Exploring engagement with a web-based self-directed psychoeducational program for advanced cancer patients and their caregivers (iFOCUS): A sub study analysis of the DIAdIC trial

BACKGROUND: Supporting psychoeducational functioning for advanced cancer patients and informal caregivers (dyads) can be challenging. Self-managed digital interventions offer a possible cost-effective alternative but often face low engagement. AIM: To examine engagement with the iFOCUS intervention and to understand why it failed to improve the expected outcomes. DESIGN: iFOCUS, a four-session digital self-managed 12-week intervention for dyads, was tested in six European countries as part of a randomized controlled trial. However, it showed no effects on outcomes. Using process evaluation data with 121 dyads, measures of engagement were examined to identify how engagement predicts dropout and to identify associations with patient/caregiver characteristics, post-intervention outcomes, and patient/caregiver evaluation of the intervention. RESULTS: Measures of engagement showed variation in associations with participant characteristics. Lower engagement with the intervention among dyads at the outset, was associated with greater odds of dropout and engagement with the intervention decreased as the dyads progressed. Patients' level of education and caregivers' baseline emotional function, self-efficacy, dyadic coping, and knowledge of cancer were associated with engagement. However, there was no consistent evidence that engagement was associated with outcomes or evaluation of the intervention. DISCUSSION: While we identified several associations between engagement and patient/caregiver characteristics, there were inconsistencies in the extent and nature of the associations, with more evidence that baseline characteristics impacted engagement, than evidence that engagement impacted on outcomes. However, using multiple measures of engagement did provide additional insights. A key recommendation from this study is the need for consideration of assessments of engagement for digital interventions.