Prescribing Technology to Increase Uptake of Depression Treatment in Primary Care: A Pre-implementation Focus Group Study of SOVA (Supporting Our Valued Adolescents)

Abstract

Supporting Our Valued Adolescents (SOVA) is a web-based technology intervention designed to increase depression and anxiety treatment uptake by adolescents in the context of an anonymous peer community with an accompanying website for parents. With a goal of informing the design of a hybrid effectiveness-implementation randomized controlled trial, we conducted a pre-implementation study in two primary care practices to guide implementation strategy development. We conducted focus groups with primary care providers (PCPs) at three different timepoints with PCPs (14 total) from two community practices. A baseline survey was administered using Evidence-Based Practice Attitude Scale (EBPAS) and Physician Belief Scale (PBS). Subsequently, during each focus group, PCPs listened to a relevant presentation after which a facilitated discussion was audio recorded and transcribed. After timepoint 1, a codebook based on Consolidated Framework for Intervention Research (CFIR) and qualitative description were used to summarize findings and inform implementation strategies that were then adapted based on PCP feedback from timepoint 2. PCPs were provided with resources to implement SOVA over 5 months and then a third focus group was conducted to gather their feedback. Based on EBPAS and PBS, PCPs are willing to try new evidence-based practices and have positive feelings about taking care of psychosocial problems with some concerns about increased burden. During focus groups, PCPs expressed SOVA has a relative advantage and intuitive appeal, especially due to its potential to overcome stigma and reach adolescents and parents who may not want to talk about mental health concerns with their PCP. PCPs informed various implementation strategies (e.g., advertising to reach a wider audience than the target population; physical patient reminders). During timepoint 3, however, they shared they had a difficult time utilizing these despite their intention. PCPs requested use of champions and others to nudge them and priming of families with advertising, so that the PCP would not be required to initiate recommendation of the intervention, but only offer their strong endorsement when prompted. The process of conducting a pre-implementation study in primary care settings may assist with piloting potential implementation strategies and understanding barriers to their use.

Trial registration NCT03318666.

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Fig. 1

Availability of data and materials

The datasets during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

AVS:

After visit summary

CFIR:

Consolidated framework for implementation research

EBP:

Evidence-based practice

EBPAS:

Evidence-Based Practice Attitude Scale

EHR:

Electronic health record

FG:

Focus groups

IP:

Internet protocol

PBS:

Physician Belief Scale

PCP:

Primary care physician

SOVA:

Supporting our valued adolescents

T:

Timepoint

UPMC:

University of Pittsburgh Medical Center

UTAUT:

Unified Theory of acceptance and use of technology

YRAB:

Youth Research Advisory Board

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Acknowledgements

We thank Cassandra Long for assistance with research recruitment and interview transcription. We thank Sharanya Bandla for technical assistance. We thank the University of Pittsburgh Clinical and Translational Science Institute’s (UL1TR001857) Pediatric PittNet practice-based research network for enhancing our recruitment efforts in their affiliated pediatric offices in the greater Pittsburgh area. We thank and acknowledge the pediatric practices and primary care providers, practice managers, and insurance representatives for informing this study and making it possible.

Funding

Dr. Radovic was supported on an institutional career development award during this study (AHRQ PCOR K12 HS 22989-1) and is currently on a second career development award (NIMH 1K23MH111922-01A1). This research was also supported in part by UPMC Children’s Hospital of Pittsburgh and the University of Pittsburgh School of Medicine. The project described was also supported by the National Institutes of Health through Grant Number UL1TR001857.

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The authors are fully responsible for the reported research, have all met requirements for authorship, and have read and approved the final document. AR wrote the first draft of this manuscript for which no payment was received.

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Correspondence to Ana Radovic.

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The original study protocol was approved by the University of Pittsburgh Institutional Review Board. All individuals provided verbal consent to participate.

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Appendix

Appendix

See Table 3.

Table 3 Consolidated Framework for Implementation Research Constructs based on PCP Feedback

FOCUS GROUP 1 – Informing Implementation Script:

INTRODUCTION: Hello, my name is Ana Radovic and this is my research coordinator, [name]. I am an adolescent medicine physician studying interventions to increase the uptake of depression treatment for adolescents identified in primary care. Thank you so much for participating in this focus group today.

Prior to starting I’d like you to complete two brief surveys about your thoughts about whether an intervention like this is needed and your comfort taking care of adolescents with mental health problems. These are anonymous so please do not write your name. These should take no more than 5 minutes.

Evidence-Based Practice Attitude Scale

Physician Psychosocial Belief Scale

I will be using an audio recorder and will inform you when I am recording. This is an anonymous interview and we will not be recording your names or any other identifying information. If in the process of the discussion, you would like to describe a patient you’ve seen, in accordance with HIPAA, please refrain from giving me any patient’s name or any other identifying information. Answering questions is voluntary and if there are any questions you do not want to answer, you may choose not to. If there’s anything you would like to add, please do so. This focus group should last no more than sixty minutes, but if we are interrupted, we can continue at a later time.

Are there any questions before we start?

I will begin recording now.

-----OVERALL WEBSITE DESIGN-----

A powerpoint presentation to facilitate discussion and key concepts will be displayed.

Websites (sova.pitt.edu and wisesova.pitt.edu) will be pulled up on projector and screen.

(intervention source)

Several years ago, I interviewed a group of CCP clinicians about treating adolescent depression. They told me they love having improved access to behavioral health services, but for some families, they’d still run into difficult discussions about treatment with teens and especially with parents. It’d be hard to address if families did not accept a depression diagnosis or had worries or concerns about treatment. 

Hand out article I published on PCP beliefs

(design)

The purpose of these two website tools – one for parents (wisesova.pitt.edu) – and one for adolescents (sova.pitt.edu) – is to give PCPs a tool for families at the same time they recommend depression or anxiety treatment.

Each website aims to: 

  1. (1)

    Educate about depression diagnosis and treatment

  2. (2)

    Inform about potential negative attitudes about depression

  3. (3)

    Offer access to a community of peers who have experienced depression and benefited from treatment in themselves or in their child

  4. (4)

    Offer positive interactions with therapist moderators.

This website is moderated by behavioral health trainees in psychology and social work 24-7.

(evidence)

The design of these websites has been informed by stakeholders including your primary care practice and the behavioral health clinicians who worked with you. We’ve tested the sites and found that adolescents and parents find them highly usable and acceptable. And we have encountered no safety concerns and have successfully moderated all new content.

(relative advantage)

Before we test them to see if they actually result in what we think they do: increase social support, decrease negative health beliefs, and improve parent-adolescent communication, we want to make sure they are adapted in a way that PCPs could actually use them in practice. The advantage of this is instead of testing an intervention that only works in a research setting, we will produce something that is ready to use off the shelf.

Our research group envisions after you recommend treatment, you would offer this website as a supportive intervention providing information and moderated peer support that we hypothesize will help adolescents and parents accept treatment for depression or anxiety.

My first question for you is:

Perceptions about current practice

1. What is your current practice after recommending depression or anxiety treatment to a patient?

…What do you do if someone does not seem interested in treatment? Or raises negative health beliefs such as thinking treatment doesn’t work?

Need for Intervention

2. Do you feel an intervention like this is needed? Why?

Potential Barriers and Facilitators to Implementation

3. How do you envision introducing this intervention to your patients/their parent?

…What kinds of things would help you implement this intervention?

(possible suggestions: Epic Best Practice Alerts, a modified patient education handout, an EHR smartphrase and integrating with workflow, getting feedback, educational outreach visits, ongoing training, developing a toolkit, business card size with name of website, screensaver on computer screen, having the website on their own phones, adaptations to website itself – keeping track of score)

…What kinds of things would stand in the way of implementing this intervention?

Acceptability to Patients

4. Do you think adolescents and parents would find this intervention acceptable?

….if no, what would make it more acceptable?

5. Before we end, is there anything else you’d like to share?

I will now turn off the audio device.

Thank you very much for your time. Your WePay card will be filled within 24 hours. Please contact me if there is any difficulty with using it or you have any further questions.

---- After this first Focus Group I will develop a prototype implementation strategy based on PCP feedback ----

FOCUS GROUP 2 – Evaluating Implementation Strategy

Script:

I will be using an audio recorder and will inform you when I am recording. This is an anonymous interview and we will not be recording your names or any other identifying information. If in the process of the discussion, you would like to describe a patient you’ve seen, in accordance with HIPAA, please refrain from giving me any patient’s name or any other identifying information. Answering questions is voluntary and if there are any questions you do not want to answer, you may choose not to. If there’s anything you would like to add, please do so. This focus group should last no more than sixty minutes, but if we are interrupted, we can continue at a later time.

Are there any questions before we start?

I will begin recording now.

Based on our last discussion, you informed me that the following adaptations would need to be made to SOVA: (summarize FG1 discussion points).

This helped inform the following implementation strategy: (explain strategy).

My first question for you is:

  1. 1.

    What do you think of this implementation strategy?

  2. 2.

    Do you have any remaining concerns about implementation?

  3. 3.

    What else could be changed to improve it?

  4. 4.

    Do you still anticipate any potential barriers to introducing the websites to adolescents and their parents?

  5. 5.

    Before we end, is there anything else you’d like to share?

I will now turn off the audio device.

Thank you very much for your time. Your WePay card will be filled within 24 hours. Please contact me if there is any difficulty with using it or you have any further questions.

---- After this first Focus Group, PCPs will be offered use of the implementation strategy which will most likely take advantage of clinic resources they already have such as patient education handouts, or will involve adapting advertisements about the sites (creating business cards, etc.). They will begin to offer the websites to patients and their parents. ----

FOCUS GROUP 3 – Feedback on Implementation Strategy

Script:

I will be using an audio recorder and will inform you when I am recording. This is an anonymous interview and we will not be recording your names or any other identifying information. If in the process of the discussion, you would like to describe a patient you’ve seen, in accordance with HIPAA, please refrain from giving me any patient’s name or any other identifying information. Answering questions is voluntary and if there are any questions you do not want to answer, you may choose not to. If there’s anything you would like to add, please do so. This focus group should last no more than sixty minutes, but if we are interrupted, we can continue at a later time.

Are there any questions before we start?

I will begin recording now.

  1. 1.

    Please tell me your overall impression about offering the SOVA websites.

  2. 2.

    During prior focus groups, we discussed using the following implementation strategy (describe). Were you able to use this strategy?

    … If not at all, why not?

    … If somewhat, why did you modify it?

  3. 3.

    What were some challenges of implementing offering the SOVA websites?

  4. 4.

    What were some things which helped you offer it?

  5. 5.

    Before we end, is there anything else you’d like to share?

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Radovic, A., Odenthal, K., Flores, A.T. et al. Prescribing Technology to Increase Uptake of Depression Treatment in Primary Care: A Pre-implementation Focus Group Study of SOVA (Supporting Our Valued Adolescents). J Clin Psychol Med Settings 27, 766–782 (2020). https://doi.org/10.1007/s10880-019-09669-5

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Keywords

  • Adolescent
  • Depression
  • Anxiety
  • Technology
  • Health services
  • Implementation science
  • Primary health care
  • Pediatrics