Barriers and facilitators of telehealth for caregivers and older adults with dementia 

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However, few studies analyze existing barriers and facilitators on programmes for caregivers and older people with dementia. Purpose: To analyze the barriers and facilitators of a telehealth program for caregivers of older people with dementia during the COVID-19 pandemic. Methods: This quantitative-qualitative study took place online, from 2021 to 2022. 41 caregivers and 41 older people with dementia participated in an online intervention consisting of psychoeducation and barriers management techniques, a 12 week physical exercise programme and participants meetings. Barriers and facilitators were measured in 6 time-points throughout the intervention by questionnaire. After intervention, a focus group was applied with the caregivers. Descriptive and comparative analysis between the six time-points were carried out by generalized estimating equations. Qualitative data were analyzed and categorized through Bardin's content analysis. Results : From a total of 254 barriers, 24.4% were related to the caregiver; 49.2% to the older person and 26.4% to other aspects. The facilitators were the offered programme being online, flexible schedules, the high quality of services provided, a self-explanatory platform and the quality of the materials available. The number of barriers were higher in the first time-point compared to the fourth time point (p=0.023). Modifiable barriers (n=69) were different between the six time-points with superior values from the first to the third and fourth time-point (p=0.003). Conclusion: This study highlights the importance of analyzing conditions and factors that can hinder or contribute to the functioning and adherence to telehealth programs. Future similar programs to be offered may benefit from the results of this investigation. Trial Registration Number: Research Ethics Committee on Human Beings at the Federal University of São Carlos-SP (CAAE: 34696620.0.0000.5504/CEP: 6.428.315) Study registration: Registered in the Brazilian Registry of Clinical Trials (accession number RBR-825p57). Date of Registration: 10/08/2020. Barriers COVID-19 Caregivers Dementia Feasibility studies Older Adults Telehealth. Figures Figure 1 Figure 2 Figure 3 Figure 4 BACKGROUND Dementia among older adults is characterized by functional, cognitive, and behavioral impairments. It affects the quality of life of family caregivers and the individuals themselves. Over 55 million people worldwide live with dementia, with Alzheimer disease being the most prevalent and accounting for 60% of cases 1 . In Brazil, approximately 1.2 million people already have some type of dementia 2 . The vulnerability of this population has become even more evident with the unfolding of the COVID-19 pandemic. Older adults with Alzheimer disease or other types of dementia exhibit the highest rates of morbidity and mortality related to the direct and indirect effects of the coronavirus compared with other older adults 3 . Furthermore, changes in family routines and the breakdown of social support networks have increased stress for both caregivers and older individuals with dementia 4 . Strategies to address these new challenges have become essential for this population 1, 2, 5 . In this scenario, telehealth programs has been considered an alternative for promoting health services in the context of distance.. Telehealth is defined as a type of remote health service delivery that relies on the use of information and communication technology 6,7 . It is a low cost strategic tool with cognitive and functional benefits among older individuals with dementia, becoming a daily support network for patients and caregivers within the home environment 1, 7, 8, 9, 10 . However, when analyzing the barriers and facilitators influencing the effectiveness of these programs for people with chronic diseases, results from a systematic review indicated that some remote programs may not be as effective or may have low adherence rates in the presence of poor internet quality and/or electronic handling inability 6 . Nevertheless, professional preparation in managing barriers and technical support from interveners can ensure facilitators that enhance patient user adherence 11 . The studies that explored telehealth and older individuals with dementia are mostly from developed countries or solely focus on the effectiveness of these programs 5, 6, 12, 13, 14 . Therefore, there is a need for an expansion of studies regarding the operational characteristics of telehealth programs and interventions for caregivers and older individuals residing in developing countries, such as Brazil. Considering this context, the present study aimed to analyze the barriers and facilitators encountered in a telehealth program for older individuals with dementia and their family caregivers during the COVID-19 pandemic, as perceived by the caregivers, in Brazil. Additionally, we identified potential changes in barriers and their types throughout the intervention. Methods Design This is a mixed-methods study conducted in the southeast region of Brazil from 2021 to 2023 by a remote format. This research is part of a randomized clinical trial in collaboration between researchers from Brazil and Australia, named: "Telerehabilitation as an alternative to the COVID-19 pandemic and its effects on the functional capacity, mental health, and quality of life of older individuals with dementia: a randomized controlled clinical trial" (Registration: RBR-825p57 vwv). Further information can be obtained in the study protocol 15 . Population and Sample Older individuals diagnosed with some type of dementia (except Parkinson disease) and their caregivers were invited to participate in the study. Recruitment was conducted through digital media and distribution of pamphlets in physical locations, resulting in a total of 41 caregivers and 41 older individuals with dementia. The exclusion and inclusion criteria are described in the study protocol 15 . Intervention Figure 1 represents the intervention of the Telehealth Training Group (TS), which lasted 12 weeks and followed the proposed protocol based on the Home Exercise Alzheimer Disease (AD-HOMEX) 15, 16 , divided into two sub-areas: Psychoeducation Covered the execution and guidance of physical exercises, motivational factors for the volunteers, safety criteria, and execution were previously recommended to the caregiver, who was trained by the intervention team from the initial phase. During these meetings, behavioral and cognitive changes related to dementia were discussed with the caregivers in order to teach how to manage these behaviors with the older adults. This included monitored and synchronous mentoring during the first six physical exercise sessions. To monitor the volunteer and improve adherence, a duly trained researcher makes periodic calls every fortnight to collect information on perceived barriers. After collecting the data, the team discussed options for facilitating the intervention, which will be promptly explained to the caregivers to ensure immediate solutions to the barriers encountered. Additionally, tips were provided on how to improve the home environment to facilitate and ensure the autonomy and self-care practices of the participant and the caregiver themselves. Physical Exercises Three weekly sessions, each lasting 50 minutes, were supervised by a physiotherapist or physical education/researcher, providing support to the caregiver, ensuring compliance with all safety criteria, and guaranteeing the proper execution of physical exercises. Dual-task physical exercises, specific to older people, were made available on the Védius platform (www.vedius.com.br) through demonstrative videos to assist caregivers in understanding and guiding the execution of physical exercises. Support group The “Coffee and care” was a once-a-month meeting among the caregivers addressed by a psychologist to manage barriers and support doubts and to give orientation about the disease symptoms and behavior management. After the six-week monitoring and training period, caregivers had to continue accessing the program asynchronously, i.e., without the remote presence of a monitor but with a support network via WhatsApp where they could seek help or clarify doubts. To ensure better monitoring of physical exercises during the asynchronous period, an online diary was created where caregivers recorded their routines, as well as pre and post-session vital signs, physical exercises that were not performed, conduct-related doubts, and personal records that could aid in both the physical exercise practice and emotional support. Data Collection Instruments To gather more information about barriers and facilitators, data collection occurred at different times, involving different actors, domains, frequencies, data collection moments, and instruments. A structured questionnaire developed by researchers on barriers and facilitators for physical exercise practice and program participation was administered every fifteen days, totaling six applications over the 12 weeks of intervention. This frequency of evaluation was proposed to guarantee many opportunities of caregivers to report their perception during the intervention. Additionally, at the end of this period, caregivers participated in a focus group to collect qualitative data about their program participation, including barriers and facilitators. Data Collection Procedures a) Questionnaire: Researchers developed a specific questionnaire with open-ended and multiple-choice questions about barriers and facilitators, applied bi-weekly to family caregivers of the older adults through recorded calls with caregiver authorization, on Google Meet ® with a duration of 20 minutes. Responses were filled in on the Google Forms ® platform for easy transcription and record-keeping in a spreadsheet 17 . The questionnaire model was based on a systematic review study by Almathami et al. (2020) 6 , which categorizes barriers and facilitators as internal and external. The following items were evaluated: a) Physical exercise participation barriers: potential difficulties perceived during the older person's exercise. b) Program participation barriers and facilitators: five open-ended questions and eight multiple-choice questions, such as: "List a situation or more that you consider hindered your participation in the program"; "Did you face difficulties regarding: internet quality, program website, home environment, tablet/cell phone handling, managing the older during physical exercise, handling equipment, caregiver's physical or personal ability, feelings of privacy/security/resistance of the caregiver? If yes, what were these difficulties? (examples of options provided by the interviewer in case the caregiver mentions any difficulty)"; "If you recall any situation not listed in this document, describe it here"; "Do you think there is any aspect(s) in the program format we offered that facilitated your participation?"; "Name 3 reasons that made you start participating in the program" (to be answered only in the first approach − 15 days after starting the intervention); "Name 3 reasons that made you stay in the program until the end" (to be answered only in the last approach before post-intervention). b) Focus Group: After 12 weeks of participation in the intervention, caregivers were invited to participate in the focus group to qualitatively describe perceptions of barriers and facilitators for remote intervention practice proposed for family caregivers and older individuals with dementia, via Google Meet® , lasting 60 minutes and recorded with prior consent from all participants. The focus group application was based on the technique proposed by Pelicioni (2001) 18 and facilitated by an external professional experienced in group mediation and not directly involved in the research. Ethical Aspects This project was approved by the Research Ethics Committee on Human Beings at the Federal University of São Carlos-SP (CAAE: 34696620.0.0000.5504/CEP: 6.428.315). Participants were informed about the procedures they would undergo, and primary family members/caregivers received the Informed Consent Form and the image usage consent form via email. Results Analysis Quantitative Data - Multiple-choice question data were imported into Excel and calculated as mean, standard deviation, median, interquartile range, absolute frequency, and relative frequency. For comparative analyses between the six data collection moments, generalized estimating equation analysis was used, considering the Akaike Information Criterion value to choose the best graphical distribution of residuals and adherence indices between the Poisson distribution model or Gaussian distribution model. Qualitative Data - Open-ended questionnaire responses and focus group narratives were transcribed, analyzed, and categorized using Bardin's content analysis (Bardin, 2011) 19 . Categories created by the program were analyzed, systematized, and synthesized into tables and excerpts of representative reports for each category. According to these authors, in thematic analysis, themes or patterns within the data can be identified by induction or deduction. Themes and categories were analyzed, systematized, and synthesized into tables and excerpts of representative reports for each category. Results The 41 older participants had an average age of 79.4 ± 6.4 years, with 75.0% female and 8.7 ± 6.1 years of education. The 41 caregivers in the program had an average age of 52.6 ± 10.2 years, with 89.9% being female and an average of 16.5 ± 4.7 years of education. Concerning the caregiving time, caregivers had an average of 32.3 ± 31.3 months of care and spent 12.49 ± 8.35 hours caregiving. Regarding the degree of relationship, the majority of caregivers were 73.1% sons and 12.2% spouses. Throughout the 12 weeks of intervention, a total of 150 barriers assessments were conducted, categorizing 17 different types of barriers. At the end of the assessments, a total of 254 barriers were observed, of which 125 (49.2%) were related to the older person with dementia; 62 (24.4%) to the caregiver; and 67 (26.4%) to other aspects. The main barriers related to the origin group were: 1) older person with dementia: resistance and refusal to perform physical exercises (36.0%); decline in physical and cognitive conditions over time (22.4%); illness (16.0%); 2) caregiver: lack of time, organization, and fatigue (64.5%); physical and personal ability (22.6%); equipment handling (4.8%); and 3) other aspects: internet quality (41.8%); home environment (20.9%), routine changes (16.4%). The main program facilitators were: being a remote/online program (55.6%); having guidance, support, and attention from professionals before, during and after the intervention (14.6%); and being a self-explanatory platform (9.5%) (Fig. 2 ). The figure illustrates the barriers at the six data collection moments (n = 254) that occurred during the intervention. The median number of barriers was 1 (IQR = 3), ranging from 0 to 6 barriers. Comparative analysis through the generalized estimating equation showed a difference between the six data collection moments (p < 0.013), with a significant difference between moments 1 and 4 (p = 0.023). In relation to the types of barriers, 185 (72.8%) were considered modifiable (eg. refusal of exercises, feelings of privacy and security, deconcentration and distraction, management of the elderly, physical and personal ability, lack of time and organization, equipment management, internet quality, home environment, platform website, changing the elderly’s routine), and 69 (27.1%) were non-modifiable (eg. declining physical and cognitive health, fatigue and disposition of the elderly, Illness (hospitalization, cold, COVID), Others). The comparative analysis of only the modifiable barriers reported by caregivers showed a significant difference over the assessments [X2( 5 ) = 24.2; p = 0.001] with higher values in the first assessment compared to the third assessment (p = 0.001) and fourth assessment (p = 0.003) (Fig. 4 ). Discussion The main results of this study indicated that the main barriers for caregivers were the difficulty of managing during physical exercise, restricted physical and personal skills, lack of time, and organization of the routine. Regarding the behavioral aspects of the older adults, barriers included resistance and refusal to participate in physical exercises, decline in physical and cognitive conditions over time, and illness. The most significant facilitators for participation were the remote/online format of the program, the quality of services provided, such as guidance and support from professionals, and the self-explanatory nature of the platform. Concerning the people with dementia sample, the majority were women, belonging to older age groups, with high education levels, and moderate cognitive decline. The predominance of female participants in these programs is likely due to the higher prevalence of dementia among women and a longer life expectancy compared to men 20 . The caregiver participants were predominantly women, married, with high levels of education, an average age above 50 years, and a high degree of kinship, mostly daughters of the older adults with dementia. The feminization of caregiving and its correlation with caregiver overload, especially when care is provided by women, is consistent with other studies 21, 22 . The study identified the lack of time and physical and personal handling skills of the caregiver during physical exercises as the most prevalent barriers. This may be attributed to the older age group of the caregivers, lack of experience with physical exercises for both the caregiver and the older adults, difficulty in following physical exercises directly on digital devices, overload from other tasks, and physical and mental fatigue 23, 24 . The barriers related to the behavioral aspects of the individual included resistance and refusal to participate and the decline in the physical and cognitive conditions of the older adults over time. These are essential aspects to consider in future interventions with older individuals with dementia. Considering that cognitive and behavioral changes are particular to elderly people with dementia, such barriers were important to identify in the present study as a way of considering the practice of physical exercise among these people. The psychoeducation carried out in the program is a way to reduce these effects. The results indicated a significant decrease in the number of barriers during the first two months of the intervention, with a slight increase in the last month. The absence of professionals in the last month of the intervention, where caregivers were responsible for implementing physical exercises by themselves, may have influenced the increase in the number of barriers. Other studies indicate that the presence of a professional can determine the adherence of caregivers and the older adults in physical exercise programs 25 . Modifiable barriers reported by caregivers showed significant differences over the assessments, with a similar pattern to the overall barriers. This result indicates the importance of barrier maintenance strategies for programs for this target audience 11 . In addition to the mentioned barriers, the study also presented facilitators that contributed to program participation, with the main ones being the remote offering of the program and professional support. The support group addressed by the psychologist once a month was a relevant strategy reported by the caregivers. These facilitators are similar to those identified in other studies, reinforcing the importance of remote care and professional support offered through video calls and the WhatsApp platform 26 . The strengths of this study include the analysis of data from a randomized clinical trial, ensuring high methodological rigor. The diversity of approaches and quantitative and qualitative data collection methods for the same outcome provided a broader range of information from different intervention periods and perspectives of caregivers over time. However, the study has limitations. Despite the program being offered to all older people in the national territory, the lack of internet access or a primary caregiver who could accompany the older person during the program may have restricted the participation of more Brazilians. Since the participation on the intervention required a device with internet, it is possible that this intervention model targeted predominantly higher income individuals and with a more extensive social support network. Additionally, this intervention attended only participants from the southeast region of the country, which can limit the generalization of the data for other brazilian older adults. Future studies should test similar programs for caregivers and older people from lower income settings, with strategies that ensure access and optimization of technological resources routinely used by this social group. Conclusion This program contributed to understanding the Brazilian local reality regarding the use of information technology for health services and subsidizing future proposals for implementing services in this modality for elderly people with dementia. Even so, the identification of facilitators and barriers can provide a database for future clinical trials and will serve as a reference for future programs to implement these services for the population residing in developing countries and for scientific advances in the area of technology, management and gerontology. Declarations Acknowledgements The authors express their gratitude to the entire team of professionals and participants in the Telehealth program and the volunteers of this research. Contributions from other collaborators It is important to thank all the professionals who participated in the construction and development of the Telehealth program, as well as the Védius platform that provided all the support and care in providing guidance and assistance to the caregiver. Competing interests The authors have no conflicts of interest to disclose. Ethics approval and consent to participate This project was approved by the Human Research Ethics Committee of the Federal University of São Carlos-SP (CAAE: 34696620.0.0000.5504). Participants were informed about the procedures they would undergo and family members and/or primary caregivers received the Free and Informed Consent Form (ICF) by email and sent written responses to the researchers if they agreed to take part in the research. Likewise, authorization was requested via email regarding the use of images. The work is being conducted in accordance with the standards of Resolution 466/2012 of the National Health Council on research involving human beings. Funding Acknowledgment The authors would like to thank the National Council for Scientific and Technological Development (CNPq) for funding the project (ID 370) under the Institutional Program for Technological Development and Innovation Scholarships - PIBIT. 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Barreiras E Facilitadores Na Implementação Da Telereabilitação Em Um Serviço De Reabilitação Durante a Pandemia Da Covid-19: Relato De Experiência. In: Tecnologias Emergentes Na Saúde: Inovações E Tendências Na Gestão Dos Cuidados Em Saúde. Guarujá: Científica Digital; 2021. p. 140. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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01:08:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4457447/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4457447/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60354857,"identity":"9900f11f-2d88-493c-af3c-eee1b55804be","added_by":"auto","created_at":"2024-07-15 23:54:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":73959,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic Representation of the Intervention Protocol\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4457447/v1/dbc31916b83f827ae62a073e.png"},{"id":60354858,"identity":"f2d46800-88bb-4861-84fc-833f10bbcf1d","added_by":"auto","created_at":"2024-07-15 23:54:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":79871,"visible":true,"origin":"","legend":"\u003cp\u003eDescriptive data about participation Facilitators\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4457447/v1/033d73e079eac2d8cbd27bc2.png"},{"id":60355378,"identity":"d724b4fc-0676-4cab-b12d-4fd8f66ca6a8","added_by":"auto","created_at":"2024-07-16 00:02:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":43050,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in the Number of Barriers Over Time (n=41) missing: 5 older people and 5 caregivers\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4457447/v1/d6ea6f7f0336dafeba224659.png"},{"id":60354860,"identity":"c606921b-6b15-4b08-a7bb-e2cb5018319a","added_by":"auto","created_at":"2024-07-15 23:54:39","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":32037,"visible":true,"origin":"","legend":"\u003cp\u003eModifiable and Non-Modifiable Barriers Over Time\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4457447/v1/8168f65f3ff4abc1892e4347.png"},{"id":100785636,"identity":"9376a407-b0af-46a4-9b4d-97684e23fc66","added_by":"auto","created_at":"2026-01-21 11:57:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":817482,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4457447/v1/80278cbe-2135-44fc-8392-36d2904af8cd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers and facilitators of telehealth for caregivers and older adults with dementia ","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eDementia among older adults is characterized by functional, cognitive, and behavioral impairments. It affects the quality of life of family caregivers and the individuals themselves. Over 55\u0026nbsp;million people worldwide live with dementia, with Alzheimer disease being the most prevalent and accounting for 60% of cases\u003csup\u003e1\u003c/sup\u003e. In Brazil, approximately 1.2\u0026nbsp;million people already have some type of dementia\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe vulnerability of this population has become even more evident with the unfolding of the COVID-19 pandemic. Older adults with Alzheimer disease or other types of dementia exhibit the highest rates of morbidity and mortality related to the direct and indirect effects of the coronavirus compared with other older adults\u003csup\u003e3\u003c/sup\u003e. Furthermore, changes in family routines and the breakdown of social support networks have increased stress for both caregivers and older individuals with dementia\u003csup\u003e4\u003c/sup\u003e. Strategies to address these new challenges have become essential for this population\u003csup\u003e1, 2, 5\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this scenario, telehealth programs has been considered an alternative for promoting health services in the context of distance.. Telehealth is defined as a type of remote health service delivery that relies on the use of information and communication technology\u003csup\u003e6,7\u003c/sup\u003e. It is a low cost strategic tool with cognitive and functional benefits among older individuals with dementia, becoming a daily support network for patients and caregivers within the home environment\u003csup\u003e1, 7, 8, 9, 10\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHowever, when analyzing the barriers and facilitators influencing the effectiveness of these programs for people with chronic diseases, results from a systematic review indicated that some remote programs may not be as effective or may have low adherence rates in the presence of poor internet quality and/or electronic handling inability\u003csup\u003e6\u003c/sup\u003e. Nevertheless, professional preparation in managing barriers and technical support from interveners can ensure facilitators that enhance patient user adherence\u003csup\u003e11\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eThe studies that explored telehealth and older individuals with dementia are mostly from developed countries or solely focus on the effectiveness of these programs\u003csup\u003e5, 6, 12, 13, 14\u003c/sup\u003e. Therefore, there is a need for an expansion of studies regarding the operational characteristics of telehealth programs and interventions for caregivers and older individuals residing in developing countries, such as Brazil.\u003c/p\u003e \u003cp\u003eConsidering this context, the present study aimed to analyze the barriers and facilitators encountered in a telehealth program for older individuals with dementia and their family caregivers during the COVID-19 pandemic, as perceived by the caregivers, in Brazil. Additionally, we identified potential changes in barriers and their types throughout the intervention.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003eDesign\u003c/h2\u003e\n \u003cp\u003eThis is a mixed-methods study conducted in the southeast region of Brazil from 2021 to 2023 by a remote format. This research is part of a randomized clinical trial in collaboration between researchers from Brazil and Australia, named: \u0026quot;Telerehabilitation as an alternative to the COVID-19 pandemic and its effects on the functional capacity, mental health, and quality of life of older individuals with dementia: a randomized controlled clinical trial\u0026quot; (Registration: RBR-825p57 vwv). Further information can be obtained in the study protocol\u003csup\u003e15\u003c/sup\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\"\u003e\n \u003ch2\u003ePopulation and Sample\u003c/h2\u003e\n \u003cp\u003eOlder individuals diagnosed with some type of dementia (except Parkinson disease) and their caregivers were invited to participate in the study. Recruitment was conducted through digital media and distribution of pamphlets in physical locations, resulting in a total of 41 caregivers and 41 older individuals with dementia. The exclusion and inclusion criteria are described in the study protocol\u003csup\u003e15\u003c/sup\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003eIntervention\u003c/h2\u003e\n \u003cp\u003eFigure 1 represents the intervention of the Telehealth Training Group (TS), which lasted 12 weeks and followed the proposed protocol based on the Home Exercise Alzheimer Disease (AD-HOMEX)\u003csup\u003e15, 16\u003c/sup\u003e, divided into two sub-areas:\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePsychoeducation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCovered the execution and guidance of physical exercises, motivational factors for the volunteers, safety criteria, and execution were previously recommended to the caregiver, who was trained by the intervention team from the initial phase. During these meetings, behavioral and cognitive changes related to dementia were discussed with the caregivers in order to teach how to manage these behaviors with the older adults. This included monitored and synchronous mentoring during the first six physical exercise sessions. To monitor the volunteer and improve adherence, a duly trained researcher makes periodic calls every fortnight to collect information on perceived barriers. After collecting the data, the team discussed options for facilitating the intervention, which will be promptly explained to the caregivers to ensure immediate solutions to the barriers encountered. Additionally, tips were provided on how to improve the home environment to facilitate and ensure the autonomy and self-care practices of the participant and the caregiver themselves.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical Exercises\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThree weekly sessions, each lasting 50 minutes, were supervised by a physiotherapist or physical education/researcher, providing support to the caregiver, ensuring compliance with all safety criteria, and guaranteeing the proper execution of physical exercises. Dual-task physical exercises, specific to older people, were made available on the \u003cem\u003eV\u0026eacute;dius\u003c/em\u003e platform (www.vedius.com.br) through demonstrative videos to assist caregivers in understanding and guiding the execution of physical exercises.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSupport group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe \u0026ldquo;Coffee and care\u0026rdquo; was a once-a-month meeting among the caregivers addressed by a psychologist to manage barriers and support doubts and to give orientation about the disease symptoms and behavior management.\u003c/p\u003e\n \u003cp\u003eAfter the six-week monitoring and training period, caregivers had to continue accessing the program asynchronously, i.e., without the remote presence of a monitor but with a support network via WhatsApp where they could seek help or clarify doubts.\u003c/p\u003e\n \u003cp\u003eTo ensure better monitoring of physical exercises during the asynchronous period, an online diary was created where caregivers recorded their routines, as well as pre and post-session vital signs, physical exercises that were not performed, conduct-related doubts, and personal records that could aid in both the physical exercise practice and emotional support.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\"\u003e\n \u003ch2\u003eData Collection Instruments\u003c/h2\u003e\n \u003cp\u003eTo gather more information about barriers and facilitators, data collection occurred at different times, involving different actors, domains, frequencies, data collection moments, and instruments. A structured questionnaire developed by researchers on barriers and facilitators for physical exercise practice and program participation was administered every fifteen days, totaling six applications over the 12 weeks of intervention. This frequency of evaluation was proposed to guarantee many opportunities of caregivers to report their perception during the intervention. Additionally, at the end of this period, caregivers participated in a focus group to collect qualitative data about their program participation, including barriers and facilitators.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eData Collection Procedures\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003ea) Questionnaire:\u003c/h2\u003e\n \u003cp\u003eResearchers developed a specific questionnaire with open-ended and multiple-choice questions about barriers and facilitators, applied bi-weekly to family caregivers of the older adults through recorded calls with caregiver authorization, on \u003cem\u003eGoogle Meet\u003c/em\u003e\u0026reg; with a duration of 20 minutes. Responses were filled in on the \u003cem\u003eGoogle Forms\u003c/em\u003e\u0026reg; platform for easy transcription and record-keeping in a spreadsheet\u003csup\u003e17\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eThe questionnaire model was based on a systematic review study by Almathami et al. (2020)\u003csup\u003e6\u003c/sup\u003e, which categorizes barriers and facilitators as internal and external. The following items were evaluated: a) Physical exercise participation barriers: potential difficulties perceived during the older person\u0026apos;s exercise. b) Program participation barriers and facilitators: five open-ended questions and eight multiple-choice questions, such as: \u0026quot;List a situation or more that you consider hindered your participation in the program\u0026quot;; \u0026quot;Did you face difficulties regarding: internet quality, program website, home environment, tablet/cell phone handling, managing the older during physical exercise, handling equipment, caregiver\u0026apos;s physical or personal ability, feelings of privacy/security/resistance of the caregiver? If yes, what were these difficulties? (examples of options provided by the interviewer in case the caregiver mentions any difficulty)\u0026quot;; \u0026quot;If you recall any situation not listed in this document, describe it here\u0026quot;; \u0026quot;Do you think there is any aspect(s) in the program format we offered that facilitated your participation?\u0026quot;; \u0026quot;Name 3 reasons that made you start participating in the program\u0026quot; (to be answered only in the first approach \u0026minus;\u0026thinsp;15 days after starting the intervention); \u0026quot;Name 3 reasons that made you stay in the program until the end\u0026quot; (to be answered only in the last approach before post-intervention).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eb) Focus Group:\u003c/h2\u003e\n \u003cp\u003eAfter 12 weeks of participation in the intervention, caregivers were invited to participate in the focus group to qualitatively describe perceptions of barriers and facilitators for remote intervention practice proposed for family caregivers and older individuals with dementia, via \u003cem\u003eGoogle Meet\u0026reg;\u003c/em\u003e, lasting 60 minutes and recorded with prior consent from all participants. The focus group application was based on the technique proposed by Pelicioni (2001)\u003csup\u003e18\u003c/sup\u003e and facilitated by an external professional experienced in group mediation and not directly involved in the research.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003eEthical Aspects\u003c/h2\u003e\n \u003cp\u003eThis project was approved by the Research Ethics Committee on Human Beings at the Federal University of S\u0026atilde;o Carlos-SP (CAAE: 34696620.0.0000.5504/CEP: 6.428.315). Participants were informed about the procedures they would undergo, and primary family members/caregivers received the Informed Consent Form and the image usage consent form via email.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results Analysis","content":"\u003cp\u003e \u003cb\u003eQuantitative Data\u003c/b\u003e - Multiple-choice question data were imported into Excel and calculated as mean, standard deviation, median, interquartile range, absolute frequency, and relative frequency. For comparative analyses between the six data collection moments, generalized estimating equation analysis was used, considering the Akaike Information Criterion value to choose the best graphical distribution of residuals and adherence indices between the Poisson distribution model or Gaussian distribution model.\u003c/p\u003e \u003cp\u003e \u003cb\u003eQualitative Data -\u003c/b\u003e Open-ended questionnaire responses and focus group narratives were transcribed, analyzed, and categorized using Bardin's content analysis (Bardin, 2011)\u003csup\u003e19\u003c/sup\u003e. Categories created by the program were analyzed, systematized, and synthesized into tables and excerpts of representative reports for each category. According to these authors, in thematic analysis, themes or patterns within the data can be identified by induction or deduction. Themes and categories were analyzed, systematized, and synthesized into tables and excerpts of representative reports for each category.\u003c/p\u003e\n\u003ch3\u003eResults\u003c/h3\u003e\n\u003cp\u003eThe 41 older participants had an average age of 79.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4 years, with 75.0% female and 8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1 years of education. The 41 caregivers in the program had an average age of 52.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2 years, with 89.9% being female and an average of 16.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 years of education. Concerning the caregiving time, caregivers had an average of 32.3\u0026thinsp;\u0026plusmn;\u0026thinsp;31.3 months of care and spent 12.49\u0026thinsp;\u0026plusmn;\u0026thinsp;8.35 hours caregiving. Regarding the degree of relationship, the majority of caregivers were 73.1% sons and 12.2% spouses.\u003c/p\u003e \u003cp\u003eThroughout the 12 weeks of intervention, a total of 150 barriers assessments were conducted, categorizing 17 different types of barriers. At the end of the assessments, a total of 254 barriers were observed, of which 125 (49.2%) were related to the older person with dementia; 62 (24.4%) to the caregiver; and 67 (26.4%) to other aspects.\u003c/p\u003e \u003cp\u003eThe main barriers related to the origin group were: 1) older person with dementia: resistance and refusal to perform physical exercises (36.0%); decline in physical and cognitive conditions over time (22.4%); illness (16.0%); 2) caregiver: lack of time, organization, and fatigue (64.5%); physical and personal ability (22.6%); equipment handling (4.8%); and 3) other aspects: internet quality (41.8%); home environment (20.9%), routine changes (16.4%).\u003c/p\u003e \u003cp\u003eThe main program facilitators were: being a remote/online program (55.6%); having guidance, support, and attention from professionals before, during and after the intervention (14.6%); and being a self-explanatory platform (9.5%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe figure illustrates the barriers at the six data collection moments (n\u0026thinsp;=\u0026thinsp;254) that occurred during the intervention. The median number of barriers was 1 (IQR\u0026thinsp;=\u0026thinsp;3), ranging from 0 to 6 barriers. Comparative analysis through the generalized estimating equation showed a difference between the six data collection moments (p\u0026thinsp;\u0026lt;\u0026thinsp;0.013), with a significant difference between moments 1 and 4 (p\u0026thinsp;=\u0026thinsp;0.023).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn relation to the types of barriers, 185 (72.8%) were considered modifiable (eg. refusal of exercises, feelings of privacy and security, deconcentration and distraction, management of the elderly, physical and personal ability, lack of time and organization, equipment management, internet quality, home environment, platform website, changing the elderly\u0026rsquo;s routine), and 69 (27.1%) were non-modifiable (eg. declining physical and cognitive health, fatigue and disposition of the elderly, Illness (hospitalization, cold, COVID), Others). The comparative analysis of only the modifiable barriers reported by caregivers showed a significant difference over the assessments [X2(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;24.2; p\u0026thinsp;=\u0026thinsp;0.001] with higher values in the first assessment compared to the third assessment (p\u0026thinsp;=\u0026thinsp;0.001) and fourth assessment (p\u0026thinsp;=\u0026thinsp;0.003) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main results of this study indicated that the main barriers for caregivers were the difficulty of managing during physical exercise, restricted physical and personal skills, lack of time, and organization of the routine. Regarding the behavioral aspects of the older adults, barriers included resistance and refusal to participate in physical exercises, decline in physical and cognitive conditions over time, and illness. The most significant facilitators for participation were the remote/online format of the program, the quality of services provided, such as guidance and support from professionals, and the self-explanatory nature of the platform.\u003c/p\u003e \u003cp\u003eConcerning the people with dementia sample, the majority were women, belonging to older age groups, with high education levels, and moderate cognitive decline. The predominance of female participants in these programs is likely due to the higher prevalence of dementia among women and a longer life expectancy compared to men\u003csup\u003e20\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe caregiver participants were predominantly women, married, with high levels of education, an average age above 50 years, and a high degree of kinship, mostly daughters of the older adults with dementia. The feminization of caregiving and its correlation with caregiver overload, especially when care is provided by women, is consistent with other studies\u003csup\u003e21, 22\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe study identified the lack of time and physical and personal handling skills of the caregiver during physical exercises as the most prevalent barriers. This may be attributed to the older age group of the caregivers, lack of experience with physical exercises for both the caregiver and the older adults, difficulty in following physical exercises directly on digital devices, overload from other tasks, and physical and mental fatigue\u003csup\u003e23, 24\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e The barriers related to the behavioral aspects of the individual included resistance and refusal to participate and the decline in the physical and cognitive conditions of the older adults over time. These are essential aspects to consider in future interventions with older individuals with dementia. Considering that cognitive and behavioral changes are particular to elderly people with dementia, such barriers were important to identify in the present study as a way of considering the practice of physical exercise among these people. The psychoeducation carried out in the program is a way to reduce these effects.\u003c/p\u003e \u003cp\u003eThe results indicated a significant decrease in the number of barriers during the first two months of the intervention, with a slight increase in the last month. The absence of professionals in the last month of the intervention, where caregivers were responsible for implementing physical exercises by themselves, may have influenced the increase in the number of barriers. Other studies indicate that the presence of a professional can determine the adherence of caregivers and the older adults in physical exercise programs\u003csup\u003e25\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eModifiable barriers reported by caregivers showed significant differences over the assessments, with a similar pattern to the overall barriers. This result indicates the importance of barrier maintenance strategies for programs for this target audience\u003csup\u003e11\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn addition to the mentioned barriers, the study also presented facilitators that contributed to program participation, with the main ones being the remote offering of the program and professional support. The support group addressed by the psychologist once a month was a relevant strategy reported by the caregivers. These facilitators are similar to those identified in other studies, reinforcing the importance of remote care and professional support offered through video calls and the WhatsApp platform\u003csup\u003e26\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe strengths of this study include the analysis of data from a randomized clinical trial, ensuring high methodological rigor. The diversity of approaches and quantitative and qualitative data collection methods for the same outcome provided a broader range of information from different intervention periods and perspectives of caregivers over time.\u003c/p\u003e \u003cp\u003eHowever, the study has limitations. Despite the program being offered to all older people in the national territory, the lack of internet access or a primary caregiver who could accompany the older person during the program may have restricted the participation of more Brazilians. Since the participation on the intervention required a device with internet, it is possible that this intervention model targeted predominantly higher income individuals and with a more extensive social support network. Additionally, this intervention attended only participants from the southeast region of the country, which can limit the generalization of the data for other brazilian older adults.\u003c/p\u003e \u003cp\u003eFuture studies should test similar programs for caregivers and older people from lower income settings, with strategies that ensure access and optimization of technological resources routinely used by this social group.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis program contributed to understanding the Brazilian local reality regarding the use of information technology for health services and subsidizing future proposals for implementing services in this modality for elderly people with dementia. Even so, the identification of facilitators and barriers can provide a database for future clinical trials and will serve as a reference for future programs to implement these services for the population residing in developing countries and for scientific advances in the area of technology, management and gerontology.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their gratitude to the entire team of professionals and participants in the Telehealth program and the volunteers of this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions from other collaborators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt is important to thank all the professionals who participated in the construction and development of the Telehealth program, as well as the \u003cem\u003eV\u0026eacute;dius\u003c/em\u003e platform that provided all the support and care in providing guidance and assistance to the caregiver.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was approved by the Human Research Ethics Committee of the Federal University of S\u0026atilde;o Carlos-SP (CAAE: 34696620.0.0000.5504).\u003c/p\u003e\n\u003cp\u003eParticipants were informed about the procedures they would undergo and family members and/or primary caregivers received the Free and Informed Consent Form (ICF) by email and sent written responses to the researchers if they agreed to take part in the research. Likewise, authorization was requested via email regarding the use of images. The work is being conducted in accordance with the standards of Resolution 466/2012 of the National Health Council on research involving human beings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Acknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the National Council for Scientific and Technological Development (CNPq) for funding the project (ID 370) under the Institutional Program for Technological Development and Innovation Scholarships - PIBIT. Additionally, thanks to the S\u0026atilde;o Paulo Research Foundation (FAPESP n\u0026ordm;. 2022/04912-3 and n\u0026deg;2020/08779-0) that has supported this project until December of 2023, providing financial support for achieving positive outcomes.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlzheimer\u0026apos;s Association. 2022 Alzheimer\u0026rsquo;s Disease Facts and Figures. Alzheimer\u0026rsquo;s \u0026amp; Dementia. 2022 Mar 14;18(4):700\u0026ndash;89.\u003c/li\u003e\n\u003cli\u003eDadalto EV, Cavalcante FG. O Lugar Do Cuidador Familiar De Idosos Com Doen\u0026ccedil;a De Alzheimer: Uma Revis\u0026atilde;o De Literatura No Brasil E Estados Unidos. Ci\u0026ecirc;ncia \u0026amp; Sa\u0026uacute;de Coletiva [Internet]. 2021 Jan;26(1):147\u0026ndash;57. Available from: https://www.scielosp.org/pdf/csc/2021.v26n1/147-157/pt\u003c/li\u003e\n\u003cli\u003eLivingston G, Huntley J, Sommerlad A, Ames D, Ballard C, Banerjee S, et al. Dementia prevention, intervention, and care: 2020 Report of the Lancet Commission. The Lancet [Internet]. 2020 Jul 30;396(10248):413\u0026ndash;46. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30367-6/fulltext\u003c/li\u003e\n\u003cli\u003eSchapira M. Impacto Psicosocial De La Pandemia Por COVID-19 En Adultos Mayores Con Demencia Y Sus cuidadores. Revista Argentina de Salud P\u0026uacute;blica. 2020 Jul 24;12(12):5\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eBanbury A, Parkinson L, Gordon S, Wood D. Implementing a peer-support Programme by Group Videoconferencing for Isolated Carers of People with Dementia. Journal of Telemedicine and Telecare. 2019 Oct;25(9):572\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eAlmathami HK, Win KT, Vlahu-Gjorgievska E. Barriers and Facilitators That Influence Telemedicine real-time Online Consultation at Patients\u0026rsquo; home: a Systematic Literature Review. (Preprint). Journal of Medical Internet Research [Internet]. 2019 Sep 25;22(2). Available from: https://www.jmir.org/2020/2/e16407/\u003c/li\u003e\n\u003cli\u003eSoares SM. Tecnologias Digitais No Apoio Ao Cuidado Aos Idosos Em Tempos Da Pandemia Da COVID-19. Enfermagem gerontologica no cuidado do idoso em tempos da COVID 19. 2021;19(5):28\u0026ndash;33.\u003c/li\u003e\n\u003cli\u003eCavaleiro APG, de Abreu J\u0026uacute;nior MJ, Grygorczyk S. Telessa\u0026uacute;de: Novos Caminhos Na Aten\u0026ccedil;\u0026atilde;o \u0026Agrave; Sa\u0026uacute;de Frente \u0026Agrave; Infec\u0026ccedil;\u0026atilde;o Pelo Novo Coronav\u0026iacute;rus. Revista Aproxima\u0026ccedil;\u0026atilde;o. 2020 Jul 31;2(04).\u003c/li\u003e\n\u003cli\u003eDi Lorito C, Masud T, Gladman J, Godfrey M, Dunlop M, Bosco A, et al. Deconditioning in People Living with Dementia during the COVID-19 pandemic: Qualitative Study from the Promoting Activity, Independence and Stability in Early Dementia (PrAISED) Process Evaluation. BMC Geriatrics. 2021 Oct 7;21(1).\u003c/li\u003e\n\u003cli\u003eDinesen B, Nonnecke B, Lindeman D, Toft E, Kidholm K, Jethwani K, et al. Personalized Telehealth in the Future: a Global Research Agenda. Journal of Medical Internet Research [Internet]. 2016 Mar 1;18(3):e53. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795318/\u003c/li\u003e\n\u003cli\u003eWeiss EF, Malik R, Santos T, Ceide M, Cohen J, Verghese J, et al. Telehealth for the Cognitively Impaired Older Adult and Their caregivers: Lessons from a Coordinated Approach. Neurodegenerative Disease Management. 2021 Feb;11(1):83\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eCotelli M, Manenti R, Brambilla M, Gobbi E, Ferrari C, Binetti G, et al. Cognitive Telerehabilitation in Mild Cognitive impairment, Alzheimer\u0026rsquo;s Disease and Frontotemporal dementia: a Systematic Review. Journal of Telemedicine and Telecare. 2017 Nov 8;25(2):67\u0026ndash;79.\u003c/li\u003e\n\u003cli\u003eTurunen M, Hokkanen L, B\u0026auml;ckman L, Stigsdotter-Neely A, H\u0026auml;nninen T, Paajanen T, et al. Computer-based Cognitive Training for Older adults: Determinants of Adherence. Ginsberg SD, editor. PLOS ONE. 2019 Jul 10;14(7):e0219541.\u003c/li\u003e\n\u003cli\u003eZhen X, Wang L, Yan H, Tao H, Cai Y, Wang J, et al. Modifiable Facilitators and Barriers to Exercise Adherence in Older Adults with MCI/dementia Using the Theoretical Domains Framework: a Systematic Review Protocol. BMJ Open. 2020 Sep;10(9):e034500.\u003c/li\u003e\n\u003cli\u003eTsen C, Andreatto CA de A, Aily JB, Pelicioni PHS, Neto DB, Mattiello SM, et al. Effects of Telehealth on Functional capacity, Mental Health and Quality of Life among Older People with dementia: LAPESI Telehealth Protocol for a Randomized Controlled Trial. Physiotherapy Research International. 2022 Nov 29;28(2).\u003c/li\u003e\n\u003cli\u003eCezar NOC, Ansai JH, de Andrade LP. Home‐based Multimodal Exercise Program in Older People with Alzheimer disease: Randomized Controlled Trial Protocol. Physiotherapy Research International. 2021 Feb 15;26(2).\u003c/li\u003e\n\u003cli\u003eMota JS. Using Google Forms in Academic Research. Humanities \u0026amp; Innovation. 2019 Sep 9;6(12):371\u0026ndash;80.\u003c/li\u003e\n\u003cli\u003eIervolino SA, Pelicioni MCF. A Utiliza\u0026ccedil;\u0026atilde;o Do Grupo Focal Como Metodologia Qualitativa Na Promo\u0026ccedil;\u0026atilde;o Da Sa\u0026uacute;de. Revista Da Escola De Enfermagem Da USP. 2001 Jun;35(2):115\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eBardin L. An\u0026aacute;lise De Conte\u0026uacute;do. 1\u0026deg; ed. S\u0026atilde;o Paulo: 70 Edi\u0026ccedil;\u0026otilde;es; 2016.\u003c/li\u003e\n\u003cli\u003eSantos C de S dos, Bessa TA de, Xavier AJ. Fatores Associados \u0026Agrave; Dem\u0026ecirc;ncia Em Idosos. Ci\u0026ecirc;ncia \u0026amp; Sa\u0026uacute;de Coletiva. 2020 Feb;25(2):603\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eOliveira APP de, Caldana RHL. As Repercuss\u0026otilde;es Do Cuidado Na Vida Do Cuidador Familiar Do Idoso Com Dem\u0026ecirc;ncia De Alzheimer. Sa\u0026uacute;de \u0026amp; Sociedade. 2012 Sep;21(3):675\u0026ndash;85.\u003c/li\u003e\n\u003cli\u003eSilva JMS, Cardoso VC, Abreu KE, Silva LS. The Feminization of Care and the Burden on women-mothers during the pandemic. Revista Feminismo [Internet]. 2020 Jan 7;8(3):149\u0026ndash;61. Available from: https://periodicos.ufba.br/index.php/feminismos/article/view/42114\u003c/li\u003e\n\u003cli\u003eFerreira NCLQ. The Difficulties of Family Members Who Care for Elderly People with Alzheimer\u0026rsquo;s disease: a Literature Review. Ci\u0026ecirc;ncia ET Praxis. 2017 Apr 24;8(15):35\u0026ndash;42.\u003c/li\u003e\n\u003cli\u003eMoura KR, Souza EMS, Pereira KLA, Barroso LMFM, Miranda MS, Carvalho GCN. Sobrecarga De Cuidadores Informais De Idosos Fragilizados. Revista De Enfermagem UFPE. 2019 May 1;13(5):1183\u0026ndash;91.\u003c/li\u003e\n\u003cli\u003eBernocchi P, Giordano A, Pintavalle G, Galli T, Ballini Spoglia E, Baratti D, et al. Feasibility and Clinical Efficacy of a Multidisciplinary Home-Telehealth Program to Prevent Falls in Older Adults: a Randomized Controlled Trial. Journal of the American Medical Directors Association. 2019 Mar;20(3):340\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eOliveira JFP, Zuqui AC, Schiavo KV, Silva AR, Paula IS, Gomes CMS. Barreiras E Facilitadores Na Implementa\u0026ccedil;\u0026atilde;o Da Telereabilita\u0026ccedil;\u0026atilde;o Em Um Servi\u0026ccedil;o De Reabilita\u0026ccedil;\u0026atilde;o Durante a Pandemia Da Covid-19: Relato De Experi\u0026ecirc;ncia. In: Tecnologias Emergentes Na Sa\u0026uacute;de: Inova\u0026ccedil;\u0026otilde;es E Tend\u0026ecirc;ncias Na Gest\u0026atilde;o Dos Cuidados Em Sa\u0026uacute;de. Guaruj\u0026aacute;: Cient\u0026iacute;fica Digital; 2021. p. 140.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Barriers, COVID-19, Caregivers, Dementia, Feasibility studies, Older Adults, Telehealth. ","lastPublishedDoi":"10.21203/rs.3.rs-4457447/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4457447/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Telehealth programmes have become an alternative to the social isolation imposed by the pandemic. However, few studies analyze existing barriers and facilitators on programmes for caregivers and older people with dementia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eTo analyze the barriers and facilitators of a telehealth program for caregivers of older people with dementia during the COVID-19 pandemic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis quantitative-qualitative study took place online, from 2021 to 2022. 41 caregivers and 41 older people with dementia participated in an online intervention consisting of psychoeducation and barriers management techniques, a 12 week physical exercise programme and participants meetings. Barriers and facilitators were measured in 6 time-points throughout the intervention by questionnaire. After intervention, a focus group was applied with the caregivers. Descriptive and comparative analysis between the six time-points were carried out by generalized estimating equations. Qualitative data were analyzed and categorized through Bardin's content analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: From a total of 254 barriers, 24.4% were related to the caregiver; 49.2% to the older person and 26.4% to other aspects. The facilitators were the offered programme being online, flexible schedules, the high quality of services provided, a self-explanatory platform and the quality of the materials available. The number of barriers were higher in the first time-point compared to the fourth time point (p=0.023). Modifiable barriers (n=69) were different between the six time-points with superior values from the first to the third and fourth time-point (p=0.003).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThis study highlights the importance of analyzing conditions and factors that can hinder or contribute to the functioning and adherence to telehealth programs. Future similar programs to be offered may benefit from the results of this investigation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration Number: \u003c/strong\u003e\u0026nbsp;Research Ethics Committee on Human Beings at the Federal University of São Carlos-SP (CAAE: 34696620.0.0000.5504/CEP: 6.428.315)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy registration: \u003c/strong\u003eRegistered in the Brazilian Registry of Clinical Trials (accession number RBR-825p57). Date of Registration: 10/08/2020.\u003c/p\u003e","manuscriptTitle":"Barriers and facilitators of telehealth for caregivers and older adults with dementia ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-15 23:54:34","doi":"10.21203/rs.3.rs-4457447/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3f96c169-15d8-4e62-a2a5-c8f671736d46","owner":[],"postedDate":"July 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-21T11:17:18+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-15 23:54:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4457447","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4457447","identity":"rs-4457447","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}