A multimedia campaign to improve back beliefs in patients with non-specific low back pain: a process evaluation

The study population for this process evaluation consisted primarily of LBP patients that participated in the trial. These patients were recruited through their participating HCPs. Patients in the trial allocated to the intervention group were invited to participate in this process evaluation by means of a quantitative evaluation questionnaire. Patients that completed the questionnaire were asked if they were also willing to participate in a qualitative evaluation of the intervention, and if so, these patients were personally contacted by telephone and e-mail. Furthermore, patients from the intervention group were invited to participate in the qualitative analysis by means of a call in monthly newsletters, and through calls via social media. The majority of the trial patients were native Dutch or western immigrants. Because 35% of Amsterdam citizens consists of non-western ethnic minorities of which the majority is of Turkish, Moroccan or Surinamese origin [14], extra effort was put into recruiting Turkish, Moroccan, and Surinamese LBP patients for this process evaluation to gain insight into their experiences and satisfactions as well. These patients did not participate in the trial but received access to parts of the intervention for the sole purpose of evaluating these parts of the process. These patients were recruited in several ways, including a personal invitation to evaluate the intervention by their HCP; via posters and take-away brochures in HCP practices and university buildings, and via posters in various meeting places in the city.

The multifaceted implementation strategy for patients consisted of a multimedia eHealth campaign that comprised of several components, described in more detail below.

This process evaluation was based on components developed by the Linnan and Steckler framework [11]. Using a mixed methods approach, quantitative and qualitative methods were applied to collect data on the components: recruitment, reach, dose delivered, dose received, satisfaction and barriers and facilitators (Table 1).

Forty-four semi-structured, qualitative interviews were conducted among patients with LBP, of which 19 participated in the entire study, and 25 only participated in this process evaluation. Fifteen patients were of Dutch or other western origin (mean age 57), 9 were of Moroccan origin (mean age 44.3), 10 were of Surinamese or Indonesian origin (mean age 34.6), and 10 were of Turkish or Iraqi origin (mean age 37.6). The overall mean age of the patients was 45 years, 25 were female and 18 were male. The majority of patients (n = 25) had a high educational level, followed by 15 patients with vocational education, and 4 patients with elementary education. The characteristics of these 44 patients are shown in Table 6. Data of the interviews were analysed and categorised into four themes, discussed by theme below.

The satisfaction and experiences with the content of the intervention did not vary much between the various ethnic groups. Non-western patients (i.e. from Moroccan, Turkish/Iraqi or Surinamese/Indonesian origin) were more often not satisfied with the medium used, and indicated that they would have preferred a more modern, quick and on-the-go approach to information transfer than a website, for example using a mobile app that they could consult easier and more often. Non-western patient also viewed the exercises more often, and attached more importance to the translation of strategy materials than native Dutch patients.

The low reach found in the present study is in line with other implementation studies, for example that performed by Tonnon et al. [17], where the implementation of a lifestyle intervention in a workplace setting reached only 2.4% of the target population. The reach of the current study was not as high as for example the study performed by Buist et al., where the reach was 22.4% in an integrated healthcare system [18]. It must be noted that assessing the actual reach of a target population in implementation research is hard to measure, as is also discussed by Van Vilsteren et al. in their process evaluation of a workplace intervention for workers with rheumatoid arthritis [19]. For example, the amount of patients that were invited to participate could have been an overestimation, since the HCPs inviting the patients could have excluded patients without reporting exclusions to the research team. The reach of this implementation study can be compared to awareness levels of back pain mass media campaigns that have been conducted in other countries. For example, an effective Australian campaign reported that up to 86% of survey respondents reported having seen the mass media campaign [20]. While this is a high percentage, similar studies from Norway, Canada, and Scotland have reported awareness levels of 40, 50, and 60% respectively [21‐23].

The results of this study suggest several possible reasons for the low use of the intervention. One explanation could be the quick recovery from LBP by some patients, after one visit to the website, or even before the visit. Another barrier might be the fact that the HCPs rarely discussed the website with their patients, and slightly more patients, although only 5%, were actually referred to the website by their HCP. This is supported by the qualitative results, in which patients indicated that referral to the website by their HCP leads them to trust the website more. This implicates that eHealth interventions should be blended in usual care, so called blended eHealth intervention. Thereby, involvement of HCPs may increase use of the campaign. These findings are in line with other studies in comparable primary care settings, for example a study performed by De Jong et al. [24], who offered a web-based counselling program for employees on sick leave due to non-specific low back pain or neck pain, and their occupational physicians (OPs). Although their participants appreciated the program, actual program utilization by the employees as well as by the OPs was low in the study by De Jong [24]. However, the low use in the current study was not in line with the aims and expectations of the intervention providers. Since the HCPs also received a multifaceted implementation strategy, and played an important role in including patients for the study, it was expected that they would play a bigger role in activating patients to use the eHealth campaign [13]. A literature review on public engagement with eHealth has suggested that health professionals play an important role in endorsement and promotion of eHealth services to patients [25]. The same review also suggested that trust might influence patients’ perception of eHealth services, for example concerns about scientific sources of the information provided [25]. An observational study on self-management of chronic neck and LBP showed that adherence to non-pharmacologic self-management strategies increased when patients received information about their illness and the effectiveness of the self-management strategy during the clinical course from their HCP [26]. From the current study it seems that involvement of the HCP and the perceived trustworthiness of the eHealth service may be related and their combination could be a factor in the use of the eHealth campaign. Unfortunately, both barriers seem to have influenced the use of this campaign in the current study.

Another barrier for usage of the eHealth campaign might be the dissatisfaction with the content and layout of the website. Many patients indicated that the information provided on the website was already known to them, and that the layout and design of the website did not trigger return visits. This is in line with the importance of both content and design of eHealth intervention that has been shown in previous studies [27, 28]. It seems not only important that patients receive the intervention (i.e. the information) in a timely manner (at the start of their first episode of LBP), but that the information also be communicated in a state-of-the-art manner. Designing eHealth intervention with high levels of interactivity in an interpersonal, dynamic, and engaging digital environment seems to be an important aspect in increasing the usage and effectiveness of eHealth interventions [24, 28, 29]. In the current study, mainly non-western immigrant patients were dissatisfied with the medium used. This may be explained by the difference in mean age and gender of the patients. Non-western immigrant patients were on average 18 years younger (mean age 38.8 years) than native or western-immigrant patients, and were mostly female (n = 18). The Centres for Disease Control and Prevention have shown that women are more likely than men to use the Internet for health information [30]. National statistics from the United States and the United Kingdom have shown that Internet use among 15–44 year olds is highest, and that usage decreases with the increase of age [31, 32], although there is no evidence that this is true for health information seeking specifically. Research has also shown that health care utilisation is higher among the immigrant population than among the native Dutch population [33‐35], and that ethnicity is a predictor for health care utilisation regardless of health status [35, 36]. It also seems that immigrant patients with LBP have a worse prognosis than their native Dutch counterparts [37]. A possible explanation for these differences between ethnic groups might be that health care interventions insufficiently take the various needs and perspectives of immigrant patients into account. Therefore, to better cater to the needs of this population group, it is important to account for these ethnic differences. This could be done by targeting health care interventions specifically to this population and their beliefs.

For non-western immigrant patients, the lack of full translation of all intervention components also seemed to be an important barrier for intervention use. By translating the most important items of the intervention (i.e. the video-messages and home page information), the current study aimed to actively involve these patients. Although it might seem common sense to ensure that interventions are linguistically understandable to a broad group of patients, research has shown that it is not the only important aspect playing a role in involvement of culturally diverse patients [38, 39]. In all phases of the research process, from recruitment through staff that reflects cultural diversity to the use of linguistically and culturally appropriate materials, it is important to dwell upon the needs of various patient groups in order to involve them in health research and intervention. Assessing the needs of these patients prior to the development of healthcare interventions might increase the usefulness and effectiveness of these interventions.

When interpreting the results of this study, some limitations have to be taken into account. Although effort was put into the recruitment of LBP patients with non-western ethnic backgrounds (especially Turkish, Moroccan, and Surinamese patients) in the trial, most participating patients were native Dutch or western immigrants. This led to ad-hoc recruitment of these ethnic patients for the sole purpose of the current process evaluation. The patients in the qualitative evaluation only received access to parts of the intervention (i.e. the website and social media), and thus did not have the full-experience of the entire intervention. This might have influenced their satisfaction and experiences with the website. Furthermore, it is plausible that illiterate and thus low or non-educated respondents were underrepresented in this study. Another notable finding in this study was that the majority of patients had a high educational level. Although this is in line with other research [40], it is important to put effort into the recruitment and participation of lower educated patients. The fact that the majority of patients that participated in the quantitative process evaluation had a high educational background might have influenced the results, as these patients may have different needs and opinions than lower educated patients. Also, the dose delivered component should be interpreted with caution, as it is an arbitrary quantification of parts of the full strategy, and has its own limitations. For example, due to planning issues, only 11 out of 12 video-messages, and 17 out of 24 newsletters were delivered on the planned date.

This is also true for the dose received, which was defined as the proportion of patients who logged into the website at least once. Whether these measures reflect effective doses is debatable, but it makes a first step in increasing the quality of the current study. Ideally, if technical opportunities allow for this, intervention providers should collect data on actual use, for example by tracking time spent on the website or website components used. To further increase the quality of this process evaluation, a mixed methods approach to data collection and analysis was applied. Triangulation of these methods (i.e. descriptive quantitative analysis, regression modelling, and qualitative data analysis) improved the quality of this evaluation. Furthermore, to ensure correct analysis and interpretation of qualitative data, a large random sample of all interviews were coded and discussed by two independent researchers.

The results of this study showed that many patients did not use the intervention at all or only once, and this is an important finding in the light of the future effect evaluation of this implementation study. As this patient based eHealth campaign was part of a larger implementation study, it was designed to support the HCP based implementation of a guideline that advocates reduced referral rates for diagnostic imaging and consultations with medical specialists [13]. The current process evaluation showed that HCPs rarely discussed the eHealth campaign with their patients, indicating that the patient based and the HCP based campaigns were too independent of each other. This may be reflected in the final results of the implementation study (i.e. reduced referral rates for LBP). HCPs should discuss with and stimulate the use of eHealth interventions by their patients, and implementation strategies that are targeted at changing patient outcomes should ideally also pay more attention in their strategy to the improvement of HCP behaviour and attitude towards these interventions.