Background & Aims
Shoulder pain significantly impacts function and quality of life, burdening healthcare systems.[1] Clinical guidelines recommend exercise and education interventions for shoulder pain, yet mixed clinical trial findings prompt further exploration. Often overlooked, intervention fidelity, encompassing delivery, receipt, and enactment, is pivotal for understanding complex interventions like exercise and education.[2,3] While fidelity of delivery focuses on the intervention provider delivering it as intended in the trial protocol, fidelity of receipt and enactment, known as fidelity of engagement, highlight how well participants receive and enact the intervention.[3] Few trials assess intervention fidelity, often concentrating solely on delivery and overlooking engagement.[4] This study aimed to understand how well patients with shoulder pain engaged with an exercise and education intervention delivered over telehealth, including their satisfaction, receipt, learning, and enactment.
Methods
This study used a convergent mixed methods design within a randomized controlled trial (RCT) comparing a leaflet (G1), one session (G2), and six sessions (G3) of physiotherapist-led, telehealth exercise and education, supported by informative materials/website, over 12 weeks for shoulder pain. Quantitative data were collected from RCT participants receiving the intervention (>18 years, SPADI score> 30 points, rotator cuff related shoulder pain). We measured participants’ satisfaction (Telehealth Usability Questionnaire (TUQ)), participants’ receipt and learning (website metrics, self-reported questions, knowledge test), and participants’ enactment (self-reported questions, home exercise adherence) at 13 weeks. Qualitative data was obtained from interviews with a purposive sample based on geographical location and exercise adherence. Sampling until no new insights were identified in two consecutive interviews. Interviews were analysed via inductive thematic analysis.
Results
Quantitative analysis included 181 participants (G2 n=90; G3 n=91), with 20 interviewed for qualitative analysis. Overall, G3 participants were slightly more satisfied with the intervention than G2 (TUQ score G2=5.49 (1.17); G3=6.20 (0.90), p=0.00). Although participants spent little time on educational webpages, their knowledge improved across domains over 13 weeks. Most accessed the educational leaflet 1-2 times (G2=40 (46%); G3=39 (43%)) and implemented advice (G2=53 (60%); G3=54 (60%)). G3 participants completed more weekly exercise sessions (>3) than G2 (55% vs. 70%). Qualitative analysis identified five themes: (1) Expectations and advice quality influenced reactions/satisfaction, (2) Exposure to multiple approaches facilitated learning, yet individual and environmental challenges exist, (3) Multiple interpretations for the same advice, (4) Regular supervised sessions are motivating but not needed for everyone, and (5) Commitment to exercises comes from multiple sources.
Conclusions
Our findings indicate that participants engaged more with exercise components than with the educational ones, indicating the latter could be improved. Satisfaction, receipt of intervention materials, and enactment to home exercises were higher among participants who had up to six supervised sessions, suggesting a positive impact of professional supervision on engagement. While learning was facilitated by offering various intervention materials (e.g., leaflets, videos, exercise logs) to participants, we identified several factors influencing the need for these materials and supervised sessions. These factors provide insights that can be used to tailor intervention components and materials, aiming for better fidelity of intervention engagement. Additionally, simple approaches and strategies identified in this study can be used to enhance engagement with home exercises.
References
1.Marks D, Comans T, Bisset L, et al. Shoulder pain cost-of-illness in patients referred for public orthopaedic care in Australia. Aust Health Rev 2019;43(5):540-48.
2.Major DH, Roe Y, Grotle M, et al. Content reporting of exercise interventions in rotator cuff disease trials: results from application of the Consensus on Exercise Reporting Template (CERT). BMJ Open Sport Exerc Med 2019;5(1):e000656.
3.Ginsburg LR, Hoben M, Easterbrook A, et al. Fidelity is not easy! Challenges and guidelines for assessing fidelity in complex interventions. Trials 2021;22(1):372.
4.Walton H, Spector A, Tombor I, et al. Measures of fidelity of delivery of, and engagement with, complex, face-to-face health behaviour change interventions: A systematic review of measure quality. Br J Health Psychol 2017;22(4):872-903.
Presenting Author
Luis Fernando Sousa Filho
Poster Authors
Topics
- Patient Engagement and Co-Creation in Research and Education