A theory-based approach was helpful in developing and delivering an online behavioral health intervention because it served as a framework to identify content of the program, outcome variables, and how the intervention was delivered. The OHRC was found to be user-friendly (mean PHWUQ score, 74.04 ± 7.26), and the OHRC usage levels were also promising. Out of seven modules, two (Care Needs in a Long-Term Care Facility and Care Needs in the Rehabilitation Unit) were not appplicable for all participants. The average total visits to the site were 11.2 per participant and the average total time spent on the site was 132.1 ± 97.1 minutes. On average, participants viewed five modules while they were in the study.
During the study, some CRs were readmitted to the hospital for other health issues, causing their CGs to go through another stressful event. This is an important aspect in the provision of care to hip fracture patients, and this topic will be added when the OHRC if modified in a future trial.
The proposed sample size was recruited with an attrition rate (25%) lower than the projected rate (30%). The recruitment period was on schedule; however, there was a lack of eligible dyads in the hospitals located in the inner-city underserved areas. For future larger-scale trials, the recruitment hospitals may need to be stratified based on geographic locations.
Generally, the number of available CR-CG dyads is much smaller than that of individual CRs or CGs, and it took many more resources to get in contact with both the hip fracture patients and their CGs than initially planned. When the field nurse visited patients, it was often right after surgery, which necessitated a follow-up visit. Their CGs were often not present when the nurse visited participants. Those challenges were mitigated through working with clinical staff; for example, meeting with the CGs after they attended the discharge planning meeting or avoiding CRs’ therapy times.
Prior studies have shown challenges in recruiting CGs of older adults (Murphy et al., 2007
; Steinhauser et al., 2006
). Many CGs take on caregiving responsibilities in addition to their other obligations, and some CGs have their own health problems (Steinhauser et al., 2006
). Recruitment of hip fracture patient–CG dyads in acute settings imposes additional challenges. Hip fracture patients stay in the hospital only for a few days for surgical procedures and then are transferred to another setting. This is a very busy and stressful time for the CGs, and the field research nurses must be able to make proper judgments when they approach participants. Those aspects must be discussed in field staff training, which is a vital component of successful studies (Leonard et al., 2003
Caregivers’ knowledge about how to take care of hip fracture patients was improved significantly after completion of the OHRC (t
= 3.17, p
= .004). Although effectiveness of the OHRC intervention needs to be tested further, the results suggest a good potential for using the OHRC for CGs of hip fracture patients. Use of online programs can be a particularly timely and effective approach considering the increasing popularity of the Internet (80% of American adults are online; Zickuhr, 2010
) and CGs’ busy schedules (51.9% had a regular job). The OHRC also can help clinicians use their time more efficiently as they can refer CGs to the OHRC for general information while they focus on more individualized and specific aspects of care.
There was a significant improvement in eHealth literacy (t
= 2.43, p
= .022). eHealth literacy is defined as “the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem” (Norman & Skinner, 2006a
). By improving eHealth literacy, individuals can be empowered to be more informed consumers of health care. Although the changes in the other variables (CG strain, stress, and computer-mediated social support) were in the expected direction, they were not statistically significant. Considering the small sample size, however, the findings are promising, and selected variables were found to be appropriate for future study.
Caregivers reported high compliance (80–100%) for the major CG activities that were general and encouraging in nature. Fewer CGs, however, performed activities related to caring for themselves. Considering the nature of the survey questions, social desirability response bias is a concern. The sensitivity of the items included in this survey will need to be evaluated also.
In this study, statistically significant effects on the CRs’ outcomes were not expected because of their distal position to the intervention. Rather, the main purpose of CR outcome analyses was to explore whether significant relationships exist within CR-CG dyads. Although a significant correlation was shown between the changes in CGs’ knowledge and CRs’ SEOMA and the changes in CG’s computer-mediated social support and CRs’ Self-Efficacy for Osteoporosis Medication Adherence, the impact of CG support on CR outcomes needs further investigation.
An active lifestyle is important in hip fracture recovery, as CR participants who were more active prior to the injury were also more active at follow up. More CR participants were engaged in moderate-intensity exercise (e.g., pool exercise, exercycle) at follow-up than at baseline (this could have been related to the physical therapy). This finding has important public health implications addressing the need for increased activity among older adults. Furthermore, a hip fracture event could serve as an excellent opportunity to inform older adults about the importance of exercise and changing their daily health behaviors (e.g., increasing exercise).
This was a feasibility study for a future large scale randomized controlled trial, so the generlaizability of findings is limited. It is thought that online users tend to be more affluent. Once the intervention is proven to be effective, additional efforts must be made to implement these types of online interventions for underserved populations. Some of the strategies could include using computers in the library or at work during lunch or break times.
Comprehensive online CG resource programs can be beneficial to the CGs of hip fracture patients, who face the situation without much preparation. This study showed some promising findings for using the OHRC. This program is particularly timely considering the wide use of Internet technology and most CGs’ busy lives. Caregivers can obtain timely support and information at their convenience. From the clinician’s perspective, as the length of hospital stay for hip fracture is getting shorter, limited time is available for patient education during the hospital stay. By using this type of online resource program, clinicians will be able to focus on more individualized needs. During this study, specific challenges were identified in recruiting hip fracture patient–CG dyads for online studies in acute settings (e.g., complex composite eligibility criteria for the dyad, brief hospital stay, and CGs’ stress levels and busy schedules) (more detailed information about recruitment was published in Nahm et al., 2011
). These findings provide helpful insights for future trials. Further studies, however, will be needed to investigate the impact of these programs on CR-CG dyads.