Digital habits of PR service-users: Implications for home-based interventions during the COVID-19 pandemic

Introduction

Pulmonary rehabilitation (PR) is commonly delivered in outpatient settings but due to the Coronavirus Disease 2019 (COVID-19) pandemic and suspension of face-to-face clinical encounters, alternative ways of delivering PR are vital. Many home-based options involve digital platforms and Internet access. ^{1 –3} However, contemporary data on the digital access and behaviour of PR service users are limited. We aimed to investigate digital access and behaviour and PR delivery preferences in current service users.

Methods

Harefield Hospital PR team, UK, initiated a survey of all service users between 24 February 2020 and 9 March 2020 as part of a service-improvement initiative. It comprised basic demographic details and questions on access to digital devices, confidence, frequency and motivation in using these devices; willingness to view PR components digitally; and PR delivery preference. Data were summarised using descriptive statistics and bar charts.

Results

Of the 193 surveyed, responses were received from 170 (88%); 133 (78%) and 7 (4%) were enrolled in conventional and home-based PR, respectively, and 30 (18%) were awaiting enrolment. Baseline demographics were age 72 (10) years (mean (SD)), 52% women, and primary respiratory diagnosis of 68% COPD, 11% chronic asthma, 7% bronchiectasis, 5% interstitial lung disease and 9% other diagnoses.

Most respondents possessed a mobile phone (89%), but access to other devices was more heterogenous (Figure 1(a)). In all, 31% and 26% reported using mobile phone for emailing or Internet browsing, respectively (Figure 1(b)).

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Figure 1.

(a) Percentage of respondents with access to digital devices (b) Percentage of respondents using mobile phone functions. SMS: Short Message Service (Text messaging).

Fifty-one per cent used the Internet daily, but 31% had never accessed it (Figure 2(a)). Older age, but not sex, was associated with a lack of Internet access (odds ratio (95% confidence interval) 0.94 (0.91 to 0.99); p < 0.01). Less than half felt “extremely” or “quite” confident using the Internet (Figure 2(b)). Only 16% had experience of video calling.

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Figure 2.

(a) Frequency of Internet access. (b) Confidence with using the Internet.

Self-management education was the most popular (45%) PR component respondents were interested in accessing digitally (Figure 3(a)), with 29% reporting no interest in accessing any PR information digitally.

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Figure 3.

(a) Percentage of respondents who would access components of PR through an app from a digital device. (b) Percentage of respondents who would like different modes of PR delivery.

The majority of respondents (79%) preferred PR delivered face to face in a hospital or community setting, with 11% and 9% stating a preference for an exercise manual at home supervised by weekly telephone calls or a Web-based app with no supervision (Figure 3(b)).

Discussion

This study provides contemporary data on digital access and behaviour of PR service users. Our main finding is the wide variability in Internet access and confidence which has implications for the remote delivery of PR during the COVID-19 pandemic and raises questions about the readiness of service users to adopt digital PR.

The survey was initiated in anticipation that the COVID-19 pandemic would lead to restrictions on face-to-face clinical encounters. Indeed, the British Thoracic Society advised the suspension of face-to-face PR on 23 March 2020 and encouraged the use of online PR resources.

Although recent trials of PR delivered through Web-based platforms have shown promise, a common limitation was selective trial population. For example, one study included only those with Internet access and the ability to operate a Web platform² and in another more participants were excluded because of no Internet access (n = 111) than participants recruited (n = 103).¹ These trials provide limited information on the digital ability of unselected PR service users.

A strength of our study is that it provides contemporary real-world information on the feasibility of digital interventions during the COVID-19 pandemic. However, as a large proportion of respondents were enrolled in conventional PR, views on the acceptability of home-based options were likely to be biased.

In conclusion, digital access and behaviour among PR service users is heterogeneous with a significant proportion unable or unwilling to access Web-based healthcare. This has implications for remote PR delivery during the COVID-19 pandemic and provides insight into the feasibility of digital PR adoption.