The results present the major themes related to the research aim to identify perceived facilitators and barriers to DIALOG+ implementation by four key groups of stakeholders. Two developed themes (Frequency of intervention delivery; Suggested changes to the intervention) are more broadly associated with DIALOG+ implementation. Differences between participant groups are explored within the identified themes. Views from the interviewed person were in line with views elicited in focus groups.
Six major themes were developed: Intervention characteristics; Attitudes and perceived preparedness of potential adopters; Carers’ involvement; Perceived potential patient and organisational benefits; Frequency of intervention delivery; and Suggested changes to the intervention (Figure 1). countries in Southeast Europe (SEE).
Each major theme was developed from subthemes, summarized in Table 2.
The intervention’s characteristics, likely the starting point of adopters’ engagement with the intervention, were largely interpreted as facilitators to the implementation across participant groups. Clinicians, patients and policymakers viewed DIALOG+ as clear and easy to use. Clinician45 from Serbia expressed “[DIALOG+] couldn’t be simpler”. Yet, a few patients expressed ambiguity when asked about their understanding of the DIALOG+ rating scale and its items. Previous familiarity with Likert scales and quality of life measures is likely to influence how easily patients can understand the rating scale that is part of the intervention.
Patient31: Yes, [DIALOG+ rating scale] is a classic Likert scale.
Patient30: [About the rating scale] when there are such gradations, one gets confused. I think there is no need for more than five [options]. It should be simpler.
Clinicians, patients and policymakers viewed DIALOG+ as adding structure to routine clinician-patient meetings while involving the psychosocial needs of the patient. Clinicians spoke about DIALOG+ creating a workflow for patients and clinicians that could lead to more comprehensive therapeutic approaches. Regularly using DIALOG+ would make it less likely for clinicians to omit topics that might be relevant to treatment.
Clinician9: I like that this intervention is well-structured, involving all the most important areas of one’s life and visual approach that doesn’t let us forget some domain.
Clinicians, patients and carers found the ability of the intervention to track patients and their treatment progress as particularly attractive.
Carer11: [With DIALOG+] there will be a follow up of [the patient’s] condition, which is the most important thing for the patient, number one issue (…) Simply, his condition is monitored, how is it today, is it getting worse or better, are there any improvements.
Attitudes and Perceived Preparedness of Potential Adopters
Some patients, policymakers and carers expressed that the resources to implement DIALOG+ in their facilities are readily usable and available.
Patient19: The medical personnel are sufficient [to implement DIALOG+]. Policymaker3: [DIALOG+] is basically free. There are lots of things that I would like to implement here, but they are expensive (…) But this can be delivered by nurses as well.
However, when asked about resources that might be lacking, other participants expressed serious concerns about the limited resources available, particularly regarding time, staff, funding and space. Conflicting views regarding the existing resources to implement the intervention may reflect resource differences in the explored services.
Patient2: Medical staff of this clinic, they are great, but there just aren’t enough of them.
Carer39: I will give a specific example [of a usual clinical meeting] in my experience as both a caregiver and a patient. The doctor asks me – “Are things better? Are life’s problems worse than before?” but I try to make my conversations with the doctor as brief as possible. I can see there are so many patients waiting to be examined. I can see that patients come from all over the country with their bags, waiting to be examined. So with the doctor, I speak shortly and concretely. [DIALOG+] is something else; this is likely to last longer.
Policymaker26: In Serbia, it is practically impossible in the conditions of usual ambulatory controls, we do not have time for it, really.
Clinician34: You have to give tablet computers to every clinician and pay for tablets and software and everything else. If there is no money for it, how...
Clinicians, patients and policymakers viewed DIALOG+ as consistent with existing norms, policies and procedures in their services. However, participants from Serbia and North Macedonia questioned the suitability of DIALOG+ with the current funding policies that prioritize the quantity of patients examined. Furthermore, some policymakers expressed that implementing DIALOG+ might lead to “loss of individualized approach” to patients. This is likely motivated by the difference between the current, largely unstructured clinical meetings in mental health care compared to the structured procedure of using DIALOG+ supported by technology. It is interesting that the same characteristics of the digital intervention which are considered to dehumanize the intervention by some are also highly appreciated by others.
Policymaker25: DIALOG+ would fit well, I think, very well in the current practice, because, it is actually a modification of the practice that is already being done, but it is more effective and faster.
Policymaker2: I am just afraid of robotizing sessions after certain period of time.
Opposing views were expressed regarding the motivation across participants and peers to implement DIALOG+. Some participants expect that there will be clinicians’ resistance to innovation. Such views likely reflect the context of mental health services in the countries, where digital interventions are not a common practice.
Clinician9: I think that [using DIALOG+] is related to the [clinician’s] individual approach; surely some of our colleagues would be thrilled.
Policymaker4: As a member of a management board, I strongly believe that this can be implemented in our routine practice when we do all the legal work needed for something to become a routine intervention… certification, coding, and setting up the price. I am definitely in for implementing this.
Patient5: I could use it every time… I need to talk more, to tell what’s on my mind, but the doctor never has enough time
Policymaker2: I think opinions would be divided. You cannot expect all [clinicians] to accept something; some people have resistance towards technology…
For most clinicians in the study it is vital that their service managers support them in the implementation of DIALOG+. Clinician14 stated “I think that we must first have the support of management”.
Additionally, all participant groups reported that skills and experience to implement DIALOG+ by key stakeholders are already existent. Some clinicians and patients asked for more information on how to use DIALOG+. Participants only received a short presentation describing the intervention, which is likely the motivation for such accounts. A few patients reported the need for training due to their lack of familiarity with smart phones/tablets.
Clinician3: We would have to get some instructions, this presentation was great, but we would need detailed training.
Policymaker8: No, [DIALOG+] won’t be different [in the skills required] (…) all of these [clinicians] are trained and they talk to patients – some for therapy, some for supportive psychotherapy – and each of them has his own way.
Patient3: I am good with computers, this is too easy.
Patient10: I don’t use a smart phone… so I would need [training].
An important implementation facilitator interpreted from the data is the participants’ perceived need for DIALOG+ implementation, particularly as it supports innovation in mental health care. Patients and carers express need for the intervention because current clinical meetings are perceived to last too short to fully understand the patient and limiting in the scope of conversation.
Patient45: [Clinicians] also pay little attention to the patient during the appointments, only 10-15 minutes or 5, irrelevant, but I think [DIALOG+] is already better.
Clinician9: I think that [DIALOG+] is very useful, that is exactly what we need.
Policymaker17: In the new National Strategy that is under preparation, we have included a mental health category. So this project comes at the right time so that we can think about which services we can develop. We are very thin in this field. It should start inter-sector cooperation at the local level. This project can help us a lot…
Carer26: I think it will succeed, [implementing DIALOG+] is a step forward in medicine, having in mind how patients are treated, all is done in the old fashioned way, and nothing has improved until now.
Participants expressed that poor mental health of patients can be a barrier to DIALOG+ implementation. Policymaker2 said that “[DIALOG+ areas are significant when patients reach remission, when they can handle real-life situations.” This result highlights that the intervention may not be suitable for all patients and some selection criteria may be necessary.
Carers’ Involvement in Intervention
Participants expressed varying views regarding involvement of carers in DIALOG+ implementation, although all participant groups saw carers to have a facilitating role. Clinicians and carers proposed carers to be involved in the planning and execution of actions agreed from the sessions. Clinicians expressed that DIALOG+ could offer carers psycho-education. However, patients and clinicians also showed reluctance about the extent to carers’ involvement during sessions. The accounts suggest that the level of carers’ involvement with such an intervention requires adjustment to the patient’s needs.
Clinician10: We should just keep caregivers away from assessing areas instead of patients.
Policymaker3: I think caregivers should take part in this. Whether they take part on the sessions or afterwards… it depends on what the patient wants...
Patient8: I would like [family members to be involved] in that part where doctor gives tasks to family members and me. I wouldn’t like them there all the time.
Patient56: [Carers] could encourage and stimulate clients, and at the same time they could help clinicians be better informed about their clients’ problems – from a different point of view. I think carers could understand and explain certain issues more objectively than clients themselves.
Perceived Potential Patient and Organisational Benefits
Clinicians, patients and carers reported patient empowerment and an improved therapeutic relationship as potential benefits of the intervention to the patient. Other potential benefits at an organisational level were also reported: DIALOG+ would help shift the mental health services away from a typical medical approach to care by reinforcing a psychosocial care approach (clinicians, patients, carers); care could become more patient-centred (patients and carers); the structure and follow-up of care could be improved (all participant groups), and DIALOG+ could offer an opportunity for care to be standardized across services (by policymakers). These subthemes reflect how DIALOG+ could add to the routine service delivery and the elicited views are likely related to what participants are missing from their current care.
Carer36: The clinician gets closer to the patient, and the patient increases his confidence in the clinician [with DIALOG+]. If this intervention goes on for a longer time, this can only deepen and expand the relationship
Patient3: I like that we have freedom, that we can follow this app and that we have information from previous sessions. We see if we have made progress or not, we can see if the doctor’s therapy, advice, or drug were adequate.
Patient56: It would motivate me to work harder on myself and spend less time doing nothing but wandering around.
Policymaker2: [DIALOG+] would be good because we would standardize appointments in time, content, and approach.
Clinician3: It increases functionality in every aspect, what is important for the patient, engages patients in decision-making process, motivates them. That increases self-confidence and empowers the patient.
Clinician45: The mere fact that conversations with my patients would cover eight life areas would bring change, since that was not part of my routine clinical practice so far. I think that structured conversation would allow us to discuss more things in less time and to be sure that we didn’t miss any important life area
Frequency of Intervention Delivery
Some participants provided brief answers about the frequency of DIALOG+ delivery. Once per month was the most common view, particularly among clinicians and policymakers. Some patients and carers requested more frequent delivery, for instance weekly or bi-weekly. Less frequent delivery, such as “once in two months” and “at least twice a year”, was favoured by some other patients and carers. Carer38 proposed DIALOG+ be delivered every six months because changes to patients’ life satisfaction take time. Carer37 expressed that DIALOG+ “should be applied regularly during outpatient appointments”. These accounts suggest that the frequency of DIALOG+ sessions should be determined by the individual patient’s needs.
Suggested Changes to the Intervention
Some participants’ accounts contained broad recommendations about changes to DIALOG+, however these was not explored in detail. Suggestions about the DIALOG scale were made, such as adding a miscellaneous field so patients can discuss topics not included in the scale, and reducing it to a 5-point Likert scale. Clinician46 expressed that “it might be practical and easy to use smartphones for [delivering DIALOG+]”. About the area ‘job situation’, policymaker4 said “it should be clearer that it also refers to education, or how the patient is dealing with being unemployed.” Clinician36 spoke about the longer time needed to see changes in patients’ satisfaction with areas such as ‘job situation’ and ‘accommodation’ than that with their mental health, thus “perhaps these should be assessed only at a 6-month interval.”