Tailored implementation of internet-based cognitive behavioural therapy in the multinational context of the ImpleMentAll project: a study protocol for a stepped wedge cluster randomized trial

Bührmann, Leah; Schuurmans, Josien; Ruwaard, Jeroen; Fleuren, M.A.H.; Etzelmüller, Anne; Piera-Jiménez, Jordi; Finch, Tracy; Rapley, Tim; Potthoff, Sebastian; Aouizerate, Bruno; Batterham, Philip J.; Calear, Alison L.; Christensen, Helen; Pedersen, Christian Bonde; Ebert, David Daniel; Eycken, Erik Van der; Fanaj, Naim; Genugten, Claire van; Hanssen, Denise; Hegerl, Ulrich; Hug, Juliane; Kleiboer, Annet; Mathiasen, Kim; May, Carl; Mustafa, Sevim; Oehler, Caroline; Cerga-Pashoja, Arlinda; Pope, Catherine; Qirjako, Gentiana; Rosmalen, Judith; Sacco, Ylenia; Samalin, Ludovic; Skjøth, Mette Maria; Tarp, Kristine; Titzler, Ingrid; Zanalda, Enrico; Zbukvic, Isabel; Smit, Johannes H.; Riper, Heleen; Vis, Christiaan

doi:10.1186/s13063-020-04686-4

Cited by 31 publications

(58 citation statements)

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“…There was also a good geographical representation of services across both Albania and Kosovo. The findings of our study provide a unique contribution to the literature in relation to the barriers and facilitators for implementing iCBT in these regions and can be used to develop context-specific solutions for implementing iCBT [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

“…Qualitative focus group discussions (FGDs) were conducted with mental health care stakeholders involved on the ImpleMentAll study, a multinational trial funded by the European Union’s Horizon 2020 program. The project aimed to (1) develop and apply tailored implementation strategies for implementing evidence-based iCBT services for common mental disorders in routine mental health care through and (2) conduct a stepped wedge-cluster randomized trial to investigate the effectiveness of tailored implementation, when compared to implementation as usual (more information about the trial can be found in the trial protocol by Bührmann and colleagues [ 17 ]). Participants were recruited from 7 CMHCs across Albania (located in Tirana, Shkoder, and Korce) and Kosovo (Prizren, Gjilan, Prishtine, and Mitrovice).…”

Section: Methodsmentioning

confidence: 99%

“…The aim of this study was to undertake a qualitative examination of organizational readiness for implementing an internet-based cognitive behavioral therapy (iCBT) intervention for people with depression in 7 community mental health centers (CMHCs) across Albania and Kosovo who were partaking in a large multinational trial on the implementation of iCBT (ImpleMentAll trial, further information about the trial can be found in the Methods section) [ 17 ]. To our knowledge, this study will be the first to explore organizational readiness for implementing iCBT as well as a mental health service more broadly in Albania and Kosovo.…”

Section: Introductionmentioning

confidence: 99%

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Organizational Readiness for Implementing an Internet-Based Cognitive Behavioral Therapy Intervention for Depression Across Community Mental Health Services in Albania and Kosovo: Directed Qualitative Content Analysis

Doukani¹,

Pashoja²,

Fanaj³

et al. 2021

JMIR Form Res

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Background The use of digital mental health programs such as internet-based cognitive behavioral therapy (iCBT) holds promise in increasing the quality and access of mental health services. However very little research has been conducted in understanding the feasibility of implementing iCBT in Eastern Europe. Objective The aim of this study was to qualitatively assess organizational readiness for implementing iCBT for depression within community mental health centers (CMHCs) across Albania and Kosovo. Methods We used qualitative semistructured focus group discussions that were guided by Bryan Weiner’s model of organizational readiness for implementing change. The questions broadly explored shared determination to implement change (change commitment) and shared belief in their collective capability to do so (change efficacy). Data were collected between November and December 2017. A range of health care professionals working in and in association with CMHCs were recruited from 3 CMHCs in Albania and 4 CMHCs in Kosovo, which were participating in a large multinational trial on the implementation of iCBT across 9 countries (Horizon 2020 ImpleMentAll project). Data were analyzed using a directed approach to qualitative content analysis, which used a combination of both inductive and deductive approaches. Results Six focus group discussions involving 69 mental health care professionals were conducted. Participants from Kosovo (36/69, 52%) and Albania (33/69, 48%) were mostly females (48/69, 70%) and nurses (26/69, 38%), with an average age of 41.3 years. A directed qualitative content analysis revealed several barriers and facilitators potentially affecting the implementation of digital CBT interventions for depression in community mental health settings. While commitment for change was high, change efficacy was limited owing to a range of situational factors. Barriers impacting “change efficacy” included lack of clinical fit for iCBT, high stigma affecting help-seeking behaviors, lack of human resources, poor technological infrastructure, and high caseload. Facilitators included having a high interest and capability in receiving training for iCBT. For “change commitment,” participants largely expressed welcoming innovation and that iCBT could increase access to treatments for geographically isolated people and reduce the stigma associated with mental health care. Conclusions In summary, participants perceived iCBT positively in relation to promoting innovation in mental health care, increasing access to services, and reducing stigma. However, a range of barriers was also highlighted in relation to accessing the target treatment population, a culture of mental health stigma, underdeveloped information and communications technology infrastructure, and limited appropriately trained health care workforce, which reduce organizational readiness for implementing iCBT for depression. Such barriers may be addressed through (1) a public-facing campaign that addresses mental health stigma, (2) service-level adjustments that permit staff with the time, resources, and clinical supervision to deliver iCBT, and (3) establishment of a suitable clinical training curriculum for health care professionals. Trial Registration ClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Organizational Readiness for Implementing an Internet-Based Cognitive Behavioral Therapy Intervention for Depression Across Community Mental Health Services in Albania and Kosovo: Directed Qualitative Content Analysis

Doukani¹,

Pashoja²,

Fanaj³

et al. 2021

JMIR Form Res

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“…To generate internationally comparable research results and facilitate multi-country studies and cross-border initiatives (Bührmann et al, 2020), translating reliable and valid instruments into languages other than English is essential (Schweizer, 2010).…”

Section: Introductionmentioning

confidence: 99%

Psychometric Testing of the German Versions of Three Implementation Outcome Measures

Kien

Griebler

Schultes

et al. 2021

Glob Implement Res Appl

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Internationally comparable assessments of implementation outcomes are a prerequisite for the accurate and useful exchange of implementation science results. We translated the English versions of the acceptability of intervention measure (AIM), the intervention appropriateness measure (IAM), and the feasibility of intervention measure (FIM) into German following recent guidelines. We tested the structural validity, the internal consistency (Cronbach’s α), and the construct validity (known-groups validity) in a hypothetical situation study of secondary school teachers (n1 = 142) and the structural validity and the internal consistency in a pilot field study of primary school teachers participating in a school health promotion project (n2 = 61). The hypothesized three-factor solution (acceptability, appropriateness, and feasibility) revealed the best model fit in the hypothetical situation study (CFI = 0.97; RMSEA = 0.08). The second study tended to support these results (CFI = 0.99; RMSEA = 0.05) only when the error terms of two items from different constructs were allowed to correlate with each other (“seems like a good match” [IAM] and “seems possible” [FIM]). Furthermore, the intercorrelations between the three factors were higher in the pilot field study than in the hypothetical vignette study (0.71–0.86 vs. 0.06–0.35). The instruments’ internal consistency proved to be high in both studies (Cronbach’s α: 0.91–0.97). We gathered positive evidence for the known-groups validity, as participants who received different stimuli before answering the instruments rated them statistically significantly different. Our study showed that the German versions of the instruments could successfully be applied in health promotion research. We suggest using the four items per instrument rather than an abbreviated version and discuss recommendations for the instruments’ application.

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“…The authors recommend that implementation practitioners consider such determinants to achieve better implementation results and use these to design and apply specific implementation activities. The research project ImpleMentAll aims to find evidence for such an intervention (the ItFits-toolkit) through the development, application, and evaluation of tailored implementation strategies in ongoing eHealth implementation initiatives [68].…”

Section: Principal Findings and Comparison With Prior Workmentioning

confidence: 99%

Barriers and Facilitators for Referrals of Primary Care Patients to Blended Internet-Based Psychotherapy for Depression: Mixed Methods Study of General Practitioners’ Views (Preprint)

Titzler¹,

Berking²,

Schlicker³

et al. 2020

Preprint

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BACKGROUND Major depressive disorder (MDD) is highly prevalent and often managed by general practitioners (GPs). GPs mostly prescribe medication and show low referral rates to psychotherapy. Many patients remain untreated. Blended psychotherapy (bPT) combines internet-based interventions with face-to-face psychotherapy and could increase treatment access and availability. Effectively implementing bPT in routine care requires an understanding of professional users’ perspectives and behavior. OBJECTIVE This study aims to identify barriers and facilitators perceived by GPs in referring patients to bPT. Explanations for variations in referral rates were examined. METHODS Semistructured interviews were conducted with 12 of 110 GPs participating in a German randomized controlled trial (RCT) to investigate barriers to and facilitators for referrals to bPT for MDD (10 web-based modules, app-based assessments, and 6 face-to-face sessions). The interview guide was based on the theoretical domains framework. The interviews were audio recorded and transcribed verbatim, and the qualitative content was analyzed by 2 independent coders (intercoder agreement, k=0.71). A follow-up survey with 12 interviewed GPs enabled the validation of emergent themes. The differences in the barriers and facilitators identified between groups with different characteristics (eg, GPs with high or low referral rates) were described. Correlations between referrals and characteristics, self-rated competences, and experiences managing depression of the RCT-GPs (n=76) were conducted. RESULTS GPs referred few patients to bPT, although varied in their referral rates, and interviewees referred more than twice as many patients as RCT-GPs (interview-GPs: mean 6.34, SD 9.42; RCT-GPs: mean 2.65, SD 3.92). A negative correlation was found between GPs’ referrals and their self-rated pharmacotherapeutic competence, <i>r</i>(73)=−0.31, <i>P</i><.001. The qualitative findings revealed a total of 19 barriers (B) and 29 facilitators (F), at the levels of GP (B=4 and F=11), patient (B=11 and F=9), GP practice (B=1 and F=3), and sociopolitical circumstances (B=3 and F=6). Key barriers stated by all interviewed GPs included “little knowledge about internet-based interventions” and “patients’ lack of familiarity with technology/internet/media” (number of statements, each k=22). Key facilitators were “perceived patient suitability, e.g. well-educated, young” (k=22) and “no conflict with GP’s role” (k=16). The follow-up survey showed a very high agreement rate of at least 75% for 71% (34/48) of the identified themes. Descriptive findings indicated differences between GPs with low and high referral rates in terms of which and how many barriers (low: mean 9.75, SD 1.83; high: mean 10.50, SD 2.38) and facilitators (low: mean 18.25, SD 4.13; high: mean 21.00; SD 3.92) they mentioned. CONCLUSIONS This study provides insights into factors influencing GPs’ referrals to bPT as gatekeepers to depression care. Barriers and facilitators should be considered when designing implementation strategies to enhance referral rates. The findings should be interpreted with care because of the small and self-selected sample and low response rates.

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Tailored implementation of internet-based cognitive behavioural therapy in the multinational context of the ImpleMentAll project: a study protocol for a stepped wedge cluster randomized trial

Cited by 31 publications

References 56 publications

Organizational Readiness for Implementing an Internet-Based Cognitive Behavioral Therapy Intervention for Depression Across Community Mental Health Services in Albania and Kosovo: Directed Qualitative Content Analysis

Organizational Readiness for Implementing an Internet-Based Cognitive Behavioral Therapy Intervention for Depression Across Community Mental Health Services in Albania and Kosovo: Directed Qualitative Content Analysis

Psychometric Testing of the German Versions of Three Implementation Outcome Measures

Barriers and Facilitators for Referrals of Primary Care Patients to Blended Internet-Based Psychotherapy for Depression: Mixed Methods Study of General Practitioners’ Views (Preprint)

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