Abstract
The study findings provide stakeholder-identified barriers and facilitators, as well as stakeholder-informed recommendations, for technology training protocols that may support uptake of telerehabilitation in occupational therapy.
Only 35.5% of people with stroke-related disability access recommended outpatient rehabilitation services (Ayala et al., 2018). Telerehabilitation, or the use of information and communication technology to deliver rehabilitation services in a virtual environment, provides an opportunity to improve access to poststroke rehabilitation services (Nuara et al., 2022). Despite the prominence of telerehabilitation delivery models for outpatient stroke rehabilitation, including occupational therapy, during the coronavirus disease 2019 (COVID-19) pandemic (Duncan & Bernhardt, 2021), therapists and patients reported concerns about the quality of care delivered and received through these platforms (Albahrouh & Buabbas, 2021; Malliaras et al., 2021
; Remy et al., 2020). This may be because protocols supporting remote delivery via specific technology platforms are not well developed. Long-standing telerehabilitation guidelines propose the modification of treatment materials and techniques and require appropriate staff training in the use of equipment and assurance of the equipment’s usability by people with disabilities (Brennan et al., 2010). However, specific modifications and training requirements are not delineated. Furthermore, the PACE (
A recent Cochrane review of 22 stroke telerehabilitation trials suggests that interventions addressing depressive symptoms, quality of life, and independence in activities of daily living produce effects that may be roughly equivalent to those produced by face-to-face interventions or usual care (Laver et al., 2020). Although people with neurological disabilities report openness to receiving such interventions remotely using telerehabilitation platforms, they are concerned that the quality of care may be lower than that of in-person care (Edgar et al., 2017; Remy et al., 2020). They may also face challenges associated with the device’s user interface that have negatively effected their experience with telerehabilitation (Annaswamy et al., 2020). Furthermore, rehabilitation clinicians report a lack of knowledge required to conduct assessments, provide intervention remotely, and navigate technological challenges encountered in virtual environments (Albahrouh & Buabbas, 2021; Malliaras et al., 2021; Tyagi et al., 2018).
Despite the challenges faced by people providing and receiving telerehabilitation, documented provision of training in telerehabilitation trials is rare. A scoping review that sought to identify training provided in telerehabilitation studies and guidance documents identified that only 4 of 11 studies documented the provision of training to providers and that the included articles assumed that clients possess the skills to access platforms to engage in telerehabilitation (Anil et al., 2021). In addition, telerehabilitation encompasses numerous types of software, hardware, and delivery models. Although general guidelines and frameworks for telerehabilitation exist (Brennan et al., 2010, Little et al., 2021), protocols designed to support stakeholders’ uptake of specific types of technology and delivery models in telerehabilitation remain in development (e.g., Chen et al. [2020] used one-on-one videoconferencing and gaming systems, and Cherry et al. [2017] used a robotic arm). When designing protocols for specific types of software, hardware, and delivery models, qualitative studies are necessary to clarify stakeholders’ needs. The current study is a step toward protocol development and builds on our prior work focused on the use of videoconferencing to deliver group-based stroke rehabilitation (Kringle et al., 2021).
The purpose of this study was to (1) explore stakeholders’ experiences with engaging in a group-based intervention delivered through videoconferencing during the COVID-19 pandemic and (2) identify barriers, facilitators, and strategies that may enable remote intervention delivery using videoconferencing among adults with stroke-related disability.
Method
This ad hoc exploratory qualitative study was initiated in response to the COVID-19 pandemic. The ENGAGE pilot study used a single-arm, multisite study design to determine the preliminary feasibility of an intervention that facilitates community and social participation after stroke. The main findings of the study are reported elsewhere (Kersey et al., 2022). The focus of this ad hoc qualitative study was to gain insight into stakeholders’ experiences using a new videoconferencing software to access the ENGAGE intervention during the COVID-19 pandemic. A pragmatic approach guided the study (Creswell & Poth, 2018). The research was approved by the University of Pittsburgh institutional review board and registered at ClinicalTrials.gov (registration number NCT04019275). Participants provided informed consent.
Intervention
ENGAGE consists of eight 2-hr group sessions that include four to eight group members and are co-led by an occupational therapist and peer facilitator. The intervention integrates social learning (peer mentoring, group process) and guided problem-solving to identify and address barriers to community and social participation after stroke. Session content encompasses the following topics: building community participation plans, understanding the stroke experience, advocating for self and others, using social networks, strategies for participation, staying active, staying well, engaging in civic and volunteer activities, applying what I learned, and sharing what I learned. Session content is delivered using educational vignettes, group discussion, role-playing, action planning, and debriefing. These sessions are complemented by three self-directed community outings that participants complete using plans developed during these sessions (Skidmore et al., 2020). A participant workbook that contains all materials required for each session is provided before the first group session. The intervention protocol was adapted for synchronous delivery using videoconferencing during the COVID-19 pandemic (Zoom Videocommunications, 2020).
To support group members’ access to Zoom during the study, study staff worked with each group member individually to identify training needs. Paper-based educational materials that provided step-by-step log-in information were provided to all participants. For group members who used a study-owned device, study staff visited their homes (following COVID-19 safety procedures) to deliver the device and provide hands-on training. Several group members enlisted their family members to assist with managing the device and logging in to the Zoom platform. Both occupational therapist facilitators had prior experience using Zoom in educational settings, and each of them provided technology education to the peer cofacilitator on the basis of identified needs. After individual training was provided, and before the first ENGAGE session, Session 0 was held, during which the only goal was for all group members and both facilitators to log into the Zoom platform to introduce themselves. The occupational therapist facilitator demonstrated basic Zoom functions during this session (e.g., mute and unmute, video on and off) and gave group members the opportunity to ask questions.
Participants and Setting
Group members were community-dwelling, low-income adults with chronic stroke (≥3 mo), mild to moderate disability (National Institutes of Health Stroke Scale score ≤ 16) and community participation restrictions (Activity Card Sort score < 80% of prestroke level) and without dementia, major depressive disorder, bipolar or psychotic disorder, and recent substance abuse. They were recruited using university research registries and study flyers. In March 2020, group members were notified that groups would be held using videoconferencing. Study-owned devices with cellular data plans were made available to those who desired to participate but did not have access to the technology. All study-owned devices were iPads because they are lightweight, have relatively intuitive user interfaces, and were readily available in the laboratories at each site.
Group members and study personnel who were responsible for leading groups and technology training were invited to complete a 30-min interview. Study personnel included group leaders and study staff. Group leaders were occupational therapists and peer leaders. Peer leaders had stroke-related disability. Occupational therapists and peer leaders were trained in the intervention by the principal investigator (PI) team during a 2-day workshop that included facilitators from all three sites and debrief meetings with the PI team after every three to four sessions. Study staff included research coordinators with expertise in coordinating stroke rehabilitation studies and trained research assistants (occupational therapy graduate students).
Research Team
The all-female research team consisted of occupational therapists with more than 10 (Emily A. Kringle) and 25 (Joy M. Hammel, Elizabeth R. Skidmore, and M. Carolyn Baum) years of experience, and an occupational therapy graduate student (Christine Rogers). Two researchers (Kringle and Skidmore) had previously delivered remote interventions, but not through synchronous videoconferencing. The ENGAGE developers (Skidmore, Baum, and Hammel) held meetings with the group leaders at regular intervals but did not interact with the group members. All researchers experienced a substantial increase in their use of videoconferencing for meetings and community events at the onset of the COVID-19 pandemic.
Data Collection
A semistructured interview guide was developed by Kringle in collaboration with Skidmore, Baum, and Hammel (Appendix). Kringle conducted audio-recorded interviews over the telephone within 2 wk of the last group (between August and September 2020). The purpose of the research was explained before each interview, and field notes were taken. Interviews were transcribed (TRINT, London, United Kingdom) and verified by Kringle.
Analyses
Interviews were analyzed using NVivo (Version 12). An inductive thematic approach was applied (Braun & Clarke, 2006). The analysis team was composed of three researchers (Kringle, Rogers, and Hammel). They followed the following 6 steps: (1) read transcripts for familiarization, (2) coded transcripts by interview question, (3) iteratively coded transcripts using descriptive codes, (4) iteratively discussed emergent themes, (5) discussed coding scheme and themes with the ENGAGE pilot study PIs (Skidmore, Baum, and Hammel), and (6) applied the final coding scheme to all transcripts. Findings were validated following methods described by Creswell and Poth (2018), which account for the researcher’s lens (documenting the researchers’ experiences relevant to the topic under study, maintaining an audit trail), participant’s lens (member checking with group leaders and study staff who were interviewed), and reader’s lens (holding a peer debrief regarding the research process and data interpretation at a laboratory meeting).
Results
Stakeholders
Group members (n = 13, 4 using study-owned devices) were enrolled in the parent pilot study, and 3 withdrew during technology training. The remaining group members (n = 8), group leaders (n = 4), and study staff (n = 4) completed interviews. Stakeholder characteristics are described in Table 1. Group members ranged in age from 26 to 81 yr and had a stroke chronicity of 1 to 24 yr. Group members used iPads (50%) and personal computers (50%) to access the videoconferencing software. Group leaders and study staff ranged in age from 23 to 71 yr and had 1 to 15 yr of experience. Group leaders and study staff used iPads (37.5%) and personal computers (62.5%) to access the videoconferencing software.
Stakeholder Characteristics
Note. A = Asian; ACS = Activity Card Sort; B = Black; F = female; G = group member; L = group leader; M = male; PC = personal computer; S = study staff; SBT = Short Blessed Test; W = White.
Scores range from 0% to 100%.
Scores range from range = 0 to 28; higher scores = lower function.
Used a borrowed device.
Thematic Analyses
Two overall themes were identified: (1) stakeholder experiences with the ENGAGE intervention during the COVID-19 pandemic and (2) stakeholder experiences using videoconferencing software to access and engage in intervention.
Stakeholder Experiences With the ENGAGE Intervention
Stakeholders characterized the ENGAGE intervention as time to learn, do, and connect. Group members valued the opportunity to “hear about different solutions that those people had stumbled upon or discovered to add to my own toolbox of problem solving” (G09). Group members also described the process that they learned for setting goals, planning for, and doing community activities. They felt supported in doing activities related to their goals, even if the activity did not go as planned. One group member offered an example: “One of my personal goals was to go to [a restaurant…] and I couldn’t go inside [because of COVID]. And I came back the next week and told what happened and . . . the main thing they said is that you tried” (G15). Group members also gained new insights from connecting with others who had shared stroke-related experiences: “Some of the things that I’ve been experiencing, I didn’t think nobody had that experiences [sic] but me. . . . I know now that people who’ve had a stroke, most people have similar experiences. They’re not all just unique to one person” (G18).
In some instances, ENGAGE enhanced group members’ activity engagement during the COVID-19 pandemic. One group member’s caregiver noted that her family member “had not really gone shopping. . . . She stays in the car. And during this ENGAGE period when we were participating in activities . . . she did it [went into the store]” (G18). In other instances, COVID-19 restricted group members’ activities. One group member described this: “I wanted to go fishing. That was one of the things that I wanted to do—when I had my main accident it was—I was fishing. So I wanted to try to get back over and do it. But I can’t do that, or I [couldn’t] do it this time because of the COVID [sic]” (G05).
Stakeholder Experiences Using Videoconferencing During Intervention
Stakeholders identified (1) advantages and disadvantages of remote relative to in-person sessions, (2) barriers and facilitators of intervention delivered via videoconferencing, and (3) recommendations for training to support future interventions that use videoconferencing.
Advantages and Disadvantages of Intervention Delivered via Videoconferencing
Advantages and disadvantages of remote sessions centered on social factors. Stakeholders highlighted that remote sessions allowed people who lived in diverse geographic regions to connect. One group leader noted that “we would have never had the group of people together that we had together if it was in-person because they lived in all different areas of the city” (L02). Stakeholders also noticed that “on Zoom I think that people were more relaxed [in their own homes] than if I had met them in person” (G17). Stakeholders acknowledged disadvantages related to cultivating new connections over videoconferencing. Stakeholders noted that “it was harder to like, kind of break the ice at first” (S03) and that they would “probably initiate more conversation before and after the meeting” (G21) relative to in-person sessions. In addition, stakeholders acknowledged that “it’s definitely harder to get a read on the other people in the group when you’re not actually in the same room as them” (G09).
Facilitators of and Barriers to Intervention Delivered Via Videoconferencing
Remotely delivered sessions required stakeholders to learn how to access the technology and then to actively engage in the intervention sessions using the software. Factors that facilitated these processes for some stakeholders were barriers for others. These factors affecting technology access included attitude toward technology, past technology experiences, and the amount of time allotted for training. Factors affecting intervention engagement included group size, stakeholders’ physical environments, navigation of technology disruptions, and the design of the intervention workbook. Exemplar quotes are presented in Table 2. Social support from study staff and family caregivers facilitated technology access. One stakeholder explained that “if [my daughter] had not been here to help me I would probably still not have had one good meeting on the Zoom” (G18).
Facilitators of and Barriers to Technology Access and Intervention Engagement
Note. G = group member; ICAN = Identify Choose Adapt Notice; IT = information technology; L = group leader; S = study staff.
Training Recommendations to Support Intervention Delivered via Videoconferencing
Stakeholders described training modalities and content that may overcome barriers to technology access and intervention engagement (Table 3). Recommended training modalities include tailored training, the use of a checklist, written materials, demonstration, and repetition. Study staff noted that training content should include information on both the device and the videoconferencing software for group members who have limited prior experience with the device. Stakeholders also recommended training content that included specific videoconferencing functions, the physical and social environment, and leadership strategies.
Technology Training Recommendations
Note. G = group member; L = group leader; S = study staff.
Discussion
This ad hoc exploratory study highlights the need to design tailorable telerehabilitation protocols that support stakeholders’ technology access and active intervention engagement. Although the training provided during ENGAGE focused on the software itself (i.e., Zoom functionality), stakeholders highlighted the importance of providing information about the physical and social environment setup and, for the group leaders, adapting facilitator approaches to the videoconferencing environment. The primary training modalities used in the current study were written materials and demonstration, which were among the recommended training modalities suggested. Furthermore, social support may play an important role in technology training protocols.
Factors that were considered barriers to technology access by some stakeholders facilitated technology access for others. This suggests a need for technology training protocols that can be tailored to stakeholders’ needs, aligning with evidence suggesting that tailored training leads to improved mastery of skills relative to one-size-fits-all training approaches (Parker et al., 2013) and existing telerehabilitation guidelines (Brennan et al., 2010; Little et al., 2021). The present findings build on these recommendations by suggesting that stakeholders’ attitudes toward technology and past technology experiences may be indicators of specific tailoring approaches. Identifying additional indicators, such as knowledge gaps, levels of confidence, and learning styles, may guide the development of tailored training algorithms.
Remotely delivered interventions should include training that enhances social interactions over videoconferencing. Although the literature suggests that stakeholders expect outcomes similar to those from in-person rehabilitation and believe that telerehabilitation can be delivered safely, providers report a lack of training to deliver intervention remotely (Albahrouh & Buabbas, 2021; Laver et al., 2020; Malliaras et al., 2021; O’Connor et al., 2016; Peterson et al., 2022; Sarfo et al., 2018; Zhou & Parmanto, 2019). This lack of training may be reflected in patients’ reports of less personal interaction and lower intervention quality during remote relative to in-person sessions (Gentry et al., 2019; O’Connor et al., 2016; Peterson et al., 2022). Despite concerns about quality, patients in studies conducted before COVID-19 have been satisfied with the format but also prefer in-person or hybrid delivery models that combine in-person and virtual meetings (Caughlin et al., 2020; Edgar et al., 2017; Gentry et al., 2019; Taylor et al., 2012). Stakeholders valued the connectedness that they experienced during ENGAGE, suggesting that remote interventions may support connectedness in the absence of in-person delivery options. Training rehabilitation providers in strategies for remote delivery, navigation of technology disruptions, and optimization of the social and physical environment, and ensuring that the physical materials support remote delivery protocols, may further enhance patients’ intervention engagement using videoconferencing.
Social support facilitated group members’ technology access. Study staff, group leaders, family members, and caregivers bolstered group members’ willingness and ability to learn new technology. Evidence suggests that social support facilitates new technology skills among older adults (Tsai et al., 2017), during group-based interventions (Banbury et al., 2018), and among people with stroke (Chen et al., 2020; Taylor et al., 2012). Tailored technology-based protocols should include strategies to involve the just-right amount of social support from the patients’ desired sources of support throughout intervention.
The COVID-19 pandemic provided an opportunity to glean insight from stakeholders with a range of technological experiences rather than from only those who volunteer for telehealth research because they have a particular interest in technology (Foster et al., 2015). Efforts to mitigate the spread of the pandemic accelerated the use of videoconferencing technology for socialization (Haase et al., 2021), education (Young & Donovan, 2020), and health care (Werneke et al., 2021). Group members’ decision to enroll in ENGAGE and stakeholders’ perceptions of their experiences may be influenced by what was considered safe during the COVID-19 pandemic (Peterson et al., 2022).
Limitations
Restrictions on community-based research during COVID-19 and the ad hoc nature of this study pose several limitations. The interview guide was not piloted before its use in this study. Literature was consulted that focused on older adults’ learning processes related to new technology; however, questions were intentionally left open ended and guided by an assumption that stakeholders were adult learners who know their own needs and preferences. The sample size was limited to those who were already enrolled in the ENGAGE pilot study. The themes represent the breadth of experiences among group members, group leaders, and staff but lack the perspectives of the participants who withdrew during the technology training period. A broader sample that contains these participants would ensure that saturation was achieved and strengthen confidence in the findings. A strength of our sample is diversity in age (25–81 yr), educational attainment (high school to doctorate degree), race (31% Black), and cognition (Short Blessed Test scores ranging from 0 to 15). These characteristics may be potential tailoring variables (Gonzalez et al., 2021; Tsai et al., 2017). However, the sample size precluded exploration of users’ experiences stratified by these characteristics.
Implications for Occupational Therapy Practice
This thematic analysis documented stakeholders’ experiences using videoconferencing to engage in a remotely delivered group-based intervention during the COVID-19 pandemic. The study has the following implications for occupational therapy practice: ▪ Tailored training protocols may be required to facilitate equitable access to telerehabilitation. ▪ Training content should include information about the technology functions, setting up the physical environment, and establishing social expectations. ▪ Formal and informal sources of social support are important facilitators of access to and engagement in telerehabilitation interventions.
Conclusion
Delivering rehabilitation interventions using videoconferencing requires technology training protocols that ensure access to the virtual environment among all stakeholders. This may include tailored training protocols that facilitate access to technology, provision of training to enhance active engagement during group-based interventions, and social support. Future research that identifies specific tailoring variables and tests technology training protocols for individually delivered videoconferencing interventions is warranted.
Footnotes
Acknowledgments
We thank Curtis Comer for his valuable contributions during data collection. We also extend our gratitude to the group members, group leaders, and study staff for sharing their experiences with our team. This research was funded by the National Heart, Lung and Blood Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under Award Numbers T32HL134634, K23HL159240, UL1TR001857, and UL1TR002345. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.