Digital engagement and telehealth coaching intervention provides physical and mental health improvements for cancer patients: Results from a PROMIS-10 evaluation

doi:10.21203/rs.3.rs-4469180/v1

Purpose: People with cancer have unmet needs during the acute and survivorship phases of treatment and rehabilitation, which negatively impact both their ability to perform everyday tasks and their quality of life. Cancer Coach by Osara Health™️ addresses the holistic needs of people with cancer through telehealth coaching supported by a mobile application and digital participant engagement platform. This study evaluated the impact of the Cancer Coach by Osara Health™️ on the mental and physical health of people with cancer.

Methods: Telephone surveys administered at the start and completion of the program measured global physical, mental and social health, using the Patient Reported Outcome Measurement Information System 10 - Question Short Form - Global Health (PROMIS-10). Pre- and post-scores were compared using Wilcoxon Signed Rank Tests to assess for significant difference between pre and post PROMIS-10 scores.

Results: There were significant improvements in Global Physical Health, z=-4.966, p=<0.001, with more than a moderate effect size of r=0.37 and Global Mental Health, z=-4.533, p<0.01, with more than a moderate effect size of r=0.34 after the intervention. A significant number of participants improved their mental health scores from ‘good’ to ‘very good’ after the program.

Conclusion: Participants demonstrated significant improvements in physical and mental health after participating in the Cancer Coach by Osara Health™️ intervention.

Implications for Cancer Survivors: Digital engagement interventions for people with cancer, supported by health coaching, can improve emotional and mental health as well as physical well-being.

cancer

digital

telehealth

coaching

mental health

physical health

Countries with strong health care systems have seen increased cancer survival rates due to improvements in early detection and treatment of cancer that contribute to increased survival rates[1]. However, cancer treatment side effects can impact physical, cognitive, psychological and emotional wellbeing, not only in the acute phase of treatment, but for months or years afterwards [2]. Managing the immediate and the long-term side effects can be further complicated by healthcare funding shortages and a lack of services [3]. Globally, rehabilitation options for addressing the long-term holistic survivorship needs of people with cancer, including resuming everyday roles and occupations and improving quality of life, are limited[4].

Health coaching is a collaborative and client-centred intervention that aims to improve the physiological, behavioural, psychological and social wellbeing of people with chronic illness [5]. It offers cancer patients a more holistic approach to managing overall health and wellbeing beyond that of the primary oncology care team [6]. Health coaches use various techniques including motivational interviewing, goal setting, and behaviour change strategies to support and empower people to improve their overall health [7]. Technological advances in digital and telehealth options have reduced the need for traditional in-person health coaching, which has further developed since the global COVID-19 pandemic of 2019 as a way of staying connected with people during periods of isolation [8]. Digital options are also beneficial to those in rural areas with community access difficulties, and/or caring and work responsibilities.

These digital health programs can improve global, physical, and mental health while providing support in an ambulatory setting for people with cancer in managing their disease, by enhancing patients’ self-efficacy, as well as helping providers track and respond to patient-reported outcomes [6]. Further, digital cancer health coaching programs have also been found to improve physical and mental health scores ([9], [10], [11].

The aim of this study was to determine the impact of a telehealth coaching program, supported by a mobile application and digital participant engagement platform, on the physical and mental health, as well as overall wellbeing of people with cancer, through changes in PROMIS-10 scores [12–17].

Study Population and Data Collection

This study was approved by the University of Sydney Ethics Committee (Approval No.: 2024/HE000297). Participants in the Cancer Coach by Osara Health™ฏ were derived from referrals to Osara Health™ฏ through their employer or insurer, or an Australian public hospital. Participation in the study was voluntary, and all participants provided verbal consent, as well as a signed online consent form at enrolment. Data was collected from August 2020 to November 2022 and stored in secure online forms and databases. All participants included in the study had a recent cancer diagnosis, and only participants who had completed the PROMIS-10 pre- and post-program surveys were included in the analysis.

Intervention

After completing the pre-test PROMIS-10 questionnaire, participants commenced the Cancer Coach by Osara Health™. Participants received resources, exercises and evidenced based information and education through a mobile application and web-based platform. This included support by a health coach who provides 3–4 calls throughout the program. Participants completed the PROMIS 10 questionnaire on the first and last day of their Cancer Coach by Osara Health™ program. Additional details about the Cancer Coach by Osara Health™ can be found in Supplementary Information.

Statistical Analysis

Physical and mental health were measured via the PROMIS-10 to determine the impact of the Cancer Coach by Osara Health™ (telehealth program supported by a mobile application and digital participant engagement platform). Descriptive statistics were used to establish ranges and means of variables. Tests for normality showed that the data did not fit normal distributions, and therefore non-parametric testing was used. The data was paired from one cohort (pre-test, post-test) and the Wilcoxon signed-rank test was used to compare the paired groups to determine if there was a statistically significant (p⪬0.05) difference. The effect size of the Willcoxon signed-rank test was calculated and considered in terms of Cohen’s classification of effect sizes (0.1 = small effect, 0.3 = moderate effect, 0.5 or above = large effect). [18] PROMIS-10 GPH and GMH Scores were converted to T Scores to compare to US population norms [13, 17, 19] (Heart Beat Medical, 2021; Northwestern University HealthMeasures, 2023; Ortho ToolKit, n.d.).A T-Score of 50 (± 10) is considered to be a healthy score, and these are further categorised into categories of wellbeing [13, 20]. Data was analysed using IBM SPSS Data Package v.29.

Participants

Between August 2020 and November 2022, a total of 200 participants completed a PROMIS-10 survey at either the start or end of the intervention, 93 of whom had both pre and post data. The 55% attrition rate was due to participants not completing the post program PROMIS-10 survey due to health, family or work reasons. Four participants were excluded due to missing data, resulting in a final dataset of 89 participants. Table 1 provides participant demographic data.

Table 1: Participant Demographics

Demographic

Participants (n=89)

Sex

Male

Female

32 (36%)

57 (64%)

Age

Range

Mean

23-82 years of age

52.86 years of age

Cancer Type

Breast

Bowel

Blood

Head / neck

Other

34 (38%)

8 (9%)

31 (34.8%)

Referral Source

Insurers

Hospitals

Employers

78 (88%)

10 (11%)

1 (1%)

Length of Program

Mean

52 days

PROMIS-10 Questions, Global Health Scores and T-Scores

All individual PROMIS-10 items had significant (p<0.05) positive changes in pre and post scores and effect size (Table 2). The largest changes were in Q7 Everyday physical activities (z=-4.181; p<0.001), and moderate effect size of r=0.31, Q9 Fatigue (z=-3.900; p<0.001) and small effect size of 0.29, Q3. Physical Health (z=-4.202; p<0.001) and a moderate effect size of r=0.31Q8 Emotional Wellbeing (z=-3.411; p<0.001) and a small effect size of 0.26 and Q1 General Health (z=-4.118; p<0.001) and moderate effect size of r=0.31. There was a significant positive change in GPH, z=-4.966, p=<0.001, with more than a moderate effect size of r=0.37 following participation in Cancer Coach by Osara Health^TM. There was also a positive change in GMH, z=-4.533, p<0.01, with more than a moderate effect size of r=0.34 after the intervention.

Table 2: Pre- and post- PROMIS 10

				Wilcoxon Signed Ranked Test for Effect Size
Question	Pre Mean	Post Mean	Mean Change (points)	z value	p (two tailed)	Effect Size (r)
Q1. General Health	2.76	3.21	0.45	-4.118	<0.001	0.31
Q2. QOL	3.18	3.57	0.39	-3.144	0.002	0.24
Q3. Physical Health	2.53	3.01	0.48	-4.202	<0.001	0.31
Q4. Mental Health	3.0	3.43	0.43	-3.442	<0.001	0.26
Q5. Social Activities	3.18	3.65	0.47	-3.393	<0.001	0.25
Q6. Usual social roles and activities	2.7	3.13	0.43	-3.265	0.001	0.24
Q7. Everyday physical activities	2.98	3.57	0.59	-4.181	<0.001	0.31
Q8. Emotional wellbeing	3.01	3.49	0.48	-3.411	<0.001	0.26
Q9. Fatigue	2.63	3.13	0.5	-3.900	<0.001	0.29
Q10. Pain	3.51	3.72	0.21	-1.665	0.096	0.12
Global Physical Health	11.64	13.44	1.8	-4.966	<0.001	0.37
Global Mental Health	12.37	14.15	1.78	-4.533	<0.001	0.34

Further changes in self-reported physical and mental health were evaluated using the Wilcoxon Signed Rank Test (Table 3). Positive Ranks indicate the number of participants with PROMIS-10 scores that were higher after the Osara Health intervention. The highest mean positive ranks were Q9 Fatigue (34.98), Q8 Emotional Health (32.18) and Q4 Mental Health (30.91).

Table 3: Pre- and post- PROMIS 10 Wilcoxon Signed Ranked Test Mean Results


		N	Mean Rank
Q1. General Health	Negative Ranks	13	25.12
	Positive Ranks	43	29.52
	Ties	33
	Total	89
Q2. Quality of Life	Negative Ranks	17	27.85
	Positive Ranks	41	30.18
	Ties	31
	Total	89
Q3. Physical Health	Negative Ranks	12	23.63
	Positive Ranks	42	28.61
	Ties	35
	Total	89
Q4 Mental Health	Negative Ranks	16	29.38
	Positive Ranks	44	30.91
	Ties	29
	Total	89
Q5 Social Activities	Negative Ranks	16	26.00
	Positive Ranks	41	30.17
	Ties	32
	Total	89
Q6 Usual social roles and activities	Negative Ranks	16	28.38
	Positive Ranks	42	29.93
	Ties	31
	Total	89
Q7 Everyday physical activities	Negative Ranks	13	25.88
	Positive Ranks	45	30.54
	Ties	31
	Total	89
Q8 Emotional Wellbeing	Negative Ranks	17	29.71
	Positive Ranks	45	32.18
	Ties	27
	Total	89
Q9 Fatigue	Negative Ranks	18	27.83
	Positive Ranks	47	34.98
	Ties	24
	Total	89
Q10 Pain	Negative Ranks	19	27.00
	Positive Ranks	33	26.21
	Ties	37
	Total	89
Global Physical Health	Negative Ranks	23	27.52
	Positive Ranks	59	46.95
	Ties	7
	Total	89
Global Mental Health	Negative Ranks	23	32.54
	Positive Ranks	60	45.63
	Ties	6
	Total	89

Table 4 outlines changes in both Global Physical and Mental Health T-Scores. There was a statistically significant 4.43 point change in GPH T-Score (p<0.001), but the score remained in the ‘Good’ category of wellbeing. There was also a statistically significant 4.48 point change in GMH T-score (p<0.001), after participating in the Osara Health intervention. The post- GMH T-Score was 49.052 and represented participants overall mental health improving from ‘good’ to ‘very good’.

Table 4: Global Physical Health and Global Mental Health T Scores

		Pre	Post
Global Physical Health	Mean T Score	42	47.09
	Standard Deviation	±6.745	±6.655
	Category	Good	Good
	Change (points)	4.43
	p value	0.001
Global Mental Health	Mean T Score	44.47	49.052
	Standard Deviation	±8.233	±7.4992
	Category	Good	Very Good
	Change (points)	4.58
	p value	0.001

The Cancer Coach by Osara Health™ offers a digital intervention to provide support to people with cancer aimed to fill the current gap in cancer rehabilitation services available in the community. This study has evaluated the outcomes of the Cancer Coach by Osara Health™ and showed that participants with a variety of cancers significantly improved their physical and mental health after participating in the program, as measured through the PROMIS-10.

Participants increased their GPH PROMIS-10 score after using the Cancer Coach by Osara Health™ intervention. These findings support the growing body of research supporting the benefits of non-pharmacological interventions to improve physical wellbeing and pain and fatigue experienced by people with cancer. The findings of this study align with a systematic review which found a range of different digital and telehealth-based interventions improved physical activity for cancer survivors [21]. However, in contrast to these study findings, most research is focused on in-person delivery of exercise-based programs. A systematic review demonstrating the benefits of physical exercise for people with cancer excluded studies that had behavioural interventions to promote exercise or encourage lifestyle behaviours [22], such as the Cancer Coach by Osara Health™. Whilst the Osara Health™ intervention may not directly implement exercise programs, it provides participants with education on the importance of exercise for cancer management in layman’s terms and can work with the participants’ understanding, and support plans for implementation [23].

The Cancer Coach by Osara Health™ also addressed the performance of everyday activities, work ability and participation [24, 25]. Cancer related fatigue is a persistent and troublesome cancer side-effect that can impact on work and engagement in activities. Cancer survivors have described fatigue in terms of both physical and cognitive characteristics [24]. In the PROMIS-10, fatigue is incorporated into the GPS. However, an argument could be made that post-cancer fatigue encompasses both physical and mental health measures. Exercise has been found to improve cancer related fatigue together with a range of other evidence-based interventions including fatigue education, yoga, energy conservation, and psychosocial support, cognitive behavioural therapy [26–29]. In this study, fatigue had the highest mean positive rank for any question, indicating it was the area in which there was the most improvement in participants. Whilst the Osara Health™ intervention does not provide an in-person intervention, the use of motivational interviewing techniques to instigate and support behavioural change encourages people with cancer to participate in evidence-based interventions to address the effects of fatigue. Cancer Coach by Osara Health™ also provided individualised psychosocial support for goal setting to address managing fatigue and resuming normal activities. Our study did not use a fatigue-specific measure, but the results suggest that a digital intervention combined with health coaching may improve fatigue in people with cancer.

Evidence-based non-pharmacological interventions (mindfulness-based cognitive therapy, guided imagery and progressive muscle relaxation and emotional and symptom focused engagement) for the management and reduction of pain for people with cancer are supported by a systematic review and meta-analysis [30]. Physical activity and exercise have also been shown to reduce pain in people with cancer [4]. This study also found small reductions in pain levels. The Cancer Coach by Osara Health™ helped manage pain symptoms (i.e., pain, gastrointestinal issues, fatigue, hot flushes, loss of appetite) through digital or journal tracking, during and after treatment. Other studies have indicated this can reduce hospitalisation and improve quality of life [31].

In this study, the GMH T-Score moved from the ‘good’ to the ‘very good’ category after participating in the Cancer Coach by Osara Health™. Of the four questions that contributed to the GMH score, Q8 Emotional Wellbeing had one of the highest raw point changes in our study. Mental health disorders (depression, anxiety, somatic or trauma related disorders) are common in people with cancer often in response to the distress of the cancer diagnosis, poor prognosis, the side effects of treatment, or the ongoing fear of recurrence. [32]. People with cancer need to access early assessment and interventions (i.e., individual or group-based psychotherapy, various techniques within cognitive behavioural therapy, counselling, coping and psychological support, psychoeducation) matched to their specific mental health condition, which may not be accessible online [33] [28] [32]. Untreated mental health conditions in people with cancer could lead to poor treatment adherence and symptom management, reduced participation in everyday occupations and poor quality of life and increased health care utilisation and mortality [34]. The Cancer Coach by Osara Health™ did not include specific psychosocial interventions, but the collaborative nature of the Cancer Coach by Osara Health™ may have contributed to this positive mental health finding [35].

The complex nature of cancer related pain, fatigue, cognitive difficulties and mental health makes it difficult to evaluate or treat each symptom independently. However, an intervention such as exercise can address several of these side effects of cancer survivorship simultaneously. Similarly, a holistic approach such as health coaching can also be beneficial to addressing a aspects of health and wellbeing in a collective way [36, 37]. An earlier study of Cancer Coach by Osara Health™ also indicated participation assisted people with cancer resume work activities [25]. This holistic approach could also provide a more effective form of health service delivery as it targets a wider group of people with cancer. If a digital and telehealth coaching program can assist with improving pain, fatigue, mental and physical health, this may also have a cost benefit by reducing health utilisation such as GP consultations [41] and hospital visits [42], [38].

Limitations

This study had a small sample size and 65% female participants, with breast cancer being the dominant diagnosis, possibly contributing to gender bias and reflecting men’s reluctance to seek psychological or emotional help when dealing with cancer [39]. Given the variations in delivery of digital and telehealth solutions, more research is required to establish the effectiveness of online health coaching.

Participation in Cancer Coach by Osara Health™ showed a significant and positive change in physical and mental health among individuals with various cancer diagnoses, as indicated through the PROMIS-10 survey. These preliminary results suggest that, where in-person services are not feasible, digital engagement interventions for people with cancer, supported by health coaching, can improve fatigue, emotional and mental health as well as physical well-being.

Acknowledgements:

The authors would like to thank the participants in this study for sharing their experiences which enabled this research.

Funding:

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Competing Interests:

The authors have no relevant financial or non-financial interests to disclose.

Author Contributions:

Conception and design: RM-G, TA; Data collection and analysis, first draft manuscript writing: JL; Data collection and analysis: SW; all authors: interpretation of results and manuscript writing: all authors; read and approved the final manuscript: all authors.

Data Availability:

The datasets generated during and/or analysed in the current study are available on request from the corresponding author (RM-G).

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the University of Sydney Ethics Committee on 8 April 2024 (Approval No.: 2024/HE000297).

Consent to participate

Informed consent was obtained form all participants included in the study.

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No competing interests reported.

PROMIS10StudyFINALSUPPLEMENTARYINFORMATION.docx

Digital engagement and telehealth coaching intervention provides physical and mental health improvements for cancer patients: Results from a PROMIS-10 evaluation

Status:

Version 1

Abstract

Background

Methods

Study Population and Data Collection

Intervention

Statistical Analysis

Results

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1