Category 1: ‘That wasn’t so hard!’.

This category emphasized how easy HIPPER was to use and how the information was clear, relevant, and well explained. It also reflected how preparation for a major surgery is not as daunting as it seems.

Easy to use reflects the participants’ comments about the functionality of the HIPPER modules.

Many participants remarked generally having a hard time with technology; however, they still found HIPPER easy to navigate and use. “[I found working through the modules] simple, and I’m a person who generally has difficulty with technology” (man, 70 years). Furthermore, many participants appreciated how organized HIPPER was, making the preparation for surgery smooth.

“It pieced the information into really digestible chunks, and also the way the modules were organized was useful because it was a nice gradual progression towards the surgery date” (woman, 54 years).

While the content is presented in a logical and chronological order, participants were able to jump to different modules if they wanted, which made HIPPER customizable and therefore helpful to individual situations.

Most participants were quite happy with the online delivery and the many benefits that came with it, such as not having to travel to receive an in-person lecture, especially for participants living in more rural settings. Another benefit all participants appreciated was being able to revisit and relearn forgotten information.

“I think the option of breaking it up and the option of repeating it or if you do miss something or thinking [you] misunderstood something and going back is obviously preferable to just a one-time boom there it is” (man, 70 years).

The asynchronous aspect of HIPPER was especially helpful for participants who did not have a set date for surgery. Having continued access to HIPPER allowed them to learn at their convenience and to their preference.

Participants also noted that in the preparation before surgery, they received information from many different sources such as their friends’ experiences, equipment booklets from the Red Cross, and checklists from their surgeons, which made it hard to keep track of relevant information. Referring to HIPPER, one participant remarked, “You’re not looking for a bunch of different papers. It’s all there in a package for you” (woman, 59 years), appreciating having all the information easily accessible in the HIPPER program.

Learning information speaks to the participants’ reflections regarding the content included in the module.

All participants thought that they learned relevant and useful information from HIPPER. Most participants were happy with the clarity and level of detail of the content, remarking, “You know, it was just enough. And it was funny because it covered what you needed to know without creating any kind of nervousness, or any kind of questions” (woman, 54 years)

HIPPER utilizes different learning styles such as videos, text, quizzes and images. This catered to the variety of learning styles that participants had. As a result, all the participants were happy with the online modality of delivery.

“I like the mix. So, for me, where there was a narrator, giving the information first with the text to read, and then maybe a little video that reinforced what they were saying or demonstrated it like with those conversations with people. And then I liked the little quizzes at the end” (woman, 54 years).

While most participants were happy with the way HIPPER delivered information, there were diverging opinions for certain sections, such as patient interviews. Despite appreciation for patient interviews and testimonials, one participant found them self- explanatory and tedious. “I think the only part that I kind of got bored at were the interviews with people” (woman, 79 years). The participant thought that the motivation to exercise was self-motivated, and videos would not change that. Overall, the feeling was that HIPPER presented clear, relevant and detailed information with a variety of learning styles allowing users to learn easily at their own pace as they prepared for a major surgery.

Appreciating HIPPER demonstrates the participants’ gratitude for the HIPPER modules.

Participants appreciated receiving HIPPER and attributed their successful recovery to it.

“What you gave me was awesome. It helped me perfectly, you know, it’s amazing. [...] And you know it’s helped me through everything. It gave me a better life [...] I’m glad I was a part of it” (woman, 61 years).

Participants were asked how HIPPER compared to their expectations for it. Many participants had experiences contrary to their low expectations. They found HIPPER to be engaging and interesting, making it easy to complete the self-paced program. When asked about how engaging HIPPER was, a participant remarked,

“I thought it was spot on myself, it helped me understand everything that was going on and I was quite interested in it too, just to see what I was about to experience through it all” (woman, 61 years).

In addition, many participants expressed a desire for eHealth tools for different procedures to benefit themselves, friends, and family members. “I’m really glad I was able to be part of it. Yeah, yeah, I think it’s a really great idea. And it’s funny because I have a colonoscopy booked and I’m really hoping that they have something online now” (woman, 54 years). Participants were grateful and expressed positive attitudes towards HIPPER, with many participants not wanting to change anything.

Category 2: ‘I’m ready’.

This category demonstrated how HIPPER prepared the participants and their supporters for a major surgery. It explains what aspects of HIPPER prepared them for surgery and how it made post-surgery recovery easier.

Being prepared for surgery and recovery reflects the aspects of the HIPPER modules that participants found useful.

Almost all the participants were satisfied with the way HIPPER prepared them for surgery, expressing gratitude for specific modules. The exercise module was frequently highlighted as helpful as it explained the importance of going into the surgery in good shape. “The module about health before surgery, which I think is so important. I think it’s why, because I was healthy before surgery, why I had a really good experience” (woman, 65 years). Additionally, most participants emphasized the helpfulness and relatability of past patient interviews. They found these videos reassured and boosted their confidence going into the surgery.

Participants highly regarded the equipment module as it made the preparation for post-surgical care much easier. Participants gained confidence learning hip precautions, house preparation and useful tips. This module also provided direct resources to purchase necessary materials. “Being able to say, okay, this is what you’re supposed to do, check, [...] gives you a little bit of, well gives you self confidence that you’re ready. [...] They gave a peace of mind” (woman, 65 years).

Another module that participants appreciated was pain management. Many participants were experiencing pain and discomfort and appreciated learning strategies to reduce pain and what to expect. They were grateful for the emphasis put on this module as it directly correlated with being better equipped for surgery.

Other modules that participants enjoyed included nutrition and the surgical process. Participants remarked “the nutrition part was actually quite good, and knowing what has to be done before the surgery. Like, what pills we are not allowed to take, which a lot of the doctors don’t tell you” (woman, 59 years). In one case, the information about the process encouraged one participant to get the surgery.

From using HIPPER, most participants noted being able to get everything ready, understand the process and know what to do. “The key was probably what to expect before the surgery and after. [...] So, going through the module helped clarify a lot of the fears that I would have.” (woman, 59). This established and managed participant expectations, removing the daunting aspect of the unknown. HIPPER also helped to correct misconceptions and created a positive mind-set, thus reducing anxiety.

Overall, most participants had increased confidence and reassurance going into the surgery. Participants felt prepared and did not feel as if they had missed any important pieces of information.

Having a good and smooth experience speaks to the peace of mind HIPPER gave participants.

Even if participants had previous knowledge or understanding about preparation for THR, participants highlighted the emotional benefit of going through HIPPER, finding it soothing.

“For me it was more of an emotional thing about just laying it out very calmly and very reassuring. [...] It made me better prepared” (woman, 54).

A participant who had multiple surgeries prior to THR said, “I’ve had 34 surgeries so this was one of the easiest that was prepared for and set up to go when I got home” (woman, 61 years). In addition to useful content, HIPPER emphasized the importance of having a support system which allowed participants to manage their expectations and have support ready. By emphasizing the serious nature of surgery, while making preparation straightforward, HIPPER contributed to a smooth preparation, and subsequent recovery.

A benefit seen from HIPPER was patients being able to bring knowledge to their healthcare teams and ask them informed questions, increasing their confidence and making the process better for both the patient and healthcare providers. One participant described how the care team at the hospital was impressed with his preparedness. Overall HIPPER helped create a strong mindset and allowed users to have a good and smooth experience throughout their surgery and recovery.

Category 3: ‘I’d like to have seen’.

This category focused on potential changes and additions that can be implemented into HIPPER. It highlighted aspects of HIPPER that were not as helpful and identified areas of improvement.

Having differing experiences reflects on participants’ experiences that deviated from their expectations with HIPPER.

The majority of participants had a positive experience with HIPPER, attributing their success and smooth experience to the content and presentation of the program. However, some participants experienced technical difficulties or had diverging experiences compared to those presented in HIPPER. As a result, a few participants did not find HIPPER to be personalized (relevant to their situation).

One participant found the program slow as she felt the pace was more suited towards less computer literate seniors. “I just found it slow” (woman, 55 years). On the other side of computer literacy, a few participants experienced difficulty accessing and using HIPPER online. Sometimes participants lost access to HIPPER through technical issues, “I couldn’t get in” (woman, 79 years) and sometimes participants found logging in or navigating HIPPER difficult “it was complicated to me” (woman, 61 years). To combat this, more detailed log in instructions were suggested, “there would be an audience that could actually use a step-by-step guide” (woman, 55 years). Most people used a laptop, computer or iPad to complete the program, however one participant used a phone to access the program. They noted that the program was more user friendly for their laptop.

Experiences that differed from participants’ expectations were related to specific items of information in HIPPER rather than entire sections. In one case, the videos made putting on pants seem easier than it was. “They made it look so easy. It was not easy at all” (woman, 79 years). Another participant had a unique negative experience with the explanation of the anesthetic used in surgery, suggesting a better explanation. “That really freaked me out. I think it could have been explained better” (woman, 58 years).

Five participants did mention a few equipment suggestions being not applicable to their situation. This was based on personal preference. One participant mentioned the equipment purchase recommendations were not as relevant for people who were not living in major cities. “There’s a few little changes that when you’re in Yukon that you wouldn’t see in Vancouver or bigger centers” (man, 67 years). Despite this, they mentioned “you can’t do it individually that way” (man, 67 years), explaining how adding such a specialized slide would mean the module would have to be specifically tailored for one individual which would not be feasible on a larger scale.

Finally, six participants noted not using or revisiting HIPPER post-surgery. Instead, they used the pamphlets and exercise books provided by the hospital upon discharge. “I had no needs that I thought could be met by looking at modules post-surgery” (man, 69 years). However, they still credited HIPPER for their good post-surgery experience.

Suggesting additions demonstrate potential refinements identified by participants.

Participants suggested additional beneficial features. A few participants noted that it was hard to visually differentiate between completed modules and to-do modules. There were some recommendations for more colour contrast to differentiate the two. “That might be made more clear in terms of the contrast of you know the colour, like the little checkmark, or little boxes change” (man, 69). This would also benefit the participants who experienced technical glitches and were not able to resume where they left off last. Another suggestion was to have the checklist pinned or more visible on the main menu, “Having it more visible on the toolbar [...] rather than having the checklist kind of buried in the modules” (woman, 54).

There were few suggestions on the depth of the content. However, one participant wanted more explanation on why certain emphasised content, such as hip precautions, were important to learn. Building on the lack of use of HIPPER post-surgery, discussed in the having differing experiences subcategory, one participant mentioned the need for detailed explanations for post-surgery activity. While they were mostly referring to the book provided by the hospital, they did also mention a lack of explanation in HIPPER. “I actually think that the one thing that is missing really in both [the booklet and HIPPER] is a little bit more detail in terms of the post-surgical activity that is needed” (woman, 55). The participant emphasised the need to encourage patients to continue doing exercise even after the six-month post-surgery mark.

Participants also discussed specific tips such as utilising a golfer’s reach for grabbing items or reversing your crutch for getting into and out of bed. Other tips suggested were knowing your weight prior to the surgery so you can provide an accurate value to the anaesthetist, and bringing in your own food as participants did not enjoy the hospital food. Furthermore, there were some equipment suggestions. One participant found a foam wedge useful to sit on the bed post-surgery while another participant utilised a grabber. There were some suggestions such as utilising a grabber or additional resources for food services that were already present in HIPPER, however this could be attributed to the long time between HIPPER use and the interview.

Other suggestions centred around alternative workouts when participants struggled to complete the outlined exercises. One participant noted being in too much pain to complete the regular exercises and wished HIPPER had some form of cardio workouts. Instead, they used online deep-seated cardio workouts to stay fit while waiting for surgery. “I think if someone’s going to wait for a long long time for surgery, then I think that might be useful” (woman, 77). On the same note, another participant also found upper body workouts useful. “Doing the upper body exercises really made me feel better” (woman, 54).

The main suggestion made by participants was the desire for assistance. One option given was a communication portal which would allow them to ask questions. “The only thing that I found that I would have liked to have had [was] somebody to ask questions” (woman, 68). However, when all participants were asked if they felt like they wanted to ask questions while they were going through HIPPER, some participants said they did not feel the need to. A second option was to have a feedback survey after a few modules to ascertain how participants were finding the program and whether they needed any assistance. This way the team could determine whether someone was struggling or not. “Have a little click, a little survey monkey. How was that for you? And then a second one, do you need assistance or somebody to go over it with you?” (man, 56). The participant who suggested this noted that they saw many elderly patients in pain at the hospital and thought it would be helpful for the older demographic to receive assistance with HIPPER if needed.