The results of this feasibility study showed that although OPs and employees are generally positive about the web-based counselling program in terms of content and user-friendliness, in practice usage was low, particularly among OPs. Some employees returned to work during the program which may have been why they stopped using it. Some barriers limited the use of the program. For example, both OPs and employees mentioned that they prefer therapies with personal contact. This finding is in line with results reported by Steele et al. . Their process evaluation of an internet-based program to change physical behaviour reveals that participants in the internet group preferred face-to-face sessions. They would have performed better had they been able to report to someone who gave them personal reinforcement for their behaviour change. This raises the question of whether greater involvement by a therapist might have improved the usage by employees. In our study the involvement of the OP in the program was low. Employees experienced no support from their OP in using the program. In a meta-analysis of internet-based interventions for anxiety and depression, Spek et al. found that the effect of interventions with therapist support was considerably larger than the effect of interventions without a therapist . A review by Copeland and Martin on different types of internet-programmed interventions with little or no direct therapist involvement showed that many of such studies have high dropout rates . Postel et al. also stressed the importance of working with professional therapists in online treatment programs since the skill and good sense of the therapist are important factors in the efficacy of a given treatment . Although these findings are based on research on E-therapy for mental health problems, we find the involvement of a therapist is also of importance for physical health problems as well. A physiotherapist could take on the role if the employee is undergoing therapy. Since the physiotherapist is actively involved in treating all stages of back and neck pain and is involved in the recovery process he may provide proper feedback to employees . The ways in which the physiotherapist could be involved should be investigated.
An issue mentioned by OPs and one employee is to focus on the prevention of sick leave as well. Broadening the program's focus to the prevention of sick leave and working with back or neck pain would increase the target population and could improve usage by OPs and employees.
To our knowledge, our study is the first to use a customized web-based program in occupational health care for non-specific back or neck pain. A strength of the study was that the program was applied in a real-life occupational healthcare setting. Therefore, the generalizability of the results is good. A second strength is that the web-based content conforms to the Dutch practice guidelines for employees with back and neck complaints [17, 18]. Finally, we would like to emphasize that our study is an example of how qualitative information can complement quantitative information on the use of web-based programs.
This study also has limitations. First, the value of the results derived from interviews with OPs who only received training without including any employees is questionable since their answers were based on their opinions, not on their use of the program. Furthermore, since we interviewed only a limited number of employees and OPs, we may have missed relevant information. We possibly did not achieve full saturation, especially among employees. A recollection bias also needs to be taken into account, since the interviews took place more than six months after the intervention. We controlled for this partly by giving the respondents the opportunity to look at the website before the interview. There may have been some response bias during the interviews as well. Participants may have provided more desirable feedback about the program when faced by the interviewer. However, prior to starting the interview, we stressed that it was of great importance to be honest. A selection bias may have occurred if the only participants were those people who were positive about the program. However, we included OPs and employees who used the program to different extents (i.e. based on the number of filled in questionnaires and opened documents).
Overall, our study stresses the importance of assessing needs of both employees and OPs in preparation for intervention development. Needs assessment and context analysis is a systematic study of the discrepancy between what is and what should be needed in a group and situation of interest. A program can only be effective if there is a real problem or need . A rigorous evaluation of the barriers and facilitators for implementation on the level of the innovation itself, care provider and context, could tailor the program better to the needs of the users and target group [20, 21]. The involvement of the target group in the program development is important. Earlier research reveals that systematic development of interventions and tailoring their content and format to the specifics of the target group and setting seems necessary to improve the effectiveness of patient care . Our study confirms this finding, since the format of the intervention did not entirely satisfy the needs of OPs and employees.
More general research on the use of web-based programs for musculoskeletal disorders in occupational health care is desirable. Since our intervention study was limited to OPs and employees from two transport companies it would be interesting to apply the web-based program to other target groups, for example, in the health care sector.