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.

Asmae Doukani,Andia Meksi,Sevim Mustafa,Naim Fanaj,Arlinda Cerga Pashoja,Juliane Hug,Gentiana Qirjako,Christiaan Vis

doi:10.2196/29280

Abstract

BackgroundThe 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.ObjectiveThe 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.MethodsWe 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.ResultsSix 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.ConclusionsIn 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 RegistrationClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883

Highlights

Albania and Kosovo are upper-middle-income countries in the Southeast of Europe
A range of barriers was 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 internet-based cognitive behavioral therapy (iCBT) for depression
Participants represented a spectrum of health professionals working at and in association with community mental health center FGD (CMHC), with nursing profession accounting for the highest number of participants (25/69, 38%), followed by social workers (13/69, 19%), psychiatrists (13/69, 19%), psychologists (11/69, 16%), general practitioners (GPs) (4/69, 6%), occupational therapist (1/69, 2%), and speech and language therapist (1/69, 2%)

Summary

Introduction

Albania and Kosovo are upper-middle-income countries in the Southeast of Europe. Situated in close proximity to high-income countries with well-resourced health care systems, the state of mental health care in Eastern Europe has gone unnoticed and has been referred to as a global blind spot [1]. In 2017, the burden of mental illness in Albania was estimated to be 3888 per 100,000 people, with disproportionately lower human resource availability, including only 1 psychiatrist, 1 psychologist, and 7 nurses per 100,000 people [2]. In Kosovo, the rate of mental illness has been notably higher due to the conflict that took place in 1998-1999 [3,4]. Very little research has been conducted in understanding the feasibility of implementing iCBT in Eastern Europe

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