Embedding lifestyle interventions into cancer care: has telehealth narrowed the equity gap?

Advantages

Telehealth has many advantages over traditionally in-person services, which may enhance reach and access to lifestyle interventions for cancer survivors. Telehealth-based lifestyle interventions, including online physical activity programs, are safe and well accepted by patients (34-37). Overall, cancer survivors describe telehealth services as flexible, convenient, and easy to use (34,35) due to the reduced need for travel, thereby saving time and cost. This is particularly relevant for individuals referred to lifestyle services, such as physical activity programs, where common barriers to use include travel distance, parking, fatigue, and patients feeling overwhelmed with appointments (38,39). In 1 study set in rural Utah (40), patients averaged savings of $2799 and 40 travel hours using a telehealth approach compared with in-person appointments.

Telehealth demonstrates significant benefits for managing cancer-related physical and psychosocial effects such as fatigue, cognitive function, health-related quality of life, and functional capacity (34,36,41). For lifestyle practices, telehealth interventions show particular promise. A recent overview of the efficacy and challenges of telehealth in cancer survivorship care identified 29 systematic reviews, 15 of which (52% of reviews included in the overview) specifically evaluated telehealth’s role in health promotion and disease prevention (41). Of these, all 15 concluded that telehealth interventions were associated with improved physical activity behavior, with additional improvements in body weight (n = 7) and diet quality (n = 4) (41). These findings are supported by another recent meta-analysis of telehealth interventions showing improvements in physical activity and dietary behavior regardless of mode of delivery (42). Although promising, it should be acknowledged that most trials of telehealth-delivered lifestyle interventions conducted to date have been delivered via simple telephone models or web-based platforms (34,41,42). Given the nature of lifestyle interventions, particularly those including physical activity, the rise in video conferencing and use of wearable technologies may offer even more benefits from telehealth than other aspects of medicine such as doctor visits and supportive care outcome assessment. This may be achieved through real-time feedback, self-monitoring, virtual supervision, and embedded social support options offering a truly personalized experience. These benefits highlight the potential utility of telehealth for reaching traditionally underserved and inaccessible communities of cancer survivors.

Challenges

Although telehealth may reduce some disparities in access to quality lifestyle interventions, there is concern it may exacerbate health inequities. Currently, most telehealth research has been conducted in homogenous White samples, with limited data in populations who face growing health disparities (43). Engagement in telehealth interventions usually relies on ownership of a suitable device and access to stable broadband to enable connectivity, which is often limited in rural and underserved settings (44). Access to this infrastructure is much lower in the United States than in other developed countries (45). In rural areas, where people are more likely to experience poorer health and are less able to access and receive care, up to one-third of households continue to have poor access to broadband internet (46). Despite these challenges, the digital divide between rural and non-rural Americans is rapidly declining.

Sufficient health and digital literacy are also required to engage with more complex telehealth interventions (47) as well as access to reliable internet. For example, in a recent study, only 58% of participants attending a survivorship clinic in rural Virginia had adequate broadband access (48). They also experienced difficulty with technology and required assistance to use a cellular-enabled tablet (48). Poor telehealth access may further be compounded by lower socioeconomic status because the hardware of more affordable devices may not always be compatible with telehealth software. Choice of technology for telehealth may also be driven by what insurance will cover (47). A study of newly diagnosed cancer survivors accessing telehealth appointments found uptake was highest in those with the highest socioeconomic status (67% uptake) compared with the lowest socioeconomic index (47% uptake) (49), suggesting that multiple drivers may be at play (eg, socioeconomic status, behavior change, digital literacy). Therefore, implementation of any telehealth intervention for health promotion requires careful and pragmatic consideration based on context.

Real world examples: putting telehealth into practice for vulnerable populations

This article reports novel findings related to the feasibility of using telehealth to deliver lifestyle interventions in vulnerable populations from 2 studies conducted by coauthors of this commentary: 1) older cancer survivors (GO-EXCAP), and 2) rural cancer survivors (weSurvive). GO-EXCAP was a single-arm pilot study testing a mobile health exercise intervention for older patients receiving chemotherapy for myeloid malignancies (50). weSurvive was a single-arm telehealth-based nutrition and physical activity promotion intervention designed to improve the quality of life of rural Appalachian cancer survivors (51). These 2 studies include all 3 forms of telehealth: 1) use of technology to monitor, track, and inform health; 2) enabled health communication between health professionals and patients; and 3) collection, management and use of digital health data. Telehealth domain descriptions for each study are described in Table 1, and study characteristics are detailed in Table 2.

Lessons learned and practical recommendations

These 2 real world examples highlight lessons learned about enhancing equitable implementation of lifestyle telehealth interventions in future studies. We present practical recommendations based on these lessons, which are supported by recent recommendations published by American Society of Clinical Oncology to help providers and clinicians integrate telehealth into oncology practice (34). To promote health equity when implementing telehealth lifestyle interventions, the following should be considered:

1. Provide training or orientation for patients.

   Increasing digital literacy is critically important, and this process may come in a variety of formats (eg, written, electronic, verbal with study personnel). Both patients and providers should be provided with education on how to use technology that will be used to deliver the intervention, such as mobile phone, web platform, or wearable device. The telehealth experience for older adults can be improved by fostering basic competencies and providing guidance (53,54). This could take place in the form of initial email comprising URLs and expectations, followed up by a telephone call or in-person visit for further explanation. In-person orientations should also be considered to build trust and develop rapport with participants as well as to ensure safety for participants. Unlike other areas of telehealth, many physical activity interventions need participants to be able to coordinate use of their device with a safe environment to perform exercise, and this includes performing a falls risk assessment, which is particularly relevant for older cancer survivors.

2. Provide skills training for health professionals.

   The COVID-19 pandemic has increased comfort with contemporary technologies, both for health care and other communication platforms (55,56). However, some health professionals may remain hesitant to engage with these technologies, particularly those who provide physical lifestyle interventions such as physical therapists (57). Ensuring they are adequately trained with telehealth technology will ensure they can educate survivors and deliver effective telehealth-based interventions.

3. Use simple, portable technology with sufficient capabilities and promote policies to address lack of broadband access.

   Although the digital divide is shrinking among rural and older populations, many may still have limited or no access to cellular networks or devices. Providing a cellular-enabled device to participants who need them may assist with this issue. For those with their own devices, using patients’ own technology (eg, patient’s existing smartphone health app) can promote long-term adherence and sustainability. For example, many smartphones include health-monitoring apps that track relevant data related to step count, body weight, and diet. Drawing attention to these preexisting apps may therefore facilitate accountability for lifestyle behavior change. Supporting costs for data storage for application downloads may also be considered.

4. Include additional functions to facilitate use of technology platforms and incorporate an initial in-person visit where possible.

   Participants have diverse hearing, visual, and literacy needs. The incorporation of additional functions (eg, text-to-speech, large font size) in telehealth interventions can facilitate participation and promote adherence. In-person visits can also reduce stigma associated with digital literacy and maximize access for people with hearing, vision, or cognitive limitations. Prospective, in-person visits may be particularly useful where physical assessment is required, such as taking vitals during a fitness assessment or assessment of injury. These visits should be conducted in a central location that is readily accessible to all residents of the target population rather than relying on participants to assume travel burdens.

5. Integrate the patient’s care team or support network throughout the process.

   This integration can support recruitment and, when progress is communicated back to them, support the participant’s behavior change. A team member (eg, clinical, research, community partner) should be available to support troubleshooting of technology issues if using videoconferencing or mobile apps. This is particularly relevant in the context of delivering group physical activity classes or education sessions to ensure smooth operation.

6. Personalize the telehealth intervention.

   Personalized goals and feedback, with an emphasis on the importance of flexibility (eg, “it is okay to not exercise on the days of chemotherapy”), can promote participation and reduce emotional distress for participants not able to meet their goals. Tailoring the intervention modality (eg, telephone vs video conference) and content (eg, aerobic walking vs strength training) based on patient preferences and needs will optimize the patient experience. For example, patients requiring dietary counseling who only have access to a telephone may benefit from simple phone calls, whereas patients wanting to participate in an exercise class may require a more sophisticated intervention involving remote monitoring and videoconferencing. Lifestyle interventions that include user-centered design processes can further support intervention uptake, adherence, and long-term success (58,59).

7. Embed socially supportive structures into the telehealth intervention.

   Social support (eg, group classes and activities, dyadic enrollment) can build the social networks of cancer survivors. Developing cohorts for group sessions, synchronous and/or asynchronous chat opportunities between participants, or 1-on-1 coaching can support human connectedness.

8. Involve the population of interest in designing the intervention.

   For intervention sustainability and long-term behavior change, it is important to engage the population of interest (ie, end user) in the intervention design process. Patient advocates and/or community members should be given a voice in shaping the intervention content, delivery, and implementation. This may take the form of including community partners or patient advocates as advisory board members or coinvestigators on grant applications. Such engagement supports the creation of culturally relevant and sensitive materials, which ultimately aids in developing interventions that are both appropriate for and valuable to their intended audiences.