Scaling Holistic e-health Solutions in Cancer Care Using a Qualitative Realist Framework

Samar J Melhem^1,2*Reem Kayyali²Shereen Nabhani-Gebara²Nailya Bulatova¹Hamzeh Almomani¹Rimal Mousa¹Ahmed AlMousa¹Yazan AlRashdan¹Omar Nimri^3,4Ibrahim Alabbadi¹

• ¹The University of Jordan, Aljubeiha, Jordan
• ²Kingston University, Kingston upon Thames, England, United Kingdom
• ³Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States
• ⁴Ministry of Health (Jordan), Amman, Amman, Jordan

Background: While e-health innovations have advanced cancer-care delivery in high-income countries, middle-income countries (MICs) face distinct systemic, infrastructural, and sociocultural challenges in adopting and scaling digital-health interventions. There is a growing imperative to explore how holistic digital platforms can be implemented effectively in oncology within resource-constrained settings. Objective: This study aimed to investigate the barriers and facilitators influencing the scalability and adoption of a comprehensive e-health solution in cancer care, drawing on a realist paradigm to determine what works, for whom, and under which circumstances, in the context of Jordan. Methods: A qualitative study, underpinned by a realist paradigm, was conducted using in-depth, semi-structured interviews with oncology healthcare professionals from diverse clinical settings in Jordan. Interviews were conducted in Arabic, translated into English, and analyzed using a hybrid inductive–deductive framework approach. The Implementation of Change Model guided interpretation of the findings, enabling the identification of multi-level contextual influences. Results: The analysis yielded a central theme—Facilitators and Barriers to Implementing a Holistic e-health Solution—comprising six deductive subthemes derived from the Implementation of Change Model: (A) Innovation; (B) Patients; (C) Healthcare professionals; (D) Organizational context; (E) Social context; and (F) Economic and political context. Across these subthemes, interpretive codes were classified as barriers or facilitators. Participants emphasized the necessity of assessing e-health readiness prior to implementation, and the importance of integrated, cross-sectoral approaches to support scalable, sustainable solutions. Conclusion: This study provides novel, contextually grounded insights into the implementation dynamics of digital transformation in oncology within MICs. It offers actionable guidance for policymakers and system designers aiming to foster sustainable, equitable digital-health ecosystems.