Exploring Patient Factors, Engagement, and Symptom Outcomes in a Provider-Guided Online Symptom Management Intervention: A Mixed Methods Study (Preprint)
Authors: Wang Yan , Dabbs Annette DeVito , Thomas Teresa Hagan , Campbell Grace , Donovan Heidi Ann 
Published: February 2025

BACKGROUND

Cancer survivors often experience declining engagement in digital health interventions (DHIs). However, predictors of engagement with provider-guided DHIs remain unclear. Nurse WRITE, an effective 8-week nurse-directed symptom management DHI, offers an opportunity to identify factors influencing engagement and enhance intervention efficacy evaluation.

OBJECTIVE

This study aims to (1) understand engagement phenomena (dimensions, influencing factors, and challenges) and (2) assess the relationship between engagement and patient symptom control in Nurse WRITE.

METHODS

The study included 68 women with recurrent ovarian cancer randomized to the Nurse WRITE arm of a 3-arm symptom management trial. We analyzed socio-affective and cognitive engagement through message board data and behavioral engagement using website usage data. Regression analyses examined patient characteristics, engagement, and symptom control perceptions. Through content analysis, we explored participant challenges and activities before disengagement.

RESULTS

Regarding influencing factors, higher education was associated with a 22% increased likelihood of engagement (p = 0.04). Education positively influenced cognitive and socio-affective engagement, including total count of cognitive classes (p = 0.01) and total word count (p = 0.03), with marginal associations for socio-affective classes (p = 0.07). Comorbidities tended to reduce both socio-affective (p = 0.06) and cognitive class counts (p = 0.07). Regarding behavioral engagement, education increased the odds of completing an extra symptom care plan by 23% (p = 0.02) and a plan review by 29% (p = 0.02). We observed a trend that higher symptom severity increased the odds of completing an additional plan review by 21% (p = 0.09). The most common engagement challenges included worsening health and treatment, busy family life, and website difficulties. Moderate and low engagers also experienced confusion about the intervention timeline and process. Among low engagers, 63% discontinued communication at specific intervention phases: introduction (33%), symptom representational assessment (21%), and goal setting and planning (21%).
Regarding the relationship between engagement and symptom control at the end of the intervention, improved symptom control was associated with higher overall engagement (p = 0.02), a higher frequency of cognitive engagement classes (p = 0.02), average question completion percentage (p = 0.01), a higher frequency of socio-affective classes (p = 0.01) and total word count (p = 0.01), as well as a higher total count of completed symptom care plans (p = 0.04).

CONCLUSIONS

Participant education level significantly influenced Nurse WRITE engagement across socio-affective, cognitive, and behavioral dimensions. Comorbidity and symptom severity warrant further investigation. Future provider-guided DHIs should employ additional strategies to engage less well-educated participants, address challenges like health issues and family activities, and re-engage participants during critical phases. Our findings underscore the importance of meaningful engagement through socio-affective, cognitive, and behavioral dimensions in Nurse WRITE, informing future DHIs to aim for a balance of protocol adherence and flexibility to enhance engagement and improve outcomes.