Integrating People, Context, and Technology in the Implementation of a Web-Based Intervention in Forensic Mental Health Care: Mixed-Methods Study

Abstract

Background While eMental health interventions can have many potential benefits for mental health care, implementation outcomes are often disappointing. In order to improve these outcomes, there is a need for a better understanding of complex, dynamic interactions between a broad range of implementation-related factors. These interactions and processes should be studied holistically, paying attention to factors related to context, technology, and people. Objective The main objective of this mixed-method study was to holistically evaluate the implementation strategies and outcomes of an eMental health intervention in an organization for forensic mental health care. Methods First, desk research was performed on 18 documents on the implementation process. Second, the intervention’s use by 721 patients and 172 therapists was analyzed via log data. Third, semistructured interviews were conducted with all 18 therapists of one outpatient clinic to identify broad factors that influence implementation outcomes. The interviews were analyzed via a combination of deductive analysis using the nonadoption, abandonment, scale-up, spread, and sustainability framework and inductive, open coding. Results The timeline generated via desk research showed that implementation strategies focused on technical skills training of therapists. Log data analyses demonstrated that 1019 modules were started, and 18.65% (721/3865) of patients of the forensic hospital started at least one module. Of these patients, 18.0% (130/721) completed at least one module. Of the therapists using the module, 54.1% (93/172 sent at least one feedback message to a patient. The median number of feedback messages sent per therapist was 1, with a minimum of 0 and a maximum of 460. Interviews showed that therapists did not always introduce the intervention to patients and using the intervention was not part of their daily routine. Also, therapists indicated patients often did not have the required conscientiousness and literacy levels. Furthermore, they had mixed opinions about the design of the intervention. Important organization-related factors were the need for more support and better integration in organizational structures. Finally, therapists stated that despite its current low use, the intervention had the potential to improve the quality of treatment. Conclusions Synthesis of different types of data showed that implementation outcomes were mostly disappointing. Implementation strategies focused on technical training of therapists, while little attention was paid to changes in the organization, design of the technology, and patient awareness. A more holistic approach toward implementation strategies—with more attention to the organization, patients, technology, and training therapists—might have resulted in better implementation outcomes. Overall, adaptivity appears to be an important concept in eHealth implementation: a technology should be easily adaptable to an individual patient, therapists should be trained to deal flexibly with an eMental health intervention in their treatment, and organizations should adapt their implementation strategies and structures to embed a new eHealth intervention.

eHealth Technology in Forensic Mental Healthcare: Recommendations for Achieving Benefits and Overcoming Barriers

“…Participants indicated that patients often do not possess the required skills for using technologies. For example, in case of webbased modules, many patients were said to have difficulty reading and writing and lack the motivation to individually work on assignments at home, which appears to be a major barrier hindering the use of these types of interventions (Kip et al, 2020). Consequently, developers of eHealth interventions should take the skill level and preferences of patients into account to prevent a mismatch between the technology and patient.…”

“…Amongst other things, not all therapists and patients have a positive attitude toward technology. For example, many therapists are not enthusiastic about using web-based interventions in a "blended" way with their face-to-face treatment (Kip et al, 2020). Also, there is not much knowledge on the potential positive or negative impact of technology on treatment, which can be a barrier for uptake by either management or professionals.…”

Shaping Blended Care: Adapting an Instrument to Support Therapists in Using eMental Health

“…Despite the benefits of blended care, implementation in practice is very challenging [ 11 , 14 - 16 ], partly due to the barriers experienced by therapists [ 17 ]. Among other things, they often do not think of introducing the possibility of using eMental health interventions to their clients as these are not in their system and thus are not on top of their mind [ 17 , 18 ]. Furthermore, especially therapists with little eMental health experience are unsure about the topics that they need to address when introducing or discussing the use of eMental health interventions in treatment with a patient [ 15 , 17 ].…”

“…Furthermore, especially therapists with little eMental health experience are unsure about the topics that they need to address when introducing or discussing the use of eMental health interventions in treatment with a patient [ 15 , 17 ]. In addition, therapists often decide whether to use eMental health by themselves, based on their own estimation of the patient, instead of considering its applicability together with the patient via shared decision making [ 18 ]. If eMental health interventions are used, they are often viewed as a separate addition instead of an equal, fully integrated part of the treatment [ 19 ].…”

“…By integrating eHealth interventions in treatment, the quality of forensic mental health care can be improved, for example, by tailoring eHealth interventions to patient characteristics, by adding persuasive elements that can increase engagement and adherence, or by offering new ways for patients to work on their treatment [ 25 , 26 ]. However, as is the case in mental health care in general, successful implementation of eHealth interventions in existing treatment is considered to be a major barrier [ 18 , 26 , 27 ].…”