Barriers to and Facilitators of Engaging With and Adhering to Guided Internet-Based Interventions for Depression Prevention and Reduction of Pain-Related Disability in Green Professions: Mixed Methods Study

Abstract

Background Internet-based interventions (IBIs) are effective for the prevention and treatment of mental disorders and are valuable additions for improving routine care. However, the uptake of and adherence to IBIs are often limited. To increase the actual use of IBIs, it is important to identify factors for engaging with and adhering to IBIs. Objective We qualitatively evaluated barriers and facilitators regarding a portfolio of guided IBIs in green professions (farmers, gardeners, and foresters). Methods Interview participants were selected from 2 randomized controlled trials for either the prevention of depression (Prevention of Depression in Agriculturists [PROD-A]) or the reduction of pain interference (Preventive Acceptance and Commitment Therapy for Chronic Pain in Agriculturists [PACT-A]) in green professions. The intervention group in PROD-A (N=180) participated in an IBI program, receiving access to 1 of 6 symptom-tailored IBIs. The intervention group in PACT-A (N=44) received access to an IBI for chronic pain. Overall, 41 semistructured qualitative interviews were conducted and transcribed verbatim. Barriers and facilitators were identified via inductive qualitative content analysis, with 2 independent coders reaching almost perfect intercoder reliability (Cohen κ=0.92). A quantitative follow-up survey (30/41, 73%) was conducted to validate the results. Subgroup analyses were performed based on intervention characteristics. Results We identified 42 barriers and 26 facilitators, which we assigned to 4 superordinate categories related to the intervention (20 barriers; 17 facilitators), work (4 barriers; 1 facilitator), individual (13 barriers; 8 facilitators), and technical (5 barriers; 0 facilitators) aspects. Key barriers (identified by at least 50% of the interviewees) were time-consuming work life (29/40, 73%) and time-consuming private life (23/40, 58%). Similarly, the most frequently identified facilitators included presence of motivation, curiosity, interest and perseverance (30/40, 75%), flexible time management at work (25/40, 63%), and support from family and friends (20/40, 50%). Although agreement with barriers in the quantitative follow-up survey was rather low (mean 24%, SD 11%), agreement with facilitators was substantially higher (mean 80%, SD 13%). Differences in agreement rates were found particularly between intervention completers and noncompleters. Completers agreed significantly more often that perceived IBI success; being motivated, curious, interested, and perseverant; and having a persisting level of psychological strain have been facilitating. Noncompleters agreed more often with experiencing the e-coach contact as insufficient and technical problems as hindering for intervention completion. Conclusions Based on these results, strategies such as customization of modules for more flexible and adaptive use; video chat options with the e-coach; options to facilitate social support by family, friends, or other participants; or using prompts to facilitate training completion can be derived. These approaches could be evaluated in further quantitative research designs in terms of their potential to enhance intervention use in this occupational group. Trial Registration German Clinical Trials Register DRKS00014000, https://tinyurl.com/3bukfr48; German Clinical Trials Register DRKS0001461, https://tinyurl.com/ebsn4sns

Lessons Learned from an Attempted Pragmatic Randomized Controlled Trial for Improvement of Chronic Pain-Associated Disability in Green Professions: Long-Term Effectiveness of a Guided Online-Based Acceptance and Commitment Therapy (PACT-A)

“…Further, there was a trend towards a higher proportion of men and persons with a lower education level in the sample of non-completers. This is in line with research suggesting that lower digital literacy seems to be associated with higher age and lower educational level [ 120 ] as well as with the significantly higher agreement rates with technical difficulties as barriers to intervention use we observed in the context of a mixed-method study with a subsample of participants from this RCT as compared to participants of a trial evaluating a portfolio of online interventions for participants working in green professions and being at risk for depression [ 100 ]. Possibly, this subgroup of predominantly men of higher age and lower educational level burdened with chronic pain might be an especially hard-to-treat sample.…”

“…Similar to a parallel trial evaluating a tailored online intervention program for persons occupied in green professions and at risk for depression [ 39 ], we observed a pragmatic intervention use over a large time frame of several months. This is in line with participants reporting time restrictions due to high workload in work and private life as key barriers to intervention use in the context of qualitative interviews conducted [ 100 ]. Thus, it seems the primary outcome was terminated too early at 9 weeks after randomization.…”

Using the Consolidated Framework for Implementation Research to evaluate a nationwide depression prevention project (ImplementIT) from the perspective of health care workers and implementers: Results on the implementation of digital interventions for farmers

“…These barriers are in accordance with previous studies indicating that help-seeking behavior is lower and stigmatization of mental disorders is higher among farmers compared to other occupational groups (25). Furthermore, many of our identified barriers and facilitating factors are in line with findings of qualitative results of another substudy of ImplementIT (31) from the perspective of users (farmers who participated in digital services to prevent depression), including "location independence" and "anonymity" as positive drivers and a "lack of time" and "inhibitions about using the internet" as negative drivers for the acceptance of and satisfaction with the IMI program (17,32,33).…”

“…The implementation study “ImplementIT” ( 31 ) aims to evaluate the implementation of the digital interventions into routine care. First qualitative results regarding acceptance of and satisfaction with the digital intervention as well as barriers and facilitators for use from the perspective of participating farmers, forest owners, and gardeners have been explored ( 17 , 32 , 33 ). The results indicate that these offers could be suitable for the target group as interviewees reported that digital interventions helped them overcome barriers to treatment and brought specific benefits such as “flexible use”, “anonymity”, and “location independence” ( 32 , 33 ).…”

“…The results indicate that these offers could be suitable for the target group as interviewees reported that digital interventions helped them overcome barriers to treatment and brought specific benefits such as "flexible use", "anonymity", and "location independence" (32,33). At the same time, "time-consuming work life" and "time-consuming private life" were the most often mentioned barriers regarding intervention use (32). However, besides RCT participation, in which low adherence regarding intervention use (28,29) and recruitment difficulties (34) are reported for IBIs, not much is known about routine care use.…”