Delivering cognitive behavioural interventions in an internet-based healthcare delivery environment

Abstract

Introduction

This exploratory qualitative study assessed the feasibility of transitioning three face-to-face, cognitive behavioural interventions for adults with chronic health conditions to online delivery, by examining clinician and clients' satisfaction with intervention training and delivery.

Method

The interventions adapted for online delivery were: ‘Managing Chronic Disease’, a programme for individuals who were nonadherent to prescribed rehabilitation regimens; ‘Real-World Strategy Training’, an occupation-based intervention for individuals with subjective cognitive decline; and ‘Learning the Ropes’, a memory programme for persons with mild cognitive impairment. Two occupational therapists and one nurse received training in, and then delivered one of the three interventions. Qualitative feedback interviews with participants, and archived video recordings of intervention sessions were analysed thematically.

Results

Key features of each manualised intervention were evident in the online sessions and perceived by clients as enhancing engagement (for example, peer support and strategy training). Clinicians felt that meeting individually with intervention experts was helpful to problem-solve technical issues and ensure adherence to protocols.

Conclusion

Three cognitive behavioural interventions transitioned to online delivery were acceptable to older adults and clinicians. A next step would be to complete randomised controlled trials investigating whether the interventions yield equivalent health benefits, using online and face-to-face delivery.

Keywords

Chronic disease ageing self-management telerehabilitation cognition cardiovascular disease

Introduction

With an ageing population, managing chronic disease has become a priority public health issue (Prince et al., 2015). Individuals with chronic disease are frequent users of healthcare and social services, costing governments billions of dollars annually (Peel et al., 2005; Prince et al., 2015). Most importantly, chronic disease can have devastating effects on the wellbeing of those living with the condition, as well as contributing to high levels of stress for family caregivers (Alonso et al., 2004). The pervasive effect of chronic disease has spurred scientific enquiry toward developing and evaluating interventions that enhance older adults' ability to self-manage chronic conditions (Holman and Lorig, 2004). Interventions with proven effectiveness need to be delivered in ways that make them readily accessible in early stages of disease trajectories. Consequently, telehealth solutions that allow for in-home delivery of interventions with known efficacy, have great potential for ensuring that individuals receive the healthcare services they need in a timely fashion (Doarn et al., 2008).

Self-management interventions are being increasingly offered within healthcare systems by occupational therapists and other rehabilitation professionals (for example, social workers and psychologists) (Chodosh et al., 2005). Individuals are supported to monitor symptoms and/or physiological changes, as well as implement and adhere to health-promoting behaviours (Holman and Lorig, 2004). A range of cognitive behavioural strategies are part of the interventions, including education, counselling, goal-setting, peer support and problem-solving strategies (Michie et al., 2015). Evidence-based self-management approaches have been shown to improve health behaviours and/or reduce hospitalisations and disease symptoms for individuals with a variety of conditions, including diabetes (Pillay et al., 2015), chronic obstructive pulmonary disease (Blackstock and Webster, 2007) and stroke (Lennon et al., 2013). An important next step is to determine whether these interventions can be adapted for delivery using technology, and yield similar benefits.

Telehealth is defined as the use of telecommunication technologies to deliver a healthcare intervention (Bashshur et al., 2011). Critical reviews of telehealth programmes included different programme models, such as telemonitoring through the use of mobile apps, wearable technologies or other home monitoring devices, to record and relay information on symptoms, vital signs and high-risk alerts; internet-based health service delivery through asynchronous and synchronous educational and/or psychosocial intervention programmes; and use of telephones to support communication between patients and clinicians (McLean et al., 2011).

Internet-based health service delivery is now feasible through the use of multiple devices (computers, tablets, smartphones, and so on), and studies have shown that individuals with chronic disease are receptive to interactions with healthcare providers through technology (Gorst et al., 2016; Maeder et al., 2015). Although the internet is not uniformly available, mobile devices and improved internet connectivity in developed and developing nations means that health services can be accessed in more locations and at times convenient to individuals and service providers (Wicks et al., 2013). Similarly, videoconferencing technology allows for synchronous communication between patients and providers (Wilson and Maeder, 2015). Videoconferencing has the capability of replicating more closely clinic-based, face-to-face intervention programmes, as they allow clinicians and clients to interact through technology in real time. However, the limited visual information available through videoconferencing, and the fact that health professionals and clients are not in the same location, may mean certain interventions are less amenable to online delivery or require adaptation to existing protocols. Transitioning evidence-based healthcare programmes to an online platform is therefore an important step in the process of developing internet-based interventions.

Another advantage of using the internet for health services delivery is that the same platform can be used for training clinicians in the delivery of cognitive behavioural interventions. Internet and videoconferencing technology may enhance the reach of intervention training, enabling clinicians in different locations to participate in individual mentoring sessions, or more formal training workshops. Thus, when transitioning evidence-based cognitive behavioural intervention programmes from in person to online delivery, it is imperative that clinician training programmes are provided, and ideally manualised, so that clinicians can refer to the online training materials when they need to. However, few studies have explored the experiences of clinicians who participated in an online intervention training, or whether the key intervention strategies from manualised cognitive behavioural interventions can be replicated when the clinician has received remote training in an internet health service delivery environment (Khatri et al., 2014).

The overarching purpose of this exploratory qualitative study was to assess the feasibility of transitioning manualised cognitive behavioural interventions for adults with chronic disease to an internet-based intervention platform. Feasibility was assessed by exploring both clinicians and clients' satisfaction with the online interventions. The ecare platform used in this study had been developed and used to deliver interventions for caregivers of persons with dementia (Marziali and Donahue, 2006), and consists of four modules that support (a) online training for clinicians so that they can learn to deliver evidence-based intervention programmes reliably, (b) online delivery of the interventions in a small group format, (c) evaluation of intervention programme benefits and (d) access to disease-specific information handbooks and information about strategies for maintaining health and wellbeing. Our overarching research question was can three cognitive behavioural interventions, traditionally delivered in person (face to face), be delivered from an internet-based intervention platform. The specific study objectives were first, to understand clinicians' experiences of delivering a cognitive behavioural programme using the internet-based intervention platform and second, to understand clients' experiences of receiving an online intervention, and responses to the cognitive behavioural intervention strategies delivered using the internet platform.

Method

Three interventions for adults with chronic diseases were transitioned to be delivered from the ecare platform, and a qualitative descriptive approach (Sandelowski, 2010) was used to understand participants experiences using the internet-based intervention platform. Ethical approval was obtained from the Baycrest Research Ethics Board.

Interventions

The three interventions studied were ‘Managing Chronic Disease’ (MCD) (Marziali, 2009), ‘Real-World Strategy Training’ (RWST) (Dawson et al., 2014) and ‘Learning the Ropes’ for living with mild cognitive impairment (LTR) (Murphy, 2014; Murphy et al., 2014). In brief, MCD is a semi-structured psychosocial support programme provided in group format. It uses education and peer support to help people with chronic disease (cardiovascular, type 2 diabetes, stroke or chronic obstructive pulmonary disease) to address personal and environmental barriers to adopting and maintaining prescribed health-enhancing behaviours (Marziali, 2009). The aim is to help participants to select personally relevant strategies to achieve diet and exercise goals, monitor their goal achievement and sustain changed behaviours over time (Marziali, 2009). RWST is a semi-structured intervention programme delivered in a group format to healthy older adults with subjective cognitive decline (Jessen et al., 2007). RWST includes education about healthy ageing, and teaches older adults to use a metacognitive strategy (Goal-Plan-Do-Check) to enhance their performance of meaningful occupations (Dawson et al., 2014). LTR is a structured intervention programme delivered in group format to older adults at risk of future dementia due to greater than age-expected memory decline, characterised as mild cognitive impairment (MCI). LTR provides education on lifestyle factors that influence memory function, as well as training in a range of strategies to compensate for memory problems (such as using a memory organiser or spaced retrieval for rehearsing information) (Murphy, 2014; Murphy et al., 2014). All three intervention programmes were selected as they have evidence supporting their efficacy (for RWST, see Dawson et al., 2014; for LTR, see Fogarty et al., 2016; Troyer et al., 2008; for MCD, see Marziali, 2009), and have manualised intervention protocols suitable for online delivery (Marziali, 2009), or that were adapted by our team for use in an internet-based health service delivery environment.

Technology

A password-protected, designated website (ecarecfo-cfm), developed and evaluated over a period of 10 years, was the platform used to conduct the study (Marziali and Donahue, 2006; Marziali et al., 2006). The website housed content for all three intervention programmes within four modules:

(a) Patient resources: technology training manual, disease-specific information handbooks, self-monitoring tools and pre-post evaluation questionnaires;

(b) Clinician training: technology training manual, intervention training manual and intervention tools such as pdfs and powerpoint slides uploaded during intervention sessions;

(c) Videoconferencing: embedded password-protected videoconferencing module formated for session scheduling and archiving;

(d) Health and wellbeing: evidence-based information with regard to the importance of exercise, diet, stress control, cognitive stimulation and social engagement for optimal management of chronic diease.

Within the website there were three levels of security. The site administrator had access to all links and user groups, the clinicians administering each intervention had access only to the resources, links and user information for those registered within the groups that they facilitated, and the participants receiving the online intervention programmes had access only to the resources and links for the intervention they were receiving.

Participants

Three clinicians and nine older adults with chronic conditions were recruited to participate in the study. Depending on the bandwidth available, the quality of video connection could be affected with large groups. As such, we planned to have between three and six people per group in this study. Henceforth, the term ‘clients’ is used to describe individuals who received one of the three online interventions, and the term ‘clinicians’ is used to describe the health professionals who facilitated the interventions. All clients and clinicians provided written informed consent.

Clinicians represented a convenience sample of professionals who had expressed interest in learning one of the three interventions. Clinicians were registered health professionals (one nurse and two occupational therapists) with between 1 and 19 years of clinical experience, and were employed in different settings (ambulatory care, primary care and clinical research). Criteria for participant inclusion for MCD clients was as follows: aged 45 years or over, had a medical diagnosis of either cardiovascular disease or type 2 diabetes and were identified by a healthcare team as nonadherent to prescribed rehabilitation regimen. Inclusion criteria for RWST clients were as follows: aged 60 years or over, had no known neurological condition, history of head trauma, or co-morbid psychiatric illness, and identified changes in cognitive function via positive response to the question ‘Do you feel like your memory or thinking is becoming worse?’ and ‘Does this concern you?’ (Jessen et al., 2007). Inclusion criteria for LTR clients were as follows: referred by a physician with a diagnosis of MCI (Petersen et al., 1999), aged 60 years or over and had no known history of head trauma or significant psychiatric illness. For all programmes, participants were excluded if they did not have access to a computer with a webcam and internet access, had a coexisting psychiatric condition influencing their ability to provide informed consent or if they did not speak English. With the exception of the RWST intervention, each clinician advertised the study at their workplace, recruiting participants who were interested in receiving the intervention they had been trained in. Participants who received the RWST intervention were recruited from a hospital research volunteer database.

The three MCD clients had a diagnosis of type 2 diabetes, two were female and the average age was 60 (range: 55–65) years. All were university educated, and one worked part time, one was unemployed and one was retired. The three clients in the RWST group had subjective cognitive decline, two were female and the average age was 75 (range: 70–80) years. All were university educated and retired. The three LTR clients had a diagnosis of MCI, two were male and the average age was 75 (range: 70–79) years. Two had university degrees and one had high school education, and all were retired. All nine clients resided in Canada, most in major cities (n = 7), with two living in a rural area.

Procedures

Data collection occurred between February and November in 2014, according to the procedures outlined below.

Clinician training

Clinicians were initially trained technically to access and navigate the ecare platform. Technology training included instructions for registering clients so they could use the platform, and assisting them in navigating relevant website modules. Next, each clinician received training in the intervention programme that they would be delivering. Clinicians studied the intervention-specific training manual available on the ecare website, and then met online with an intervention expert using videoconferencing. The first meeting with the expert interventionist was for discussion of the intervention strategies specific to the programme each clinician would be delivering, and all subsequent meetings were to review and discuss recorded intervention sessions, and to problem-solve any issues arising. Each intervention training manual was developed by the expert interventionist who had previously evaluated the efficacy of the specified intervention programme when delivered in person. Manuals described the theory and evidence for the intervention, protocols for administration and how to deliver intervention strategies, by stages of the intervention (early, middle and late).

Intervention delivery

Each clinician delivered the intervention programme in which they had received training. The MCD programme had 10 weekly 1 h group meetings, RWST had seven weekly 2 h group meetings plus two 1 h individual sessions and LTR had nine 1.5 h group meetings. Clients in all three online intervention programmes attended 83% of their online sessions, on average (range: 60–100%). Session by session, strategies were specified and, at times, modified to accommodate online delivery. For instance, the LTR protocol reduced the session length from 2 h to 90 min to avoid participant fatigue from sitting for too long at a computer. To accommodate this change, the facilitator spent less time during the videoconferencing sessions on the topic of lifestyle factors for optimising brain health, and directed clients to the supplementary online resources providing lifestyle education.

Of note, the expert clinician intervention training sessions and all videoed intervention sessions were archived for subsequent coding to assess whether intervention strategies and protocols were consistent with the manualised approach. Response data to working via an internet platform consisted of archived treatment sessions and qualitative feedback interviews with clients and clinicians, during which they discussed their experiences and perceptions of the online intervention.

Data analysis

Archived videoed intervention sessions and qualitative interviews were analysed using thematic analysis (Braun and Clarke, 2006). One author (EN) and a research assistant with experience in qualitative research methods separately observed, transcribed and coded the archived videoed sessions. Peer checking occurred through in-person meetings to discuss and compare codes, leading to the development of a consensus coding framework for each intervention. Codes were related to the intervention process (for example, working on personally meaningful goals), as well as responses to intervention strategies (for example, engagement in therapy) and clinician or client perceptions of the value of the intervention (for example, addressing memory problems in everyday life). The same two team members then recoded transcripts, applying the consensus coding framework. Data were then organised by codes and themes were identified by grouping data addressing similar concepts together. Themes were presented and discussed with all authors, and were compared with existing literature. Qualitative data from feedback interviews were analysed similarly. Transcripts were read to increase familiarity with the data. One author (EN) and a research assistant then coded two client transcripts and one clinician transcript and developed a coding framework. This framework was applied to the remaining interviews and data were then extracted into an Excel file and organised by codes. Once extracted the data were used to form higher- and lower-order themes. These themes were compared with data gathered from the analysis of archived intervention sessions. Rigour was enhanced through triangulation (multiple data sources and perspectives), peer checking and maintaining an audit trail throughout theme development.

Results

Clinicians' experiences of delivering a cognitive behavioural programme using the internet-based intervention platform

Two themes characterised how clinicians experienced learning to deliver the cognitive behavioural intervention and how to practise in an internet-based service delivery environment. Theme 1, ‘Adhering to protocol, and applying face-to-face cognitive behavioural intervention strategies in the online delivery of the target intervention’, reflects the clinicians’ experience of learning and then delivering a new cognitive behavioural intervention, and that they seemed to do so in a manner consistent with the intervention principles and protocols. Theme 2, ‘Learning to deliver therapy using technology’, reflects the clinicians’ perception that there was a learning period, during which they became familiar with the technology and adapted to working in an internet-based service delivery environment.

Adhering to protocol and applying face-to-face cognitive behavioural intervention strategies in the online delivery of the target intervention

In the qualitative interviews, all three clinicians expressed that they wanted to ensure they were adhering to the intervention protocol. They spent time before, during and after the online group sessions reflecting on whether they were delivering the intervention in a manner consistent with the intervention principles and protocols. Thematic analysis of the content of group intervention sessions showed that clinicians were consistently using manualised intervention strategies and principles. For example, the clinician delivering the MCD programme was less directive and instead encouraged clients to share their experiences and to direct the topics of discussion, which was consistent with the protocol. The clinician delivering the RWST intervention provided information on executive functioning, and on applying a problem-solving strategy in everyday life, utilised guided discovery and encouraged strategy use and dynamic performance analysis, which were key principles of the intervention. The clinician delivering the LTR programme provided instruction on the use of strategies to address everyday memory problems and incorporated frequent repetition to reinforce learning, particularly in relation to the ROPES acronym and associated memory strategies (record, organise, practice, elaborate, stop, see it and say it). All three clinicians provided education on how healthy lifestyle behaviours can influence both physical and cognitive health. Educational content was referenced by directing clients to access disease-specific handbooks and health and wellbeing modules on the website. Group members were encouraged to raise for discussion any questions arising from their reviews of the website information related to healthy lifestyle behaviours.

Learning to deliver therapy using technology

All clinicians learned to use new technology, adapted to working in an internet-based healthcare delivery environment and felt the technology training manuals were clear and helpful. The design of the website had distinct colour-coded modules, which made it easy to navigate and which they felt was important for their clients, many of whom had cognitive impairments. Ongoing practise with using the website and videoconferencing software was critical to the learning process.

Clinicians reported that meeting with an expert interventionist soon after beginning the groups was helpful in addressing intervention-specific challenges, and in developing skills in engaging clients in group programming in an internet-based healthcare delivery environment. The limited amount of visual information available on a videoconferencing screen made it difficult for clinicians to interpret non-verbal cues. Specific adjustments that clinicians made to their practise approach included: (a) implementing communication strategies that supported group facilitation in an online environment (for example, asking specific questions, naming the person you were asking for feedback, and signposting who would speak so that participants knew when it was their turn); (b) learning when to be directive and when to let clients lead the discussion; (c) adapting the amount of time spent discussing different topics to accommodate for clients' learning needs; and (d) using technology challenges (for example, difficulty remembering to turn on the microphone) as an opportunity for clients to practise using the problem-solving or memory strategies they were learning as part of the intervention, and/or an opportunity for group bonding. The following quote illustrates the process of learning to use the technology, and how a clinician adapted her communication style to suit the internet-based healthcare delivery environment:

um it took a little while for me to figure out that I needed to be asking really specific questions about the exercises in the workbook and then once I started doing that then I was getting a bit more feedback from people… I needed to draw people out a bit more I think (Clinician 3).

Clients' experiences of receiving an online intervention and how they responded to the cognitive behavioural intervention strategies

Two themes characterised how clients experienced these interventions. Theme 1, ‘The value of learning cognitive behavioural strategies, and of peer support’, reflects clients’ perceptions of the intervention features they found most helpful, and that they appear to respond to cognitive behavioural intervention strategies in a manner similar to face-to-face interventions. Theme 2, ‘Satisfaction with the online delivery method’, reflects participants’ satisfaction with using the technology to receive this type of support intervention.

The value of learning cognitive behavioural strategies, and of peer support

Behavioural change strategies used in all three interventions were, goal-setting, use of peer support and education techniques to scaffold learning, and these were perceived by participants to enhance their engagement in the programme and to facilitate behaviour change.

Goal-setting

All three clinicians used a collaborative process for goal-setting. Clients identified a problem they wished to address and converted these into a specific, measurable and attainable goal. In the MCD group, goals were formulated at each meeting based on within-group discussions related to diet and exercise habits for each client. In the RWST and LTR programmes, prior to the first online group session, each client formulated personally relevant goals in an individual semi-structured interview with the clinician interventionist. A standardised measure (the Canadian Occupational Performance Measure) (Law et al., 2014) was used to identify activities that clients needed or wanted to be able to do but were having difficulty with (RWST), or an everyday memory problem that they wanted to better manage (LTR). Self-ratings of performance and satisfaction with performance on either the occupational or memory problems were made pre- and post-programme completion in the RWST and LTR programmes, respectively. Clients reported that goal-setting promoted engagement in rehabilitation, as they were motivated to work towards something personally meaningful. For example:

I think we're exploring the whole idea of motivation and finding how we keep ourselves motivated to do the things that we actually have set out for ourselves. I think it's easier to motivate ourselves if it's our own goals (Client 5).

Peer support

Analysis of group processes within the videoconferencing milieu showed that group cohesion was achieved within all three intervention programmes. Member-to-member initiated discussion increased with parallel reduction in dependency on the clinician-initiated discussion. Members increasingly interspersed humour as they shared personal stories with greater frequency.

Client 1: I'm really impressed because you know there's pain and yet you're still doing it [walking], you're trying to push through it and figure it out. Client 2: No, no I have not really been doing it much. … Client 1: Well I think though that maybe you're not giving yourself credit, you're saying you're not doing it much. But your attitude is at least to figure out and see if there's a way, so you haven't abandoned it altogether (Clients 1 and 2).

Emotional support was evident through mutual empathic responses to shared concerns, which ‘normalised’ clients’ concerns and/or experiences. Informational support was provided when the group discussed a specific problem (such as managing type 2 diabetes in the MCD programme), offering advice as to strategies that had worked for them. Enhanced motivation was the most commonly cited benefit of the group format. Clients described feeling a sense of accountability and a desire to support their fellow group members which motivated them to attend sessions, do their homework, and participate more fully in the group discussions.

Yeah if there is someone who seems [to be] falling a bit behind people are just automatically giving a boost and getting the person back up to speed again you know. It was it was very supportive which is the atmosphere you want to create and I think that they were very effective in doing that (Client 8).

Educational strategies

In all three programmes the clinicians combined didactic and self-directed learning and used real-world examples to support transfer and generalisation. Guided discovery, a key aspect of the RWST intervention that refers to the use of Socratic questioning to support learning by guiding clients to discover new information (Polatajko and Mandich, 2004), was used across the sessions. In the LTR programme, repetition was used extensively to enable clients to learn and recall memory strategies. Real-world activities were used to practise applying intervention strategies in the RWST and LTR programmes. The facilitator asked clients to provide examples of how they were using specific cognitive strategies in their daily lives to support generalisation of learning to other situations and contexts:

Clinician 3: …So I am going to give you an example: where is your toothbrush right now? Client 7: In my shaving kit. Client 8: And mine is in the bathroom cabinet. Clinician 3: Ok and why do you know where your toothbrush is right now? Client 7: Well I leave my toothbrush in the same place at home all the time. Clinician 3: Exactly yeah so you are in the habit of putting it back in the same spot (Discussion between Clinician 3 and Clients 7 and 8).

Qualitative analyses suggest that as the sessions progressed clients became more independent in recalling strategies they were using (Brief Action Planning, Goal-Plan-Do-Check and LTR memory strategies for clients in the MCD, RWST and LTR programmes, respectively). This was demonstrated by more spontaneous and correct naming of strategies, and by giving examples of how they had or could have used the strategies to address goals outside of the online sessions. Participants also commented that the strategies were helping manage functional difficulties that they encountered in their daily life. For instance, in the quote below, an RWST client reported using the problem-solving strategy (Goal-Plan-Do-Check) more to improve their organisation, and help them to achieve their goals.

I was using to-do lists which did help, but the idea of turning some of the items on the to - do lists into goals with plans and check points and plan b's, and then thinking about them afterwards as to how well they worked, which was the programmes you know model, um it did help yep (Client 4).

Satisfaction with the online delivery method

Participants had varying levels of satisfaction with the internet-based delivery method. Challenges for clients receiving an intervention online included taking longer to get to know other group members, having limited opportunities to speak one-on-one with the facilitator and getting distracted by technology problems when they arose. Although some clients said they would have preferred working face-to-face, they could all see value in internet-based delivery, both in gaining new knowledge of technology and in the convenience of working from home. Also, they suggested that working online was ‘the way of the future’. Several participants expressed that their interest in telehealth and/or technology was what motivated them to participate in this study. Having trust in the clinician facilitating the group was another factor influencing their decision to participate.

All participants had access to either a desktop computer or laptop with a video camera. Software that supported the videoconferencing sessions was embedded in the secure ecare platform. Technical support was available to participants throughout the project implementation. Because of variation in users’ internet service providers and browsers, there were problems with both audio and video feeds. Despite the frustration caused by the technical issues clients persisted in solving technical problems and attending sessions: ‘You know there were a few little technical glitches but that's very small and certainly we didn't let it stop us at all, so no, nothing really’ (Client 5).

Discussion

The broad purpose of this study was to assess the feasibility of transitioning evidence-based and manualised cognitive behavioural interventions from in person, to internet-based delivery. Three interventions were provided using an internet platform, and the content, group format and key intervention strategies and principles were replicated in the online delivery. Clinician and client satisfaction with the online delivery methods was assessed through qualitative feedback interviews. Intervention strategies appreciated by clients paralleled those evident in face-to-face programmes (for example, collaborative goal-setting, peer support and use of specific educational strategies such as practical exercises incorporating real-world examples). Technology support and specific hardware (computers and webcams) was essential for programme delivery, and for supporting clinicians and older adults who were learning how to work in an internet-based healthcare delivery environment. The data suggested several strategies may be important when transitioning face-to-face interventions to an internet-based healthcare delivery environment, including provision of technology training and support, having manualised intervention protocols and using videoconferencing technology to facilitate clinicians' training in evidence-based interventions. These strategies are elaborated in more detail below and summarised in Table 1, as suggestions for other researchers and clinicians wishing to adapt face-to-face interventions for online delivery.

Table 1.

Transitioning face-to-face intervention programmes to online delivery.

Professional college telehealth policies	Clinicians should consult local healthcare and professional college telehealth policies to ensure the technology platform meets all security/privacy standards.
Technology training	Technology training for participants and clinicians includes instructions for navigation of the online platform, such as scheduling online sessions, directions for online completion of evaluation instruments and guidelines for resolving technology glitches.
Technology support	During the intervention training phase of the online programme, technical support is needed, especially for clinicians and participants who have minimal computer skills. We have found that provision of a brief, simple technology guideline listing steps for engaging with the online platform was sufficient for most of the clinicians and participants who were somewhat computer literate. For group programmes, having an assistant provide technology support enables the clinician to focus on intervention delivery.
Explicit communication	For example, clinicians need to use explicit instructions and/or questions to ensure participants are clear on expectations, to facilitate clarity of group interaction and to ensure ongoing monitoring of participants' understanding of concepts.
Technology platforms	Technology platforms can store all intervention-relevant content; for example, online intervention manuals, reference materials and evaluation instruments. Platforms can provide videoconferencing to facilitate communication between expert trainers and trainees, and between clinicians and clients. Similarly, platforms have recording/storing capacity for all intervention sessions, making them available for teaching/training purposes as well as subsequent session analysis to ascertain reliable adherence to intervention protocols.
Group size: online groups function best with a minimum of three to a maximum of six participants, plus one interventionist	From our experience in providing online group intervention programmes over the past 10 years, we have found that a minimum of three and a maximum of six participants ensures optimal conditions for group bonding and a cohesive therapeutic environment; however, we acknowledge that optimal online group size warrants further study and depends on the objectives of the intervention.
Intervention manuals	The expert trainer and trainee require intervention manuals for training purposes and to insure reliable adherence to intervention protocol. Intervention manuals need to be developed for each programme transitioning from face-to-face delivery to online delivery. Intervention manuals include theoretical premises, session-by-session intervention strategies, examples of participant responses and a brief overview of challenges when using technology for clinical service delivery.

Unique elements of this study were the use of technology that included: (a) access to a password-protected platform that provided disease-specific information, intervention training manuals, technology training manuals, information about importance of healthy lifestyle behaviours and access to videoconferencing software; (b) the use of intervention training manuals and videoconferencing consultation to train clinicians remotely to deliver the interventions reliably; (c) the use of technology training manuals to support clinicians and clients to access and navigate the platform; and d) the use of secure videoconferencing software to deliver the interventions. The utility and reliability of both the platform design, its components and content were based on the results of previous studies that evaluated website design criteria for older adult users, as well as design and delivery of online intervention programmes for family caregivers of persons with Alzheimer's disease and other dementias (Marziali, 2009; Marziali and Donahue, 2006; Marziali et al., 2006).

This study showed that three interventions could be transitioned to be delivered using an internet platform despite variation in levels of session structure. The programmes ranged from a highly structured intervention (LTR) (Murphy, 2014; Murphy et al., 2014) to a semi-structured psychoeducational support group in which the group members direct the topics for discussion (MCD) (Marziali, 2009). Aspects of intervention formats designed to facilitate behaviour change were evident in archived online intervention sessions suggesting that clinicians can be trained remotely to reliably deliver cognitive behavioural interventions. This study also suggested that client responses to intervention strategies parallel those evident when programmes are delivered in person (Dawson et al., 2014; Marziali, 2009; Troyer et al., 2008). For instance, as expected, goal-setting helped to engage clients to work on issues that were personally meaningful.

The success of any online intervention programme is dependent on the ability of users to access and manage the technology (Wilson and Maeder, 2015). In this exploratory study, the availability of well-designed and researched technology training manuals supported clinicians and clients in navigating three of the four ecare website modules (Marziali and Donahue, 2006; Marziali et al., 2006). More challenging for the clinicians was the use of the videoconferencing software. The website-embedded software required the clinician to register each client to access the videoconferencing meetings and also schedule meetings online. Use of the ecare website requires the availability of a technology support person to train clinicians in the more complex aspects of using software, in this instance, the videoconferencing software. In previous studies we found that technology-savvy family members could be recruited to provide clients with assistance in navigating the technology (Ng et al., 2013). Similarly, health system technology support staff can play important roles in training clinicians to use technology effectively. Although clients had varying levels of satisfaction with the technology, all were motivated to continue engaging in the therapy programme. This is very encouraging, demonstrating that despite challenges in technology use, all clients were engaged and made progress in changing behaviours.

Although the learning curve was high for the technical aspects of the ecare platform, privacy and security of client information within the videoconferencing mode was robust (Fischer et al., 2016). Given, potential identity exposure in internet environments, it is essential that internet-based healthcare delivery meet the privacy standards of face-to-face delivery. Clinicians considering using telehealth delivery methods should consult local healthcare and professional college policies, and ensure that the technology platforms they plan to use meet privacy standards.

Our data supports other studies showing that clinicians face challenges practising in a videoconferencing environment (Damianakis et al., 2008), highlighting a need for specific training to prepare clinicians for how to work online. The learning process for clinicians corresponds with other telehealth research studies, and centred around learning the intervention (adhering to protocol) and learning to work in an online environment with limited visual information (Damianakis et al., 2008). Clinicians commented positively on the manualised intervention and technology training, which they could refer to whenever needed, and the videoconferencing meetings with an expert interventionist as facilitating their learning. These may be useful training methods to use in other research and clinical programmes transitioning face-to-face interventions to online delivery.

Limitations and future directions

Although this study provides preliminary support for the feasibility of delivering evidence-based cognitive behavioural intervention programmes online, and shows this method of providing and receiving therapy is acceptable to clinicians and clients, there are some study limitations. The small sample size and limited information on clients' cognitive and physical health, as well as the small number of interventions examined and variation in interventionist clinical and technology experience, limits the generalizability of the findings. Additionally, we examined clinicians' and clients' experiences and perceptions of the intervention process through qualitative analysis of archived intervention sessions and qualitative feedback interviews, and more objective measures of outcome could be included in future studies evaluating these interventions. This study underscores the need for randomised controlled trials of sufficient sample size to determine whether internet-based intervention programmes yield health improvement benefits equivalent to those resulting from services delivered face to face.

In summary, this study has implications for service delivery in that a well-designed, multiple component, password-protected website platform can be used to: (a) provide remote training for clinicians in the technical and clinical skills required to deliver evidence-based intervention programmes online reliably; (b) provide evidence-based information about the management of chronic disease; (c) provide online evaluation instruments; and (d) provide videoconferencing software for remote interactions with professionals. Internet-based healthcare delivery is a promising way of building capacity in the system and ensuring older adults with chronic conditions have access to cognitive behavioural interventions critical to maintaining wellbeing and participation in everyday life.

Key findings

Remotely trained clinicians delivered cognitive behavioural interventions replicating face-to-face programme principles and protocols.

Behaviour change strategies (such as goal-setting and peer support) were reliably delivered in an internet-based healthcare environment and perceived to build client engagement.

What the study has added

Three cognitive behavioural interventions supporting self-management of chronic conditions were adapted for delivery using an online platform, providing clinician training, intervention delivery, evaluation of programme benefits and access to information.

Footnotes

Acknowledgements

We wish to acknowledge the contributions of Manpreet Lamba, Alisia Bonnick and Joanna Shnall who assisted with project management, recruitment, technology training and data analysis. Additionally, we wish to thank the participants for their time and contributions to this research, in particular the three clinicians delivering the interventions.

Research ethics

Ethical approval was obtained from Baycrest Research Ethics Board in December 2013 (protocol no. 13–62). All participants provided written informed consent.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a Canadian Institute for Health Research catalyst grant (no. 126531 awarded to EM, DRD, and KM) and a Canadian Institute for Health Research Strategic Training Postdoctoral Fellowship in Healthcare Technology and Place (awarded to EN). KM would also like to acknowledge support from the Morris Goldenberg Medical Research Endowment.

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