One Life Suffolk - Exploring reasons for attrition amongst vulnerable and under-served sub-groups across an online integrated healthy lifestyle service during COVID-19

On 30^th January 2020, the pandemic spread of COVID-19 was declared a Public Health Emergency of International Concern by the World Health Organisation. By the end of April 2020, the virus had infected more than 3 million people worldwide, causing more than 200,000 deaths and hence, governments across the globe imposed varying degrees of social distancing advice and nationwide lockdowns.

High attrition rates for the transition from face-to-face to online delivery of health behaviour change interventions during the COVID-19 lockdown require a better understanding of the determinants of programme adherence during such circumstances.

This is the first study to provide a comprehensive exploration of barriers and facilitators influencing attrition within a UK-based integrated healthy lifestyle service during the COVID-19 lockdown, and the first to focus specifically on vulnerable and under-served sub-groups. Attrition sub-groups comprised of children and young people (CYP), manual workers, Black, Asian or Minority Ethnic (BAME), physical disability, learning disability, and those living in areas of high deprivation. These sub-groups attended a variety of IHLS sessions including weight management (WM), smoking cessation and physical activity (PA) interventions. Such findings will be critical in ensuring digital health is used to deliver the best care possible during and beyond the current pandemic, especially to those most at risk of COVID-19 related health issues and health inequalities.

Analysis revealed results comprising of emergent themes including: Access, Rapport, Support, Perceived Competence, and Session Delivery & Content.

In terms of access, we must be aware of the disparities that impact highly deprived and vulnerable individuals and communities, as well as cultural and linguistically diverse communities that may not have access to even basic technology including mobile phones. Clients in BAME, physical disability and high deprivation sub-groups all noted access to the online IHLS sessions to be a key barrier to continued IHLS session attendance during the COVID-19 lockdown. With regards to rapport, clients within manual worker and high deprivation sub-groups noted feeling ‘disconnected’ from the practitioners and online sessions due to a lack of prior experience with technology.

“The expectation is that we either already have the equipment we need or that we can afford to buy it. It’s not like buying a pack of beans as laptops are all so expensive!”

“I feel closer to X (a IHLS practitioner) and other people on the programme now than I did before lockdown.”

Supporting clients virtually is a major challenge for practitioners. However, findings revealed favorable results across all sub-groups in relation to the options of support provided when delivering, accessing and engaging with the online sessions. In support of equity and social justice, a critical part of reducing digital attrition is ensuring all practitioners, clients and carers, especially those who are most deprived and vulnerable, are not only supported, but also have the digital literacy and competency to partake in online offers. Negative comments were noted among clients within BAME, manual worker and high deprivation sub-groups regarding competence to engage with the digital offers.

“I have never been taught how to use a computer, how to setup an email account, how to navigate through online webpages so I wouldn’t know where to start. Since the lockdown I have lost all social connections to the outside world. It is very isolating and daunting.”

Although many clients were aware that a transition to online delivery was compulsory, reflected in the positive comments regarding session delivery and content across all sub-groups, it was noted across all sub-groups that there was a preference to return to ‘normal’ face-to-face delivery as soon as possible.

A single form of service delivery is never likely to meet all individual’s needs. However, given the frequency of digital health interventions is increasing rapidly, more advanced methodologies are needed to explore the components that can make such interventions successful for as many individuals as possible.

Ensuring the right training and support is present for the delivery of digital health offers is paramount. Further research remains necessary to explore how best to ensure such offers are scalable and accessible to all.