Development of a framework for the implementation of synchronous e-mental health: a protocol for a realist synthesis of systematic reviews

Digital mental health and peer support: Building a Theory of Change informed by stakeholders' perspectives

Digital Mental Health and Peer support has the potential to bridge gaps in support through its scalability and accessibility. Despite the increasing use of these platforms, there remains a lack of understanding of how they operate in real life, from initial engagement to longer-term impact. We aimed to explore the key inputs, processes, user interactions, assumptions, barriers, facilitators, outcomes, and impacts associated with the use of DMH and peer support platforms by developing a Theory of Change with stakeholders. Stakeholders (n = 77) contributed to the formulation of the Theory of Change through a series of online workshops, focus groups, interviews, and open-ended survey feedback. Workshops were structured to capture information related to aspects of the Theory of Change and to allow stakeholders to provide feedback to improve the diagram. A thematic framework approach was used to analyze transcripts to enable comparisons of factors reported by members, commissioners, and platform staff. Stakeholders identified a variety of factors contributing to initial inputs, processes, outcomes, and impact. Engagement emerged as the most significant barrier to the use of platforms. Motivations for use included filling in gaps in available support, connecting with others and upskilling. Different member types determined how users would interact with the platform which could influence the social response of others. Outcomes were largely positive including provision of a safe online space, improvement in wellbeing, and feeling connected to others. Stakeholders noted impact was harder to identify due to the preventative nature of these platforms but suggested this related to the knowledge of available support, reduction in waiting for support and in referrals, and increasing engagement and uptake of the platforms. Stakeholders identified assumptions regarding internet access as a significant barrier. The Theory of Change illustrated three distinct pathways in digital mental health and peer support. Further research is needed to improve engagement and factors influencing engagement, the member experience and how impact is measured.

Development of a Framework for the Implementation of Synchronous Digital Mental Health: Realist Synthesis of Systematic Reviews

BACKGROUND

The use of technologies has served to reduce gaps in access to treatment, and digital health interventions show promise in the care of mental health problems. However, to understand what and how these interventions work, it is imperative to document the aspects related to their challenging implementation.

OBJECTIVE

The aim of this study was to determine what evidence is available for synchronous digital mental health implementation and to develop a framework, informed by a realist review, to explain what makes digital mental health interventions work for people with mental health problems.

METHODS

The SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, and Research type) framework was used to develop the following review question: What makes digital mental health interventions with a synchronous component work on people with mental health problems, including depression, anxiety, or stress, based on implementation, economic, quantitative, qualitative, and mixed methods studies? The MEDLINE, EBM Reviews, PsycINFO, EMBASE, SCOPUS, CINAHL Complete, and Web of Science databases were searched from January 1, 2015, to September 2020 with no language restriction. A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR-2) was used to assess the risk of bias and Confidence in Evidence from Reviews of Qualitative Research (CERQual) was used to assess the confidence in cumulative evidence. Realist synthesis analysis allowed for developing a framework on the implementation of synchronous digital mental health using a grounded-theory approach with an emergent approach.

RESULTS

A total of 21 systematic reviews were included in the study. Among these, 90% (n=19) presented a critically low confidence level as assessed with AMSTAR-2. The realist synthesis allowed for the development of three hypotheses to identify the context and mechanisms in which these interventions achieve these outcomes: (1) these interventions reach populations otherwise unable to have access because they do not require the physical presence of the therapist nor the patient, thereby tackling geographic barriers posed by in-person therapy; (2) these interventions reach populations otherwise unable to have access because they can be successfully delivered by nonspecialists, which makes them more cost-effective to implement in health services; and (3) these interventions are acceptable and show good results in satisfaction because they require less need of disclosure and provide more privacy, comfortability, and participation, enabling the establishment of rapport with the therapist.

CONCLUSIONS

We developed a framework with three hypotheses that explain what makes digital mental health interventions with a synchronous component work on people with mental health problems. Each hypothesis represents essential outcomes in the implementation process.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020203811; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020203811.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.12688/f1000research.27150.2.