Comparing a ses-sensitive and an all-ses implementation strategy to improve participation rates of patients with a lower socioeconomic background in a web-based intervention for depressive complaints: a cluster randomised trial in primary care

Abstract

Background: Depression is a major public health concern, which is most pronounced in population segments with a lower social-economic status (SES). E-health interventions for depressive complaints are proven to be effective, but their reach needs to be improved, especially among people with a lower socioeconomic status (SES). Implementing e-health interventions in the primary care setting with SES-sensitive guidance from General Practice nurses (GP nurses) may be a useful strategy to increase the reach of e-health in lower SES groups. We implemented an evidence-based online intervention that targets depressive complaints in primary care.

Methods: A pragmatic cluster-randomised trial was conducted in two parallel groups where a SES sensitive (SES-sens) implementation strategy with additional face-to-face guidance by GP nurses was compared to an all-SES implementation strategy. The primary outcome was the percentage of lower SES participants in either condition. Participation was defined as completing at least 1 face-to-face session and 2 online exercises. Participation rates were evaluated using logistic mixed modelling.

Results: In both conditions, the participation rates of lower SES participants were quite high, but were notably lower in the SES-sens implementation condition (44%) than in the all-SES implementation condition (58%). This unexpected outcome remained statistically significant even after adjusting for potential confounders between the conditions (Odds Ratio 0.43, 95%-CI 0.22 to 0.81). Less guidance was provided by the GP nurses in the SES-sens group, contrary to the implementation instructions.

Conclusions: From a public health point of view, it is good news that a substantial number of primary care patients with a lower SES level used the implemented e-health intervention. It is also positive that an all-SES implementation strategy performed well, and even outperformed a SES-sensitive strategy. However, this was an unexpected finding, warranting further research into tailoring implementation strategies of e-health interventions towards specific target groups in the primary care setting.

Trial registration: Netherlands Trial Register, identifier: NL6595 , registered on 12 November 2017.

Keywords: Depression; E-health; Implementation; Lower socio-economic status; Primary Care.

Fig. 1

Flowchart of study

Fig. 2

Patient satisfaction with the CDMIs for the all-SES and SES-sensitive implementation conditions

Fig. 3

Patients’ satisfaction (%) with GP nurse guidance in the SES-sensitive (n = 24) and all-SES (n = 45) implementation groups

Fig. 4

GP nurse satisfaction with the CDMIs and implementation materials for the all-SES and SES-sensitive implementation conditions

Fig. 5

Implementation sub-strategies used by the GP nurses in the all-SES and SES-sensitive implementation conditions