Achieving clinically meaningful outcomes in digital health: a six-step, cyclical precision engagement framework (ENGAGE)

By leveraging everyday technologies such as mobile apps, wearables, and AI-enabled tools, digital health interventions (DHIs) offer new pathways to integrate self-management and intervention programs into the fabric of daily life, while bridging gaps in care through continuous, context-aware support. Yet many tools underperform clinically because digital engagement ("screen time") is conflated with impact, while behavioral science is retrofitted, if applied at all. We propose the ENGAGE Framework: a cyclical, six-step model of precision engagement that integrates user needs, behavioral science, and adaptive personalization to transform initial curiosity into sustained real-world habits. By leveraging available data, users can be segmented according to their need (Step 1: Enroll & Segment), targeted with the most relevant and engaging message to increase micro-engagement (Step 2: Nudge & Hook), and persuaded to engage in real-world health behavior change (Step 3: Guide Behavior). From this macro-engagement step, additional core behavioral science principles are used to reinforce the real-world behaviors long enough to positively impact health outcomes (Step 4: Anchor Habits), while measuring progress (Step 5: Generate Evidence) to inform adaptive and optimized engagement strategies (Step 6: Expand & Evolve with AI) for tailored interventions and communications based on user characteristics, context, and clinical data for both new and existing users. Each step of the ENGAGE Framework maps to evidence-based techniques, implementation tactics (e.g., integration pathways and operational deployment strategies), and metrics that help translate superficial engagement into long-lasting behavior change and measurable clinical outcomes. We synthesize relevant engagement literature, identify gaps and challenges (e.g., measurement heterogeneity, lack of focus on macro-engagement, product development challenges, ecosystem barriers), and offer a practical checklist for innovators. By focusing on who needs what support, when and why, ENGAGE aims to help DHI developers and researchers design interventions that are effective, equitable, and empirically testable.