Introduction

Stroke is the third-leading cause of long-term disability in the adult population worldwide, often leading to difficulties with returning to a previous way of living life [1]. Many people with stroke find it challenging to engage in daily activities, especially in places outside the home, affecting their social contentedness and sense of belonging. This can negatively influence their patterns of daily activities in an ordinary day or week, that is, how, where and with whom they occupy their time [2]. In turn, the possibility to achieve a healthy occupational balance [3, 4], defined as a subjective experience of having a satisfying amount and variation of daily activities, becomes disrupted. A person with stroke who experiences an unhealthy occupational balance may also experience less value and meaning in daily activities, which is important for health and life satisfaction [5]. This often become obvious after discharge from the hospital, when the person no longer has access to health care poststroke and yet faces persistent challenges in everyday life [6, 7].

Rehabilitation that support self-management [8]–when clients are provided knowledge and skills to actively manage everyday life and facilitate their adaption to the consequences of stroke is therefore needed [7, 9–11]. However, access to rehabilitation in the later phases of stroke, is insufficient and unequally geographically distributed [12, 13]. Unfilled needs in daily activities are also common since the rehabilitation offered does not often specifically focus on facilitating an active everyday life [7, 13, 14]. In line with this, the action plan for stroke in Europe [15] emphasizes the need to develop services targeting life after stroke. An improved support to help people self-manage long-term issues to come to terms with their new situation is requested. In this, it is suggested that new modes of services need to be used as resource. Reviews [16–18] show a growing use of digital components in parts of the rehabilitation process after stroke, commonly for assessment or training. However, the use of internet-based solutions in supporting self-management of activities in everyday life is sparse. Thus, to complement the rehabilitation provided at rehabilitation facilities, new self-management programs that take advantage of the potential of new modes of delivery are needed. For instance, internet-based services can remove transportation barriers and reduce the personal effort and stress related to accessing rehabilitation facilities. Receiving internet-based services can increase motivation and enhance the implementation of flexible individually tailored rehabilitation anchored in everyday life [19–23]. To meet these needs, the internet-based intervention "Strategies for Empowering activities in Everyday life" (SEE, version 1.0) [14] was developed.

SEE [14] is developed for people with neurological conditions, such as stroke, who need support during the change process they go through when adapting to their new life situations. The content of SEE is designed to enable clients to “see” their daily activities in a new light by self-reflection and to develop self-initiated management strategies in the activities. The goal is thereby to empower clients to take an active role in preventing and overcoming problems and challenges in everyday life in a way that becomes sustainable over time [14]. The development of SEE follows the Medical Research Council guidance (MRC) for how complex interventions are developed and evaluated [24]. Prior stages of the SEE development phase involved reviewing and developing evidence to underpin the intervention and modelling the prototype in collaboration with stakeholders [14]. The development phase of SEE has now reached the stage of initially testing the prototype in clinical practice. As the intervention is new (both in terms of delivery and content), it is important to identify possible alterations and improvements before a larger-scale feasibility study is performed. Testing SEE on a few cases, closely following both clients and clinical occupational therapists (OTs) during pre- and postintervention, can provide important knowledge of SEE’s (i) feasibility and acceptability, with a focus on delivery and content, as well as (ii) experienced changes and outcomes.

Material and methods

Recruitment

A consecutive selection of potential participants was performed from a list of patients who had received early supported discharge and rehabilitation in the home from a hospital in the northern part of Sweden according to the inclusion criteria: (i) stroke onset > 6 months, (ii) aged 18–75 years, (iii) moderate disability or good recovery based on the extended Glasgow Outcome Scale [26], (iv) able to express themselves verbally and in writing, (v) access to the internet (computer, tablet, or phone they were able to use), and (vi) be motivated to change activities in everyday life. Their motivation to change was explored by a set of questions [27] investigating if daily activities were a problem and if there were a readiness to implement a change. The person needed to respond positively on the questions to be included. The exclusion criteria were (vii) other illnesses/injuries affecting daily activities and (viii) depression based on Hospital Anxiety and Depression scale [28]. The client participants inclusion included a three steps process, as the information at the clinic did not provide updated information on all criteria. Therefore, supplementary assessment needed to be conducted by the researchers (step two and three).

In the first step of the inclusion process, an OT at the clinic identified potential participants based on criteria (i-iv, vii) Research information letters were sent to potential participants, including information about the intervention and that participation was voluntary. Those who were interested in participating were instructed to send a written response to the clinic. Those who did not respond were contacted by the OT by telephone to ensure that no potential participants were missed. Contact information for those who were interested was forwarded to the research team. In the second step of the inclusion process, the potential participants were contacted by the research team (IMB, MR) by phone to screen for inclusion criteria (iii, v). In a third and final step of the inclusion process, a last screening (criteria vi, viii) was conducted in a video meeting. Throughout the inclusion process, besides the written information letters, potential client participants received verbal information about the research and their possibilities to withdraw at any time. Those who were assessed eligible to participate were informed again before their verbal and written informed consent was sought. All client participants agreed in written to participate.

In all, twenty-one potential participants with stroke were asked to participate. Four agreed to participate, two could not be reached and fifteen declined. The four clients were between the ages of 59 and 69 years (Table 1).

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Table 1. Characteristics of the client with stroke receiving SEE, n = 4.

https://doi.org/10.1371/journal.pone.0296364.t001

Two OTs at the rehabilitation clinic were also recruited to provide SEE to the clients. The OTs received verbal information about the study and an information letter before they provided their verbal and written informed consent to participate. The OTs (one man and one woman) had ten and twenty-four years of experience in the profession and had substantial clinical experience working with clients with stroke.

Data collection and procedure

To follow the intervention process and evaluate the feasibility of SEE, data were collected with several methods on four occasions (i-iv) (Table 2). In the evaluation phase/baseline (i), standardized assessment tools were used to evaluate the complexity of an active everyday life and changes herein to support and evaluate the outcome of the process. The primary outcome assessments focused on aspects of activities in everyday life and how these had been managed based on both self-reports and professional assessment. These were an interview instrument based on a time-use diary—the profiles of occupational engagement (POES) [30, 31]—and self-reports using the occupational balance questionnaire (OBQ11) [32, 33] and the occupational values with predefined items (Oval-pd) [34]. The secondary outcome assessments included additional aspects that further can be affected and contribute to interpretation of the potential results. These were the life satisfaction questionnaire (Lisat-11) [35], the work ability index (WAI) [36] (if the clients worked) and the general self-efficacy scale (S-GSE) [37, 38]. The data collection process at baseline (i) started with that the assessment tools (Table 2) were sent to clients, who returned them by regular mail. Thereafter, a video meeting took place to complete the assessments and, through dialogues, support their self-reflections on their activities of everyday life and management strategies. The content of dialogues (i) was summarised in field notes. The assessment tools (Table 2) were again applied in a similar way combined with the dialogue at the four-month follow-up (iv) by the same researcher involved in the evaluation phase.

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Table 2. Overview and timeline of the data collection.

https://doi.org/10.1371/journal.pone.0296364.t002

Throughout the intervention process (ii), the OTs completed registration forms of the implementation of SEE for each client after each module/session until the intervention ended. The forms covered how the technology used in the intervention functioned (health care platform, web program, video meetings) for both the client and the OT, whether the client adopted the intervention as intended, how the process evolved, and whether the education and intervention guide supported them in applying the various modules/sessions. If contacts were established with clients for any reason during the intervention process, filed notes were made to document the occasion. The researchers did not have access to the 1177 treatment platform or medical records.

At the one-month follow-up, which took place after the web program and establishment of the activity plan (iii), qualitative semi-structured interviews [39] with clients (by IMB, MR) and their OTs (by IMB, MLL) were conducted by video meetings. The interview guides for the clients focused on their experiences with SEE´s content and delivery. The questions covered the clients’ use of technology, barriers and facilitators related to technology use, as well as aspects of convenience, safety, and security. Questions were also asked about their experiences with each module/session and whether the SEE supported the development of self-management strategies. Finally, the clients were also asked how they established the activity plan with the OT and whether they would be able to implement it independently with the support of the OT. The interviews with the OTs focused on their experiences with providing SEE, including both technology use and the client´s intervention process. Furthermore, there was a need to further develop web-based education or the intervention guide.

At the follow-up four months after the intervention started (iv), semi-structured interviews were again conducted with the clients (by IMB, MR) and their OTs (by IMB, MLL) through video meetings. This time, the clients’ interview guides focused on the implementation of their activity plan, potential changes in everyday life and eventual needs for developing the intervention. The interview guide with the OTs covered how they had supported clients in implementing their activity plan/their change process, whether SEE changed their work and whether they had missed any content in SEE or support in the implementation. All the interviews (iii, iv) were audio recorded and transcribed verbatim.

One client did not complete the intervention. Therefore, after the fifth module in the web program, the one-month interview was conducted during a home visit. Additionally, observations of the use of the web program were documented in field notes. A complementary telephone interview with the client finalized the data collection.

Results

The results consist of three categories: A) not being able to take on the internet-based intervention, B) being facilitated in the change process of daily life through the internet-based intervention, and C) providing a new internet-based intervention is a transition from ordinary practice. Each category includes two to four subcategories (Table 3), reflecting how aspects of SEE content and delivery were experienced differently in the three categories, as presented below. The presentation includes descriptions of whether changes were found in the outcome assessments for clients and detailed information of their descriptive values is given in Table 4.

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Table 3. Categories describing clients with stroke and their occupational therapists’ experiences of the intervention process of SEE, reflecting feasibility and acceptability with a focus on content and delivery and experienced changes and outcomes of SEE.

https://doi.org/10.1371/journal.pone.0296364.t003

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Table 4. The outcome of SEE in clients with stroke (n = 4).

https://doi.org/10.1371/journal.pone.0296364.t004

Discussion

The aim of this study was to explore and describe how clients with stroke and their OTs experienced the intervention process of SEE and whether SEE has the potential to promote an active everyday life. The first test of the intervention process indicates that the content and delivery of SEE can be feasible and acceptable both for clients and OTs. The findings suggest that SEE has the potential to support clients’ self-reflections and their adoption of strategies that influence engagement in daily activities and satisfaction with life in various ways. Additionally, the educational program and the intervention guide of SEE together with supervision have the potential to support OTs in guiding clients forward in their change process. However, the results need to be considered in the light of the case study design and the fact that this initial clinical testing of SEE was limited to one rehabilitation setting. The result indicates, in line with recent research [21, 41, 42], the potential to develop stroke rehabilitation by applying various internet-based solutions. In contrast to other new (occupational therapy based) interventions [42–44] that foremost incorporate internet-based solutions as a component of the program, SEE is completely internet-based throughout the interventions process. The results can therefore provide important knowledge when other internet-based interventions are developed. As other stroke interventions foremost focus on needs in the earlier phases after stroke and on restoring functioning [45]. The results add insights in how the change process people need to go through to adapt to an active everyday life on new conditions can be targeted in programs in the later phases of rehabilitation. Moreover, our results indicate that after some minor adjustments, the evaluation of SEE is ready to move to the next phase, i.e., the feasibility phase including research with larger samples and a quantitative approach, in accordance with the guidelines for the development of complex interventions [24].

All four clients perceived that the content of SEE was relevant for their needs (Table 3). This indicates that the SEEs’ focus, and content match clients’ rehabilitation needs that were previously identified through reviews of research during the development of the intervention [14, 46–48]. However, for one of the clients (category A), it was found that the internet-based format of delivery was not suitable. The results indicate that this can be difficult to detect through dialogues, especially if a client have not tested the format before and if they are not fully aware of their abilities to use the health care platform. It can also be difficult to detect whether a client can take on an active role in their change processes prior to starting the intervention. Playing an active role in their change processes is also associated with the clients’ motivations being changeable [27]. If something in the intervention becomes unmanageable, such as technology, motivation can be lost. Consequently, it is as important to want to change as it is to be ready and able to change (e.g., use needed technology) [49]. When difficulties occur, as for the client in category A, it is important to provide support sensitive to why SEE is not working or to offer another form of rehabilitation. In the future, assessments of the ability to use technology [50–52] might be a way to identify whether the internet-based format is suitable for a client.

As it was the first time that the included clients and OTs participated in an internet-based intervention, the feasibility and acceptability of SEE delivery were influenced by the participants’ ability to manage the technology involved as well as environmental aspects. The results revealed the importance of reviewing whether the physical, social, and organizational work environment [53] supports the transition to an internet-based service by providing, e.g., individual rooms, technological equipment, education, support, and digital solutions for time management. This is in line with recent discussions [54, 55] of urgent issues to maximize the potential of the digital transformation of health care. For both parties, it was important to prepare for the modules and e-meetings to optimise their outcomes, e.g., by setting aside enough time and choosing a place to avoid interruptions. Based on these experiences, some small amendments related to SEE delivery have been made. The intervention guide as well as the client information now includes recommendations on how to prepare for the intervention sessions. Routine documents have been established to support OT, e.g., in how to contact clients digitally and how to share screens with clients when the activity plan is established.

The results from the three clients in category B and their OTs show how technology, when working as intended, can be perceived as advantageous over physical face-to-face meetings. The three clients described, in line with research [56], how they saved energy and time by not having to transport themselves to the clinic. Instead, valuable time could be spent on processing and repeating the content of the intervention. From the two OTs’ perspective, this improved their ability to support clients’ change process. Our results indicate that the therapeutic relationship and dialogue can be enhanced by SEE, where OTs can spend more time supporting clients in processing content rather than providing information. This confirms the value of applying the flipped-classroom methodology [57] as a means for supporting distance-based learning and processes in health care services.

The experiences of the three clients in category B reflected how SEEs’ content and delivery fostered them to take responsibility and lead their change processes. Based on the knowledge gained from the modules, their self-reflections of engagement in daily activities were developed, and new strategies were adopted. This indicates, similar to occupational therapy models [58–60] and interventions with a similar focus [61–63], the advantages of supporting peoples’ self-reflections on patterns, balance and values in activities in everyday life. Additionally, the results indicate in accordance with occupational therapy models [58–60] that focusing on engagement in daily activities has advantages both as a therapeutic means and as a goal in the change process. Facilitating people’s management resources and self- initiated strategies in activities of everyday [64] can be seen as important due to the changes taking place in the health care system [65, 66], here people is expected to take responsibility and act proactively to promote their own health. As existing occupational therapy models [60, 67] focuses on professional strategies rather than on clients own self- initiated strategies, future intervention research as of SEE can contribute to model development.

The fact that the clients were responsible for their own change processes and self-reflections allowed their change processes to develop in different ways. This was described by the two OTs as new and challenging for supporting clients. On the other hand, in line with the literature on motivational interviewing [49], this was perceived by the OTs to strengthen the sustainability of the intervention in the long term. As SEE involves a transition from the OT´s ordinary way of working, both in terms of content and delivery, education and supervision are needed. Based on the participants’ experiences, the educational program, the intervention guide, and the structure for supervision were updated. A completed activity plan was included as an example in the intervention guide. Moreover, to support the clients’ preparation prior to establishing the activity plan, information sheets supporting self-reflection have been developed.

The results indicate that SEE, when implemented as intended, has the potential to change everyday life (engagement in daily activities, occupational balance, occupational value, and aspects of life satisfaction). Notably, client 2 in category B, who chose not to establish an activity plan and continue the process without guidance from the OT, did not achieve positive changes that were reflected in the assessments to the same extent as clients 3–4, who completed the whole SEE process. However, the qualitative descriptions (from both client 2 and the OT) reflected that those changes in everyday life had been implemented successfully even if the changes were reflected to a limited extent in the assessments. After improvements in SEE, feasibility studies are needed to further explore potential effects as well as to deepen the understanding of components influencing the intervention processes and their outcomes from both a client and an OT perspective. Future research also needs to investigate resource utilization as time consumption in relation to outcomes of SEE and how the change of the OTs practice (using SEE) can be integrated with the practice of other professionals in interdisciplinary teams.

Methodological considerations

The qualitative descriptive case study design, including both clients and their OT, combining multiple data collection methods resulted in rich descriptions from various aspects of each case that enhance the understanding of credibility and transferability [40] of the results. Even if this first clinical test is based on a small sample, i.e., four clients and two OTs, the results contributed with information that led to several improvements in SEE content and delivery. From an ethical and resources utilization perspectives, it can be favorable to limit the initial testing to a few cases prior to implementing feasibility studies with larger samples. It is possible that the credibility [40] of the data might have been limited since the participants knew the researchers who collected the data and were a part of the team who developed and evaluated SEE. This could potentially have hampered them from talking freely about their experiences, even if they were repeatedly told that positive and negative experiences were equally important to developing SEE. The client participants were consecutively invited from a list with a potential to ensure we reach a variation of participants. When four had agreed to participate the inclusion needed to stop due the COVID-19 outbreak. This resulted in a rather homogeneous sample even if the number of women and men included in both participant groups were equal. If more participants had been included, they would probably have contributed with additional perspectives. However, the depth of data of the cases comprised were judged to be sufficiently rich to ensure the quality of the first clinical test. Further, it was beyond the scope of this case study to focus on differences related to the participant’s background data. In forthcoming feasibility studies, it will be important to ensure variation of participants related to background data as age and, also, to include several rehabilitation settings. The authors, all of whom were OTs, had various experiences of clinical rehabilitation, distance-based learning, and research. To ensure trustworthiness [40], the authors served different roles with their various expertise to support each other to remain open during the analysis process when the results evolved.

Conclusion

In conclusion, the first test of the intervention process indicates that the content and delivery of SEE can be feasible and acceptable to both clients and OTs. The findings suggest that SEE has the potential to support clients’ self-reflections and their adoption of strategies that influence engagement in daily activities and satisfaction with life in various ways. This study identified several minor improvements in content and delivery needed to strengthen the implementation of SEE intervention processes in the forthcoming feasibility phase.

Acknowledgments

The authors are grateful to the participants who took on the new intern-based intervention and shared their experiences. We are also grateful to the management team for Paramedicine, Sunderby Hospital, Region Norrbotten, for enabling the implementation of SEE.