IMPlementation of A Relatives’ Toolkit (IMPART study):Examining the critical success factors, barriers and facilitators to implementation of an online supported self-management intervention in the NHS

Background Digital health interventions (DHIs) have the potential to improve the delivery of psychoeducation to people with mental health problems, and their relatives. Despite substantial investment in the development of DHIs, successful implementation into routine clinical practice is rare. Objectives Implementation of the Relatives’ Education And Coping Toolkit (REACT) for psychosis/bipolar disorder to identify critical factors affecting uptake and use, and development of an implementation plan to support delivery of REACT. Design Implementation study using a mixed-methods, theory-driven, multiple case study approach. We developed and tested a study-specific implementation theory for REACT based on normalisation process theory (NPT), and developed iterations of an implementation plan to address the key factors affecting implementation. Setting Early intervention teams in six NHS mental health trusts in England (3 North, 3 South). Participants In all, 281 staff and 159 relatives’ accounts were created; 129 staff and 23 relatives took part in qualitative interviews about their experiences; 132 relatives provided demographic data, 56 baseline data, and 21 data at 12 weeks’, and 20 at 24 weeks’ follow-up. Interventions REACT is an online supported self-management toolkit, offering 12 evidence-based psychoeducation modules and support via a forum and confidential direct messaging service for relatives of people with psychosis or bipolar disorder. The implementation intervention was developed with staff and iteratively adapted to address barriers identified. Adaptations included modifications to the toolkit, and how it was delivered by teams. Main outcome measures The main outcome was factors impacting on implementation of REACT, assessed primarily through in-depth interviews with staff and relatives. We also assessed quantitative measures of delivery (staff accounts and relatives’ invites), use (relatives’ logins and time spent on the site) and impact of REACT (relatives’ distress (GHQ-28); carer wellbeing and support (CWS questionnaire). Results Staff and relatives were generally positive about the content of REACT, seeing it as a valuable resource that could help services improve support and meet clinical targets, but only within a comprehensive service that included face-to-face support, and with some additional content. Barriers to implementation included high staff caseloads and difficulties prioritising supporting relatives; technical difficulties using REACT; poor interoperability with trust IT systems and care pathways; lack of access to mobile technology and IT training; restricted forum populations leading to low levels of use; staff fears of managing risk, online trolling, or replacement by technology; and uncertainty around REACT’s long-term availability. There was no evidence that REACT would reduce staff time supporting relatives (which was already very low), and might increase it by facilitating communication. In all, 281 staff accounts were created, but only 57 staff sent relatives invites. In total, 355 relatives’ invites were sent to 310 unique relatives, leading to the creation of 159 relatives’ accounts. The mean number of logins for relatives was 3.78 (SD 4.43) but with wide variation from 0–31 (median 2, IQR 1–8). The mean total time spent on the site was 40.6 minutes (SD 54.54 minutes) with a range of 0–298 minutes (median 20.1, IQR 4.9–57.5). There was a pattern of declining mean scores for distress, social dysfunction, depression, anxiety, and insomnia, and increases in relatives’ wellbeing and eHealth literacy, but no changes were statistically significant. Conclusions DHIs, such as REACT, should be iteratively developed, evaluated, adapted and implemented, with staff and service user input, as part of a long term strategy to develop integrated technology-enabled services. Implementation strategies must instil a sense of ownership for staff and ensure they have adequate training, risk protocols, and resources to deliver the technology. Cost effectiveness and impact on workload and inequalities in accessing healthcare need further testing. Limitations REACT was offered by the same team running the IMPART study, and perceived by staff and relatives as a time-limited research study rather than ongoing clinical service, which affected engagement. Access to observational data was limited. Future work The effectiveness and generalisability of our findings to other DHIs requires testing. Study registration and funding details ISCTRN 16267685. This study was funded by the National Institute of Health Research (NIHR), Health Services and Delivery Research 14/04/16. The views expressed are those of the author(s) and not necessarily those of the NHS, NIHR, or the Department of Health. 692 words