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eSignposting: A Rapid, System-Level Approach to Increase Access to Behavior Change Interventions

  † Joint first author.

Submitted:

16 July 2026

Posted:

20 July 2026

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Abstract
Despite strong evidence supporting behavior change interventions, their population-level impact faces a persistent research-to-practice gap. This perspective piece argues this is partly due to barriers within health systems, including a reliance on clinician-led referral pathways. We introduce electronic signposting (eSignposting) for rapid, proactive, and scalable access to behavior change interventions. It identifies eligible individuals through electronic health records and delivers automated digital signposting to behavioral support. We demonstrate implementation of eSignposting within the NHS to increase reach with minimal workload. We consider the mechanisms that influence its adoption/effectiveness, and how ecosystem mapping and implementation blueprints can support wider adoption and integration. We argue that redesigning implementation at the health-system level is needed for population-level reach.
Keywords: 
signposting
;  
digital health
;  
public health
;  
patient pathways
;  
intergrated care
;  
cancer prevention
Subject: 
Public Health and Healthcare  -   Public Health and Health Services

Introduction

The research to practice gap
Cancer accounts for one in four deaths in the UK annually, and one in six deaths globally however, it is estimated that nearly 40% of cancers could be prevented by modifying health behaviors [1,2,3]. Evidence-based interventions and services exist to support health behavior changes that prevent cancer, such as support to stop smoking, reduce alcohol consumption, and manage weight. From a policy perspective, these are viewed as individual-level interventions [4], but with the potential to be delivered at a population level [5]. However, despite over four decades of research evidence to support the use of behavior change interventions, population level reach remains limited resulting in a persistent research to practice gap [6], with studies reporting the uptake of smoking cessation services to be as low as 0.2% and 5% for alcohol cessation services [7,8].
Within the UK, and worldwide, ageing populations, workforce shortages, and widening health inequalities are increasing pressure on health services and emphasizing the need for effective prevention approaches, such as behavioral interventions [9]. Behavioral interventions are typically implemented through screening, advice, and referral within routine healthcare. These pathways rely heavily on clinician time, clinicians’ confidence to deliver advice and knowledge of services, and the skills and training required to deliver interventions and appropriate referrals [10]. Despite evidence that implementation strategies, such as financial incentives, can influence provider behaviour and improve screening and referral rates [11,12], structural and organisational barriers within health systems have persisted for decades such as fragmented patient pathways, poorly integrated services, and geographical discrepancies. This results in slow, expensive, and inconsistent uptake of behavioural interventions [13,14]. Traditional pathways may also reinforce existing inequalities in access to preventive support by reaching those already engaged with healthcare services [15]. Population-level impact may therefore need approaches that extend beyond these traditional referral pathways.
The expanding reach of electronic health systems and digital health technologies is transforming the healthcare landscape, with more than three in five Americans and half of UK residents engaging with online patient portals and digital health apps [16,17,18]. This creates opportunities to expand access to evidence-based interventions and services, accelerating the translation of research into routine practice and at scale [19,20,21]. This perspective piece argues that the persistent research-to-practice gap is perpetuated by implementation pathways that were not designed to achieve rapid, population-level reach, particularly within complex and fragmented health services. Closing this gap requires a paradigm shift from improving provider referral pathways for individuals to redesigning implementation and referral at a health system level via digitisation and automation of pathways to effective services and interventions [22]. We introduce electronic signposting (eSignposting) as a promising system-level adjunctive intervention with the potential for rapid implementation, widespread adoption, and population level reach in healthcare systems.

Review

The innovation: eSignposting
eSignposting uses existing patient electronic health records (EHRs) to identify and deliver targeted and timely digital signposting to people who may benefit from behavioral interventions or services [23]. Whilst numerous terms exist in the literature for this approach, such as digital signposting and digital outreach, for clarity and consistency for this commentary paper we use the term eSignposting throughout.
eSignposting shares some similarities with approaches such as ‘nudges’ and proactive referral, which are often used to improve uptake of vaccinations and screening appointments [24]. However, these approaches differ in how implementation is initiated and delivered. The term “nudges” has been criticized for lack of a clear definition of the types of interventions to which it applies and in practice many nudge interventions tend to target clinician referral behaviors, limiting the direct reach to target populations [25]. Nudges often deliver generic reminders that do not always use EHR data to target eligible populations [26], which limits the ability to accurately identify and target eligible populations. While different, proactive referrals are subject to similar bottlenecks as they are often initiated by clinicians, limiting their scalability and rapid delivery [27,28,29].
In contrast, eSignposting automates EHR identification and proactively signposts individuals to relevant behavior change interventions or services, via digital communication channels (e.g. text-messages, email, and patient portals), which enables rapid and large-scale delivery with minimal additional workload [23]. A substantial benefit of eSignposting is that it can be integrated within existing electronic healthcare systems, reducing barriers to implementation. In doing so, it increases the speed of achieving population reach and subsequent engagement with treatment [15,30,31]. eSignposting addresses both the lack of awareness of existing services among the general population, as well as system-level barriers to prevention. Specifically, as an adjunctive intervention [31], eSignposting enhances the reach of and engagement with existing evidence-based services without requiring clinician referral, which fundamentally reconfigures implementation from sequential pathways to parallel, population-level delivery, i.e., simultaneous signposting across at-risk groups. Through its approach, eSignposting is able to address health disparities by providing targeted proactive outreach to identify at-risk populations, automatically connecting individuals to recourses which can help with physical, mental, and social factors impacting health [23]. Additionally, eSignposting can reach individuals who may not actively seek out health care or have limited access to traditional health care and can be presented in accessible formats to reach individuals who may have language, skills, or literacy barriers.
Mechanisms of action
eSignposting operates within the complexity of healthcare systems, and therefore to accelerate the uptake of eSignposting among healthcare providers, we need to understand how it works within real-world settings. Middle-range theories, such as programme theories, help us to understand what type of eSignposting works, for whom, and in what circumstances [33,34,35]. A realist review synthesizing evidence on electronic signposting to interventions that prevent cancer [30] found that engagement with eSignposting may be influenced by mechanisms such as buy-in, usability, and technological optimism, which are shaped by intervention features including tailored messaging, use of familiar communication channels, and alignment with user needs and organizational priorities. These mechanisms are more rapidly activated when eSignposting is delivered through familiar, low-burden technologies (e.g. SMS for patients; seamless EHR integration for providers), aligned with organizational priorities, and supported by leadership and governance. In turn, this facilitates more rapid adoption and integration into routine practice [30,34].
The wider digital health and service delivery literature, including eHealth, telemental health, clinician–patient digital communication, and conventional (e.g., clinician initiated) signposting, also provide valuable insights on mechanisms for improving engagement and effectiveness. Trust is found to be a key mechanism for uptake of the technology [36,37,38]. Programme theories also emphasise user capability and digital inclusion; an individuals’ confidence, skills, and access impact their level of engagement with digital health tools, creating the potential for exclusion of marginalised groups [38,39]. A realist review of traditional signposting, i.e., non-digital, clinician-initiated, identified the importance of actionability and system navigability, where support options must be viewed as relevant, accessible, and feasible to access within complex systems [39]. These mechanisms help to explain how eSignposting can work within complex, real-world healthcare systems, where effectiveness, adoption and integration is influenced by the organizational context, user characteristics, system readiness, and the interactions between contextual factors and mechanisms.
OptiMine as case study
eSignposting has predominantly been evaluated in the US (e.g., [41,42]). An illustrative example of how eSignposting can be operationalized within routine healthcare settings in the UK is provided by the OptiMine study, a mixed-method implementation study examining the acceptability, feasibility, and reach of electronic signposting to behavior change interventions [23]. eSignposting was implemented within an acute care NHS hospital, to identify patients who were current smokers and/or consuming alcohol above recommended levels. Identified patients were signposted to NHS behavior change apps via text-messages. Patients were sent messages at a time unrelated to a clinic visit and as such, were not actively seeking support.
eSignposting demonstrated acceptability to patients and staff, feasibility within IT and public health departments, and significant levels of reach within a large population of at-risk patients. In total, 1526 text-messages were delivered to identified at-risk patients, and 13.56% of recipients clicked the embedded link to access the NHS apps, representing initial engagement in a non-help-seeking population and exceeding the 5% a priori success criterion. Of this 13.56% who clicked the embedded link, 143 (69.1%) accessed the NHS apps within 3 days of message delivery, demonstrating rapid reach and potential engagement [23]. The Designing for Accelerated Translation (DART) framework theorizes that even system-level innovations with newer, emerging evidence bases can have strong implementation potential and scale quickly when the tools have appeal and perceived benefit (i.e., demand), low risk of harm (i.e., risk), and limited financial or operational disruption (i.e., cost). Through this lens, OptiMine was found to have robust appeal at multiple levels (i.e., system leaders, clinicians, and individuals targeted for direct benefit). It also bore very minimal risk of harm by signposting to NHS resources and little cost given the use of existing EHR and digital pathways along with lower time burden for clinicians [43]. This demonstrates how eSignposting can initiate rapid engagement with evidence-based support at a population level without relying on help-seeking behaviour or clinician interaction.
It should be noted that the context surrounding the implementation of eSignposting in the OptiMine study likely heavily contributed to its success. eSignposting was implemented in a Global Digital Exemplar NHS Trust, a hospital internationally recognized for delivering healthcare through the effective use of digital technologies (1 of 17 in the UK). The hospital’s digital infrastructure and electronic health record enabled the identification of eligible patients and automated delivery of text-message signposting as part of routine care. At the time of implementation, incentives for smoking and alcohol screening and referral were available to hospitals, aligning the innovation with organizational priorities [23,44]. The OptiMine team included a public health consultant and senior IT lead from the participating Trust, who facilitated collaboration across departments and provided senior-level buy-in, which proved an indispensable asset to the success of the study. This favourable environment enhanced the acceptability and feasibility of eSignposting at the provider level [23]. However, the conditions that supported implementation in OptiMine are unlikely to be present in all healthcare settings. Organisations will need to use implementation strategies that address local barriers, build organisational readiness, engage key stakeholders, and support integration of eSignposting within existing workflows and systems.
Implementation strategies for spread and scale-up
Spreading or scaling eSignposing to settings that may not have such favorable conditions for implementation, as those present in the OptiMine study, requires planning and support. Ecosystem mapping provides a structured approach to understanding the service landscape within which eSignposting is implemented and can be viewed as a form of needs assessment during pre-implementation planning [45]. Services can be mapped across community, commercial, and voluntary sectors alongside the pathways through which people access them, and the relationships and dependencies between services. For example, an ecosystem map of behavioral weight management services highlighted a complex and fragmented system, where access is often reliant on self-referral or clinician referral routes and influenced by variation in eligibility, digital access, and service availability [46]. Ecosystem maps also help illustrate the practical challenges experienced by individuals in navigating support, as well as gaps, duplication, and lack of coordination across services. Ecosystem mapping is not considered an implementation strategy in its own right, but provides the understanding needed to plan how eSignposting can be introduced, including where it can link into existing pathways, which barriers need to be addressed and how to minimize unintended consequences.
Implementation blueprints build on this understanding by describing the workflows, roles, and governance arrangements required to operationalize eSignposting within routine care [47]. The OptiMine blueprint outlines how eligible populations can be identified using electronic patient record data, how messages can be delivered using digital communication tools, such as text-messages, emails and patient portal messages, and how outcomes can be monitored via click-through rates and other service outcomes, e.g., incentive uptake. Blueprints can also highlight how eSignposting aligns with existing services and fits within current clinical and information governance processes, helping to ensure that activity is consistent, proportionate, and safe and how it can be implemented with available resources, adapted to local systems, and refined over time.
Ecosystem mapping and implementation blueprints provide complementary approaches to supporting the spread and scale-up of eSignposting. Ecosystem mapping helps organisations understand the local service landscape by identifying existing services, referral pathways, gaps, dependencies, and barriers to access. This understanding can then inform implementation blueprints, which translate these insights into practical plans for delivery by specifying workflows, responsibilities, governance arrangements, and evaluation processes. These approaches work together to support the assessment of acceptability, feasibility, and reach, as well as address infrastructure, leadership, workforce, and governance requirements. As such, they can support the integration of eSignposting into routine care.
A forward-looking outlook
Future system-level integration of eSignposting
A key strength of eSignposting is the feasibility with which it can be integrated with existing electronic health systems. Implementation at national scale could include integration into NHS England's population health management agenda, which involves the segmentation and risk stratification of populations, proactive identification of eligible individuals, and automated delivery of targeted outreach [48]. In large health systems, such as the NHS, this involves coordinated working across analytics, population health, and digital delivery teams to use linked data to identify cohorts at risk of adverse outcomes and deliver preventive interventions at scale. Achieving this will require investment in new or adapted roles, responsibilities, and infrastructure to support implementation and evaluation.
Health systems adopting eSignposting will also need pragmatic evaluation approaches, informed by implementation outcomes frameworks [49]. This could include measures of reach (e.g., proportion of eligible patients, including socio-demographics, identified and contacted), implementation speed (e.g., time from identification to contact and from contact to engagement), engagement as a proxy for effectiveness (e.g. click-through and service uptake), and sustainability (e.g. consistency of delivery overtime within routine workflows). Routine evaluation would enable comparison with traditional referral pathways and support continual service improvement. Further research is needed to examine eSignposting across different healthcare settings and population groups, particularly its accessibility and effectiveness among digitally excluded and underserved communities, noting NHS digital inclusion priorities [50]. Long-term sustainability should also explore how eSignposting is governed, maintained, and adapted, considering workforce turnover and ever-changing healthcare priorities.

Conclusion

Despite decades of evidence, behaviour change interventions remain limited in reach due to slow, inconsistent, and inequitable implementation. This commentary argues that this research to practice gap is driven by the design of current implementation pathways, in addition to known intervention and provider barriers. eSignposting demonstrates how implementation can be reconfigured at a health-system level, using existing digital infrastructure to proactively identify eligible individuals and facilitate automated, scalable access to evidence-based support. While its successful implementation is likely to depend on contextual factors, including organisational readiness, and digital infrastructure, approaches such as ecosystem mapping and implementation blueprints may support spread and scale-up across diverse healthcare settings, and using pragmatic evaluation informed by implementation outcomes to justify its sustainability. As healthcare systems increasingly adopt population health management approaches, eSignposting represents a promising approach to accelerating reach and engagement with preventive interventions. Reorienting implementation beyond clinician referral pathways and towards system-level delivery may be an important step in narrowing the research-to-practice gap and increasing the population impact of behaviour change interventions.

Author Contributions

ZK was responsible for: Conceptualization; Writing – original draft; Writing – review & editing, Funding acquisition. EM was responsible for: Conceptualization; Writing – original draft; Writing – review & editing. TB, ATR, SE-T, MA, LA, and HJ were responsible for: Conceptualization; Writing – review & editing

Acknowledgment

Ella Malloy and Tracey Brown are funded by Cancer Research UK (no. RCCCEA-Nov23/100002). The effort of Sherine El-Toukhy has been supported by the Intramural Research Program, National Institute on Minority Health and Health Disparities (ZIA MD000011), National Institutes of Health (NIH). The effort of Alex Ramsey has been supported by the National Institute on Drug Abuse (K02DA065836).

Competing Interests

The authors declare that they have no competing interests to declare.

Disclaimer

This work was supported by Cancer Research UK (no. RCCCEA-Nov23/100002). The funders had no role in the study design, data collection, data analysis, writing of the report, or the decision to submit for publication. This research was supported [in part] by the Intramural Research Program of the National Institutes of Health (NIH). The contributions of the NIH author(s) are considered Works of the United States Government. The findings and conclusions presented in this paper are those of the author(s) and do not necessarily reflect the views of the NIH or the U.S. Department of Health and Human Services.

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