Co‐Designing the iCanBlend Model: A Blended Psychological Therapy Intervention for Treating Anxiety and Depression in the Context of Cancer

ABSTRACT

Background

Treatment uptake for depression and anxiety in psycho‐oncology is low. Blended psychological therapy (BT), which combines self‐guided digital content with clinician‐delivered sessions, may improve treatment access and engagement. In Australia, no BT program exists in routine cancer care.

Objective

To co‐design a BT intervention clinically appropriate for anxiety/depression treatment in cancer patients and investigate its potential acceptability and feasibility for implementation in psycho‐oncology in Australia.

Method

Qualitative, co‐design focus groups were conducted via videoconference with psycho‐oncology psychologists in two stages: co‐design of a cancer‐specific BT model prototype (stage I) and confirmation of prototype content and structure acceptability (stage II). Participants provided iterative feedback on cancer‐specific CBT elements to include in the BT intervention. Data were analyzed using an Interpretive Description approach.

Results

Fourteen clinicians participated across five co‐design workshops. In stage I, identified themes were: (i) importance of the intake interview and orientation to the program; (ii) the prominent role of face‐to‐face contact in the BT model; and (iii) suitability of content for digital delivery. Stage II themes were: (i) feasibility of BT in psycho‐oncology; and (ii) perceived importance of face‐to‐face for improved content delivery. The resulting BT intervention model (“iCanBlend”) had a higher dose of face‐to‐face over digital sessions to promote treatment engagement and enhance duty‐of‐care online.

Conclusion

Overall, iCanBlend was acceptable and clinically appropriate for the cancer context in Australia, although feasibility was not confirmed, given participants' preference for face‐to‐face support for digital content. Future research is required with clinicians and patients to determine usability.

1. Background

Depression and anxiety are prevalent among adults with cancer [1], impacting adherence to cancer treatment and quality of life [2]. Effective treatment options for anxiety and depression in the context of cancer are available [3], with Cognitive‐Behavioural Therapy (CBT) being recognised as the gold standard approach [3]—including Internet‐Based CBT (iCBT) [3, 4, 5]. Research [6] reports anxiety and depression symptoms as often intertwined, justifying a transdiagnostic approach to treatment [7]. Transdiagnostic iCBT interventions have demonstrated efficacy in the context of cancer [5, 8], including a cancer‐specific, transdiagnostic iCBT intervention for cancer survivors (“iCanADAPT Early”) which demonstrated significant decrease in anxiety and depression symptoms (g = 1.51) [5].

However, barriers to psycho‐oncology treatment uptake exist [9]. Digital (online) therapy may increase treatment reach in cancer care [10] but treatment engagement is low [8, 11]. Barriers to engagement include difficulties in accessing and/or using standalone digital programs and preference for more clinician involvement in therapy [11]. A blended model of therapy may address some of these concerns [8]. Blended psychological therapy (BT) combines face‐to‐face with digital therapy into one treatment plan [12, 13]. Evidence on BT's efficacy and cost‐effectiveness is growing [14, 15], however few studies address the acceptability and feasibility of BT in psycho‐oncology, or have identified the optimal BT model design [13]. A systematic review and meta‐analysis [13] classified BT models according to their design. For example, integrated [12] BT models have face‐to‐face/digital components organised and delivered within the same treatment timeline, while sequential [12] designs have face‐to‐face/online sessions organised and delivered in separate, sequential blocks (for other BT model design variations, see Figure 1). Results from a qualitative interview study [16] with psycho‐oncology clinicians in Australia indicated that cancer‐specific BT would be acceptable, although confirmed the need to engage psychologists working in oncology in co‐designing the intervention. Stakeholder involvement in co‐designing the BT program would improve its potential feasibility and acceptability prior to implementation [17]. Co‐design involves iterative co‐participation in the process of developing an intervention based on participants' experience and needs [18]. This methodology supports implementation of complex interventions [19] by integrating end‐users’ preferences into the intervention, providing guidance on BT application in clinical settings [20].

FIGURE 1.

BT designs.

1.1. Study Aims

This study aimed to co‐design a Cognitive‐Behavioural Therapy (CBT)‐based, transdiagnostic BT model for treating anxiety and depression in adult cancer patients; and explore the views of psycho‐oncology psychologists and clinical researchers regarding potential acceptability and feasibility of the intervention in psycho‐oncology.

2. Methods

2.1. Study Design

This two‐stage study used a qualitative, iterative, experience‐based co‐design (EBCD) approach [21], following strategies recommended for supporting the implementation of complex interventions [19]. Videoconference (Zoom) focus groups were conducted, supplemented with a short, online demographics survey. This study was approved by The University of Sydney Human Research Ethics Committee (2023/HE000713).

2.2. Participants

In stage I, eligible participants were (i) Psycho‐oncology clinicians (psychologists, clinical psychologists) working clinically with adult cancer patients in Australia with CBT training or (ii) Psycho‐oncology clinical researchers with experience in intervention development. Stage II participants were Psycho‐oncology clinicians (psychologists, clinical psychologists) trained in CBT, working clinically with adult cancer patients in Australia and naïve to stage I. Stage II participant eligibility criteria focused on currently practicing clinicians because they are key representatives of the current Australian professional culture in psycho‐oncology, hence able to provide expert and practical clinical feedback based on lived experience in working within current health service models of care.

2.3. Procedures

Potential participants were recruited via email invitation sent through professional networks mailing lists, snowballing and advertisements in social media (e.g., “X”). The invitation included a link to a Redcap [22] online survey, which contained the participant information statement, consent form and demographics questionnaire. Researchers trained in focus group facilitation (KN, JS) conducted each 60‐min co‐design focus group. Meetings were recorded, transcribed and qualitatively analyzed. Consensus feedback was iteratively integrated.

2.4. Intervention Content

In stage I, CBT‐based intervention elements sourced from published CBT treatment protocols [23] and from an online, cancer‐specific, evidence‐based CBT program (iCanADAPT Early) [5] were presented to participants as a scaffold for co‐designing a BT model prototype. Intervention elements were organised into a standard CBT structure (psycho‐education; behavioral activation (BA); cognitive restructuring (CR); relapse prevention). Participants were able to add additional CBT content as necessary.

In stage II, participants used the content and structure of the model prototype designed in stage I to refine the co‐designed BT intervention model.

2.5. Data Collection

2.5.1. Online Survey

Questionnaires collected demographics (e.g., gender; country of birth) and professional characteristics (e.g., clinical role; years of service) of participants.

2.5.2. Focus Groups

Stage I co‐design process focused on inclusion of CBT elements into an initial BT model prototype, while in Stage II participants reviewed the prototype to co‐design a further structured BT intervention. In stage I, a scaffold of the BT model outlining elements common to CBT interventions was emailed to participants (Supporting Information S1) prior to meetings. Semi‐structured, open questions elicited group discussions regarding CBT elements to be incorporated into the program. Upon reaching consensus through group discussions, participants allocated content to face‐to‐face and/or digital sessions (model prototype development). Participants were contacted post‐meeting to confirm consensus that all changes reflected the agreed structure. From stage I, a model prototype and draft clinician manual describing structure and content were designed (intervention refinement).

In stage II, the prototype (Supporting Information S2) served as a background for co‐designing the structure and content of the BT intervention. During each meeting, semi‐structured, open questions guided participants' iterative feedback on the proposed model and on its potential acceptability and feasibility. In‐group decisions were circulated post‐meeting to confirm consensus. See Figure 2 for a co‐design flow diagram, and Supporting Information S3 for an example on how participants' feedback translated into changes in the prototype.

FIGURE 2.

Co‐design flow.

2.6. Data Analysis

Survey data were summarised and tabulated. Feedback from participants were transcribed, thematically analyzed using an Interpretive Description (ID) approach [24], which guided data coding and the development of a coding framework [25]. Themes captured key insights about BT in both co‐design stages. Strategies for addressing trustworthiness [26] criteria are reported in Supporting Information S4. The Consolidated Criteria for Reporting Qualitative Studies (COREQ‐32) [27] was used to guide study reporting (Supporting Information S5).

In stage I, the draft model prototype was iteratively updated until consensus was reached. The prototype was subsequently integrated into a draft intervention delivery protocol which was reviewed by the research team. In stage II, participants' feedback was incorporated into the draft protocol, which was reviewed again by the research team and finalised.

3. Results

3.1. Participants Characteristics

Sixteen psycho‐oncology clinicians consented and fourteen (87%) participated in the co‐design process (Stage I, n = 4; Stage II, n = 10). Stage I participants included researchers with clinical training and stage II only included currently practicing clinicians. Sample characteristics are listed in Table 1.

TABLE 1.

Demographic characteristics of participants (n = 14).

Characteristic	Participants n (%)
	Stage I, n = 4	Stage II, n = 10
Self‐identified gender
Female	4 (100%)	7 (70%)
Male	—	3 (30%)
Country of Birth
Australia	1 (25%)	5 (50%)
Other	3 (75%)	5 (50%)
First language
English	2 (50%)	9 (90%)
Area of role in Psycho‐oncology
Clinical	4 (100%)	10 (100%)
Years of clinical experience in mental health
10 +	2 (50%)	7 (70%)
5–10	—	2 (20%)
2–5	1 (25%)	1 (10%)
Not disclosed	1 (25%)	—
Years working in psycho‐oncology
10+	2 (50%)	6 (60%)
5–10	—	3 (30%)
2–5	2 (50%)	1 (10%)
Workplace
Public	1 (25%)	4 (40%)
Mix public/private	1 (25%)	6 (60%)
Private	1 (25%)	—
Not disclosed	1 (25%)	—
Oncology population
Adult	2 (50%)	8 (80%)
Adolescents and young adults	2 (50%)	2 (20%)

3.2. Co‐Design Results

3.2.1. Stage I

Four clinicians participated in co‐design workshops. Firstly, two workshops were conducted with four attendees each. Subsequently, two sessions were completed with one and two participants respectively. Qualitative analysis identified three themes: (i) “Importance of the intake interview and orientation to the program”; (ii) “The prominent role of face‐to‐face contact in the BT model”; and (iii) “Suitability of content for digital delivery”. Stage I model structure and content are summarised in Table 2.

TABLE 2.

BT model prototype structure and content distribution following co‐design Stage I.

Session #	Mode	Topics (examples of content)
I	Face‐to‐face (#1)	– Topic 1: Treatment basics (introduction to anxiety/depression; the CBT model; the iCanBlend model) – Introduction to topic 2: Thought management (introduction to thought identification, monitoring and challenging)
II	Digital (#1)	– Topic 2: Thought management (psycho‐education (PED); cognitive restructuring (CR); and behavioral activation (BA) on identifying, monitoring and challenging thoughts) – Topic 3: Helpful coping strategies (PED/CR/BA on worry management; reassurance seeking) – Topic 4: Behavior management (PED/CR/BA on identifying & tackling unhelpful behaviors)
III	Face‐to‐face (#2)	– Checking‐in, agenda and digital activities recap – Introduction to topic 5: Adjusting to change (introduction to PED/CR/BA on values and goals; pacing activities) – Introduction to topic 6: Avoidance (introduction to PED/CR/BA on subtle avoidance; exposure stepladder) – Introduction to topic 7: Mastering skills (introduction to PED/CR/BA on pitfalls in exposure; writing worry stories) – Introduction to topic 8: Relapse prevention (introduction to lapses/relapses concepts)
IV	Digital (#2)	– Topic 5: Adjusting to change (PED/CR/BA on changing and adapting processes; dealing with distressing physical symptoms) – Topic 6: Avoidance (PED/CR/BA on avoidance behaviors; underlying fears; graded exposure)
V	Digital (#3)	– Topic 7: Mastering skills (further PED/CR/BA on safety behaviors; reassurance seeking; exposure) – Topic 8: Relapse prevention (further PED/CR/BA on lapses and relapses)
VI	Face‐to‐face (#3)	– Checking‐in, agenda setting and digital activities recap – Topic 8 in‐depth: Relapse prevention (treatment evaluation; relapse prevention plan; skills & strengths practice)

3.2.1.1. Theme 1: Importance of the Intake Interview and Orientation to the Program

Participants highlighted the importance of initial individual assessment to guide case formulation and determine the appropriateness of BT for each patient. Assessment would be based on clinical judgment and assisted by psychometric assessment provided by the service (e.g., The Hospital Anxiety and Depression Scale [28]; The Distress Thermometer [29]). Factors for consideration included severity of symptoms; cancer treatment stage/effects; and patient preference.

P01: It depends on the stage at which they are, whether it's just after diagnosis or whether they're into treatment (…) Some [patients] don't know how to get on Zoom or just have a telephone preference.

Participants also preferred face‐to‐face mode for introducing topics regarding the BT treatment process; CBT model; and anxiety/depression signs to ensure patient understanding.

P03: Initial face‐to‐face [to] outline the programme and the rationale of it, also [for] effectiveness, so people feel that's been shown to work.

3.2.1.2. Theme 2: The prominent Role of Face‐to‐Face Contact in the BT Model

Participants determined that the first BT session should be face‐to‐face, emphasising the importance of clinician‐facilitated sessions for establishing and maintaining rapport; providing a safe space for patients; and fostering engagement.

P03: Start with an interaction with the clinician for long term engagement (…) It's important that they get that initial feel, or an explanation that (…) there is a continuous person who will be checking in (…) clarifying that this program is about engaging and learning skills, and strategies (…) So get them [patients] interested and excited about it.

Face‐to‐face was participants' mode of choice for discussing more complex, sensitive and/or challenging topics (e.g., “subtle avoidance”) to ensure meaningful reflection on content and to reduce potential for patient disengagement.

P04: The ‘reducing checking’ (…) in‐session because there's a potential for it to be invalidating. (…) There's a danger in [exclusively] online components, they [patients] just kind of add everything and it becomes more like a routine they're not actually fully engaged with.

Participants also recognised for greater efficiency there is a need for digital modules to provide therapeutic content and enhance acceptability of the blended model.

P03: [Face‐to‐face] it should be quite heavy at the start, but (…) to make it sustainable and effective, you don't want to just replace face‐to‐face sessions with face‐to‐face sessions, with a little bit of [online] on the side. I feel the [online] sessions also have to be, for blended, standalone.

3.2.1.3. Theme 3: Suitability of Content for Digital Delivery

Participants considered most psycho‐education regarding “avoidance”, which generally covers common safety behaviors, appropriate for patients to undertake on their own, digitally.

P01: Psychoeducation… the obvious avoidance behaviours they can do online, like common safety. That whole thing they can do online.

Similarly, basic behavioral techniques (e.g., controlled breathing) should be readily accessible to patients online. However, participants suggested those topics needed to be introduced face‐to‐face to check for patient understanding.

P02: [about basic techniques] You could try one in session in person and then (…) online there's other techniques you might try.

Participants confirmed face‐to‐face introduction and follow‐up as required for more complex content covered online (e.g., “exposure stepladder”) to ensure patient understanding and to consolidate therapeutic work completed online.

P02: Exposure stepladders could be interactive, online (…) I would want to orient them to make sure that we've got their consent to do an exposure. I’d want to do that in person.

Participants diverged about allocation of “thought management” content to online sessions. For some, subtopics such as “challenging unhelpful thoughts/behaviors” would suit self‐directed online learning. Others perceived allocation as dependent on how psychologically minded a patient was (i.e., how easily the individual grasps meaning and/or intention of psychological concepts).

P02: It depends on how psychologically minded the patient is. For some patients all of this could be online (…) others might need to be stepped through it (…) ‘Unhelpful Thinking Patterns’ definition and examples probably go nicely online.

Participants agreed that an online introduction to “relapse prevention” was suitable, but only in preparation for subsequent in‐depth face‐to‐face discussion, which would include preparing a relapse prevention plan.

P02: [Relapse prevention] could be online, but (…) it's important to have a face‐to‐face conversation around (…) normalisation, awareness that this is likely [to happen] (…) making sure there's a plan for staying well.

3.2.2. Stage II

Ten psychologists participated across three focus groups. Participants agreed on the overall BT design proposed in Stage I but highlighted problems of feasibility for implementing the program, suggesting changes to content distribution. Thematic analysis identified two themes: (i) “Feasibility of BT in psycho‐oncology”; and (ii) “Perceived importance of face‐to‐face for improved content delivery”. Stage II proposed structure and content are summarised in Table 3.

TABLE 3.

iCanBlend overall structure and content distribution outcome summary (Stage II).

Session #	Mode	Topics	Key content
I	Face‐to‐face (#1)	Checking‐in and agenda setting	–Checking‐in—patient's feelings/emotions –Therapy goals and expectations
		Topic 1: Treatment basics	–Introduction to anxiety/depression signs & symptoms –Basic techniques for depression/anxiety management –Introduction to the CBT model
		iCanBlend treatment co‐planning	–The iCanBlend treatment –Introduction to the digital program –Homework assignment
		Outlining the next digital topic—topic 2: Adjusting to change	Subtopics: –Values and goals –Responding to physical symptoms –Monitoring and pacing activities
		[Optional pre‐session II reading]	–[Adjusting to change optional digital material]
II	Face‐to‐face (#2)	Checking‐in and agenda setting	–Checking‐in—patient's feelings/emotions –Homework check & digital component queries
		Topic 2: Adjusting to change	–Changing and adapting processes –Values and goals –Survivor guilt –Adjusting to changes –Activity planning –Dealing with distressing physical symptoms –Activity and physical symptom monitoring –Activity baseline and pacing –Homework assignment
		Outlining next digital topics—Topic 3: Helpful coping; topic 4: Behavioral management	Subtopics: –Testing/challenging beliefs re rumination/worry –Checking experiment and web searching plan –Problem solving practice –Assertive communication skills –Homework assignment
III	Digital (#1)	[Optional recap]	–[Adjusting to Change]
		Topic 3: Helpful coping strategies	–Managing worries –Reducing checking and internet searching
		Topic 4: Behavior management	–Identifying and tackling unhelpful behaviors –Homework
		Next face‐to‐face session prepping	–Suggested reading—Topic 5: Thought management
IV	Face‐to‐face (#3)	Checking‐in, agenda & digital activities recap	–Checking‐in—patient's feelings/emotions –Digital session check and queries –Discussion of clinician‐selected homework
		Topic 5: Thought management	–Identifying thoughts and unhelpful thinking patterns –Challenging unhelpful thinking –Homework assignment
		Outlining the next digital topic—Topic 6: Avoidance	–Avoidance and “subtle” avoidance behaviors –Identifying underlying fears –Exposure tests and exposure stepladder
V	Digital (#2)	Topic 6: Avoidance	–Obvious' versus “subtle” avoidance behaviors –Underlying fears in the cycle of A/D –Graded exposure—tests and stepladders –Homework
		[Optional recap of session IV]	–[Thought management digital content]
VI	Face‐to‐face (#4)	Checking‐in, agenda & digital activities recap	–Checking‐in—patient's feelings/emotions –Digital session check and queries –Discussion of clinician‐selected homework
		Clinician‐selected in‐depth discussion topics	Topics might include: –“Subtle” avoidance behaviors –Graded exposure: Facing fears gradually –Graded exposure: Exposure tests –Exposure stepladders explained –Identifying underlying fears
		Outlining the next digital topic—Topic 7: Mastering skills Topic 8: Relapse prevention	Subtopics: –Reassurance seeking –Exposure to thoughts, emotions and images –Worry stories –Treatment evaluation –Definition: Lapses and relapses
VII	Digital (#3)	Topic 7: Mastering skills. Subtopics:	–Pitfalls in exposure –Challenging safety behaviors –Reassurance seeking –Exposure to thoughts, emotions & images –Worry stories
		Topic 8: Relapse prevention	–Evaluating the treatment journey –Lapses & relapses concepts/examples –What to do when having a lapse/relapse –How to prevent relapses
VIII	Face‐to‐face (#5)	Checking‐in, agenda setting and digital recap	–Checking‐in—patient's feelings/emotions –Digital session check and queries –Discussion of clinician‐selected topics
		Topic 8 in‐depth: Relapse prevention	–Relapse prevention plan –Identifying early signs of depression/anxiety –Practice: Staying well in the future –Practice: Recap skills and strengths –Progress check‐list

3.2.2.1. Theme 1: Feasibility of BT in Psycho‐Oncology

Participants perceived the model as clinically acceptable and potentially feasible for psycho‐oncology context.

P13: I really like that a lot is done digitally then (…) talked about more meaningfully in face‐to‐face sessions (…) a structure that I would feel really comfortable implementing.

However, participants indicated the tension between the need to optimise treatment delivery and the needs of patients as a challenge for program implementation, reasoning that the program would require some flexibility.

P06: The overarching thing is just that tension between delivering something that has fidelity and can be delivered as a program versus the need to be flexible (…) It depends on how far this program can be stretched, and that's flexibility, like, how many more sessions can be offered face‐to‐face to really drive home a skill. That's the question, because it's a good programme.

Participants highlighted the importance of managing patients' expectations and of setting boundaries relative to face‐to‐face sessions to keep on track with the overall blended plan.

P09: In this setting, sometimes there is no structure (…) It would be tricky not to delve into psychoeducation and not want to do some of that therapy work (…) having to set boundaries.

3.2.2.1.1. BT Program Length

Participants indicated a need to increase the number of face‐to‐face sessions as patients often require extended time to process and to engage with psychological treatment given cancer‐related circumstances.

P12: My worry is around the amount of content (…) Some patients may need more time (…) saying 'I haven't done the work because (…) I'm just dealing with fatigue’, or cognitive fatigue.

Participants suggested that an eight‐session model (five face‐to‐face, three digital) would be more feasible than the proposed six‐session program as it could potentially serve more people, including those with severe symptomology or personal preference for face‐to‐face.

P14: Maybe you could do this in six (…) if you had a very early breast cancer and minimal struggles in life. But in [locality], it's not that demographic (…) eight sessions might be more acceptable.

3.2.2.2. Theme 2: Perceived Importance of Face‐to‐Face for Improved Content Delivery

Aligned with the Stage I participants' views, there was a strong preference for starting the program face‐to‐face.

P11: Having the face‐to‐face initially is great, and necessary to build rapport. If it had been digital, I don't think this would get as much traction.

Participants confirmed additional sessions should be face‐to‐face to better facilitate therapeutic benefit. Those sessions would cover complex content (e.g., “thought management”; “adjusting to change”; “exposure”), which require more time to process.

P05: That [Thought Management] topic is such a big change to the way people might be thinking about their lives so I would want a face‐to‐face session after at least that one.

P12: Exposure takes the majority of the therapy time for me, and it's hard to take the first step. I design the first exposure task in session.

P:14: I don't think it [face‐to‐face time] would be wasted with this [‘Adjusting to Change’]. It’s the hardest part of therapy (…) you want to be able to support the patient through that.

3.2.2.2.1. Content Allocation for Better Reflecting Clinical Practice

Participants suggested reordering of program topics to better reflect patients' experience. For example, the topic of “adjusting to change” may be better delivered earlier in the intervention as it discusses key issues related to the cancer experience, as well as proposes exercises (e.g., “values and goals”) which help coping skills development.

P12: The “values and goals” (…) move that to earlier, that would be more beneficial for patients, to get them to think (…) what their values are, and that is part of the (…) behavioural change.

Similarly, participants suggested bringing behavioral activities earlier in the program leaving “thought management” content for later in the program due to its complexity. They reasoned this would help with engagement, as behavioral activities are less demanding cognitively and address practical issues that patients can identify more clearly.

P12: I find [behavioural management] easier to digest for most patients (…) Some patients are not very in touch with their [thoughts], but they know their behaviours (…) rearrange things to target that might be helpful.

Additionally, participants suggested face‐to‐face and online sessions should alternate throughout the intervention to promote better support to patients; improve monitoring of digital activities; and foster patient engagement online.

P14: Sessions four, five and six might benefit from being spaced out, or having another face‐to‐face in‐between (…) [to] break up the digital content.

3.2.2.2.2. Structured Program Versus the Need for Tailoring

Participants considered guiding features in the program (e.g., descriptions to intervention content) user‐friendly and useful for fostering clinician engagement.

P06: I like this [manual]. It's not very prescriptive.

P11: You go to topic one, the ‘cheat sheet’ is the first thing you see (…) the bulk of it is in there.

However, some participants reiterated the protocolised delivery of the intervention needed to be balanced with some flexibility, based on clinician judgment.

P13: You’d receive a lot of endorsement from clinicians and psychologists to be encouraged to implement this protocol, but with a level of flexibility (…) to meet the needs of the people we're working with.

4. Discussion

Anxiety and depression treatment uptake in cancer setting is low [9, 30]. Blended therapy holds potential to increase uptake in psycho‐oncology by combining face‐to‐face and digital modalities [12, 13]. This two‐stage co‐design focus groups study was conducted to iteratively develop a cancer‐specific, transdiagnostic, CBT‐based blended therapy (iCanBlend) for the treatment of anxiety and depression. In stage I, clinicians identified CBT components to be incorporated into the program, achieving broad consensus of how these components should be structured (model prototype). In the second stage, clinicians reviewed the prototype to collaboratively develop an eight‐session BT intervention that they perceived would be feasible in routine clinical care (intervention refinement).

All participants indicated BT was acceptable in psycho‐oncology. BT was perceived as a treatment that utilises the benefits of iCBT while maintaining the therapeutic value of interpersonal rapport building and clinician duty‐of‐care, aligned with previous research [12, 13]. The integration of core therapeutic strategies for addressing anxiety and depression within a transdiagnostic BT treatment program was endorsed, given that it allows the overlap between symptoms to be addressed [7], maximising its applicability [31]. Acceptability of the BT intervention was related to the clinical appropriateness of its content and format in the context of routine clinical use. Additionally, acceptability of BT was largely dependent on face‐to‐face contact, deemed essential to weave the overall therapeutic process together. Participants indicated that digital content for most topics require face‐to‐face introduction and follow‐up, aimed at improved monitoring of patients' progress online and fostering both clinician and patient engagement with digital content. Participant‐suggested strategies to support engagement across iCanBlend's components, including patient orientation to the digital component, were integrated into the iCanBlend clinician guide.

Aligned with the principle of collaborative empiricism in CBT [32], participants determined iCanBlend should start face‐to‐face, particularly considering the relevance of therapist skills (e.g., empathy; containment; active listening) in assisting patients to process the emotional impact that treatment formulation may entail [32, 33]. This rationale also underpinned participants' preference for face‐to‐face delivery of the last session in the program to ensure duty‐of‐care, particularly following discussions about complex topics and/or sensitive content, such as “exposure exercises” and “relapse prevention”. Consistent with previous research [34], participants confirmed a preference for a higher dose of face‐to‐face sessions in the program. Therefore, the proposed iCanBlend has eight sessions (5 face‐to‐face, 3 online) as a standard. Participants justified the higher ratio of clinician‐delivered sessions as a way of assisting patients to conserve some of the “mental power” required to go through digital topics on their own. The rationale behind this argument points to a barrier to online‐only intervention uptake described as “perceived time burden” [35], consequent to cancer‐related stressful demands which impact digital treatment engagement.

Additionally, consensus regarding the arrangement of iCanBlend's structure and content reflected treatment priorities of cancer patients. For example, stage II participants placed content regarding “adjusting to change” early in the program to best support patients going through intense treatment schedules earlier in the cancer journey [36, 37], which require considerable physical and psychological adjustments [23]. Those changes in content order were possibly facilitated by the more structured co‐design approach in stage II, which allowed participants to have a more comprehensive view of the program.

4.1. Resulting BT Design

Consensus outcomes of stages I and II aligned with an integrated [12, 13] BT design, where face‐to‐face and digital components seamlessly interweave throughout the treatment timeline. The integrated design accommodates participants' preference for a model where clinicians' role is central for facilitating the connection between face‐to‐face and digital components, via checking‐in for patient understanding and engagement with digital content as required. Moreover, participants confirmed a preference for continuous clinician input throughout treatment components. Such preference aligns with an alternate [13] mode of delivery of BT components, in which face‐to‐face/digital sessions are delivered in an interspersed manner. Consequently, the co‐designed BT intervention starts and finishes face‐to‐face, alternating face‐to‐face/online sessions initially in a 2 face‐to‐face/1 digital session ratio, then 1/1 ratio thereafter. There was consensus among participants that the BT program was suitable for those with mild‐moderate symptoms. However, participants perceived that there would need to be changes including increased face‐to‐face sessions if the intervention was prescribed for more complex presentations, suggesting BT was less acceptable for these patients.

Overall, participants favored a BT model which would allow for flexibility and tailoring of content, using the digital component mainly for supplementing face‐to‐face sessions. Nevertheless, participants also recognised the need for digital modules to provide therapeutic content rather than simply acting to reinforce face‐to‐face content. Hence, both face‐to‐face and online components within the co‐designed intervention iCanBlend are equipped to independently deliver essential, therapeutic content—characteristic of a core [13] BT design. In iCanBlend, the core design allows for the standalone delivery of psycho‐education, which was overall considered appropriate as a patient‐driven content with a standardised [13] BT design. Additionally, participants acknowledged the need for a standardised [13] structure, with the caveat of flexibility to respond to clinical changes if required. Such flexibility was not clearly defined by participants, therefore this aspect requires further investigation in a clinical setting. Overall, participants were enthusiastic about the BT intervention and indicated their interest in participating of its potential testing it in the future.

5. Implications

The eight‐session co‐designed model exceeds the average number of sessions held with both clinical psychologists (5–6 sessions) and with other psychologists (4–5 sessions) in Australia [38]. The higher dose of face‐to‐face sessions, associated with the high number of clinician‐led introductions and reviews of online content, highlighted that participants were more comfortable with a supplementary [13] BT model (i.e., where digital content only reinforces content already covered face‐to‐face). While such design might be more acceptable to clinicians, it would probably not be feasible for implementation in routine clinical practice, as clinicians' time and resources would not be optimised by adding supplementary digital content to the treatment plan.

Participants also indicated the potential need for tailoring iCanBlend content delivery. While tailoring can ensure fit and increase engagement, it may also threaten treatment fidelity and introduce therapeutic drift, which may impact quality of treatment provision and its outcomes [39]. Increased tailoring of the BT program might create a loophole, allowing clinicians to introduce non‐cancer‐specific, non‐evidence‐based digital content as part of “tailored” online activities prescribed. Considering that Australia currently lacks specific regulatory standards regarding digital technology [40], such tailoring may become a source of therapeutic drift, jeopardising treatment outcomes [41]. A manualised BT intervention format may help clinicians to avoid circumstances leading to therapeutic drift. Additionally, more flexible content delivery might result in extended time needed to cover the required therapeutic content, further threatening implementation in the “real world”. In the current climate, there is a need to optimise clinical time and resources to meet the increasing demand in cancer settings [42]. Moreover, there are chronic health workforce shortages [43], including in psycho‐oncology [44].

Participants' preference for a higher ratio of face‐to‐face sessions in iCanBlend was reasoned as a way to mitigate the perceived risk [45] of distress being triggered by complex content delivered digitally, raising concerns over patient safety online and duty‐of‐care in the digital environment [46]. Participants possible brought an attitude of risk aversion [47], underpinned by a sense that self‐directed digital treatment does not provide for the level of support and/or responsiveness offered face‐to‐face by the clinician [48]. Such perception was present throughout the co‐design process and highlighted an overall lack of trust in the digital arm of the blend, as well as a perceived need for control over therapeutic processes delivered online, aligned with previous research [16]. This may also reflect concerns over devaluation [49, 50] of the psycho‐oncology profession facing the shift toward digital interventions, driven by economic decisions within health [49]. Future studies exploring stakeholders' views on guidelines and support required to consolidate responsible use of digital interventions in mental health, may assist clinicians' trust in blended therapy.

6. Limitations

A number of study limitations were identified. Firstly, the co‐design process did not involve psycho‐oncology consumer end‐users with lived experience of cancer‐related anxiety and depression, hence their views on acceptability are yet to be confirmed. Participation in this study was voluntary, thus the views of participants may not reflect the views of non‐participating clinicians. Also, excluding non‐practicing clinically trained researchers from Stage II may have resulted in differences in themes related to feasibility and acceptability. Also, co‐design workshops were held via teleconference, which impacted some participants' experience of and contributions to discussions due to digital connection quality issues. Participants were primarily working in public psycho‐oncology services in the state of New South Wales, hence their views may not be applicable to psychologists working in other contexts and/or to those in private practice. Additionally, given the small sample no formal between‐group differences based on demographic data were possible. Finally, although the program was developed to support cancer patients across socio‐cultural backgrounds, all participants practice in English and the program's application to culturally and linguistically diverse patients remains unclear.

7. Conclusion

iCanBlend is the first co‐designed, cancer‐specific blended intervention aimed at treating anxiety and depression in adult cancer patients. The co‐design process resulted in an integrated, core, alternate and standardised [13] model. Overall, iCanBlend was considered clinically appropriate for the context of psycho‐oncology in Australia. To explore the program's usability and fit with current service models, future studies exploring end users' online engagement and self‐directed participation are required. Those may provide some reassurance to clinicians of the value of a blended therapeutic model of care. Moreover, considering Australia's social‐cultural diversity, future studies should include participants of Culturally And Linguistically Diverse (CALD) backgrounds to inform adaptations to improve the CALD user experience.

Author Contributions

Kelly Ferrao Nunes‐Zlotkowski (K.N.), Joanne Shaw (J.S.), Heather Shepherd (H.S.), Lisa Beatty (L.B.) and Phyllis Butow (P.B.) conceptualized the study and its methodology. K.N. and J.S. conducted data collection and analysis. K.N. wrote the original manuscript with feedback from J.S., H.S., P.B. and L.B. All authors contributed to editing and reviewing the final draft.

Funding

The study was conducted as part of a High Degree by Research PhD completed by Kelly Ferrao Nunes Zlotkowski at The University of Sydney. No external funding has been sought for this study.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

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Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.