Abstract
BackgroundDespite the potential of digital health interventions to improve the delivery of psychoeducation to people with mental health problems and their relatives, and substantial investment in their development, there is little evidence of successful implementation into clinical practice. We report the first implementation study of a digital health intervention: Relatives Education And Coping Toolkit (REACT), into routine mental healthcare. Our main aim was to identify critical factors affecting staff uptake and use of this online self-management tool for relatives of people with psychosis or bipolar.MethodsA mixed-methods, theory-driven (Normalisation Process Theory), iterative multiple case study approach using qualitative analysis of interviews with staff and quantitative reporting of uptake. Carer researchers were part of the research team.ResultsIn all, 281 staff and 159 relatives from Early Intervention teams across six catchment areas (cases) in England registered on REACT; 129 staff took part in qualitative interviews. Staff were positive about REACT helping services improve support and meet clinical targets. Implementation was hindered by: high staff caseloads and difficulties prioritising carers; perception of REACT implementation as research; technical difficulties using REACT; poor interoperability with trust computer systems and care pathways; lack of access to mobile technology and training; restricted forum populations; staff fears of risk, online trolling, and replacement by technology; and uncertainty around REACT’s long-term availability.ConclusionsDigital health interventions, such as REACT, should be iteratively developed, evaluated, adapted and implemented, in partnership with the services they aim to support, and as part of a long term national strategy to co-develop integrated technology-enabled mental healthcare. Implementation strategies must instil a sense of ownership for staff and ensure they have adequate IT training, appropriate governance protocols for online working, and adequate mobile technologies. Wider contextual factors including adequate funding for mental health services and prioritisation of carer support, also need to be addressed for successful implementation of carer focussed digital interventions.Trial registrationStudy registration: ISCTRN 16267685.
Highlights
Despite the potential of digital health interventions to improve the delivery of psychoeducation to people with mental health problems and their relatives, and substantial investment in their development, there is little evidence of successful implementation into clinical practice
Evolving implementation plan In wave 2 the implementation plan included the addition of: Relatives Education And Coping Toolkit (REACT) booklets and business cards with details of how to access REACT for staff to give to relatives in face-to-face meetings; Staff office reminders with the REACT logo on including mugs and pens; automated email nudges for staff and relatives; a service planner to facilitate teams to allocate staff to key roles supporting REACT; and an auditing dashboard to show staff which relatives had been invited to use REACT
REACT had reasonable coherence for staff, in that they clearly understood what the toolkit was for, who it was aimed at, and the potential benefits for both staff and relatives
Summary
Despite the potential of digital health interventions to improve the delivery of psychoeducation to people with mental health problems and their relatives, and substantial investment in their development, there is little evidence of successful implementation into clinical practice. Digital Health Interventions (DHIs) are increasingly being developed for people with severe mental health problems including psychosis and bipolar, to improve symptom monitoring [1], medication management [2], and access to information and support [3]. A recent systematic review of 26 studies reporting factors impacting on delivery of DHIs for people with psychosis or bipolar identified the following determinants of uptake: staff and service user attitudes; complexity of the user interface; staff / peer support to use the intervention; fit with existing service IT infrastructures; and costs to development and delivery [11]. The review found no studies of DHIs to support relatives of people with psychosis or bipolar
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