Abstract
Background
Interest in the use of telehealth interventions to increase access to healthcare services is growing. Group-based interventions have the potential to increase patient access to highly needed services. The aim of this study was to systematically review the available literature on group-based video teleconference services.
Methods
The English-language literature was searched using Ovid MEDLINE, PubMed, PsycINFO and CINAHL for terms related to telehealth, group therapy and support groups. Abstracts were reviewed for relevance based on inclusion criteria. Multiple study types were reviewed, including open-label, qualitative and randomised controlled trial study designs. Data were compiled regarding participants, study intervention and outcomes. Specific areas of interest were the feasibility of and satisfaction with telehealth technology, as well as the effect of video teleconference delivery on group dynamics, including therapeutic alliance.
Results
Forty published studies met the inclusion criteria and were included in the review. Six were randomised controlled trials. Among the studies, there was a broad range of study designs, participants, group interventions and outcome measures. Video teleconference groups were found to be feasible and resulted in similar treatment outcomes to in-person groups. However, few studies were designed to demonstrate noninferiority of video teleconference groups compared with in-person groups. Studies that examined group process factors showed small decreases in therapeutic alliance in the video teleconference participants.
Conclusions
Video teleconference groups are feasible and produce outcomes similar to in-person treatment, with high participant satisfaction despite technical challenges. Additional research is needed to identify optimal methods of video teleconference group delivery to maximise clinical benefit and treatment outcomes.
Introduction
Telemedicine is a rapidly growing field that holds much promise for improving access to healthcare and reducing healthcare costs. Telemedicine allows for the delivery of healthcare services to persons in remote and rural areas who may otherwise not have access to healthcare. As technology has become increasingly available to the public, there is increased demand on the part of healthcare consumers for more technologically based healthcare interventions. 1
Telehealth and telemental health are broad concepts that encompass many options for technology and methods of healthcare delivery, including mobile device applications, remote monitoring, online content, synchronous videoconferencing and asynchronous communication. 2 In the setting of telemental health, the area of greatest interest has been the use of live, interactive video teleconference (VTC) between a patient and a healthcare provider. It is well established in the literature that VTC visits can be used to provide high-quality diagnostic assessment and treatment for various mental health conditions. 3
Telemental health has been shown to be highly feasible and acceptable across different patient types, including diverse populations, adults, older adults and children.4,5 Telemental health has been used to diagnose and treat various health conditions, including depression and anxiety, as well as to provide support to patients and caregivers with co-occurring medical diagnoses such as diabetes mellitus, heart disease, and cancer.4,6 Most studies in telemental health have focused on assessment or treatment provided to individuals, whereas the literature regarding group-based treatment is limited.
2
VTC group-based treatments consist of one or more group therapists or facilitators providing an intervention to a group of participants at a distance. VTC groups may be either single point-to-point or multipoint design (Figure 1). In single point-to-point design, group members are all located in one remote VTC group room; in multipoint design, group members meet in the virtual group environment from individual remote sites.
Features of video teleconference (VTC) group design.
Group-based treatments have the potential benefit of expanding patient access to trained specialists in addition to allowing group members to find commonality and feel less isolated. In a review of information and support interventions for caregivers of people with dementia, only group-based interventions were shown to significantly decrease depression among caregivers. 7 In addition, structured group interventions have been shown to decrease distress and improve quality of life in patients with cancer. 8 Combining group-based treatment with VTC offers the potential for expanding availability of support services, reaching those isolated in remote areas, and reducing costs. However, because group treatments incorporate the interpersonal dynamics between facilitators and group members and between fellow group members, group treatment may provide unique challenges to the remote delivery of care. It is possible that VTC groups may hinder the development of a therapeutic alliance or interfere with the facilitator's ability to observe and respond to group interactions.
It remains unclear whether group psychotherapy or medical support groups can be provided via VTC with results comparable to face-to-face group treatment. 9 Only one systematic review has been published, on the related topic of telehealth delivery of home-based support groups; 10 the examination of 17 research articles showed that home-based VTC support groups were feasible, showed similar outcomes to in-person groups, and maintained group process factors. Thus, there is a substantial gap in the available literature concerning several important questions regarding the use of telehealth groups, which the current study aims to examine: (a) is group-based psychotherapy or a support group intervention via VTC as effective as similar in-person treatment? (b) do specific group processes differ between face-to-face and VTC groups? and (c) are group participants and providers satisfied with VTC technology? This current review expands on the one previous review by including both home-based and facility-based groups and by reviewing open-label and randomised controlled trials (RCTs). The overall aim of this study was to consolidate the available literature on group-based treatments that were delivered via VTC, and to examine feasibility and outcomes of group-based VTC treatments.
Methods
Search strategy and inclusion criteria
The databases Ovid MEDLINE (1946 to February 2018), PubMed, PsycINFO (1987–2018), and CINAHL were searched using the keywords group therapy, support group, group psychotherapy, self-help groups, videoconference, mhealth, mobile phone, smartphone, ehealth, remote group, telehealth, telepsychiatry, telemedicine, remote consultation, video visit, virtual visit, videotelephone, telepsychology, ehealth and econsult. Studies were included if they were open-label trials or RCTs published in English-language peer-reviewed journals and were performed in adult populations (age>18 years). A ‘telemental health intervention’ was defined as services provided by a trained professional to a group of participants. For study inclusion in our review, the intervention had to be provided by VTC format. Studies were excluded if they did not include a VTC intervention, such as studies with only text-based or telephonic communication. Studies were allowed if they included additional forms of telehealth interventions such as online chat interface or asynchronous discussion forums, as long as there was a primary VTC group component. Studies that incorporated both in-person and VTC sessions were excluded.
The titles and abstracts of the articles identified in the search were screened by one author for pertinence to the topic. Full texts of the selected studies were then retrieved and read in detail. The bibliographies of identified articles were reviewed to determine other potentially relevant articles not previously identified (Figure 2).
Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram. VTC: video teleconference.
Data collection
Relevant information from each study was summarised by one author using a data extraction sheet based on predetermined categories. These included sample size, target population, study design, technology factors (including software type and Internet speed), type of treatment intervention and outcome measures.
Results
Characteristics of group-based VTC studies.
ADLs: activities of daily living; AES: Advanced Encryption Standard; AI and AN: American Indian and Alaskan Native; BDI-II: Beck Depression Inventory Second Edition; CBT: cognitive behavioral therapy; COPD: chronic obstructive pulmonary disease; CPOSS-VA: Charleston Psychiatric Outpatient Satisfaction Scale-VA PTSD Version; FTF: face-to-face; GAD-7: Generalized Anxiety Disorder seven-item scale; GTAS: Group Therapy Alliance Scale; HbA1c: haemoglobin A1c; HD: high-definition; HIV: human immunodeficiency virus; IADLs: instrumental activities of daily living; ISDN: integrated services digital network; IT: information technology; NF: neurofibromatosis; NT: no treatment; PCP: primary care provider; PHQ-9: Patient Health Questionnaire-9; PTSD: posttraumatic stress disorder; QoE: quality of evidence; QoL: quality of life; RCT: randomised controlled trial; TBI: traumatic brain injury; VTC: video teleconference; WLC: wait list control.
Target populations were variable among studies, with inclusion criteria based on common features such as cancer survivors, caregivers of adults with dementia, or veterans with posttraumatic stress disorder (PTSD) (Table 1).
There was substantial heterogeneity among the studies included for review, including the choice of participants, the intervention provided, and the measures used to assess outcomes. Eleven of the studies were primarily qualitative.26,27,29,32,36,43,44,47,49–51
Quality of evidence scale.
Source: Modified from US Preventive Services Task Force, 52 which was developed with data from: Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979; 121: 1193–1254.
Description of technology
There was immense variability in each study's description of the technology used for providing the VTC intervention. Several studies described the computer program or teleconference technology that was used. Some described whether technical support was provided either before the intervention or during the group sessions. Some studies specifically examined technical issues and the quality of videoconferencing interaction, whereas others were limited in providing this information. Only six studies reported Internet connectivity in kilobytes per second (kB/s), with speeds ranging from 200–512 kB/s.13,15,23,28,31,33 Five studies that collected information related to technical issues indicated that this was not a major concern during the course of their intervention.9,11,14,18,38 In other studies, several types of technical difficulties were described related to video quality, 44 audio quality,21,25,29,49 low lighting29,31,33 and VTC connectivity.25,31,40,42,46,49 Two studies identified a need for increased local technical support.29,44
VTC sessions were provided with various group designs across studies, including single point-to-point groups and multipoint groups (Figure 1). In 21 studies, participants connected to the VTC with a multipoint design using a personal computer or tablet.11,19–21,25–29,34,38–40,42,43,45,46,48–51 Nineteen used either point-to-point or multipoint design with group participants gathering in one or more clinic locations where the VTC connection was provided by institutional teleconferencing equipment.9,12,14,15,17,18,22–24,30–33,35–37,41,44,47 For studies with participants at several different clinical sites, the number of participants at each location varied – that is, some remote sites would include face-to-face group participant interaction, whereas other sites would only have one participant each. In one study, the therapists delivered smoking cessation content to an in-person group, with simultaneous broadcast via VTC connections to other remote locations. 23
Description of psychological/supportive intervention
The studies included a broad range of psychosocial interventions, such as cognitive behavioural therapy, mindfulness training, coping skills training, and acceptance and commitment therapy. Studies included support groups for patients and caregivers with cancer, chronic pain, and neurodegenerative disorders (Table 1). There were also educational groups in the areas of diabetes, weight management and smoking cessation. Most studies were short-term groups of 6–14 sessions. One study was described as an emotional processing group and consisted of monthly meetings over the course of three years. 36
Participant satisfaction and evaluation of technology
Participant satisfaction with the telemental health intervention was commonly assessed with satisfaction questionnaires and/or postintervention participant interview. There is no formally identified standard measure for assessing patient satisfaction with telemedicine interventions. Two studies used the Telemedicine Satisfaction and Acceptance Scale, an 11-item questionnaire developed to study participant perceptions about variables related to mode of service delivery.18,33 None of the studies described whether this tool has been empirically validated. Some studies used individually developed patient satisfaction questionnaires. Other studies used qualitative methods to determine the participant experience with telemedicine, such as postintervention focus groups or semistructured interviews. All of the studies reviewed indicated that the participants had positive perceptions of the telehealth experience. Two studies reported that participants had concerns regarding low lighting or background noise that directly interfered with the VTC experience.29,33 One study noted difficulty with scheduling and access to the VTC rooms. 47 Only one study identified patient acceptance as a barrier to implementation, reporting that nine participants withdrew from the study because they did not contact information technology support for necessary technology upgrades to their home computers. 11
Group process outcomes
Several studies were designed to specifically examine group process indicators to determine whether group process was affected by a VTC delivery method.9,17,18,22,45 Many of the pilot/feasibility studies primarily evaluated qualitative postintervention interviews to determine participants' perceived experience. Themes of these qualitative analyses indicated that group participants reported a positive group experience, wanted to continue group sessions, felt valued by group members and felt less alone.28,36,44,46 In two of the studies, participants indicated that their group experience would have been improved by having at least one face-to-face interaction with the therapist at the beginning of treatment.30,33 Studies that directly compared group process outcomes showed some mild differences between groups, with small decreases in therapeutic alliance and group cohesion in the VTC group vs face-to-face delivery.9,12,22 These differences in group process indicators, however, did not appear to result in different treatment outcomes between the VTC and face-to-face groups. In two studies, participants indicated a preference for VTC over face-to-face interaction because it was less distracting and threatening.25,34,45
Effectiveness of group-based intervention
All studies included in this review indicated generally positive clinical outcomes but were limited in drawing conclusions about efficacy of the group-based intervention because of the absence of randomisation and/or appropriate control groups. Across studies, there was general agreement that VTC groups were feasible and well accepted by participants. Several studies used quantitative measures and indicated general posttreatment improvement in anxiety and depression symptoms,27,28,34 quality of life19,35 and perceived stress. 46
Discussion
This literature review identified several fundamental questions regarding group treatment provided via telemedicine. First, is group-based psychotherapy or a support group intervention via VTC as effective as similar in-person treatment? This question would require the comparison of two treatment groups for which similar interventions were provided, with one condition given face-to-face and another provided remotely via VTC equipment. Only six studies examined this treatment condition in an RCT fashion.9,12,15,17,18,21 This is a field of study, however, in which randomisation can present technical and clinical challenges. In particular, telemedicine serves to bring healthcare to those who live in remote areas and do not have ready access to the types of academic centres where rigorous RCTs are often performed. Participants can be randomly assigned to a VTC versus in-person treatment only if they live in close proximity to the research centre or if the research centre can send providers to remote locations for in-person treatment. Therefore, true randomisation may not always be feasible or preferable. Additional factors such as patient preference and comfort with technology may be relevant to understanding the role of telemedicine for specific populations. Five additional studies directly compared a VTC group with a face-to-face group but did not include randomisation.22–25,41 Among these 11 studies, both randomised and nonrandomised, no differences were found between VTC and face-to-face groups in terms of treatment outcomes, such as decreased PTSD symptoms or smoking cessation rates. Three of these studies were able to demonstrate through noninferiority analysis that VTC was equivalent to face-to-face delivery of the same intervention.9,12,18 All three studies were performed among male veterans with PTSD. Additional studies in other populations would be beneficial, as would other group interventions of a similar design to show equivalence of VTC groups across various populations and conditions.
The second relevant clinical question to be considered is: do specific group processes differ between face-to-face and VTC groups? Four studies specifically evaluated measures of group process,9,17,18,22 and one used a measure of satisfaction with therapy and the therapist. 45 These studies indicated mild decreases for VTC in factors related to alliance with the group or with the therapist. Batastini and Morgan 22 indicated that participants in the VTC group were less trusting and accepting of the facilitator and felt less cohesion within the group. Morland and colleagues 9 indicated that participants in the VTC group showed lower levels of self-therapist alliance. These differences in group process indicators were not associated with treatment outcomes in any of the studies. Several other noncontrolled studies used qualitative information provided by participants regarding their experience with a VTC group. In the study by Chang and colleagues, 30 participants believed that the care they received was just as good as face-to-face services. Collie et al. 31 indicated that women felt they had made strong emotional bonds with other group members. In the study by O'Connell and colleagues, 36 participants stated that they valued feeling less alone as the result of attending the group. However, in one study among 16 adult cancer survivors, participants reported treatment-related barriers, including difficulties with developing an emotional connection to other group participants and persistent technical difficulties. 46 In two studies, participants reported that they would have preferred some component of in-person contact with the facilitators, preferably at the initial session.30,33 Evidence is still limited as to the role of group process factors in relation to providing remote group treatment. Only a few studies directly examined group process indicators. There was no consistent use of standard measures to assess factors such as group cohesion and therapeutic alliance.
The potential effect of these differences in group organization and structure was not addressed directly in any of the studies. Currently, no evidence is available to suggest whether having all group participants physically located in one location, vs all participants only having remote access to each other, would influence treatment outcomes or group process factors such as adherence and therapeutic alliance. None of the studies addressed whether specific participant characteristics might contribute to a preference for different group organizational structures – for example, whether participants with certain types of physical or mental health challenges may feel more comfortable in settings without any face-to-face interaction.
The last question raised by this study is: are participants and providers satisfied with interventions using VTC technology? Several of the studies used structured interviews or internally developed patient satisfaction surveys to assess satisfaction with VTC technology. All the studies in this review indicated generally positive feedback from participants, with high ratings of satisfaction. Few studies surveyed the group therapists/providers with regard to their level of satisfaction with the use of technology. In some of the studies, it was clear that study participants would not have been able to receive the treatment at all had it not been provided via VTC. In other studies, the participants were randomly assigned to VTC or face-to-face treatment. It is reasonable to assume that participants' pre-existing preferences regarding in-person or remote treatment may have influenced their perceptions of VTC technology. Participants also interacted with the VTC technology in various ways. Some participants were located alone at home or in a clinic site. In other studies, patients were grouped together in a conference room at one remote site. In some conditions, group participants could see other group members on a split screen, whereas in other studies only the therapist was able to view all group members. Beyond the effect this may have on group process, there are also important implications for the use of technology, with more control of and technical support for groups located in clinical or research sites vs in a participant's home.
Limitations
There are several limitations of this review. Most studies were limited by small sample sizes or lack of control groups. Only four studies included a VTC treatment arm with more than 50 participants.23,26,29,49 Six studies had 10 or fewer participants per treatment group.15,17,25,28,30,45 It was difficult to draw more specific conclusions regarding treatment effects of VTC because of the great variability between study methods, interventions, and target populations. Most studies were pilot/feasibility studies and therefore not designed to show statistically significant differences between VTC and in-person treatment. Because telehealth interventions represent an emerging field of study, there is a lack of consensus on the terminology to describe them. Terminology such as telehealth, telemental health, web-based, Internet-based, online and VTC can have variable meanings and are not used consistently across the literature. Therefore, it is possible that additional studies exist in the literature but were missed because of limitations of the search methods.
Conclusion
Telemental health group treatment has been shown to be feasible and is well received by participants. More rigorous studies, especially RCTs, are warranted to ensure that a group-based telehealth intervention is sufficiently equivalent to in-person treatment. The unique elements of group dynamics can be affected by a remote, VTC format; thus, this area requires specific study. It is possible that many group dynamics, such as group cohesion and therapeutic alliance, may not be adequately represented via a telehealth intervention. As noted in the limitations, many studies were not specifically identified as providing a group-based treatment and did not specifically examine group process factors. Additional research is needed to better understand factors that would enhance the delivery of VTC group treatment and mitigate possible negative effects on group process.
Telemental health interventions are greatly needed to improve access to qualified mental health providers. Given the limited availability of mental health providers, especially in remote or rural areas, it is reasonable to consider group-based treatment as a way to disseminate evidence-based care more broadly.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.