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Eysenbach G, Schuurmans J, Aouizerate B, Atipei Craggs M, Batterham P, Bührmann L, Calear A, Cerga Pashoja A, Christensen H, Dozeman E, Duedal Pedersen C, Ebert DD, Etzelmueller A, Fanaj N, Finch TL, Hanssen D, Hegerl U, Hoogendoorn A, Mathiasen K, May C, Meksi A, Mustafa S, O'Dea B, Oehler C, Piera-Jiménez J, Potthoff S, Qirjako G, Rapley T, Rosmalen J, Sacco Y, Samalin L, Skjoth MM, Tarp K, Titzler I, Van der Eycken E, van Genugten CR, Whitton A, Zanalda E, Smit JH, Riper H. Effectiveness of Self-guided Tailored Implementation Strategies in Integrating and Embedding Internet-Based Cognitive Behavioral Therapy in Routine Mental Health Care: Results of a Multicenter Stepped-Wedge Cluster Randomized Trial. J Med Internet Res 2023; 25:e41532. [PMID: 36735287 PMCID: PMC9938445 DOI: 10.2196/41532] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/18/2022] [Accepted: 11/30/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Internet-based cognitive behavioral therapy (iCBT) services for common mental health disorders have been found to be effective. There is a need for strategies that improve implementation in routine practice. One-size-fits-all strategies are likely to be ineffective. Tailored implementation is considered as a promising approach. The self-guided integrated theory-based Framework for intervention tailoring strategies toolkit (ItFits-toolkit) supports local implementers in developing tailored implementation strategies. Tailoring involves identifying local barriers; matching selected barriers to implementation strategies; developing an actionable work plan; and applying, monitoring, and adapting where necessary. OBJECTIVE This study aimed to compare the effectiveness of the ItFits-toolkit with implementation-as-usual (IAU) in implementing iCBT services in 12 routine mental health care organizations in 9 countries in Europe and Australia. METHODS A stepped-wedge cluster randomized trial design with repeated measures was applied. The trial period lasted 30 months. The primary outcome was the normalization of iCBT delivery by service providers (therapists, referrers, IT developers, and administrators), which was measured with the Normalization Measure Development as a proxy for implementation success. A 3-level linear mixed-effects modeling was applied to estimate the effects. iCBT service uptake (referral and treatment completion rates) and implementation effort (hours) were used as secondary outcomes. The perceived satisfaction (Client Satisfaction Questionnaire), usability (System Usability Scale), and impact of the ItFits-toolkit by implementers were used to assess the acceptability of the ItFits-toolkit. RESULTS In total, 456 mental health service providers were included in this study. Compared with IAU, the ItFits-toolkit had a small positive statistically significant effect on normalization levels in service providers (mean 0.09, SD 0.04; P=.02; Cohen d=0.12). The uptake of iCBT by patients was similar to that of IAU. Implementers did not spend more time on implementation work when using the ItFits-toolkit and generally regarded the ItFits-toolkit as usable and were satisfied with it. CONCLUSIONS The ItFits-toolkit performed better than the usual implementation activities in implementing iCBT services in routine practice. There is practical utility in the ItFits-toolkit for supporting implementers in developing and applying effective tailored implementation strategies. However, the effect on normalization levels among mental health service providers was small. These findings warrant modesty regarding the effectiveness of self-guided tailored implementation of iCBT services in routine practice. TRIAL REGISTRATION ClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1186/s13063-020-04686-4.
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Affiliation(s)
| | | | - Bruno Aouizerate
- Regional Reference Center for the Management and Treatment of Anxiety and Depressive Disorders, FondaMental Advanced Centre of Expertise in Resistant Depression, Deparment of General and Academic Psychiatry, Charles Perrens Hospital, Bordeaux, France
| | - Mette Atipei Craggs
- Research Unit for Digital Psychiatry, Deptartment of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Philip Batterham
- Centre for Mental Health Research, The Australian National University, Canberra, Australia
| | - Leah Bührmann
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle Upon Tyne, United Kingdom
| | - Alison Calear
- Centre for Mental Health Research, The Australian National University, Canberra, Australia
| | | | - Helen Christensen
- Department of Medicine, University of New South Wales, Sydney, Australia
| | | | | | - David Daniel Ebert
- Professorship Psychology & Digital Mental Health, Technical University of Munich, Munich, Germany.,HelloBetter, GET.ON Institut für Online Gesundheitstrainings GmbH, Berlin, Germany
| | - Anne Etzelmueller
- Professorship Psychology & Digital Mental Health, Technical University of Munich, Munich, Germany.,HelloBetter, GET.ON Institut für Online Gesundheitstrainings GmbH, Berlin, Germany
| | - Naim Fanaj
- Mental Health Center Prizren, Prizren, Kosovo
| | - Tracy L Finch
- Department of Nursing, Midwifery and Health, Northumbria University, Newcastle Upon Tyne, United Kingdom
| | - Denise Hanssen
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ulrich Hegerl
- German Depression Foundation, Leipzig, Germany.,Department of Psychiatry, Psychosomatics, and Psychotherapy, Goethe Universität, Frankfurt am Main, Germany
| | - Adriaan Hoogendoorn
- Amsterdam Public Health research institute, Amsterdam, Netherlands.,GGZ InGeest, Amsterdam, Netherlands.,Psychiatry, Amsterdam University Medical Center - location VUmc, Amsterdam, Netherlands
| | - Kim Mathiasen
- Research Unit for Digital Psychiatry, Deptartment of Clinical Research, University of Southern Denmark, Odense, Denmark.,Centre for Digital Psychiatry, Mental Health Services of Southern Denmark, Odense, Denmark
| | - Carl May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Bridianne O'Dea
- Black Dog Institute, University of New South Wales, Sydney, Australia
| | | | - Jordi Piera-Jiménez
- Catalan Health Service, Barcelona, Spain.,Digitalization for the Sustainability of the Healthcare System DS3-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,Faculty of Informatics, Multimedia and Telecommunications, Universitat Oberta de Catalunya, Barcelona, Spain
| | - Sebastian Potthoff
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle Upon Tyne, United Kingdom
| | - Gentiana Qirjako
- Department of Public Health, Faculty of Medicine, University of Medicine, Tirana, Albania
| | - Tim Rapley
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle Upon Tyne, United Kingdom
| | - Judith Rosmalen
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ylenia Sacco
- Department of Mental Health, Local Health Authority Torino 3, ASLTO3, Torino, Italy
| | - Ludovic Samalin
- Department of psychiatry, Centre Hospitalier Universitaire de Clermont-Ferrand, Expert center for bipolar disorder (Foundation FondaMental), University of Clermont Auvergne, Clermont-Ferrand, France.,Centre national de la recherche scientifique, Clermont-Auvergne INP, Institut Pascal (UMR 6602), Clermont-Ferrand, France
| | - Mette Maria Skjoth
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Kristine Tarp
- Research Unit for Digital Psychiatry, Deptartment of Clinical Research, University of Southern Denmark, Odense, Denmark.,Centre for Digital Psychiatry, Mental Health Services of Southern Denmark, Odense, Denmark
| | - Ingrid Titzler
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | - Claire Rosalie van Genugten
- Clinical, Neuro-, & Developmental Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Amsterdam Public Health research institute, Amsterdam, Netherlands
| | - Alexis Whitton
- Black Dog Institute, University of New South Wales, Sydney, Australia
| | - Enrico Zanalda
- Department of Mental Health, Local Health Authority Torino 3, ASLTO3, Torino, Italy
| | - Jan H Smit
- Amsterdam Public Health research institute, Amsterdam, Netherlands.,Psychiatry, Amsterdam University Medical Center - location VUmc, Amsterdam, Netherlands
| | - Heleen Riper
- Clinical, Neuro-, & Developmental Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Amsterdam Public Health research institute, Amsterdam, Netherlands.,Psychiatry, Amsterdam University Medical Center - location VUmc, Amsterdam, Netherlands
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