Differences in factors influencing the use of eRehabilitation after stroke; a comparison between Brazilian and Dutch healthcare professionals


 Introduction: To improve the use of eRehabilitation after stroke, the identification of barriers and facilitators influencing this use in different healthcare contexts around the world is needed. Therefore, this study aims to investigate differences and similarities in factors influencing the use of eRehabilitation after stroke among Brazilian Healthcare Professionals (BHP) and Dutch Healthcare Professionals (DHP). Method: A cross-sectional survey study including 88 statements about factors related to the use of eRehabilitation (4-point Likert scale; 1-4; unimportant-important/disagree-agree). The survey was conducted among BHP and DHP (physical therapists, rehabilitating physicians and psychologists). Descriptive statistics were used to analyse differences and similarities in factors influencing the use of eRehabilitation. Results: ninety-nine (response rate 27%) BHP and 105 (response rate 37%) DHP participated. Differences were found in the top-10 most influencing statements between BHP and DHP; top-10 least influencing statements were mostly similar. Discussion: The results indicate that the use of eRehabilitation after stroke by BHP and DHP is influenced by different factors. A tailored implementation strategy for both countries needs to be developed; BHP were most influenced by support from the organization and the potential benefits of the use of eRehabilitation, DHP by the feasibility of the use of eRehabilitation for the patient. Statements with low influence like problems caused by patient characteristics or problems with resources, were comparable for both groups and should have less priority in the implementation strategies.


Contributions to the literature
To increase the uptake of eRehabilitation, this study identified and compared factors influencing the uptake of eRehabilitation in a western country, in which the most of the studies in this topic are performed, and a country in South-America, which may benefit most from the use of eRehabilitation.
In Brazil, the most important facilitator for the use of eRehabilitation is support from the rehabilitation organisation. In the Netherlands, this was the feasibility of using eRehabilitation by patients.
These findings underscore the importance of implementation strategies that are tailored to the context and wishes, needs and priorities of the end-users.
The rapid growth of digital health technology (1) provides efficient strategies for delivering rehabilitation while maintaining or improving effectiveness (2). Therefore, it may offer a solution for the increasing need for care, especially in stroke rehabilitation, where incidence, survival rates and healthcare costs are growing (3). Digital eRehabilitation programs offers an additional way of delivering conventional rehabilitation and can include physical and cognitive exercise programs, serious gaming, education (4)(5)(6) and e-consultations (7), delivered via a variety of information and communication technology (ICT) devices such as a computer, tablet and smartphone.
Randomized clinical trials showed that eRehabilitation can decrease stroke-related impairments (5,8,9), relieve healthcare professionals from manual labour, make rehabilitation accessible to larger number of stroke patients (2), continue therapy-related cognitive and motor activities during and after discharge (4), decrease chronic disability during and after sub-acute rehabilitation, and facilitate home-therapy (10,11). Healthcare professionals working in stroke rehabilitation exhibited a positive attitude towards eRehabilitation (12,13). The use of eRehabilitation post-stroke can be especially important in regions with a paucity of socioeconomic resources and limited access to care (14).
Those regions now have the greatest burden of stroke worldwide (15), in which eRehabilitation is likely to be the most viable strategy to reduce burden via culturallyrelevant eRehabilitation interventions (16).
Acceptance of and willingness to use eRehabilitation are hampered by factors such as 1.
lack of confidence with hardware or software (17,18), 2. fear of losing social face-to-face contact (12,19) and 3. lack of meaningful reimbursement (7,20). Additionally, eRehabilitation interventions for patients are rarely culturally-adapted (16) and the use of eRehabilitation in daily practice lacks worldwide (21). Furthermore, it has been shown that eRehabilitation interventions need to address culture-specific issues in order to be effective (22).
To improve the uptake of eRehabilitation after stroke, the identification of barriers and facilitators influencing this use is needed (16). Most of the abovementioned research about barriers/facilitators in the use of eRehabilitation is performed in western countries (America, Canada, Australia, Europe), and as far as we know, no research is performed on the differences between western countries and other regions. Therefore, the aim of this paper is to describe the differences and similarities in factors influencing the use of eRehabilitation after stroke between Brazil and the Netherlands, countries with different cultures and healthcare systems.

Methods
To identify differences and similarities in factors influencing the use of eRehabilitation after stroke between Brazilian and Dutch healthcare professionals, cross-sectional study conducted in a medical specialist rehabilitation setting involved a one-time online survey.
This survey was developed based on the results of a preceding focus group study (23) and was conducted among Brazilian healthcare professionals (BHP) and Dutch healthcare professionals (DHP) working in stroke rehabilitation. The COREQ guidelines were used for adequate design of the focus groups (24) and STROBE statements were used for adequate sampling, analyses and reporting of the survey.

Setting
Brazil: Data from a national prospective study indicate an annual incidence of 108 cases per 100,000 inhabitants. Stroke Care Guidelines are established involving pre-hospital treatment, intervention in acute stroke, and follow-up at rehabilitation centres (25,26).
Rehabilitation can take place on an outpatient basis, an inpatient basis, or during hospitalization. In all settings, interventions are delivered by multidisciplinary teams working in an interdisciplinary manner with active patient participation and family inclusion. Specialized professionals include physicians, nurses, social workers, physical therapists, occupational therapists, speech therapists, psychologists, hospital educators, physical education instructors, and nutritionists. The treatment and rehabilitation process are free of charge; the national health budget covers all costs.
Netherlands: The annual incidence of stroke in the Netherlands was estimated 107 cases per 100,000 inhabitants (27). Incidence and mortality rates decline as a result of better and faster treatment (28) and stroke burden in terms of the absolute number of people affected by stroke increase (29). About 10% of the stroke survivors follow multidisciplinary in or out-patient rehabilitation in a medical specialist rehabilitation setting (30), including physiotherapy, speech therapy, occupational therapy, psychology and a social worker, coordinated by a rehabilitation physician (31). A rehabilitation plan is made and evaluated during weekly team meetings, and patients and family are involved if needed. Rehabilitation consisted of individual and group exercise (31). Six months after stroke, on average 60% of the patients are community living again (32). Most costs are reimbursed by the healthcare insurance provider, with out of pocket costs for the patients of maximum €885,-.

Study population
Inclusion criteria for both BHP and DHP were 1) at least two years of working experience in a multidisciplinary stroke team and 2) still actively treating stroke patients. Invited BHP included neurologists, physical therapists, occupational therapists, psychologists, nurses, social workers, speech therapists, hospital educators, and physical educators from the SARAH Network of Rehabilitation Hospitals. Invited DHP included rehabilitation physicians, psychologists and physical therapists. A Dutch medical address book including most healthcare professionals in the Netherlands was used to identify all eligible healthcare professionals. BHP and DHP received an invitation email including a link to the online survey. Non-responders received two reminders, first after two weeks and second after four weeksthat.
All focus groups were audiotaped and transcribed in full in Dutch. The transcripts were qualitatively analysed using directed content analysis, in which the researchers used a theory or relevant research findings as guidance for initial code (34), in this case the model of Grol (35). This model was chosen because it provides a framework for identifying and categorizing factors that influence the use of innovations in healthcare (35). A total of 88 barriers/facilitators that impact the use of eRehabilitation were identified. Those were grouped into fourteen factors, divided at the levels of Grol; 1) Innovation (the eRehabilitation program); 2) Organizational context; 3) Individual patient; 4) Individual professionals and 5) Economic & political context (see Table 1).
To prioritize all barriers/facilitators identified in the focus groups, a survey was The survey was tested in a pilot among three DHP (2 males, 2 physical therapists, 1 occupational therapist, mean age 38 years old, mean working experience 13.3 years). The survey was tested for feasibility, legibility, readability and presentation (e.g., perceived statement difficulty, response errors, etc.). Testing led to small changes in the phrasing and layout. The survey was developed in Dutch. For the BHP, the survey was translated by a qualified Portuguese-language translator. First, the Dutch version was translated into English by the translation agency Attached Language and the translation was discussed in the project team leading to minor changes. Subsequently, the English version was translated into Portuguese and was tested by two Portuguese project members.
Differences were discussed and adaptations were made in three rounds until the Portuguese questionnaire was similar to the original Dutch version.

Data analysis
Participants who completed >90% of the survey were included in the analysis, which was executed using Statistical Packages for the Social Sciences (IBM SPSS 22.0), and we did not impute for missing values. Personal characteristics were analysed using descriptive statistics. T-test or Pearson Chi-square test was used to compare age, gender, number of new patients, work experience and the use of eRehabilitation between BHP with DHP.
Based on the median score, all statements influencing the use of eRehabilitation were given a ranking (lowest number equals large influence), separately for the BHP and DHP.
For the statements with a similar median, definite ranking was based on the mean. The top-ten most and least influencing statements were noted and differences in ranking were calculated to describe the level of agreement among DHP and BHP. The ranking of all statements for both the DHP and BHP were plotted on a scatterplot, including a 95% confidence interval (CI). Additionally, these analyses were performed with only the disciplines included both in the Netherlands and Brazil (i.e. physical therapists, psychologists and physicians).

Ethical issues and approval
All participants gave written informed consent prior to participation. Participants were anonymous and the characteristics collected were untraceable (e.g. age instead of birthday and only the IP-address was given to the researchers). This study was approved

Most and least influencing statements
On the other hand, the statements that BHP and DHP considered not influencing the use of eRehabilitation were comparable, with eight statements found in the top-10 of BHP and DHP. Factors that did not influence eRehabilitation use were related to the factor Patient characteristics (i.e., cognitive and physical disability or aphasia) and the factor Resources (i.e., problems with the internet connection or hard-and software).
The abovementioned analyses were also performed including only the disciplines that were represented in both countries (i.e. physical therapists, rehabilitation physicians and psychologists), resulting in comparable findings. Only the two statements 'Problems with the devices on which eRehabilitation is used' and 'Problems with the internet connection' were not found in the top-ten least influencing statements of this sub-analysis; the top-ten most influencing statements was fully comparable with the results of the all respondents (see table 3a and 3b).

Difference and similarities in ranking
The difference in ranking for the BHP and DHP was calculated for each statement (see additional file 1). The mean absolute difference in ranking between BHP and DHP was 11.2 (SD 15.9, range 0-58). In figure 2, the ranking of the Brazilian responses is plotted against the Dutch responses. Four statements were found outside the 95% CI. BHP reported the following statements more frequently as important than DHP: 1) 'The eRehabilitation program is accessible offline', 2) 'Exercises to train cognitive functioning' and 3). were found in the top-10 most influencing statements of respectively BHP and DHP (see Table 3a).
For the majority of the factors, the statements constituting that factor were spread out on a broad range of the scatterplot, with at least one statement within the 20 most and one statement in the 20 least influencing statements (see also additional file 1 and figure 2).
Only the statements constituting the factors Resources, Patient Motivation not to change and Patient characteristics were found only with a low influence.

Discussion
In this study, we investigated differences and similarities in factors influencing the use of eRehabilitation after stroke among healthcare professionals from Brazil and the Netherlands. The statements with the highest influence on the use of eRehabilitation differed between BHP and DHP; BHP agreed more with factors related to the benefits for the patients and organizational constrains, DHP agreed more with factors related to the feasibility of the use of eRehabilitation. The statements with the least influence on the use of eRehabilitation were comparable for BHP and DHP, and were related to patient characteristics and resources. This means that BHP and DHP indicate that the use of eRehabilitation is influenced by different factors and tailored implementation strategies for both countries need to be developed separately (16).
For BHP, and with a lesser frequency DHP, the factor Motivation to change was important.
Benefits of the use of eRehabilitation were found important before, including the possibility to train at home (36), independently continue therapy activities (4) and easily accessible contact with a healthcare professionals after discharge or during outpatient therapy (12,13). For BHP, time and support for the healthcare professional from the organization is also important. Facilitating conditions, including time, communication and education, was found to be an important facilitating factor in the use of eRehabilitation after stroke before (13,37). For DHP, a thorough helpdesk delivering support for patients and healthcare professional is crucial. This is in line with a review of Pugliese (2018) concluding that the most reported patient barrier was following instructions about how to use the device (38).
Concerning the content of the eRehabilitation intervention, for the BHP speech and cognitive exercisers are important, were the DHP focus on physical exercises, and offline accessibility seems important in Brazil but not in the Netherlands. For the DHP it is important that decisions that were made during a consult are incorporated in the eRehabilitation intervention. Therefore it can be concluded that not only the implementation strategy should be adapted to the wishes of the end-users (12), but also the eRehabilitation intervention.
Most factors were constructed of statements that were spread over a broad ranking and included both statements influencing and non-influencing the use of eRehabilitation. So some differences might remain hidden at factor level, since statements within a factor compensate for each other, differences can be found at statement levels. Therefore, it is important to investigate barriers/facilitators for the implementation of eRehabilitation in detail rather than on the level over overarching factors.
Although our study revealed some important differences and similarities among Brazilian and Dutch healthcare professionals, the results have to be interpreted with care due to some limitations. First, only 36% of the BHC were physical therapists, psychologists and rehabilitation physicians; i.e. the disciplines invited in the Netherlands. However, when only the responses of the Brazilian physical therapists, psychologists and rehabilitation physicians were taken into account, the results of the analyses were comparable with the results of all BHPs. Therefore, it seems plausible that differences are caused by the various contexts and not by the specific professional backgrounds of the respondents.
Second, the response rate of 27-37% in our study may have led to response bias because those who responded to the invitation to participate in the survey were probably more interested in eRehabilitation. As a consequence, the perspective of end-users with less interest in and experience with eRehabilitation might be missing. A third limitation is that the survey questions were based on the results of focus groups performed in the

Consent for publication
Not applicable.

Availability of data and material
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Supplementary Files
This is a list of supplementary files associated with the primary manuscript. Click to download.
Additional file 1.pdf Additional file 2; STROBE checklist.pdf