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professionals (16, 17). The use of eRehabilitation
has been associated with enjoyment, extra feedback,
physical and cognitive benefits and the possibility to
address the limitations of the current rehabilitation
system, such as limited therapy hours, low motivation
and poor adherence to exercise (18).
Despite these promising results and widespread
agreement about the importance and potential of
eRehabilitation, its implementation (i.e. making
eRehabilitation effective in stroke rehabilitation) is
lagging behind (19). A previous focus group study
explored which factors influence the implementation
of eRehabilitation (20). This study, together with
other literature, reported that the implementation of
eRehabilitation is hampered by a lack of confidence
about using hardware or software (15, 21) and the
fear that eRehabilitation could replace face-to-face
contact (13, 16, 20). Skilled healthcare professionals
or informal caregivers are needed to support patients
in using complex ICT programs (11, 14, 20). Health-
care professionals raised concerns about adapting the
rehabilitation process when added eRehabilitation (22).
Moreover, eRehabilitation is feasible only if tailored
to the individual needs of the recovering patient (18,
20). In addition, the safety of unsupervised rehabilita-
tion exercises is unknown (11) and lack of substantial
reimbursement by insurers is hampering its wides-
pread implementation (6). Healthcare professionals’
decision to start using eRehabilitation is influenced
by their beliefs about how eRehabilitation helps them
in performing their work (23).
Although the above-mentioned studies have identified
some factors influencing the use of eRehabilitation, it is
not known which factors have the greatest impact. This
insight is necessary in order to tailor an implementation
strategy to the factors that may influence use of eReha-
bilitation, and to develop an effective implementation
strategy to increase the use of eRehabilitation in stroke
patients. Therefore, the aim of this study was to as-
sess which factors are associated with willingness to
use eRehabilitation after stroke, for patients, informal
caregivers and healthcare professionals.
METHODS
Design and setting
This cross-sectional study within the Dutch medical specialist
rehabilitation setting used a single online survey, based on the
results of a previous focus group study (20). The present study
was conducted in June 2016, among stroke patients, their infor-
mal caregivers and healthcare professionals at 2 rehabilitation
centres (Basalt The Hague and Basalt Leiden). It was approved
by the Medical Ethics Review Board of Leiden University
Medical Centre [P15.281]. STROBE statements were used for
adequate sampling, analyses and reporting.
www.medicaljournals.se/jrm
Subjects
Stroke patients were selected if they met the following inclusion
criteria: aged ≥ 18 years, having started rehabilitation after June
2011 and completed it before May 2016, living independently,
able to understand and read Dutch, and having an email address.
A total of 400 patients, 200 from each rehabilitation centre, were
randomly selected from a list of approximately 2,700 eligible
patients. They received an invitation email from a rehabilita-
tion physician who was involved in this study, including an
introduction to the study and a link to the online survey. The
email also included information for the informal caregivers and
a link to a separate survey for the informal caregivers. Since not
all patients had an informal caregiver, the number of informal
caregivers invited is unknown.
Healthcare professionals were eligible if they had at least
2 years of experience working in a multidisciplinary stroke
team and were still actively seeing stroke patients in rehabilita-
tion care in the Netherlands. Invited healthcare professionals
included 3 disciplines that are commonly involved in stroke
rehabilitation: rehabilitation physicians, psychologists and
physiotherapists. These disciplines were invited since the
eRehabilitation intervention in this study concerned physical
and cognitive training, 2 domains that are mostly addressed
by these disciplines. A Dutch medical address book including
most healthcare professionals in the Netherlands was used to
identify members of the 3 disciplines. All eligible healthcare
professionals who worked in rehabilitation care received an
invitation email.
Non-responders received 2 reminders via email, 2 and 4 weeks
after the invitation. Immediately after completing the survey,
participants were sent a note thanking them for their willingness
to participate. Although participants were invited by email, they
completed the survey anonymously, with only the IP address
known to the researchers. The personal characteristics collected
were not traceable (e.g. age was used instead of date of birth).
Participants did not receive the results of the study.
Development and content of surveys
Preceding focus group study. The survey was developed based
on the results of an earlier focus group study (20). In 8 focus
groups (2 with healthcare professionals and 6 with patients/
informal caregivers), barriers and facilitators for willingness
to use eRehabilitation were identified. Participating healthcare
professionals included physiotherapists, psychologists, occupa-
tional therapists, speech therapists, rehabilitation specialists and
managers. Participating patients were selected using purposeful
sampling. The analysis and results of the focus group study have
been published in detail elsewhere (20).
Barriers/facilitators regarding related topics were merged into
factors based on Grol’s implementation model (24). This model
includes 6 levels; the innovation, the organizational context,
individual patients, individual professionals, the social context,
and the economic and political context. The focus group study
identified 14 factors at 5 levels (Fig. 1). Factors at the social
level were not identified and therefore not incorporated in the
present survey. One change was made to the factors identified in
the focus group study; for the purpose of the survey the factors
Motivation to change, at the level of both the individual patients
and the individual professionals, was divided into Motivation
to change and Motivation not to change, resulting in 16 factors
being included in the present study.
Survey content. Separate surveys were developed for patients,
informal caregivers and healthcare professionals. The surveys