“We know what we have to do, but we don’t know how to do it”
Ridde, V. (2016)
This quote from Ridde illuminates well the series of implementation blogs that will be published over the following months. This series of blogs will explore the relevance of implementation science to internet-delivered interventions, and will provide a high level overview of the field. This first blog will serve as an introduction to implementation science. The second blog will explore some of the outcomes relevant to an implementation of internet-delivered cognitive behaviour therapy (iCBT) in a healthcare system, and the final blog will elaborate on the role contextual factors play in these types of implementations, such as differing organizational structures and the need for these novel interventions to be adapted to suit their specific needs.
Internet-delivered interventions are a novel means of providing evidence-based, quality mental healthcare to patients across a number of contexts, for instance in community mental health, in-patient care or through employee assistance programmes in workplace settings. They can help address service needs such as increasing access and reaching greater numbers of patients. They can also produce positive clinical outcomes, as well as having more tangible benefits such as accessing hard-to-reach populations, being time-efficient and cost effective. Despite the noted benefits, the uptake of internet-delivered interventions for mental health by healthcare systems is still low. Some healthcare systems have begun to employ internet-delivered interventions for depression and anxiety disorders management, such as (IAPT) in England and MindSpot in Australia, but these are just some of the few success stories from routine care.
The Evidence to Practice Gap
The challenge with widespread adoption of internet-delivered treatments into mental healthcare provision is reflective of a wider evidence-to-practice gap that is commonly experienced by all novel health interventions and their integration into healthcare provision. The evidence-to-practice gap is characterised by the barriers and organisational phenomena that prevent or limit the uptake of novel procedures in healthcare provision. Researchers in this area have determined that it can sometimes take multiple years for newly researched health interventions to become adopted and integrated into healthcare provision. When considering this, it is not surprising that the uptake and scaling of internet-interventions has been slow. However, given the rapidly growing evidence base for these types of treatment and the benefits they can offer in alleviating the burden of mental health disorders, we need ways of bridging the evidence-to-practice gap to facilitate their uptake and use in general mental health service delivery.
Implementation as a Science
Implementation Science is an academic field that has developed from this evidence-to-practice gap; it endeavours to study the barriers and facilitators associated with the uptake of novel practices in professional settings, and how these practices then become integrated into service-as-usual. As a process, implementation is active and exists on the diffusion-dissemination continuum, where implementation is the phenomenon that occurs when there are systematic efforts to adopt and integrate research and new practices into normal service provision. These efforts can be numerous and varied, such as training those responsible for administering the intervention, providing them with support and motivating them for the use of the intervention through, for instance, management and clinician buy-in.
Customising for Success
Implementation Science advocates a tailored approach, where it acknowledges that the translation of evidence into every day service provision is not always clear cut, or even feasible. For example, where an organisation may wish to integrate an iCBT intervention into its service provision, they will need to consider how it would fit into their; current pathways; model of service provision. Another important consideration would be how to facilitate the use of the intervention with staff. Where internet-delivered interventions mark a departure from traditional forms of in-person psychological therapies, healthcare systems may have little experience with them, they may need to consult with the intervention developers to successfully integrate it into routine care. This may require facilitating numerous trainings in the use of the intervention, amending patient assessment templates and advertising the use of the intervention across the health system so that it becomes a part of normal service pathways. All of these efforts fall under the banner of implementation science, and the study of their outcomes can inform future implementations at different sites.
Barriers to Implementation
If implementation science can facilitate the uptake of these interventions, then why do we not pay it more attention? Some researchers have argued that the decisions necessary to implement novel or research-related procedures tend to be based on “what we know” as opposed to being evidence based. Certain attitudes towards internet-delivered interventions can hinder their implementation, where it may be viewed as inferior to face-to-face therapies. For example, if a stakeholder within the service has little buy-in to the intervention and doubts its clinical effectiveness, the uptake of the intervention may be slow, or a total failure. Appropriate implementation interventions should therefore be undertaken to mitigate the likelihood of this occurring, such as hosting information sessions on the evidence-base for these types of treatments. iCBT can offer numerous benefits to a service, but carrying the intervention into effect and reaping the benefits requires targeted effort from all levels of an organisation. However, this brings further questions; how do we implement iCBT and what are the efforts needed? How do we measure an implementation? We will be addressing these questions, and more, over the course of this series of blogs.