Pilot Study:
36 parents will be recruited to participate in the study. Additionally, 3 therapists with
extensive online support group experience to conduct the Parent-FORT videoconference
therapy sessions. Therapist competency to administer Parent-FORT will be determined by
registered professionals in counselling or psychotherapy, experience in psychosocial
oncology, specifically with parents, and having led at least one group. Interested
parents will contact the research coordinator, via telephone or email, to be screened for
eligibility and to complete the consent forms. This pilot study will serve as a first
step in potential sample size calculations and recruitment times. For this pilot study,
active recruitment will last for a period of 15 months during which 36 parents are aimed
to be recruited in order to create 4 groups of 9 participants (2 intervention conditions
and 2 WLCG). Feasibility of recruitment for the larger RCT will be determined using these
criteria: 1) If during our recruitment period less than 18 participants, recruitment for
a larger RCT, using our current recruitment strategies, will be deemed not feasible, 2)
If between 18 and 25 participants are recruited, then a larger multicentre approach for
recruitment will be considered, 3) If recruit 25 participants or more, recruitment for a
larger RCT, using our current methods, will be deemed feasible. The sample size will be
reevaluated for the larger RCT based on the results from this pilot study.
Parent-FORT consists of 7 consecutive weekly group sessions of 120 minutes each offered
through videoconference and weekly assigned homework. Parent-FORT is therapist led,
however participants will receive a workbook where they can follow along, take notes, and
complete the exercises and the homework assignments. The overall aim of Parent-FORT is to
guide Parent towards a more manageable level of worry and fear of recurrence. The key
goals are to: 1) distinguish worrisome symptoms from benign ones; 2) identify FCR
triggers and inappropriate coping strategies; 3) facilitate the learning and use of new
coping strategies, such as relaxation techniques, cognitive restructuring, communication
strategies and the use of self-care; 4) increase tolerance for uncertainty; 5) promote
emotional expression of specific fears that underlie FCR; and 6) re-examine life
priorities and set realistic goals for the future. Each session is composed of exercises
where participants have to answer questions, share with the group or watch videos.
Furthermore, homework is assigned after each session to be completed before next week's
session. Eligible participants will attend a one-on-one pre-therapy meeting with a study
therapist to prepare them for the group work (i.e.: review expectations and assess
whether group work is appropriate for the participant) and complete the 7-week
Parent-FORT intervention. Membership will be closed once groups are formed and the
sessions have started to enhance group cohesiveness and consistency. Before starting the
intervention, participants will receive a standardized manual describing each session's
activities and assignments. All participants (including those in the wait list control
group) will complete a questionnaire package pre intervention, post intervention, and at
a three month follow up via Qualtrics. Additionally, participants will be asked to
complete post session measures, namely the Working Alliance Inventory - Revised Short
Form as well as the Group Cohesiveness Scale after the 1st, 4th and 7th sessions.
Therapist Training and Supervision:
To enhance therapist adherence to treatment, the therapists recruited for the study will
be provided with a standardized Parent-FORT manual and will be trained by the research
psychologists through an online training. The research team will review the video of each
session, and the principal investigator will provide weekly 30-minute supervision to the
therapists. Furthermore, the study will use an updated version of the fidelity checklist
that was used to evaluate adherence during the previous FORT studies. If adherence is
less than 80% on any session, the research team will provide additional
over-the-telephone feedback to the therapists running the group. This approach to
monitoring treatment integrity and fidelity has been successful in previous FORT studies.
Qualitative Assessment:
To gain further insights about the feasibility, acceptability, and potential clinical
significance of Parent-FORT, all study participants will be asked to complete
semi-structured exit interviews. This will enable a holistic understanding of their
experience of Parent-FORT, elucidate key intervention processes, and identify additional
secondary outcomes. Lastly, the research coordinator will attempt to interview
participants who dropped out of the intervention, to understand any hindering factors.
Consenting participants will be asked to complete a semi structured interview (30-60
minutes) about their experience of the intervention through videoconferencing.
Randomization:
This study will use a mixed method randomized control trial design using a waitlist
control group and 3 months follow up, with 18 participants per condition. To minimize
attrition associated with waiting to enroll participants, block randomization will be
used. Specifically, a list of 4 blocks with equal numbers of intervention (I) and wait
list control (WLCG) groups (e.g. I-I-WLCG-WLCG; I-WLCG-WLCG-I, etc.) will be randomly
created. Once the first 9 participants have been recruited, they will be assigned to
whichever group came up first on the list. The next 9 participants will be assigned to
the next group on the generated list until all 4 groups have been completed. Participants
assigned to the WLCG will be offered the intervention after the 3-month period. To limit
bias, each of the 4 blocks of the list will be in separate sealed envelopes that will be
opened one at a time after 9 participants have been recruited.
Minimizing Dropouts and Attrition:
To maximize attendance, as in our prior research, participants will be told during
informed consent procedures about the importance of attending all 7 sessions to ensure
benefit from the intervention. Participants will receive two email reminders about each
upcoming session, along with "homework" and session pre-reading materials. They will be
asked to inform group therapists if they are to be absent. For participants who miss a
session, they will be offered one individual videoconference make-up session for their
first missed session before the next group; they will not be offered subsequent make-up
sessions for additional missed sessions to decrease the risk that this would encourage
those who prefer individualized attention to miss group sessions. Participants who miss
more than two sessions will be asked to stop the intervention and restart with the next
available group. This approach was successfully tested in previous FORT studies. To
minimize differential attrition from the WLCG participants, participants will be emailed
monthly with an update about the wait time.
Feasibility and Acceptability Criteria:
The following criteria will be used to assess the feasibility and acceptability of
Parent-FORT: 1) ability to recruit 36 parents in 15 months; 2) ability to randomize these
36 parents; 3) ability to deliver Parent-FORT to 27 Parent in 15 months (25% dropout
rate); 4) 80% completion of 6 out of the 7 sessions; 5) complete measures for 90% of
participants; 6) ability to deliver Parent-FORT as intended as measured by a fidelity
rating of above 80% on 75% of reviewed sessions; and 7) Parent satisfactory ratings >than
80% in terms of its content, therapists, and mode of delivery.
Quantitative analysis:
Descriptive statistics will be used to report on FCR outcomes. A linear mixed-effect
model analyses will be done on the secondary outcome measures pre- and post-intervention
and at the 3-month follow-up. All analyses will use both an intent-to-treat and per
protocol approaches. Known extraneous variables that could influence FCR (e.g., age,
education, income, cancer stage) will be measured and control for, and monitor for
participants' use of any additional psychological support at each data-collection
time-points. Dependence of the group data will be analyzed with an intraclass correlation
coefficient (p) using a multilevel model.
Qualitative Analysis:
Conventional content analysis will be used to analyse the qualitative data. Interviews
will be audiotaped, transcribed verbatim, and managed using the qualitative software
program NVivo. Transcripts will be systematically coded into anticipated (e.g.,
motivations to participate, benefits of participation) and emergent codes. This is an
iterative process whereby an initial set of themes are coded, applied to new transcripts,
and revised to adjust for new information, until no new codes emerge. Double coding of
80% of the interviews will be done by the research assistant. These codes will then be
sorted into subcategories (ideally between 10 to 15).