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When trying to access interventions to improve their well-being and quality of life, family caregivers face many challenges. Internet-based interventions provide new and accessible opportunities to remotely support them and can contribute to reducing their burden. However, little is known about the link existing between the components, the use of behavior change techniques, and the outcomes of these Internet-based interventions.
This study aimed to provide an update on the best available evidence about the efficacy of Internet-based interventions for caregivers of older adults. Specifically, the components and the use of behavior change techniques and how they impact on the efficacy of the intervention were sought.
A systematic review searched primary source studies published between 2000 and 2015. Included studies were scored with a high level of evidence by independent raters using the GRADE criteria and reported caregiver-specific outcomes about interventions delivered through the Internet for caregivers of people aged 50 years and older. A narrative synthesis identified intervention components (eg, content, multimedia use, interactive online activities, and provision of support), behavior change techniques, and caregiver outcomes (eg, effects on stressors, mediators, and psychological health). The risk of bias within the included studies was assessed.
A total of 2338 articles were screened and 12 studies describing 10 Internet-based interventions were identified. Seven of these interventions led to statistically significant improvements in caregiver outcomes (eg, reducing depression or anxiety, n=4). These efficacious interventions used interactive components, such as online exercises and homework (n=4) or questionnaires on health status (n=2) and five of them incorporated remote human support, either by professionals or peers. The most frequently used behavior change techniques included in efficacious interventions were provision of social support (n=6) and combinations of instructions to guide behavior change and barrier identification (n=5). The design and aim of the included studies did not permit determining exactly which component and/or behavior change technique was more efficacious in producing positive outcomes in caregivers. The risk for selection bias was low for all the studies, and low to high for performance, detection, and attrition biases.
In sum, Internet-based interventions that incorporate professional and social support, and provide instructions to change behavior and problem solve in an interactive manner appear to lead to positive outcomes in caregivers. Studies isolating the specific effect of components are needed to improve our understanding of the underlying mechanism of action.
A family caregiver (henceforth described as caregivers) is a person who provides care without any financial compensation for a family member, a friend, or a loved one with long-term health problems or disabilities [
The Stress Process Model [
Considering the stress and burden they experience, caregivers of older adults require health care, psychosocial, community, and respite services to prevent negative outcomes related to their caregiving role. However, caregivers experience many barriers when trying to obtain those services, such as lack of transportation to access the intervention, unavailability of a secondary caregiver to take over in their absence, and lack of flexibility to participate in a highly demanding intervention [
Internet-based interventions, also referred to as eHealth interventions or information and communication technology-based interventions, are defined as therapeutic programs with specific health objectives delivered mainly using the Internet [
To our knowledge, seven reviews [
One factor that might explain the efficacy of Internet-based interventions, aside from the components of the intervention itself, is the incorporation of behavior change techniques (BCTs). BCTs are strategies that promote behavior change by, for example, providing information on consequences of behavior on health, prompting users to identify barriers to behavior change or offering social support. A review by Webb et al [
This study aimed to provide an update on the best available evidence about the efficacy of Internet-based interventions for caregivers of older adults. Specific objectives were to (1) classify the components that are found in Internet-based interventions for caregivers of older adults, (2) describe the BCTs used in these Internet-based interventions, and (3) explore which intervention components and BCTs of Internet-based interventions are associated with efficacious outcomes in caregivers.
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [
Studies were included if they (1) were original papers published in peer-reviewed journals, (2) reported on an intervention of which the principal mode of delivery was the Internet, (3) reported caregiver-specific outcomes, (4) targeted caregivers of older adults and thus had a sample including at least one caregiver of a person aged 50 years or older, and (5) were of a high level of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria [
The complete selection process is detailed in
PRISMA flowchart of the search strategy and results.
The first author abstracted data from included studies using Excel forms to record the study characteristics, components of the Internet-based interventions, and the use of BCTs. Caregiver population, experimental and control conditions, data collection for reported outcomes, analyses performed, and additional characteristics specific to Internet-based trials as outlined in the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials) guidelines (eg, computer literacy, intended dosage, usage outcomes) [
Caregiver outcomes were classified with the Stress Process Model [
All Internet-based interventions and their components were coded using the Barack and Klein categorization [
Content: nature of the information disseminated through the program. Can be generic and educative or designed to create a therapeutic change.
Multimedia: means used to disseminate the content (eg, text, graphics, video).
Interactive online activities: opportunities given to participate actively within the program (eg, quizzes, exercises, questionnaires).
Guidance and supportive feedback: tools by which users access external information about their performance and progress. Can be offered automatically with integrated algorithms (eg, reminders) or by professionals and/or peers through asynchronous (eg, email, forums, bulletin boards) or synchronous (eg, videoconference) components.
Behavior change techniques were also extracted from the description of interventions found in the report using the taxonomy of Abraham and Michie [
Finally, although a high level of evidence per the GRADE criteria was a condition for inclusion, risk of bias was still assessed as “high,” “low,” or “unclear” for the random sequence generation and concealment of allocation (selection bias), for blinding of outcome assessors and the use of valid measures (detection bias), for the blinding of the participants (performance bias), and for how withdrawals were statistically accounted for (attrition bias). This was done as recommended by the Cochrane Handbook for Systematic Reviews of Interventions [
After applying the search strategy detailed in
The main characteristics of the included studies are presented in
Characteristics of the study population of included studies (N=12).
Author | Country | N | Mean age (SD)b | Femaleb | Relationship with care |
Diagnosis of |
Beauchamp et al [ |
USA | 299 | 46.9 (12.2) | 73% | Child (67%) | Dementia |
Blom et al [ |
Netherlands | 245 | 61.2 (12.37) | 69.4% | Spouse (58.4%) | Dementia |
Chih et al [ |
USA | 235 | 56 | 64.2% | Spouse/partner (69.3%) | Cancer |
Cristancho-Lacroix et al [ |
France | 49 | 64.2 (10.3)a | 16 (64%)a | Child (64%)a | Dementia |
DuBenske et al [ |
USA | 246 | 55.56 | 68.3% | Spouse/partner (72%) | Cancer |
Eames et al [ |
Australia | 61 | 55.5 | 64% | Spouse/partner (67%) | Stroke |
Kim et al [ |
South Korea | 36 | 53 (13.7) | NR | Spouse (66.7%)a | Stroke |
McLaughlin et al [ |
USA | 201 | NR, 34.6% aged 51-60a | 86.4%a | NR | TBI |
Namkoong et al [ |
USA | 285 | 55.56 | 68.3% | NR | Cancer |
Pierce et al [ |
USA | 103 | 54 (12.2)a | 69.4%a | Wife (41.7%)a | Stroke |
Smith et al [ |
USA | 32 | 55.3 (6.9)a | 100% | Wife (100%) | Stroke |
Torkamani et al [ |
UK, Spain, and Greece | 60 | 60.69 (13.90) | 45% | NR | Dementia |
aFor intervention group only.
bNR: none reported; SD: standard deviation; TBI: traumatic brain injury.
Description of the intervention and control groups of included studies (N=12).
Author | Intervention | Control group | ||||
na | Durationb | Description | na | Description | ||
Beauchamp et al [ |
150 | 30 days | Caregiver’s Friend: Dealing with Dementia—an ongoing worksite Web-based support program providing materials tailored to the needs of caregivers in 3 distinct modules (being a caregiver, coping with emotions, and common difficulties) | 149 | Usual care wait list | |
Blom et al [ |
149 | 5-6 months | Mastery Over Dementia: a 9-lesson online program; the first 8 lessons followed the same sequence: provision of information, exercises, homework, and feedback; lessons were about coping with behavioral problems, relaxation, arranging help from others, changing nonhelping thoughts, and communication; final lesson was a recap and booster session | 96 | E-bulletin sent by email every 3 weeks for 6 months; content did not overlap with intervention | |
Chih et al [ |
118 | 12-24 months | Comprehensive Health Enhancement Support System (CHESS): a password-protected website in which users self-directed to a variety of services (information, communication, and coaching); content covered cancer, caregiving and palliative care, emotional distress, use of coping techniques, and communication techniques | 117 | Access to the same intervention, without one component (clinical report) for 12-24 months | |
Cristancho-Lacroix et al [ |
25 | 12 weeksc | Diapason: a password-protected website offering information, skills training and a forum for caregivers; content was divided in 12 thematic sessions with videos covering caregiver stress, understanding the disease, maintaining the loved ones’ autonomy, understanding their reactions, coping with behavioral and emotional troubles, communicating, improving their daily lives, avoiding falls, pharmacological and nonpharmacological interventions for caregivers, social and financial support, and about the future | 24 | Usual care | |
DuBenske et al [ |
124 | 2 years or up to 13 months after the death of the care recipientc | Comprehensive Health Enhancement Support System (CHESS): a password-protected website in which users self-directed to a variety of services (information, communication, and coaching); content covered cancer, caregiving and palliative care, emotional distress, use of coping techniques, and communication techniques | 122 | Access to a list of cancer and palliative care websites constructed from the opinions of clinicians in addition to usual care | |
Eames et al [ |
31 | 3 monthsc | What You Need to Know About Stroke: an educational package online containing a list of 34 topics regarding stroke; the Web-based intervention was reinforced with 3 face-to-face and 3 telephone meetings with participants | 30 | Usual care for the care recipient | |
Kim et al [ |
18 | 9 weeks | A Web-based program incorporating education and resources to support self-efficacy in the home setting. Content was divided in nine video sessions covering three themes: understanding stroke, recurrence prevention, and family life | 18 | Access to an e-bulletin over the course of 6 months | |
McLaughlin et al [ |
104 | 3 months | Brain Injury Partner: a Web-based program designed to improve family advocacy skills with content covering advocacy skills, strategies for reducing stress, and to determine necessary professional support needs | 97 | Access to the Brain Injury Association of America (BIAUSA) | |
Namkoong et al [ |
141 | 2 years | Comprehensive Health Enhancement Support System (CHESS): a password-protected website in which users self-directed to a variety of services (information, communication, and coaching); content covered cancer, caregiving and palliative care, emotional distress, use of coping techniques, and communication techniques | 144 | Access to a list of high-quality patient-directed cancer and palliative care websites in addition to usual care | |
Pierce et al [ |
51 | 1 year | Caring-Web: an educational and support intervention that answered questions, discussed options, and gave up-to-date information covering frequently requested topics like stroke disease process, safe transfer techniques, and emotional changes | 52 | Specific instructions to not buy or use Internet during the study in addition to usual care | |
Smith et al [ |
15 | 11 weeks | A Web-based conferencing and video education intervention designed to provide the caregiver with knowledge, resources, and skills; content was divided in 9 weekly video topics covering how to get in touch with your feelings as a caregiver, understanding what it’s like to be a care recipient, being a good listener, nonverbal behavior, choice/control/predictability, relaxation and positive imagery to control stress, and the role of pleasant activities | 17 | Access only to one component of the intervention that presents links to resources | |
Torkamani et al [ |
30 | 6 months | A technology pLatform for the Assisted living of Dementia elDerly Individuals and their carers (ALADDIN): a Web-based program designed to provide support and information with content covering dementia and relaxation/exercises techniques | 30 | No attention or intervention given |
aBefore attrition.
bLength of access to intervention.
cIn addition to usual care.
One Internet-based intervention was designed specifically to answer the needs of caregivers who were also workers [
The setting of the interventions varied across the included studies in terms of dosage, comparison conditions, and reported adherence. Half of the Internet-based interventions were administered to the experimental group without specification regarding dosage or a “use as you will” instruction [
As detailed in
Risk of bias.a
Author | Selection bias | Performance bias | Detection bias | Attrition bias | |
Random sequence generation | Allocation concealment | Single blind | Blinding of outcome assessor | Missing data | |
Beauchamp et al [ |
+ | + | – | + | + |
Blom et al [ |
+ | + | + | + | – |
Chih et al [ |
+ | + | – | + | – |
Cristancho-Lacroix et al [ |
+ | + | – | – | – |
DuBenske et al [ |
+ | + | – | + | – |
Eames et al [ |
+ | + | – | + | + |
Kim et al [ |
+ | + | – | ? | + |
McLaughlin et al [ |
+ | + | – | + | + |
Namkoong et al [ |
+ | + | – | + | – |
Pierce et al [ |
+ | + | – | ? | – |
Smith et al [ |
+ | + | – | + | – |
Torkamani et al [ |
+ | + | – | ? | ? |
a+: low risk of bias; – high risk of bias; ?: unclear risk of bias.
The included studies reported results concerning 10 interventions because the outcomes of one intervention were reported in three different articles [
All interventions used written text as their main multimedia component and some also used videos [
Most interventions offered interactive online activities, either in the form of homework, quizzes, and exercises to reinforce the educational content [
Human support was given asynchronously (eg, forum, email, bulletin boards) [
Other common components included the provision of links to additional resources [
Component categoriesa for each category of the Internet-based interventions.
Author | Multimedia | Interactive online activitiesb | Guidance and supportive feedbackb | Otherb | |
Eames et al [ |
Text | NR | NR | NR | |
Pierce et al [ |
Text | NR | Professional support: nurse specialist and rehabilitation team respond to questions with a private asynchronous module (email forum); peer support: asynchronous discussions facilitated by a nurse (email) | List of relevant Web links | |
Torkamani et al [ |
Text | Online questionnaires on CR and CG health status | Professional support: clinicians receive answers from IOA, facilitating the speedy delivery of appropriate interventions; clinicians are also reachable with a “contact us” button; peer support: asynchronous discussion sessions (forum) | Musical entertainment; relaxation and exercise techniques | |
Beauchamp et al [ |
Text; videos | Online questionnaires on CG personal situation; changing role button to select the relationship with CR | NR | IOA used to tailor content; testimonials | |
McLaughlin et al [ |
Text; videos | Video-based skills exercises | NR | List of relevant Web links and articles | |
Blom et al [ |
Text; videos | Homework and exercises online; evaluation at the start and end of each lesson | Professional support: psychologist provides asynchronous feedback on IOA (electronic secured app); automatic reminders to send homework or attend lessons | Consultation of feedback is mandatory to have access to the next lesson | |
Cristancho-Lacroix et al [ |
Text; videos lectures | NR | Peer support: asynchronous discussion sessions moderated by a psychologist (forum) | Relaxation training; testimonials; glossary; bank of activities to stimulate CR | |
Chih et al [ |
Text; graphic | Online questionnaires on CR and CG health status; coaching service that automatically generates graphics of health status, offer decision aids, and structures an action plan | Professional support: cancer information specialist available via an “ask and expert” button.; Clinician report: summaries of users’ health available to the clinical team on demand, from a threshold alert or two days before a clinic visit; peer support: asynchronous discussion sessions moderated by a professional facilitator (bulletin board) | IOA and interactions through supportive feedback component used to tailor content; FAQs; list of relevant Web links, articles and community services; cancer news; testimonials ; personal webpage | |
Kim et al [ |
Video lectures; PowerPoint slides | Online quizzes following the viewing of video lectures | Professional support: asynchronous service to network with health professionals (email) | List of relevant Web links | |
Smith et al [ |
Text; video of enacted support group | At-home apps given by a nurse | Professional support: two times per week, a synchronous chat session directed by a nurse for the viewing and commenting of the weekly video (Adobe connect); the nurse is also available by asynchronous communication (email); peer support: asynchronous discussion sessions (email and message board) | List of relevant Web links, instructional videos and PDF files; online library of educational information; search engine |
aAs categorized by Barack and Klein [
bCG: caregiver; CR: care recipient; FAQ: frequently asked question: IOA: interactive online activities; NR: none reported.
All three Web-based education interventions used less than two BCTs [
Behavior change techniques for each category of Internet-based interventions.
Author | Behavior change techniquesa | Caregiver outcomes (ES)b | |
Eames et al [ |
NR | NSSD in caregiver strain | |
Pierce et al [ |
NR | NSSD in depression symptoms and satisfaction with life | |
Torkamani et al [ |
Social support; stress management | NSSD in caregiver burden, occurrence of psychiatric, and/or behavioral problems, depressive symptoms, and quality of life | |
Beauchamp et al [ |
Barrier identification; instructions; modeling; social support | ↓ stress (0.5); ↑ intention to get support (0.3); ↓ caregiver strain (0.2); ↑ caregiver gain (0.2); ↓ depressive symptoms (0.2); ↓ state anxiety (0.2); ↑ self-efficacy (0.2); NSSD in the use of specific stress-reduction strategies | |
McLaughlin et al [ |
Barrier identification; instructions; modeling; prompt practice; stress management | ↑ skill application (1.01); ↑ intention to use (0.7); ↑ knowledge (0.67); NSSD in satisfaction with life | |
Blom et al [ |
Barrier identification; instructions; modeling; feedback on performance; stress management; time management | ↓ symptoms of anxiety (0.48); ↓ depressive symptoms (0.26) | |
Cristancho-Lacroix et al [ |
Information on behavior-health link and on consequences; barrier identification; instructions; prompt practice; social comparison; social support; stress management | ↑ knowledge (0.79); NSSD in perceived stress | |
Chih et al [ |
Information on behavior-health link and on consequences; barrier identification; instructions; goal setting; social support; stress management; time management | ↓ negative mood at 6 and 12 months; ↓ caregiver burden at 6 months; ↑ bonding = ↑ active coping; NSSD for preparedness, physical burden, and in levels of disruptiveness | |
Kim et al [ |
Information on behavior-health link and on consequences; instructions; feedback on performance | ↑ caregiver mastery | |
Smith et al [ |
Information on behavior-health link and on consequences; intention formation; instructions; self-monitoring of behavior; feedback on performance; prompt practice; social comparison; social support; identification to role models; stress management | ↓ depression at 11 weeks and 1 month follow-up; NSSD in sense of mastery, self-esteem, and social support |
aAs categorized by Abraham and Michie [
bArrows show the direction of statistically significant differences in intervention group compared to control for outcomes measured (
Classification of the statistically significant outcomes by categories of Internet-based interventions and according to the Stress Process Model.a
Outcome | Web-based education |
Self-help Web-based |
Human-supported Web-based therapeutic |
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[ |
[ |
[ |
[ |
[ |
[ |
[ |
[ |
[ |
[ |
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Problematic behavior | 0 | ||||||||||||
Relationship quality | 0b | ||||||||||||
Disruptiveness | 0 | ||||||||||||
Caregiver gain | + | ||||||||||||
Mastery | 0 | + | 0 | ||||||||||
Self-esteem | 0 | ||||||||||||
Depression | 0 | 0 | + | + | 0 | + | + | ||||||
Anxiety | + | + | |||||||||||
Stress | +b | 0 | |||||||||||
Caregiver strain | + | ||||||||||||
Caregiver burden | 0 | 0 | 0 | + | |||||||||
Physical burden | 0 | ||||||||||||
Self-perceived health | |||||||||||||
Quality of life | 0 | 0 | 0 | ||||||||||
Intention to get support | +b | ||||||||||||
Social support | 0 | ||||||||||||
Coping | 0 | 0b | |||||||||||
Self-efficacy | +b | 0b | |||||||||||
Knowledge | +b | +b | |||||||||||
Skill application | +b | ||||||||||||
Perceived bonding | + |
a+: Statistically significant effect (
bValidation process of the measure was not reported.
A list of all the outcomes measured and statistically significant effects found at time of completion for each intervention is classified according to the Stress Process Model in
Concerning outcomes at time of completion, none of the Web-based education interventions reported statistically significant differences on any outcomes when compared to usual care [
The goal of this study was to systematically review the best available evidence regarding the efficacy of Internet-based interventions for caregivers of older adults. Specifically, we sought to narratively synthesize the components integrated in such interventions following the classification of Barack and Klein [
Results from the review concerned Web-based education intervention, self-help Web-based therapeutic interventions, and human-supported Web-based therapeutic interventions. Online counseling, Internet-operated therapeutic software (including emerging technologies such as robotics, therapeutic gaming, and three-dimensional environments), and other online activities were not found in studies of a high level of evidence, which may reflect the novelty of research in these categories. Studies from these categories of Internet-based intervention are currently either at a pilot stage or have a lower level of evidence [
Concerning the components, a combination of interactive online activities and provision of human support seemed to generally lead to better outcomes in caregivers. Exercises, homework, and questionnaires were the most used components from the interactive online activities’ category and appeared to be part of the success of the efficacious interventions. This can be explained by the fact that they linked to the use of BCTs and to the provision of human support. On one hand, exercises and homework were used to reinforce and build on the knowledge and skills caregivers learned while reading or viewing the content of the interventions, which can be viewed as the usage of “prompt practice” and “model behavior” techniques. In this way, Internet-based interventions represent a valuable advantage over telephone-based interventions or printed educational material [
Human support, either provided by a health professional or peers, asynchronously or synchronously, was a component widely used in the interventions included and might account for the reported efficacy of human-supported Web-based therapeutic interventions. Having rapid and remote access to a health professional for advice and tailored support has been reported in previous studies of Internet-based interventions for care recipients as the primary factor predicting adherence [
Despite recommendations [
The efficacy of Internet-based interventions for caregivers of older adults has been primarily demonstrated for psychological outcomes, such as a reduction in depression, anxiety, and burden, in this review and previous ones [
Methodological and reporting differences in the studies limit the conclusions that can be currently drawn concerning Internet-based interventions for caregivers of older adults. Firstly, there was considerable heterogeneity in factors that can impact on the efficacy of the intervention, namely the dosage, the adherence, and the comfort of the users with the Internet. Only half of the studies reported usage metrics or adherence statistics, making it difficult to establish the frequency and the length of usage needed for an Internet-based intervention to reach full efficacy. Without knowing if participants adhered to instructions given, it is also difficult to draw conclusions about the feasibility of the intervention or whether it adds to the burden of care. To rectify this situation, intended use should be described and adherence should be carefully monitored throughout each trial and reported as a process outcome [
Secondly, chosen control conditions for all studies, except two [
Thirdly, there were several methodological weaknesses within the studies that reduced the validity of their findings, namely lack of blinding, high rates of attrition, uncontrolled risks for co-intervention, and unclear reporting. Blinding is a difficult criterion to fulfill within psychosocial intervention trials, but not impossible as demonstrated by Blom et al [
Finally, with the current sample it is not possible to determine if positive effects of Internet-based interventions are maintained over time. Indeed, measures were mainly taken on completion of programs and only two studies had a moderate to long-term follow-up period (one and six months) [
In terms of methods, there are several limits to this systematic review. First, a meta-analysis of the data was not performed given the heterogeneity of the outcomes, which restricts the findings to the state of hypotheses. Second, initially included studies were not counterverified by a second author. To ensure that we would capture the best evidence available despite this weakness, the research strategy was expanded to all possible wording of keywords of interest. Uncertainty concerning the inclusion of a study was always resolved with a second or third opinion. Therefore, we are confident that this systematic review covers the best evidence currently available in the field of Internet-based interventions for caregivers of older adults. Third, coding of the included interventions was performed by only one author and relied on the information reported by the authors in the studies, which might not adequately represent all the components of the delivered intervention. A hallmark of this review was the use of appropriate categorizations to describe and analyze the Internet-based interventions and the use of BCTs. This proved relevant in comparing different interventions with varying levels of interactivity and guidance, which helped to draw useful conclusions.
The findings from this systematic review suggest that Internet-based interventions with tailored behavior change content that are interactive, provide human support either by professionals or peers, and incorporate BCTs, such as provision of specific instructions regarding the behavior, problem solving, and stress management, can have positive effects on the psychological well-being of caregivers of older adults. Further randomized controlled trials that demonstrate the effect of each component individually with appropriate control conditions, analyze their outcomes considering adherence to protocol, and structure their report according to reporting guidelines in eHealth are needed to strengthen the validity of these results.
MEDLINE MeSH terms and keywords.
Synthesis of components, behaviour change techniques and outcomes for each category of Internet-based interventions.
behavior change techniques
Consolidated Standards of Reporting Trials
Grading of Recommendations Assessment, Development and Evaluation
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Funding for this project was provided from grant AGEWELL NCE CRP 2015-WP2.2 with salary support from Fonds de recherche en santé du Québec (Auger, Ahmed) and Canadian Institutes of Health Research (Mortenson, Miller).
The team wishes to thank Pamela Harrison, biomedical librarian, who helped in developing the research strategy of this review.
None declared.