Implementing a Health Care Professional-Supported Digital Intervention for Survivors of Cancer in Primary Care:Qualitative Process Evaluation of the Renewed Intervention

Background: Primary care has an important role in supporting cancer survivors, yet support is limited because of practitioners’ perceived lack of expertise and time. A digital intervention for cancer survivors could provide an efficient way for primary care staff to support cancer survivors without the need to accumulate expertise and skills to help patients make behaviour changes, providing very brief support alongside this could maximise adherence to the digital interventions. Renewed is a digital intervention combining online behaviour change advice with brief healthcare practitioner support from a nurse or healthcare assistant. Knowledge about the views and experiences of primary care staff providing support alongside a digital intervention for cancer survivors is sparse, limiting understanding of the acceptability and feasibility of this type of intervention. Objective: To explore Supporters’ experiences of providing support to cancer survivors using Renewed, to understand potential barriers and facilitators to implementation of Renewed in practice, and investigate strengths and weaknesses of the intervention from the perspective of healthcare professionals.Methods: This was a qualitative process evaluation, nested within a large trial evaluating Renewed. Twenty-eight semi-structured telephone interviews were conducted with nurses and healthcare assistants. Data were analysed using inductive thematic analysis.Results: Four themes were developed during analysis which reflected factors that Supporters identified as hindering or enabling them to provide support alongside Renewed Online (Themes: Renewed Online as an acceptable digital tool with some improvements; confidence to enact the Supporter role; practicalities of delivering support alongside a digital intervention; and managing a patient-led approach). The analysis suggests that Supporters perceived that a digital intervention such as Renewed would be beneficial to support cancer survivors in primary care, and fit within current practices. However, barriers to providing support alongside a digital intervention were also identified, including concerns about how to facilitate rapport building and, in a minority, concerns about employing a non-directive approach, in which the majority of advice and support is provided through a digital intervention, with brief additional support provided by primary care staff. Conclusion: These findings add to the literature about how best to provide support alongside digital interventions, suggesting that whilst most practitioners cope well with a non-directive approach, a minority require more training to feel confident implementing this. This study suggests that barriers to providing formal support to cancer survivors in primary care could be successfully overcome with an approach like Renewed, where a digital intervention provides most of the support and expertise, and healthcare practitioners provide the additional brief human support to maximise engagement. Strategies to maximise the chances of successful implementation for this type of intervention are discussed. <br/

A randomised controlled trial of a digital intervention (Renewed) to support symptom management, wellbeing and quality of life in cancer survivors

Background: Many cancer survivors following primary treatment have prolonged poor quality of life.Aim: To determine the effectiveness of a bespoke digital intervention to support cancer survivors.Design: Pragmatic parallel open randomised trial.Setting: UK general practices.Methods: People having finished primary treatment (&lt;= 10 years previously) for colo-rectal, breast or prostate cancers, with European-Organization-for-Research-and-Treatment-of-Cancer QLQ-C30 score &lt;85, were randomised by online software to: 1) detailed ‘generic’ digital NHS support (‘LiveWell’;n=906), 2) a bespoke complex digital intervention (‘Renewed’;n=903) addressing symptom management, physical activity, diet, weight loss, distress, or 3) ‘Renewed-with-support’ (n=903): ‘Renewed’ with additional brief email and telephone support. Results: Mixed linear regression provided estimates of the differences between each intervention group and generic advice: at 6 months (primary time point: n’s respectively 806;749;705) all groups improved, with no significant between-group differences for EORTC QLQ-C30, but global health improved more in both intervention groups. By 12 months there were: small improvements in EORTC QLQ-C30 for Renewed-with-support (versus generic advice: 1.42, 95% CIs 0.33-2.51); both groups improved global health (12 months: renewed: 3.06, 1.39-4.74; renewed-with-support: 2.78, 1.08-4.48), dyspnoea, constipation, and enablement, and lower NHS costs (generic advice £265: in comparison respectively £141 (153-128) and £77 (90-65) lower); and for Renewed-with-support improvement in several other symptom subscales. No harms were identified.Conclusion: Cancer survivors quality of life improved with detailed generic online support. Robustly developed bespoke digital support provides limited additional short term benefit, but additional longer term improvement in global healthenablement and symptom management, with substantially lower NHS costs.<br/

A randomised controlled trial of a digital intervention (renewed) to support symptom management, wellbeing and quality of life in cancer survivors

Background: Many cancer survivors following primary treatment have prolonged poor quality of life. Aim: To determine the effectiveness of a bespoke digital intervention to support cancer survivors. Design: Pragmatic parallel open randomised trial. Setting: UK general practices. Methods: People having finished primary treatment (<= 10 years previously) for colo-rectal, breast or prostate cancers, with European-Organization-for-Research-and-Treatment-of-Cancer QLQ-C30 score <85, were randomised by online software to: 1)detailed ‘generic’ digital NHS support (‘LiveWell’;n=906), 2) a bespoke complex digital intervention (‘Renewed’;n=903) addressing symptom management, physical activity, diet, weight loss, distress, or 3) ‘Renewed-with-support’ (n=903): ‘Renewed’ with additional brief email and telephone support. Results: Mixed linear regression provided estimates of the differences between each intervention group and generic advice: at 6 months (primary time point: n’s respectively 806;749;705) all groups improved, with no significant between-group differences for EORTC QLQ-C30, but global health improved more in both intervention groups. By 12 months there were: small improvements in EORTC QLQ-C30 for Renewed-with-support (versus generic advice: 1.42, 95% CIs 0.33-2.51); both groups improved global health (12 months: renewed: 3.06, 1.39-4.74; renewed-with-support: 2.78, 1.08-4.48), dyspnoea, constipation, and enablement, and lower NHS costs (generic advice £265: in comparison respectively £141 (153-128) and £77 (90-65) lower); and for Renewed-with-support improvement in several other symptom subscales. No harms were identified. Conclusion: Cancer survivors quality of life improved with detailed generic online support. Robustly developed bespoke digital support provides limited additional short term benefit, but additional longer term improvement in global health enablement and symptom management, with substantially lower NHS costs

Improving quality of life in cancer survivors: Understanding how a digital behaviour change intervention works and how to maximise its implementation in practice

Many cancer survivors who finish treatment experience long-term consequences that can reduce their quality of life (QoL). Healthy behaviours (e.g. physical activity) can improve cancer survivors’ QoL. A digital intervention, titled “Renewed”, was developed to improve the QoL of breast, colon and prostate cancer survivors in primary care by providing support about physical activity, healthy eating, weight management and psychological well-being. For some, Renewed also included the option of brief support from a healthcare professional. A separate three-arm randomised controlled trial (Renewed, Renewed with support or control conditions) showed that those in the supported arm significantly increased their QoL at 12 months. Furthermore, prostate cancer survivors in the supported arm had better improvements in QoL compared to other cancer survivors. To enhance understanding of the trial results, this thesis aimed to conduct a process evaluation of Renewed to understand how the intervention achieved change in QoL, for whom, and under what circumstances. The overarching aims of this thesis were to explore, describe and characterise the mechanisms through which Renewed achieves change in QoL in cancer survivors and the barriers and facilitators to implementation by cancer survivors and healthcare professionals. Three papers explored these aims. Firstly, a qualitative study exploring thirty-three cancer survivors’ experiences using Renewed through interviews suggested that the majority found the intervention easy and convenient, with some reporting perceived behaviour changes with minimal use. However, some individuals were less motivated to use Renewed when they had comorbidities or if they joined the study to ‘give back’ or contribute to research. Additionally, prostate cancer survivors reported less availability of support outside of the intervention compared to breast and colon cancer survivors. Secondly, a quantitative usage analysis examined the relationships between using Renewed, accessing support, QoL and individual characteristics. This study demonstrated that while 55.1% (n=970/1760) of cancer survivors did not access the optional content, using Renewed more was related to better improvements in QoL. Finally, a qualitative interview study explored twenty-eight healthcare professionals’ experiences supporting those using Renewed. This study found that an approach where the expertise is provided by the intervention and brief additional support provided by a healthcare professional is an acceptable way to overcome key barriers to supporting cancer survivors in primary care. Additionally, whilst most HCPs cope well with a non-directive approach, a minority may require more support to feel confident implementing this. Together, these findings suggest a digital intervention like Renewed may be suitable for implementation in primary care with minor changes. Implications suggest that accessing support may be important to motivate greater engagement but not a critical factor in improving QoL and that presenting novel information earlier in an intervention may help to motivate continued engagement

Implementing a healthcare professional-supported digital intervention for cancer survivors in primary care: A qualitative process evaluation of Renewed

Background: Primary care has an important role in supporting cancer survivors, yet support is limited because of practitioners’ perceived lack of expertise and time. A digital intervention for cancer survivors could provide an efficient way for primary care staff to support cancer survivors without the need to accumulate expertise and skills to help patients make behaviour changes, providing very brief support alongside this could maximise adherence to the digital interventions. Renewed is a digital intervention combining online behaviour change advice with brief healthcare practitioner support from a nurse or healthcare assistant. Knowledge about the views and experiences of primary care staff providing support alongside a digital intervention for cancer survivors is sparse, limiting understanding of the acceptability and feasibility of this type of intervention. Objective: To explore Supporters’ experiences of providing support to cancer survivors using Renewed, to understand potential barriers and facilitators to implementation of Renewed in practice, and investigate strengths and weaknesses of the intervention from the perspective of healthcare professionals. Methods: This was a qualitative process evaluation, nested within a large trial evaluating Renewed. Twenty-eight semi-structured telephone interviews were conducted with nurses and healthcare assistants. Data were analysed using inductive thematic analysis. Results: Four themes were developed during analysis which reflected factors that Supporters identified as hindering or enabling them to provide support alongside Renewed Online (Themes: Renewed Online as an acceptable digital tool with some improvements; confidence to enact the Supporter role; practicalities of delivering support alongside a digital intervention; and managing a patient-led approach). The analysis suggests that Supporters perceived that a digital intervention such as Renewed would be beneficial to support cancer survivors in primary care, and fit within current practices. However, barriers to providing support alongside a digital intervention were also identified, including concerns about how to facilitate rapport building and, in a minority, concerns about employing a non-directive approach, in which the majority of advice and support is provided through a digital intervention, with brief additional support provided by primary care staff. Conclusion:  These findings add to the literature about how best to provide support alongside digital interventions, suggesting that whilst most practitioners cope well with a non-directive approach, a minority require more training to feel confident implementing this. This study suggests that barriers to providing formal support to cancer survivors in primary care could be successfully overcome with an approach like Renewed, where a digital intervention provides most of the support and expertise, and healthcare practitioners provide the additional brief human support to maximise engagement. Strategies to maximise the chances of successful implementation for this type of intervention are discussed

Experiences of using a supported digital intervention for cancer survivors in primary care:a qualitative process evaluation

Background: increasing healthy behaviours (e.g. physical activity) can improve cancer survivors’ quality of life. Renewed is a digital intervention developed to provide behaviour change advice with brief healthcare practitioner support. A three-arm randomised controlled trial (Renewed, Renewed with support or a control condition) suggested that prostate cancer survivors in the supported arm had slightly greater estimates of improvements in quality of life compared to other cancer survivors. This study explored participants’ experiences using Renewed to understand how it might have worked and why it might have provided greater benefit for prostate cancer survivors and those in the supported arm. Methods: thirty-nine semi-structured telephone interviews with cancer survivors’ (breast, colorectal, prostate) from the Renewed trial explored their experiences of using Renewed and their perceptions of the intervention. Data were analysed using inductive thematic analysis. Results: some participants only used Renewed modestly but still made behaviour changes. Barriers to using Renewed included low perceived need, joining the study to advance scientific knowledge or ‘to give back’, or due to perceived availability of support in their existing social networks. Prostate cancer survivors reported less social support outside of Renewed compared to participants with other cancers. Conclusion: Renewed may support healthy behaviour changes among cancer survivors even with limited use. Interventions targeting individuals who lack social support may be beneficial. Implications for cancer survivors: cancer survivors’ experiences may inform the development of digital interventions to better serve this population.<br/

A randomised controlled trial of a digital intervention (renewed) to support symptom management, wellbeing and quality of life in cancer survivors

Background: many cancer survivors following primary treatment have prolonged poor quality of life. Aim: to determine the effectiveness of a bespoke digital intervention to support cancer survivors. Design: pragmatic parallel open randomised trial. Setting: UK general practices. Methods: People having finished primary treatment (Results: Mixed linear regression provided estimates of the differences between each intervention group and generic advice: at 6 months (primary time point: n’s respectively 806;749;705) all groups improved, with no significant between-group differences for EORTC QLQ-C30, but global health improved more in both intervention groups. By 12 months there were: small improvements in EORTC QLQ-C30 for Renewed-with-support (versus generic advice: 1.42, 95% CIs 0.33-2.51); both groups improved global health (12 months: renewed: 3.06, 1.39-4.74; renewed-with-support: 2.78, 1.08-4.48), dyspnoea, constipation, and enablement, and lower NHS costs (generic advice £265: in comparison respectively £141 (153-128) and £77 (90-65) lower); and for Renewed-with-support improvement in several other symptom subscales. No harms were identified.Conclusion: cancer survivors quality of life improved with detailed generic online support. Robustly developed bespoke digital support provides limited additional short term benefit, but additional longer term improvement in global health enablement and symptom management, with substantially lower NHS costs