The influence of organizational models on the implementation of internet-based cognitive behavior therapy in primary care: A mixed methods study using the RE-AIM framework

Elisabet Gervind, Mathilda Ben Salem, Cecilia Svanborg, Monica Nyström, Josefine Lilja, Viktor Kaldo, Sandra Weineland

Keywords: Digitalization in Healthcare, Organizational Models, Internet-Based Cognitive Behavior Therapy (iCBT), Primary Care Implementation, RE-AIM Framework

Background:

Internet-Based Cognitive Behavioral Therapy (iCBT) holds great potential for addressing mental health issues, yet its real-world implementation presents significant challenges. While previous research has predominantly focused on centralized care models, this study examines the implementation of iCBT within decentralized organizational structures in the Swedish primary care setting, where all interventions are traditionally delivered at local Primary Care Centers (PCCs).

Research questions:

This study aims to enhance our understanding of iCBT implementation in primary care and assess the impact of organizational models on the implementation's outcome.

Method:

A mixed-methods research design was employed to identify the factors influencing iCBT implementation across different levels, involving patients, therapists and managers. Data spanning two years was collected and analyzed through thematic analysis and statistical tests. The study encompassed 104 PCC, with patient data (n = 1979) sourced from the Swedish National Quality Register for Internet-Based Psychological Treatment (SibeR). Additionally, 53 iCBT therapists and 50 PCC managers completed the Normalization Measure Development Questionnaire, and 15 leaders participated in interviews.

Results:

Two implementation approaches were identified, one concentrated and one decentralized. Implementation effectiveness was evident suggesting that iCBT is a promising approach for treating mental ill-health in primary care, although challenges were observed concerning patient assessment and therapist drift towards unstructured treatment. Mandatory implementation, along with managerial and organizational support, positively impacted adoption. Results vary in terms of adherence to established protocols, with therapists working in concentrated model showing a significantly higher percentage of registration in the quality register SibeR.

Conclusions:

This study contributes to the understanding of the practical aspects associated with the implementation of complex internet interventions. The study highlights that effective iCBT integration into primary care requires a multifaceted approach. By emphasizing these factors, our research aims to provide actionable insights that can enhance the practicability and real-world applicability of implementing iCBT in primary care settings.

Points for discussion:

The importance of organization of internetbased interventions for sustainable implementation

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