Developing a Plan for the Sustainable Implementation of an Electronic Health Intervention (Partner in Balance) to Support Caregivers of People With Dementia: Case Study

A scoping review and expert consensus on digital determinants of health

Objective

To map how social, commercial, political and digital determinants of health have changed or emerged during the recent digital transformation of society and to identify priority areas for policy action.

Methods

We systematically searched MEDLINE, Embase and Web of Science on 24 September 2023, to identify eligible reviews published in 2018 and later. To ensure we included the most recent literature, we supplemented our review with non-systematic searches in PubMed® and Google Scholar, along with records identified by subject matter experts. Using thematic analysis, we clustered the extracted data into five societal domains affected by digitalization. The clustering also informed a novel framework, which the authors and contributors reviewed for comprehensiveness and accuracy. Using a two-round consensus process, we rated the identified determinants into high, moderate and low urgency for policy actions.

Findings

We identified 13 804 records, of which 204 met the inclusion criteria. A total of 127 health determinants were found to have emerged or changed during the digital transformation of society (37 digital, 33 social, 33 commercial and economic and 24 political determinants). Of these, 30 determinants (23.6%) were considered particularly urgent for policy action.

Conclusion

This review offers a comprehensive overview of health determinants across digital, social, commercial and economic, and political domains, highlighting how policy decisions, individual behaviours and broader factors influence health by digitalization. The findings deepen our understanding of how health outcomes manifest within a digital ecosystem and inform strategies for addressing the complex and evolving networks of health determinants.

Continued Implementation and Use of a Digital Informal Care Support Platform Before and After COVID-19: Multimethod Study

Background

With the growing need of support for informal caregivers (ICs) and care recipients (CRs) during COVID-19, the uptake of digital care collaboration platforms such as Caren increased. Caren is a platform designed to (1) improve communication and coordination between ICs and health care professionals, (2) provide a better overview of the care process, and (3) enhance safe information sharing within the care network. Insights on the impact of COVID-19 on the implementation and use of informal care platforms such as Caren are still lacking.

Objective

This study aimed to (1) identify technology developers' lessons learned from the continued implementation of Caren during COVID-19 and (2) examine pre-post COVID-19 changes in usage behavior and support functionality use of Caren.

Methods

A focus group with developers of the Caren platform (N=3) was conducted to extract implementation lessons learned. Focus group data were first analyzed deductively, using the Consolidated Framework for Implementation Research domains (ie, individual characteristics, intervention characteristics, inner setting, and outer setting). Later, inductive analysis of overarching themes was performed. Furthermore, survey data were collected in 2019 (N=11,635) and 2022 (N=5573) among Caren platform users for comparing usage behavior and support functionality use. Data were analyzed using descriptive and inferential statistics.

Results

Several lessons from the continued implementation of Caren during COVID-19 were identified. Those included, for example, alternative ways to engage with end users, incorporating automated user support and large-scale communication features, considering the fluctuation of user groups, and addressing data transparency concerns in health care. Quantitative results showed that the number of ICs and CRs who used Caren several times per day increased significantly (P<.001 for ICs and CRs) between 2019 (ICs: 23.8%; CRs: 23.2%) and 2022 (ICs: 35.2%; CRs: 37%), as well as the use of certain support functionalities such as a digital agenda to make and view appointments, a messaging function to receive updates and communicate with formal and informal caregivers, and digital notes to store important information.

Conclusions

Our study offers insights into the influence of the COVID-19 pandemic on the usage and implementation of the digital informal care support platform Caren. The study shows how platform developers maintained the implementation during COVID-19 and which support functionalities gained relevance among ICs and CRs throughout the pandemic. The findings can be used to improve the design and implementation of current and future digital platforms to support informal care toward the "new digital normal."

Evaluating the web-based 'Partner in Balance' program for informal caregivers of people with Huntington's disease: A pilot study

Background

Huntington's disease (HD) poses significant challenges for both affected individuals and their informal caregivers. With the progression of HD, caregivers frequently prioritize caring for the person with HD over their own well-being. 'Partner in Balance' (PiB) is an 8-week online self-management program guided by a personal coach, developed to help caregivers of people with HD cope with challenging situations and develop skills to increase resilience and prevent overburdening.

Aims

This pilot study evaluates the feasibility and preliminary effects of the PiB-HD program.

Methods

The study employed a pre-post design. Perceived feasibility by HD caregivers was evaluated using both quantitative and qualitative measures. Preliminary effects were based on self-report measures of self-efficacy, mastery, mood, quality of life, and capability to function. Coaches' evaluations were conducted using a questionnaire.

Results

In total, 18 caregivers completed the intervention. Findings demonstrate positive responses regarding the program's usability, relevance, and acceptability. Participants found the program helpful in addressing challenges, gaining insight into their actions, and feeling better equipped with skills to face future challenges. Descriptive statistics suggest that the PiB-HD program shows potential for reducing stress and anxiety. Additionally, coaches (n = 9) viewed the program positively for its usability, integration potential into their work, flexibility, and time efficiency.

Conclusions

The PiB-HD program proved to be feasible, usable and acceptable for caregivers of people with HD. These results provide directions for further research into the effectiveness of PiB-HD, and can already be utilized to advise on the deployment of eHealth in the provision of HD care.

Determinants of Successful Implementation of Assistive Technologies for Dementia: Exploratory Survey

Background

Despite positive results for the use of assistive technologies (ATs) in dementia, the uptake of ATs lags behind. It is considered important to assess determinants of successful or unsuccessful implementation of ATs.

Objective

We explored factors that influence the implementation of ATs for community-dwelling people with dementia, with the aim to better understand potentially effective implementation strategies.

Methods

A cross-sectional survey for researchers was developed and disseminated, exploring factors that influence either successful or unsuccessful implementation of ATs for dementia. The survey consisted of closed and open questions.

Results

The response rate was 10% (21/206); the 21 respondents who completed the survey were from 8 countries. Determinants of implementation were described for 21 ATs, of which 12 were successfully and 9 were unsuccessfully implemented. Various types of ATs were included, such as online platforms, sensors, or physical aids. The main determinants of implementation success were related to the AT itself, contextual factors, research activities, and implementation strategies. There was a lack of research data on some ethical issues and cost-effectiveness.

Conclusions

This study provided insight into some main barriers to and facilitators of implementation of ATs in dementia related to the AT itself, context, research-related activities, and applied implementation strategies. Lessons were formulated for various stakeholders to improve the implementation effectiveness of ATs in dementia.

What is known about the role of external facilitators during the implementation of complex interventions in healthcare settings? A scoping review

OBJECTIVE

To synthesise current knowledge about the role of external facilitators as an individual role during the implementation of complex interventions in healthcare settings.

DESIGN

A scoping review was conducted. We reviewed original studies (between 2000 and 2023) about implementing an evidence-based complex intervention in a healthcare setting using external facilitators to support the implementation process. An information specialist used the following databases for the search strategy: MEDLINE, CINAHL, APA PsycINFO, Academic Search Complete, EMBASE (Scopus), Business Source Complete and SocINDEX.

RESULTS

36 reports were included for analysis, including 34 different complex interventions. We performed a mixed thematic analysis to synthesise the data. We identified two primary external facilitator roles: lead facilitator and process expert facilitator. Process expert external facilitators have specific responsibilities according to their role and expertise in supporting three main processes: clinical, change management and knowledge/research management.

CONCLUSIONS

Future research should study processes supported by external facilitators and their relationship with facilitation strategies and implementation outcomes. Future systematic or realist reviews may also focus on outcomes and the effectiveness of external facilitation.

Mapping Factors That Affect the Uptake of Digital Therapeutics Within Health Systems: Scoping Review

BACKGROUND

Digital therapeutics are patient-facing digital health interventions that can significantly alter the health care landscape. Despite digital therapeutics being used to successfully treat a range of conditions, their uptake in health systems remains limited. Understanding the full spectrum of uptake factors is essential to identify ways in which policy makers and providers can facilitate the adoption of effective digital therapeutics within a health system, as well as the steps developers can take to assist in the deployment of products.

OBJECTIVE

In this review, we aimed to map the most frequently discussed factors that determine the integration of digital therapeutics into health systems and practical use of digital therapeutics by patients and professionals.

METHODS

A scoping review was conducted in MEDLINE, Web of Science, Cochrane Database of Systematic Reviews, and Google Scholar. Relevant data were extracted and synthesized using a thematic analysis.

RESULTS

We identified 35,541 academic and 221 gray literature reports, with 244 (0.69%) included in the review, covering 35 countries. Overall, 85 factors that can impact the uptake of digital therapeutics were extracted and pooled into 5 categories: policy and system, patient characteristics, properties of digital therapeutics, characteristics of health professionals, and outcomes. The need for a regulatory framework for digital therapeutics was the most stated factor at the policy level. Demographic characteristics formed the most iterated patient-related factor, whereas digital literacy was considered the most important factor for health professionals. Among the properties of digital therapeutics, their interoperability across the broader health system was most emphasized. Finally, the ability to expand access to health care was the most frequently stated outcome measure.

CONCLUSIONS

The map of factors developed in this review offers a multistakeholder approach to recognizing the uptake factors of digital therapeutics in the health care pathway and provides an analytical tool for policy makers to assess their health system's readiness for digital therapeutics.

Implementation of eMental health technologies for informal caregivers: A multiple case study

Introduction

Informal caregivers offer continuous unpaid support to loved ones who are unable to live independently. Providing care can be a very burdensome commitment, that heavily impacts informal caregivers' mental health. eMental health is a possible, yet challenging, solution to improve caregivers' mental health and their overall experience of caregiving. In fact, eMental health technologies often face challenges of implementation. The present work gathers knowledge on how to best deal with these challenges by collecting testimonies of implementation experts of eight eMental health technologies for informal caregivers with the aim of comparing them and extracting lessons learned.

Methods

For this multiple case study, technologies were selected (through informal suggestions and independent search) according to the following inclusion criteria: they were intended for informal caregivers as main user group, were aimed at improving informal caregivers' mental wellbeing and caregiving experience and were available and running in real life settings in Europe. Ten interviews were conducted (two pilots and eight included cases). The interviewees were asked to provide a description of the technology and its aims and their implementation approach, method and frameworks used. Finally, determinants of implementation, the influence of the Covid-19 pandemic on implementation processes and lessons learned were investigated.

Results

The results highlight key differences between technologies developed within academia and the industry regarding efficacy testing and use and use and choice of frameworks. Also, similarities in terms of recognized barriers such as financing are illustrated.

Discussion

Possible ways to overcome main barriers and examples of best practices, such as structuring a business model and discussing tool maintenance and long-term hosting in advance, are discussed.

Implementation of e-Mental Health Interventions for Informal Caregivers of Adults With Chronic Diseases: Mixed Methods Systematic Review With a Qualitative Comparative Analysis and Thematic Synthesis

BACKGROUND

Informal caregivers commonly experience mental health difficulties related to their caregiving role. e-Mental health interventions provide mental health support in a format that may be more accessible to informal caregivers. However, e-mental health interventions are seldom implemented in real-world practice.

OBJECTIVE

This mixed methods systematic review aimed to examine factors associated with the effectiveness and implementation of e-mental health interventions for informal caregivers of adults with chronic diseases. To achieve this aim, two approaches were adopted: combinations of implementation and intervention characteristics sufficient for intervention effectiveness were explored using qualitative comparative analysis, and barriers to and facilitators of implementation of e-mental health interventions for informal caregivers were explored using thematic synthesis.

METHODS

We identified relevant studies published from January 1, 2007, to July 6, 2022, by systematically searching 6 electronic databases and various secondary search strategies. Included studies reported on the effectiveness or implementation of e-mental health interventions for informal caregivers of adults with cancer, chronic obstructive pulmonary disease, dementia, diabetes, heart disease, or stroke. Randomized controlled trials reporting on caregivers' mental health outcomes were included in a crisp-set qualitative comparative analysis. We assessed randomized controlled trials for bias using the Risk of Bias 2.0 tool, and we assessed how pragmatic or explanatory their trial design was using the Pragmatic Explanatory Continuum Indicator Summary 2 tool. Studies of any design reporting on implementation were included in a thematic synthesis using the Consolidated Framework for Implementation Research to identify barriers to and facilitators of implementation.

RESULTS

Overall, 53 reports, representing 29 interventions, were included in the review. Most interventions (27/29, 93%) focused on informal cancer or dementia caregivers. In total, 14 reports were included in the qualitative comparative analysis, exploring conditions including the presence of peer or professional support and key persuasive design features. Low consistency and coverage prevented the determination of condition sets sufficient for intervention effectiveness. Overall, 44 reports were included in the thematic synthesis, and 152 barriers and facilitators were identified, with the majority related to the intervention and individual characteristic domains of the Consolidated Framework for Implementation Research. Implementation barriers and facilitators in the inner setting (eg, organizational culture) and outer setting (eg, external policies and resources) domains were largely unexplored.

CONCLUSIONS

e-Mental health interventions for informal caregivers tend to be well-designed, with several barriers to and facilitators of implementation identified related to the intervention and individual user characteristics. Future work should focus on exploring the views of stakeholders involved in implementation to determine barriers to and facilitators of implementing e-mental health interventions for informal caregivers, focusing on inner and outer setting barriers and facilitators.

TRIAL REGISTRATION

PROSPERO (International Prospective Register of Systematic Reviews) CRD42020155727; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020155727.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2019-035406.

A systematic literature review and meta-analysis on digital health interventions for people living with dementia and Mild Cognitive Impairment

OBJECTIVES

Digital health interventions enable services to support people living with dementia and Mild Cognitive Impairment (MCI) remotely. This literature review gathers evidence on the effectiveness of digital health interventions on physical, cognitive, behavioural and psychological outcomes, and Activities of Daily Living in people living with dementia and MCI.

METHODS/DESIGN

Searches, using nine databases, were run in November 2021. Two authors carried out study selection/appraisal using the Critical Appraisal Skills Programme checklist. Study characteristics were extracted through the Cochrane handbook for systematic reviews of interventions data extraction form. Data on digital health interventions were extracted through the template for intervention description and replication (TIDieR) checklist and guide. Intervention effectiveness was determined through effect sizes. Meta-analyses were performed to pool data on intervention effectiveness.

RESULTS

Twenty studies were included in the review, with a diverse range of interventions, modes of delivery, activities, duration, length, frequency, and intensity. Compared to controls, the interventions produced a moderate effect on cognitive abilities (SMD = 0.36; 95% CI = -0.03 to 0.76; I2 = 61%), and a negative moderate effect on basic ADLs (SMD = -0.40; 95% CI = -0.86 to 0.05; I2 = 69%). Stepping exergames generated the largest effect sizes on physical and cognitive abilities. Supervised training produced larger effect sizes than unsupervised interventions.

CONCLUSION

Supervised intervention delivery is linked to greatest benefits. A mix of remote and face-to-face delivery could maximise benefits and optimise costs. Accessibility, acceptability and sustainability of digital interventions for end-users must be pre-requisites for the development of future successful services.

Development, evaluation and implementation of a digital behavioural health treatment for chronic pain: study protocol of the multiphase DAHLIA project

INTRODUCTION

Chronic pain affects about 20%-40% of the population and is linked to mental health outcomes and impaired daily functioning. Pharmacological interventions are commonly insufficient for producing relief and recovery of functioning. Behavioural health treatment is key to generate lasting benefits across outcome domains. However, most people with chronic pain cannot easily access evidence-based behavioural interventions. The overall aim of the DAHLIA project is to develop, evaluate and implement a widely accessible digital behavioural health treatment to improve well-being in individuals with chronic pain.

METHODS AND ANALYSIS

The project follows the four phases of the mHealth Agile Development and Evaluation Lifecycle: (1) development and pre-implementation surveillance using focus groups, stakeholder interviews and a business model; (2) iterative optimisation studies applying single case experimental design (SCED) method in 4-6 iterations with n=10 patients and their healthcare professionals per iteration; (3) a two-armed clinical randomised controlled trial enhanced with SCED (n=180 patients per arm) and (4) interview-based post-market surveillance. Data analyses include multilevel modelling, cost-utility and indicative analyses.In October 2021, inter-sectorial partners are engaged and funding is secured for four years. The treatment content is compiled and the first treatment prototype is in preparation. Clinical sites in three Swedish regions are informed and recruitment for phase 1 will start in autumn 2021. To facilitate long-term impact and accessibility, the treatment will be integrated into a Swedish health platform (www.1177.se), which is used on a national level as a hub for advice, information, guidance and e-services for health and healthcare.

ETHICS AND DISSEMINATION

The study plan has been reviewed and approved by Swedish ethical review authorities. Findings will be actively disseminated through peer-reviewed journals, conference presentations, social media and outreach activities for the wider public.

TRIAL REGISTRATION NUMBER

NCT05066087.

Tailoring the web-based 'Partner in Balance' intervention to support spouses of persons with frontotemporal dementia

Frontotemporal dementia (FTD) typically starts before the age of 65 years, and symptoms differ from other dementias (e.g. Alzheimer's dementia). Spouses are often caregiver and experience difficulty coping with the profound changes in personality and behavior accompanying FTD. Most interventions available to these spouses do not match their need for tailored and flexible psychosocial support. Therefore, tailored content for spouses of persons with FTD was recently incorporated in the proven effective and web-based Partner in Balance intervention.

METHODS

This feasibility study prospectively evaluated the tailored Partner in Balance content for spouses of persons with FTD. Spouses followed the 8-week intervention, and qualitative and quantitative measures were used to evaluate expectations and barriers prior to participation and aspects of usability, feasibility, and acceptability of content. Additionally, effects were explored regarding caregiver self-efficacy, sense of mastery, stress, depression and anxiety.

RESULTS

Twenty-seven spouses caring for a spouse with FTD at home started the intervention. Eventually, 20 completed the intervention (74.1%). Partner in Balance matched the expectations of participating spouses and helped them to find a better balance between caregiving and personal life, acquire more peace of mind, and facilitated coping with behavioral and communication difficulties. Before participation, time restraints were identified as a potential barrier, but afterwards spouses positively evaluated the flexibility of the web-based approach that allowed them to participate at a convenient time and place. They valued the recognizability of the videos and narrative stories on FTD. Post-intervention, spouses qualitatively felt more confident, more at ease, and strengthened as a caregiver. Quantitatively, levels of self-efficacy, anxiety and depression significantly improved.

CONCLUSIONS

Partner in Balance is a usable, feasible, and acceptable intervention for spouses caring for a spouse with FTD at home. Healthcare organizations could consider adopting Partner in Balance in their daily practice to offer flexible and tailored support to spouses.

Tailoring and evaluating the web-based 'Partner in Balance' intervention for family caregivers of persons with young-onset dementia

Young-onset dementia (YOD) poses specific challenges for caregivers involved. However, most available support does not address their specific needs. Previously, the web-based Partner in Balance intervention showed promising results and facilitated role adaptation in dementia caregivers. Although the web-based format proved a good fit for YOD caregivers, the evaluation showed a need for tailored content on YOD. Therefore, new content was iteratively developed respectively for spouses and other family caregivers of persons with YOD. This study evaluates how caregivers perceived the tailored content.

METHODS

A pre-post design was used to prospectively evaluate how end-users perceived two tailored versions of the Partner in Balance intervention, one for spouses and one for other family members of people with YOD. After the intervention, participants were interviewed for approximately 60 min in-person or by telephone using the Program Participation Questionnaire. A qualitative deductive content analysis was used to evaluate (1) usability, (2) feasibility and acceptability, (3) perceptions on intervention content. To evaluate if the intervention facilitated role adaptation, preliminary effects were examined using pre-post questionnaires on self-efficacy, mastery, stress, anxiety and depression.

RESULTS

Spouses (n = 11) and other family members (n = 14) both positively evaluated the tailored content on YOD and valued that the web-based approach could easily be integrated in daily life. Participants perceived the intervention as usable, feasible and acceptable. Participants valued the recognizability of the content. Goal-setting helped participants to translate the intervention to daily life, although for some participants setting goals was difficult. Caregivers of persons with frontotemporal dementia suggested incorporating specific content to further increase recognizability. After participation, participants felt better equipped for the caregiving role. In line with previously demonstrated effects on generic modules of Partner in Balance, the tailored version increased levels of self-efficacy in the group of other family caregivers, t(12) = 3.37, p = .006.

CONCLUSION

The tailored Partner in Balance intervention was positively evaluated by YOD caregivers. Offering participants more guidance on goal-setting and adding content about frontotemporal dementia may facilitate implementation.