Supportive Care in Cancer

, Volume 26, Issue 2, pp 499–506 | Cite as

The implementation of web-based cognitive rehabilitation in adult cancer survivors: examining participant engagement, attrition and treatment fidelity

  • Mary E. MihutaEmail author
  • Heather J. Green
Original Article



Low engagement and high attrition are common challenges in web-based interventions. Typical measures of engagement reported in the literature are not meaningful for describing participant activity within the intervention and can be misleading. This research aimed to develop a more meaningful method of measuring engagement in an online cognitive rehabilitation program whilst monitoring treatment fidelity.


A pilot study and randomised controlled trial (RCT) were conducted. Data from 60 participants were analysed from three intervention groups: pilot cancer group, pilot non-cancer group and RCT cancer group. Groups completed the 4-week eReCog program comprised of four online modules. Engagement scores were calculated based on activities completed in each module. Attrition, interaction with the program facilitator and correlations with outcome measures were analysed.


Overall engagement in the intervention was high. The non-cancer group participated significantly less than the cancer groups (p = < 0.001), whereby the percentage of activity items completed was 92, 87 and 78% in the pilot cancer, RCT cancer and pilot non-cancer groups, respectively. Attrition was higher in the pilot non-cancer group (24%) compared to the pilot cancer group (8%) and the RCT cancer group (16%). Total engagement was correlated with fewer prospective memory problems on instrumental activities of daily living (p = 0.018).


Measuring completed activities in online interventions appears a more meaningful measure of engagement than other conventional methods described in the literature and has the potential to increase treatment fidelity in web-based research.


Cancer Cognitive rehabilitation Web-based Online Engagement Treatment fidelity 



This research was supported by Breast Cancer Network Australia’s (BCNA) Review and Survey Group, a national, online group of Australian women living with breast cancer who are interested in receiving invitations to participate in research. We acknowledge the women involved in Review and Survey Group who participated in this project.

Financial support

This project was supported by a joint PhD scholarship for the first author from Griffith University and Cancer Council Queensland (CCQ).

Compliance with ethical standards

Ethical standards

This research complies with the ethical standards of the Human Research Ethics Committee at Griffith University (PSY/F4/14/HREC) and was performed in accordance with the Helsinki Declaration.


  1. 1.
    Owen JE, Bantum EO, Gorlick A, Stanton AL (2015) Engagement with a social networking intervention for cancer-related distress. Ann Behav Med 49:154–164. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Ritterband LM, Tate DF (2009) The science of internet interventions. Ann Behav Med 38:1–3. CrossRefPubMedGoogle Scholar
  3. 3.
    Morrison C, Doherty G (2014) Analyzing engagement in a web-based intervention platform through visualizing log-data. J Med Internet Res 16:e252. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Danaher BG, Seeley JR (2009) Methodological issues in research on web-based behavioral interventions. Ann Behav Med 38:28–39. CrossRefPubMedGoogle Scholar
  5. 5.
    Eysenbach G (2005) The law of attrition. J Med Internet Res 7:e11. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Classen CC, Chivers ML, Urowitz S, Barbera L, Wiljer D, O'Rinn S, Ferguson SE (2013) Psychosexual distress in women with gynecologic cancer: a feasibility study of an online support group. Psychooncology 22:930–935. CrossRefPubMedGoogle Scholar
  7. 7.
    Han JY, Kim JH, Yoon HJ, Shim M, McTavish FM, Gustafson DH (2012) Social and psychological determinants of levels of engagement with an online breast cancer support group: posters, lurkers, and nonusers. J Health Commun 17:356–371. CrossRefPubMedGoogle Scholar
  8. 8.
    Kim E, Han JY, Moon TJ, Shaw B, Shah DV, McTavish FM, Gustafson DH (2012) The process and effect of supportive message expression and reception in online breast cancer support groups. Psychooncology 21:531–540. CrossRefPubMedGoogle Scholar
  9. 9.
    Winzelberg AJ, Classen C, Alpers GW, Roberts H, Koopman C, Adams RE, Ernst H, Dev P, Taylor CB (2003) Evaluation of an internet support group for women with primary breast cancer. Cancer 97:1164–1173. CrossRefPubMedGoogle Scholar
  10. 10.
    Owen JE, Klapow JC, Roth DL, Shuster JL Jr, Bellis J, Meredith R, Tucker DC (2005) Randomized pilot of a self-guided internet coping group for women with early-stage breast cancer. Ann Behav Med 30:54–64. CrossRefPubMedGoogle Scholar
  11. 11.
    Beatty L, Koczwara B, Wade T (2016) Evaluating the efficacy of a self-guided web-based CBT intervention for reducing cancer-distress: a randomised controlled trial. Support Care Cancer 24:1043–1051. CrossRefPubMedGoogle Scholar
  12. 12.
    Wiljer D, Urowitz S, Barbera L, Chivers ML, Quartey NK, Ferguson SE, To M, Classen CC (2011) A qualitative study of an internet-based support group for women with sexual distress due to gynecologic cancer. J Cancer Educ 26:451–458. CrossRefPubMedGoogle Scholar
  13. 13.
    Duffecy J, Sanford S, Wagner L, Begale M, Nawacki E, Mohr DC (2013) Project onward: an innovative e-health intervention for cancer survivors. Psychooncology 22:947–951. CrossRefPubMedGoogle Scholar
  14. 14.
    Beatty L, Koczwara B, Wade T (2011) ‘Cancer coping online’: a pilot trial of a self-guided CBT internet intervention for cancer-related distress. Electron J Appl Psychol 7:17–25. Google Scholar
  15. 15.
    Bray VJ, Dhillon HM, Bell ML, Kabourakis M, Fiero MH, Yip D, Boyle F, Price MA, Vardy J (2017) Evaluation of a web-based cognitive rehabilitation program in cancer survivors reporting cognitive symptoms after chemotherapy. J Clin Oncol 35:217–225. CrossRefPubMedGoogle Scholar
  16. 16.
    Schover LR, Yuan Y, Fellman BM, Odensky E, Lewis PE, Martinetti P (2013) Efficacy trial of an internet-based intervention for cancer-related female sexual dysfunction. J Natl Compr Cancer Netw 11:1389–1397CrossRefGoogle Scholar
  17. 17.
    Shaw BR, Hawkins R, McTavish F, Pingree S, Gustafson DH (2006) Effects of insightful disclosure within computer mediated support groups on women with breast cancer. Health Commun 19:133–142. CrossRefPubMedGoogle Scholar
  18. 18.
    Couper MP, Alexander GL, Zhang N, Little RJ, Maddy N, Nowak MA, McClure JB, Calvi JJ, Rolnick SJ, Stopponi MA, Cole Johnson C (2010) Engagement and retention: measuring breadth and depth of participant use of an online intervention. J Med Internet Res 12:e52. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Foster C, Grimmett C, May CM, Ewings S, Myall M, Hulme C, Smith PW, Powers C, Calman L, Armes J, Breckons M, Corner J, Fenlon D, Batehup L, Lennan ECRM, Morris C, Neylon A, Ream E, Turner L, Yardley L, Richardson A (2016) A web-based intervention (RESTORE) to support self-management of cancer-related fatigue following primary cancer treatment: a multi-centre proof of concept randomised controlled trial. Support Care Cancer 24:2445–2453. CrossRefPubMedGoogle Scholar
  20. 20.
    David N, Schlenker P, Prudlo U, Larbig W (2013) Internet-based program for coping with cancer: a randomized controlled trial with hematologic cancer patients. Psychooncology 22:1064–1072. CrossRefPubMedGoogle Scholar
  21. 21.
    Bellg AJ, Borrelli B, Resnick B, Hecht J, Minicucci DS, Ory M, Ogedegbe G, Orwig D, Ernst D, Czajkowski S (2004) Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH behavior change consortium. Health Psychol 23:443–451. CrossRefPubMedGoogle Scholar
  22. 22.
    Eaton LH, Doorenbos AZ, Schmitz KL, Carpenter KM, McGregor BA (2011) Establishing treatment fidelity in a web-based behavioral intervention study. Nurs Res 60:430–435. CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    King S, Green HJ (2015) Psychological intervention for improving cognitive function in cancer survivors: a literature review and randomized controlled trial. Front Oncol 5:1–18. CrossRefGoogle Scholar
  24. 24.
    Schuurs A, Green HJ (2013) A feasibility study of group cognitive rehabilitation for cancer survivors: enhancing cognitive function and quality of life. Psychooncology 22:1043–1049. CrossRefPubMedGoogle Scholar
  25. 25.
    Mihuta ME, Green HJ, Shum DHK. (2016). Efficacy of a web-based cognitive rehabilitation intervention for adult cancer survivors: a pilot study. Manuscript submitted for publicationGoogle Scholar
  26. 26.
    Mihuta ME, Green HJ, Shum DHK. (2016). Web-based cognitive rehabilitation for survivors of adult cancer: a randomised controlled trial. Manuscript submitted for publicationGoogle Scholar
  27. 27.
    LAMS International Pty Ltd (2002) Lesson LAMS [online software] Retrieved from
  28. 28.
    Brain Resource Ltd (2011) WebNeuro (Version 1.7) [online software] Retrieved from
  29. 29.
    Hemphill JF (2003) Interpreting the magnitudes of correlation coefficients. Am Psychol 58:78–79CrossRefPubMedGoogle Scholar
  30. 30.
    Saul JE, Amato MS, Cha S, Graham AL (2016) Engagement and attrition in internet smoking cessation interventions: insights from a cross-sectional survey of “one-hit-wonders”. Internet Interventions 5:23–29. CrossRefGoogle Scholar
  31. 31.
    Strecher VJ, McClure J, Alexander G, Chakraborty B, Nair V, Konkel J, Greene S, Couper M, Carlier C, Wiese C, Little R, Pomerleau C, Pomerleau O (2008) The role of engagement in a tailored web-based smoking cessation program: randomized controlled trial. J Med Internet Res 10:e36. CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Schubart JR, Stuckey HL, Ganeshamoorthy A, Sciamanna CN (2011) Chronic health conditions and internet behavioral interventions: a review of factors to enhance user engagement. Comput Inform Nurs 29:81–92. CrossRefPubMedGoogle Scholar
  33. 33.
    Brouwer W, Kroeze W, Crutzen R, de Nooijer J, de Vries NK, Brug J, Oenema A (2011) Which intervention characteristics are related to more exposure to internet-delivered healthy lifestyle promotion interventions? A systematic review. J Med Internet Res 13:e2. CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Mohr DC, Cuijpers P, Lehman K (2011) Supportive accountability: a model for providing human support to enhance adherence to eHealth interventions. J Med Internet Res 13:e30. CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Murray E, White IR, Varagunam M, Godfrey C, Khadjesari Z, McCambridge J (2013) Attrition revisited: adherence and retention in a web-based alcohol trial. J Med Internet Res 15:e162. CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.Menzies Health Institute Queensland and School of Applied PsychologyGriffith UniversityGold CoastAustralia

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