstrates that a minority of studies report using approaches to change behavior within this context, despite these changes in behavior being vital to meet the demands of rehabilitative activities. Those who do report behavior change often lack the underpinning detail as to how the DHT-based intervention will facilitate these changes. In order for DHT-based interventions to realize their potential within rehabilitation and their impact on patient outcomes, approaches to change behavior must be embedded in the intervention and appropriately reported.

Acknowledgments

The authors would like to thank Catherine Harris (Information Specialist, University of Central Lancashire) for her assistance in developing the search strategy and running the searches, and Rebekah Murray (Undergraduate Research Intern, University of Central Lancashire) for her support with aspects of the screening and data charting process.

This work was funded by a UK Research and Innovation Future Leaders Fellowship (grant MR/T022434/1).

Data Availability

All data supporting this study are openly available from the University of Central Lancashire repository [ 153 ].

Authors' Contributions

RCS conceived the review focus and oversaw the work. HJG developed the review design and search strategy. HJG, KAJ, and RCS completed the screening of the identified sources. HJG and KAJ piloted the data charting tool. HJG completed the data charting, data analysis, and the initial manuscript draft. KAJ and RCS reviewed and made substantial contributions to the manuscript. All authors approved the final manuscript.

Conflicts of Interest

None declared.

Preferred Reporting of Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist.

Inclusion and exclusion criteria.

Full search strategy as used in Medline.

Data charting tool.

Review-specific behavior change technique taxonomy coding decisions.

Intervention characteristics (with associated references).

Behavior change theories, models, and frameworks reported (with associated references).

Individual behavior change techniques coded.

Behavior change technique taxonomy clusters identified (with associated references).

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Abbreviations

Edited by A Mavragani; submitted 15.05.23; peer-reviewed by M Broderick, G Sweeney, E Crayton, D Pogrebnoy; comments to author 11.10.23; revised version received 14.11.23; accepted 26.12.23; published 24.04.24.

©Helen J Gooch, Kathryn A Jarvis, Rachel C Stockley. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 24.04.2024.

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.