10 putting technology into practice young and well crc

Putting Technology into Practice //Evidence and opinions on integrating technology with youth health services Alice E Montague Dr Kandice J Varcin Dr Alexandra G Parker September 2014 Young and Well CRC Unit 17, 71 Victoria Crescent Abbotsford VIC 3067 Australia youngandwellcrc.org.au

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Putting Technology into Practice Evidence and opinions on integrating technology with youth health services

Alice E Montague Research Assistant Orygen, The National Centre for Excellence in Youth Mental Health Centre for Youth Mental Health, The University of Melbourne

Dr Kandice J Varcin Senior Research Assistant Orygen, The National Centre for Excellence in Youth Mental Health Centre for Youth Mental Health, The University of Melbourne

Dr Alexandra G Parker Senior Research Fellow Orygen, The National Centre for Excellence in Youth Mental Health Centre for Youth Mental Health, The University of Melbourne

ISBN: 978-0-9925966-2-0 Suggested citation: Montague, AE, Varcin, KJ & Parker, AG 2014. Putting Technology into Practice: Evidence and opinions on integrating technology with youth health services, Young and Well Cooperative Research Centre, Melbourne.

Copies of this guide can be downloaded from the Young and Well CRC website youngandwellcrc.org.au Copyright and Disclaimer The standard Young and Well CRC Copyright and Disclaimer notice will be inserted in the document during final formatting. If the report is a joint publication then copyright can be shared.

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Acknowledgements The authors would like to thank the young people from Platform and the headspace Youth National Reference Group, as well as Orygen and headspace youth service providers for providing their time, energy and expertise to this project. We would also like to thank Laura Baruch, the headspace Youth Participation Officer, and Melissa Thurley, the Orygen Youth Participation Coordinator for their invaluable input.

We would like to thank the Young and Well CRC for their partnership and support throughout the project. Finally, we would like to thank Dr Magenta Simmons, Professor Debra Rickwood, Dr Sarah Hetrick, Alan Bailey, Heidi Strickland and Jessica Stephens for their contributions throughout the duration of this project.

Young and Well Cooperative Research Centre The Young and Well Cooperative Research Centre is an Australian-based, international research centre that unites young people with researchers, practitioners, innovators and policymakers from more than 70 partner organisations.

Together, we explore the role of technology in young people’s lives, and how it can be used to improve the mental health and wellbeing of young people aged 12 to 25. The Young and Well CRC is established under the Australian Government’s Cooperative Research Centres Program.

Orygen, The National Centre of Excellence in Youth Mental Health Orygen, The National Centre of Excellence in Youth Mental Health is the world’s leading research and knowledge translation organisation focusing on mental ill-health in young people. At Orygen, our leadership and staff work to deliver cutting-edge research, policy development, innovative clinical services, and evidence-based training and education to ensure that there is continuous improvement in the treatments and care provided to young people experiencing mental ill-health.

youngandwellcrc.org.au orygen.org.au

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Table of Contents Executive summary………………………......................................................................................................... 1

Narrative review: Technology for engagement in and as a complement to face-to-face youth clinical services………………………………………...…………………...…………………...…………………...………… 4

Systematic review: Strategies for increasing ICT uptake in healthcare professionals...………….......……… 13

The views of young people and youth service providers on putting technology into practice………………… 24

References…………………………………………………………………………………………………………….. 41

Appendices…………………………………………………………………………………………………………….. 49

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Executive summary 2 Only two studies investigated how technology can be used to engage with young people in treatment

3 Only three studies have explored how technology can be used as an adjunct to youth mental health treatment

Collating the best available evidence, we conducted a comprehensive review of the literature from the year 2000 to explore three aims: 1.

2.

24 Twenty-four studies have evaluated interventions to increase the use of technologies in healthcare professionals in the past 13 years

0 But not a single study has evaluated an implementation strategy to increase technology uptake in youth health service providers, let alone in youth mental health

16x Strategies where clinicians were actively engaged in the intervention process were 16 times more likely to result in the successful uptake of technology in practice “Technology is part of life now. If you don't work healthcare into something that's such a huge part of your life, it doesn't work.”

– hY NRG member “I am always on Facebook, Google, Tumblr, or pretty much everything. Gmail, Hotmail, Yahoo… All that. If you have got healthcare staring at you right in the face… Well yeah, I think that would be great.”

– Platform youth representative “I don't think the sector has a choice. Young people… They are more and more inclined to use technology. So we will have to change.”

– Clinician

3.

How has technology been used to engage young people in face-to-face clinical services?

How has technology been used as an adjunct to face-to-face treatment in youth mental health?

What interventions have been employed to promote the uptake of technologies by healthcare professionals in practice, and what were the most successful interventions?

Of more than 11,000 articles screened, 29 were included in our final review. The included studies were assessed for their level of methodological quality.

Aim 1: Technology as a tool to engage young people in clinical practice Only two studies have investigated the use of technology to engage young people in face-to-face health or mental health clinical practice. One determined that Short Message Service (SMS) was a feasible means of coordinating appointments and interacting with clients in youth mental health outreach (Furber et al. 2011). Another utilised a tablet to electronically screen, and subsequently refer for treatment, suicidal young people in a general medical practice waiting room (Gardner et al. 2010). Although the methodological quality was low, these two studies combined provide preliminary evidence to demonstrate the viability of technological tools to engage young people in their care. They indicated that technology can assist in appointment scheduling, developing the therapeutic relationship, and engaging young people in the stepped-care process. Research in this area is limited, but the results from these studies strengthen the rationale to further investigate how technology can be used to engage young people in clinical services.

Aim 2: Technology as an adjunct therapeutic tool Only three studies were eligible for inclusion in this review under the second aim. Sethi and colleagues (2010) concluded that online Cognitive Behaviour Therapy (CBT) combined with face-to-face therapy was significantly more effective at reducing

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symptoms of anxiety and depression in university students than online CBT and a no-treatment control, and was equally as effective as traditional CBT alone. Another study found that self-tracking mood and behaviour over time with a mobile device was no more effective than tracking behaviour alone at decreasing mental health symptoms in Australian young people in a primary care setting (Reid et al.

2011). However, participants who tracked their mood were more aware of their emotions, and the tracking data was able to facilitate meaningful interaction between clinician and client in all groups.

Finally, in a study of students receiving mental health counselling, an online physical activity intervention and interactive exercise-tracking tool was found to significantly increase physical activity, which was correlated with a subsequent decrease in mental health symptomatology (Mailey et al. 2010).

While only Reid and colleagues’ study (2011) was of a high methodological quality and most participants were limited to those with mild to moderate mental health problems, this research again highlights the potential of technological tools to enhance mental health treatment and the need for further research to ascertain the benefit of adjunctive technological interventions.

Aim 3: Interventions to promote technology uptake by healthcare professionals in practice Our final aim captured 24 research studies evaluating the success of strategies to increase the use of technology by healthcare professionals in practice. To gain a comprehensive view of the current research, all levels of research were considered. The results were heterogeneous, mixed and limited. Firstly, it was clear that this area of the literature is characterised by a complex variety of intervention types, healthcare professions, health settings, and study designs. This, taken together with the low methodological quality of the vast majority of the included studies, precluded conclusions on the identification of the best type of intervention to increase technology use in practice.

However, we found that strategies where clinicians were actively engaged in the intervention (for example through hands-on practice or fundamental changes to the healthcare system process) were 16 times more likely to have good uptake of technologies in practice. A logic model of technology uptake in healthcare professionals was also developed to represent the need for tailored uptake interventions to target multiple factors at multiple levels to increase technology use in practice.

ADDING TO THE LITERATURE: FOCUS GROUP CONSULTATIONS WITH YOUNG PEOPLE AND CLINICIANS Considering the lack of high quality research in our first three aims and the need to tailor technology uptake interventions to the given healthcare setting, we conducted three focus groups to explore young people and clinicians’ opinions on how best to integrate technology and practice. One focus group was conducted online with the headspace Youth National Reference Group (hY NRG; n=16), another face-to-face with Platform youth representatives (Platform; n=5) and one with headspace and Orygen Youth Health Clinical Program service providers (n=14). Discussion was guided by three key research questions: 1.

2.

3.

How do you believe technology should and can be used to engage with young people in treatment? How have you used technology for treatment engagement in the past?

Do you believe technology is a useful complement to clinical treatment? How have you used technologies to supplement your treatment?

What strategies should be used to increase technology use by youth service providers in their practice?

The key themes related to each research question are as follows: Technology as a tool for youth treatment engagement • Overall, young people were positive about being engaged through technology by their healthcare providers, including through SMS reminders and email. They endorsed that, as technology was “such a huge part of life”, it was crucial that it be integrated into healthcare communication.

• Clinicians too agreed that technology had the potential to be a powerful engagement tool in practice.

They cited examples of how SMS, email and interactive technologies had been useful to meaningfully engage with their clients both in and between sessions.

• Young people reported differing views on their preferred mode of contact based on personal choice, available resources, and lifestyle. Clinicians and young people thus emphasised that the most reliable

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•

•

•

way to communicate with young people was to engage in a shared decision-making process to determine the best mode of contact.

Even though preferences differed, young people and clinicians generally agreed that telephone calls were the most appropriate means to first contact clients, as it was “more personal” and helped develop the therapeutic relationship.

Young people and clinicians endorsed that SMS reminders were a useful tool for increasing engagement by conveniently and quickly reducing the possibility of non-attendance due to simply forgetting an appointment.

Young people were not comfortable with being personally contacted on social media due to concerns of stigma from their peers and the potential for confidentiality breaches. They were however positive about accessing professional online profiles of clinicians to learn more about their “human side” before their initial engagement in treatment.

Technology as an adjunct therapeutic tool • Young people and clinicians both reported already using a variety of technologies to supplement treatment, such as self-care apps and games, and online support groups.

• All participants believed that if technology were to be formally integrated into treatment, it was essential that it had a clear benefit to the treatment plan of the given young person and it was tailored to their needs.

• Young people and clinicians endorsed that technology had the potential to extend care beyond the insession interaction and provide a stronger continuity of care between appointments.

• All participants were adamant that technology must not replace face-to-face interaction, and that it only supplement the existing traditional therapies.

Clinician uptake of technologies in practice • Clinicians were largely motivated to, and had a positive attitude towards, the integration of technology and practice. However, they also identified that existing organisational policy was a barrier to use.

• Clinicians endorsed that having paid time and the appropriate resources readily available to them would allow them to “try technology out”, interact together to learn collaboratively, and would ultimately facilitate use.

• Both clinicians and young people requested that any intervention to integrate technology and practice be supplemented with the appropriate evidence-based resources to indicate which available technologies were the most beneficial, as well as clarifying concerns of ambiguities around duty of care protocol.

• Clinicians and young people both suggested that young people, as the “experts” in technology, could lead training workshops for clinicians.

KEY IMPLICATIONS •

•

• • • • •

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Further research is required to explore the role of technology in face-to-face clinical practice, both for engagement and as an adjunct therapeutic tool. It is unclear what intervention, if any, will increase the uptake of technology into any given healthcare setting. It is clear that it is a complex problem that involves tackling barriers at the organisational, individual, and technology level.

Our research indicates, however, that whatever the intervention type, clinicians should be actively engaged in the professional development process. Wherever possible, meaningful engagement should be facilitated by interactive interventions and the provision of feedback.

The best mode of contact for any given client should be established in a shared decision-making process between clinician and client, and the preferred method will be the most reliable for engagement.

Any formal integration of technology and treatment should have a clear rationale and benefit to treatment.

Evidence-based resources should be developed to supplement the uptake of technology in healthcare to guide best practice and clarify ambiguities in duty of care.

There is a need to evaluate the feasibility, acceptability, safety and effectiveness of those technologies already being informally integrated into practice.

Organisational policy that does not reflect the aim to integrate technology and practice should be amended, and clinicians should have paid time to explore and collaboratively learn about technologies.

Ideally, professional development programs should be guided by the expertise of young people.

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Narrative review: Technology for engagement in and as a complement to face-to-face youth clinical services BACKGROUND AND RATIONALE More than ever before, life is mediated by technology, especially for those aged between 12 and 25 years.

Internet use is reaching ubiquity among Australian young people: 99% of young people use the internet, with 95% connecting daily (Burns et al. 2013). Young people use technology to communicate with others more than any other age group, through social networking, email, interactive multimedia, games and messaging (Burns et al.

2013; Australian Bureau of Statistics 2011). Be it at home, at school, or in public, young people are making use of new technologies to interact and collaborate, with both the consumption and production of multimedia (Livingstone & Helsper 2007; Burns et al. 2013; Vickery 2007). The internet is also the main source of information for young people (Misson Australia 2013), including health and mental health information (Burns et al. 2010; Burns et al. 2013). Young people also seek informal mental health support online, despite being reluctant to seek professional help elsewhere (Ellis et al. 2013; Barak 2007; Rickwood et al. 2005). It has been suggested that the anonymous, easily accessible space of the internet empowers young people to talk about sensitive issues, such as depression or sexuality (Burns et al. 2010; Gould et al. 2002; Nicholas et al. 2008; Suzuki & Calzo 2004).

Indeed, given the pervasive and intimate role technology plays in young people’s lives, new technologies may offer one of the most promising opportunities for the better management of mental health problems in young people (Christensen & Hickie 2010). This has immense potential, as young people are particularly susceptible to mental illness, and without appropriate treatment, are at risk of disrupting a critical period of social and intellectual development (McGorry et al. 2007).

Youth clinical services: the engagement problem Young people are particularly difficult to engage in mental health treatment, as while they frequently experience mental disorders, they tend not to seek help (Rickwood et al. 2005). This could be because of young people’s general distrust of health professionals, a fear of loss of control, fear of stigma, a sense of helplessness, or a preference for self-reliance (King 2010; Eisenberg et al. 2009; Gulliver, Griffiths & Christensen 2010). Even when referred to a clinical service, young people are ambivalent or reluctant to accept treatment more than any other age group, and may not have the positive motivation for change considered central to a good treatment response (King 2010; McKay et al. 1996). This reported ambivalence is reflected in high treatment dropout rates in young people. A retrospective study of 11,659 children and adolescents initiating outpatient treatment indicated that most patients only stayed in treatment for only two months, with 45% dropping out after only one month, and only 22% remaining in treatment for six months (Harpaz-Rotem, Douglas & Rosenheck 2004). Other research indicates that a three-month retention rate of young people was as low as nine percent (McKay & Bannon 2004).

Client disengagement is a significant obstacle to both effective service delivery and positive outcomes of treatment (Baydar, Reid & Webster-Stratton 2003; Meyers et al. 2002), especially as most drop out before they have received an efficacious dose of therapy (Pekarik 1991). This is particularly problematic as insufficient treatment of mental health issues in adolescence can have deleterious effects on psychological and social wellbeing throughout the lifespan (Aalto-Setala et al. 2002; Fergusson et al. 2005). Sadly, the more unwell, functionally impaired, and at-risk youth are more likely to disengage with treatment compared to their healthier peers, indicating that those most in need of treatment are not receiving the help they need (Rickwood et al. 2005; Killaspy et al. 2000; French et al. 2003).

Existing interventions to increase treatment engagement Intervention approaches at various levels have been implemented with the aim of improving attendance in mental health services amongst adolescents and young adults (Kim, Munson & McKay 2012). At the service level, research indicates that engagement training for clinicians (McKay et al. 1996), the addition of a case manager (Burns et al. 1996) and strategies to improve the therapeutic alliance (Karver et al. 2008) can have a significant, positive effect on treatment involvement, both at the initial and ongoing engagement phases. Similarly, family level approaches such as brief strategic family therapy (Coatsworth et al. 2001) and telephone engagement and first4

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interview engagement interventions with families (McKay et al. 1996) were significantly more successful at engaging and retaining clients throughout the treatment period. Finally, simple reminder telephone calls to clients successfully increased engagement (Sawyer et al. 2002; Watt et al. 2007) at the individual client level.

While factors related to youth disengagement from treatment have been relatively understudied (Kim, Munson & McKay 2012), barriers to attendance acknowledged in the broader healthcare field can inform an understanding of the mechanism of improved attendance in these interventions. That is, the use of a case manager, clinician engagement training, and an improved therapeutic alliance is likely to improve communication between practitioner and patient (Killapsy et al. 2000) while reminder calls reduce the changes of simply forgetting an appointment (Mitchell and Selmes 2007). Furthermore, as appointment attendance is best when clients feel ready for treatment, perceive its benefits, and share a collaborative, trusting and therapeutic strategy with their clinician (Gonzalez et al. 2005; Nakanish et al. 2006; Muson et al. 2011); it is unsurprising that interventions to enhance the therapeutic alliance and change patient attitudes proved effective. However, engaging young people in mental health treatment remains challenging and there is a general paucity of research in youth and young adults’ service engagement (Kim, Munson & McKay 2012).

The evidence gap: how can technology increase young people’s treatment engagement Young people’s high consumption of technologies provides an important opportunity to enhance treatment engagement in youth mental health services. According to Blanchard (2008), unless healthcare providers and organisations effectively incorporate evidence-based technologies into practice, they risk poor engagement of young people across the intervention spectrum. Indeed, according to Bradford & Rickwood (2014), Australian young people consistently report that electronic psychosocial assessment in a clinical setting supports disclosure without fear of judgment and enables stronger input and direct engagement of young clients in the face-to-face treatment process. Yet, despite high treatment disengagement, and the potential of technology to enhance engagement in clinical services, the potential of technology in youth services is yet to be comprehensively explored. This has produced significant gaps in knowledge: for example, reminder interventions increase engagement in young people (Sawyer et al. 2002; Watt et al. 2007), SMS reminders significantly improve appointment attendance in adults (Car et al. 2012), and young people use mobile phones more frequently than adults, but there is at yet no synthesis of research on the integration of SMS and youth services. Furthermore, as technology has been shown to facilitate communication and collaboration between young peers, there is a rationale for it to be integrated into treatment to supplement the collaborative, therapeutic relationship between clinicians and clients. However, technology’s power to coordinate and enhance face-to-face care is yet to be systematically investigated. Given technology’s role in young lives and its potential for youth engagement, it is crucial that the evidence of technology use for the engagement of young people in clinical services be synthesised.

Technology and mental health care Beyond engagement in face-to-face treatment, technology and new media have given rise to a wave of standalone technology-based interventions for mental health and wellbeing. These tools are a viable option for standalone interventions as they provide a less confronting means of support, they are anonymous, and they accessible at any time or any place (Burns et al. 2010). One example is online therapy. Australia is at the forefront of research into the development and application of effective, self-directed online therapy programs (Slade et al.

2009). There have been a number of systematic reviews indicating that various technological interventions (for example, Online Cognitive Behavioural Therapy or iCBT, teletherapy, online talk therapy via chat) are capable of replicating the benefits of face-to-face therapy for individuals with anxiety, depression and eating disorders, as well as to provide adjunctive support for patients with chronic medical conditions (Richards & Viganó 2013; Farrer et al. 2013). Effect sizes for iCBT were large for the treatment of depression and anxiety disorders, irritable bowel syndrome, female sexual dysfunction, eating disorders, substance use and pathological gambling, with online treatment particularly well established for depression, panic disorder and social phobia (Hedman et al. 2012).

The past decade has also seen the rapid development of technologies for youth mental health care beyond iCBT. The landmark launch of eheadspace, headspace Australia’s online counselling platform, “serious games” specifically targeted at young men (Burns et al. 2010), and an explosion of smartphone integrated applications and accessories aimed at promoting both health and mental health through technology, have all occurred in the past ten years. At present, there are more than one million apps available in the Apple app store alone, with many dedicated to a better self-care of physical and mental health. A small selection include apps for medication management; Smiling Mind aimed to promote youth mindfulness, MyFitnessPal to coordinate fitness routines, JawBone Up to track physical activity, as well as apps for sleep health and mood tracking. More recently, an app

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specifically tailored towards indigenous young people is being trialled as a suicide prevention tool in a RCT in Western Australia (Shand et al. 2013).

Integrating technology and treatment Despite the exponential growth of tech-based health interventions and the evidence of their benefits, how this may integrate with face-to-face clinical practice is yet to be fully investigated. For example, while online-only CBT interventions have been widely researched, complementary face-to-face (FTF) and online CBT interventions are comparatively understudied. One cluster-randomised controlled trial revealed that adults with depression who were engaged in face-to-face GP care plus an online-CBT program tended to have a more prompt and sustained resolution of depressive symptoms compared to GP care alone (Hickie et al. 2010). Similar trials of iCBT interventions as an adjunct to treatment-as-usual have been found to be effective in reducing symptomatology in younger children and adults with anxiety disorders (Spence et al. 2011; Andersson et al. 2006).

However, at present, the evidence on integration of face-to-face youth clinical services and technology remains unclear. This is due to the lack of comprehensive, systematic research into the use of technology an adjunct to face-to-face therapy with young people, a paucity that is characteristic of the youth mental health field in general (Patel et al. 2007). At the time of the present study, we could not identify a single systematic review focussed on adjunctive technological interventions in mental health treatment in any population, let alone young people. Such research is required to determine whether technology based platforms, young people’s experience with technology and face-to-face clinical services can coalesce to provide a promising tool or setting for the better management of mental disorders in young people, as Burns (2010) asserted. Such a review is also critical for identifying promising avenues for research and for determining which technological interventions are most practical and beneficial as a complement to face-to-face service.

AIMS Part 1 of this report aimed to synthesise the extant research on the integration of technology into youth clinical services, both for ongoing treatment engagement and as an adjunctive therapeutic tool. The specific aims were to review, synthesise and evaluate research evidence that investigated: • •

How technology-based tools can be used to enhance ongoing treatment engagement in young people and, The effectiveness of technology-based interventions as an adjunct to face-to-face youth mental health treatment.

METHODS Search strategy The search strategy was developed for a MEDLINE database sample (reported in detail in Appendix A) for studies published in English from January 2000 to August 2012. Healthcare professional terms, technology terms, and Cochrane recommended evidence filters were the three search sets used for the core search strategy. The MEDLINE strategy was then translated for use in the other search databases, which were the Cumulative Index of Nursing and Allied Health Literature (CINAHL), EMBASE, Educational Resources Information Center (ERIC), PreMEDLINE, PsycINFO, Web of Science and All EBM (including Cochrane Database of Systematic Reviews).

Following the initial search we followed up and included any other relevant studies from the reference lists of the studies retrieved in the original search strategy.

Inclusion/Exclusion Criteria References were considered in terms of our two aims, so included studies were required to explore either, 1) the use of technology to engage young people in face-to-face clinical treatment, or 2) how technology can be used as an adjunct intervention in face-to-face youth mental health treatment.

Articles investigating the use of new media by health professionals with patients of a mean age between 12 and 25 years were included for review for both Aims 1 and 2. All levels of evidence were considered (see Appendix B), whether qualitative or quantitative, excluding case studies. “Technology” was here defined as any technology except telephone calls, including the use of email, computers, social media, SMS or any electronic devices–for

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example, with tablet computers, smartphones, or gaming systems. It was necessary for inclusion that participants were already and continually engaged in any face-to-face clinical service, which could be any health or mental health service. Specific to our second aim, it was necessary that the patients were receiving a mental health intervention, which could include any psychoeducation, psychological intervention, or functional recovery. No single outcome measure was necessary for inclusion under either aim, and all reported data was considered.

Primary outcomes identified a priori of particular interest, however, were any reported patient outcomes, such as an index of client engagement or service attendance (Aim 1), relative engagement in face-to-face or online services or physical or psychological health outcomes. Measures of youth service providers’ and consumers’ satisfaction were also identified as secondary outcomes of interest.

Data collection All papers were initially screened on the basis of their title and abstract. Papers were included at this stage if they contained both technology terms and reference to a health service or professionals. The remaining studies were then screened according to the inclusion criteria, described above, also on the basis of the title and abstract. At this phase references were also grouped according to their aim (either Aim 1, 2 or 3). Consensus meetings were held with the three raters (AP, KV, HS) at this stage to clarify any inconsistencies in ratings. The final stage of screening was completed on the basis of an assessment the full-text article. Again, consensus meetings were held between three raters (AP, KV, AM) to reduce inconsistencies in inclusion/exclusion decisions.

The methodological quality of all the studies was assessed, using the Cochrane Effective Practice and Organisation of Care Review Group (EPOC) criteria as guidance, after inclusion and on the basis of the full text.

The full description of the assessment criteria can be found in Appendix C.

RESULTS A flowchart detailing the number of references screened, included and excluded is presented in Figure 1. There were five articles with relevant evidence to extract: one cohort study and one content analysis in the first aim; and three RCTs in the second. Results from these studies have been grouped by aim and type of intervention.

Figure 1. PRISMA Diagram of Systematic Review Screening Process

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AIM 1: TECHNOLOGY FOR ENGAGEMENT IN FACE-TO-FACE TREATMENT (TWO INCLUDED STUDIES) Study 1: SMS in a youth outreach service Study rationale Clinical experience of youth mental health outreach team in Adelaide, Australia (Youthlink) indicated that SMS might be a useful tool for facilitating direct therapist-patient contact, initial engagement and retention, and for scheduling appointments. Given the anecdotal evidence of its benefit in youth mental health care, Furber et al.

(2011) performed a content analysis of SMS messages sent and received from the outreach service over a seven-month period. The aim of the study was to formally explore the feasibility of SMS as an engagement and treatment coordination tool in youth mental health outreach.

Review of data related to engagement The majority of messages sent and received by therapists were related to appointment scheduling and coordination (75.98 percent and 60.68 percent, respectively). These messages contained discussions of appointment times and locations as well as reasons for missed appointments. Other therapist-sent message content included generic conversation (9.07 percent), information on treatment/medication (4.71 percent) or expressions of empathy (1.16 percent). Client-sent message content also included generic conversation (15.64 percent), sharing of personal information related to feelings or life events (15.04 percent) or information related to treatment (2.05 percent). Of 80 conversations, only five contained messages that were classified as inappropriate, or two percent of received messages. Three were related to self-harm and the remaining two to substance use.

No direct outcome measures of appointment attendance or treatment engagement were reported.

Risk of bias analysis The study design was a cohort study, therefore a randomisation sequence or allocation concealment was not required. Investigators analysing the content of the text messages were not blinded to the aim of the study, although efforts were made to select an unbiased coder. Any risk of assessor bias is unavoidable and perhaps irrelevant in a qualitative investigation such as this. Given that the authors chose to report the number of SMS messages rather than the number of clients involved in the study, the total number of young people engaged with the service in unclear. Nevertheless, Furber and colleagues seem to have addressed their initial aims–to explore the feasibility of an SMS service in youth mental health outreach.

Conclusion As the vast majority of SMS messages between therapists and clients were related to the dynamic, real-time coordination of appointments and only a small number (two percent) contained inappropriate content, SMS is a feasible tool for engaging with young people in mental health services. However, as patients used the SMS service to communicate personal information and the service was used, however infrequently, to relay inappropriate material, this raises issues of duty of care that must be addressed and explored in future research.

Study 2: Tablet-enabled screening and referral in primary medical care Study rationale As young people experiencing suicidal ideation are rarely identified in primary healthcare, Gardner et al. (2010) developed a tech-based, integrated care process for the identification and referral of suicidal young people in primary healthcare setting. A total of 1,547 young people between 11 and 20 years were screened for suicidal thought using the Patient Health Questionnaire for Adolescents (PHQ-A) administered via tablet computer in the waiting room of an urban primary care centre in the US. A positive answer to the suicidal thoughts question was automatically flagged for follow-up in the appointment with the general practitioner (GP). The GP then discussed the issue with the patient, referring them to a mental health evaluation if required. A triage assessment determined whether emergency management was necessary. Patients who were not in acute danger were referred for follow-up appointments.

Review of findings related to engagement Of 1,547 screened, 209 (13.5 percent) young people were identified as at risk of suicide. Of these, 205 patients were triaged, for which 152 were recommended a mental health evaluation; 109 patients were referred within the study network, while 43 were referred elsewhere and subsequently lost to follow-up. Of the 109 referred within the

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system, 71 received a face-to-face mental health service and 93% of triaged cases were referred on the day of the primary healthcare visit.

Risk of bias The risk of bias in this study was rated as high. As screening was not mandatory, and reported recruitment rates ranged from 60-95 percent, it is unclear whether there was a sampling bias in this study. Many cases (44) were missing suicidal ideation data, raising questions of a potential social desirability bias in the screening questionnaire. No explanation was offered for the attrition of 42 young people from the referral service, raising uncertainties in relation to the quality of participant follow-up and the efficacy of the referral system, especially as no intention-to-treat analysis was performed.

Conclusion The value of a computerised suicidal ideation screening and referral service in primary healthcare is not clear.

While a promising 73 percent of suicidal youths were referred for evaluation, only 47 percent of those are known to have actually received a mental health intervention. While this is likely to have been influenced by poor followup, patient attrition, or lack of individual clinical need, the role of the new technology system remains unclear. It can be concluded that an electronic screening and integrated referral service is a viable option for the identification of suicidal young people in primary care as well as for their engagement in secondary mental health care.

AIM 2: TECHNOLOGY AS AN ADJUNCT TO A FACE-TO-FACE MENTAL HEALTH INTERVENTION (TWO INCLUDED STUDIES) Study 1: Complementary face-to face and online cognitive behavioural therapy Study rationale One small RCT tested the hypothesis that face-to-face therapy in conjunction with computerised CBT would be more beneficial in decreasing symptoms of depression and/or anxiety in adolescents than other treatment combinations (Sethi et al. 2010). Thirty-eight Australian young people aged 18-23 (mean age=19.5 years) with mild to moderate levels of depression and/or anxiety were allocated to receive online (n=9), face-to-face (FTF) (n=10), combined FTF/Online (n=9) CBT, or no treatment control group (n=10). The online treatment was MoodGym, an online, automated CBT intervention. All treatments took place over three sessions over three weeks. Those in the adjunctive FTF/online group had each session divided in two: first half online and the other half FTF treatment.

Review of findings on technology as an adjunct to treatment Symptoms of depression and anxiety were measured using the DASS-21, K10 and ATQ30. There were significant differences between baseline and post-intervention scores on depression (F(1,34) = 43.10, p < .001), anxiety (F(1,34) = 7.38, p < 0.05), distress (F(1,34) = 27.58, p < 0.01) and the frequency of automatic thoughts (F(1,34) = 108.73, p < .01) for participants in all treatment groups. There were no such pre/post differences for the control group. Results indicated that conjunctive therapy was significantly more effective in reducing all symptom ratings than MoodGym alone. However, compared to standalone face-to-face CBT, conjunctive treatment was more effective at reducing anxiety scores (FTF/Online Mean – FTF Mean= -4.22, p < .01, d = 0.65) and the frequency of automatic negative thoughts (FTF/Online Mean – FTF Mean= -15.61, p < .01, d = 0.59), but with no statistically significant difference between the two groups in reducing symptoms of depression.

Risk of bias The quality of this RCT was rated as “unclear” due a poor description of the randomisation sequence generation, indicating a possible selection bias. The nature of the interventions prevented blinding of participants and therapists, and the reliance on self-report data increased the risk of bias. Furthermore, the rationale for the choice of participant group was unclear. As the mental health status of the participants was ambiguous, and they were experiencing sub-threshold depression and anxiety, it was unclear whether this was a treatment or prevention study.

Conclusion The results of this small study indicate that CBT-administered in varying modalities is effective at reducing symptoms of depression and anxiety after only a few sessions. Conjunctive CBT therapy appears to be more effective than online-only CBT, and at least equally effective as face-to-face only CBT. As this study was 9

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underpowered and of poor quality, further research is required to ascertain the relative efficacy of these treatment types, especially over a longer intervention period and at different levels of illness severity. However, this study is a promising initial indication that adjunctive face-to-face and online CBT should be considered for alleviating symptoms of anxiety and depression.

Study 2: Mobile system for behavioural and mood monitoring with primary medical care Study rationale One RCT investigated the effect of a mobile behavioural monitoring system (â&#x20AC;&#x153;mobiletypeâ&#x20AC;?) as an adjunct to faceto-face medical care with a general practitioner (Reid et al. 2011). Young people with mild to moderate mental health problems (K10 Symptom score > 16) were eligible for inclusion. A total of 114 eligible participants from Victoria, Australia (mean age=17.4 years; range 14-24 years), were randomly assigned to either intervention (n=68) or comparison (n=46) monitoring conditions. All participants were prompted at random intervals via a mobile telephone to report their present and recent behaviour in terms of: current activities and location, number of companions present, sleep quality and quantity, physical activity, and diet. Intervention participants were assessed on a further three areas of functioning: current mood, recent stressful events and recent substance use.

Both groups reviewed a summary report of their responses with a GP post-test. Participants were assessed with pre, post and six-week post-test measures of the Depression, Anxiety, Stress Scale (DASS) and an Emotional Self Awareness Scale (ESA) scale.

Review of findings on technology as an adjunct to treatment There was a medium to large significant main effect for time on depression (F(2,86.78) = 14.63, p = .001), anxiety (F(2,90.42) = 4.11, p =.020) and stress (F(2,86.41) = 8.38, p < .001) measures for participants in both groups, but with no corresponding significant group by time interaction. There was however a significant group by time interaction effect for ESA (β = 0.59, p = .48), with ESA increasing over time in the intervention group, with a medium effect size (d = 0.58). Post-hoc analyses revealed that 91.7 percent of all participants received at least one, and 55.0% at least two, pathways to care in the pre-test medical review with a GP, suggesting that GPs were intervening in relation to mental health problems regardless of mobiletype group assignment.

Risk of bias Overall, this RCT was of a high quality, with a low risk of bias. The randomisation sequence was adequately described; researchers, participants and GPs were blinded to treatment allocation, and an appropriate intention to treat mixed model analysis was conducted. However, with no usual care control group without mobile monitoring or no waitlist control (without any intervention at all), the reported effect of the mobiletype may have been confounded over time, which is of relevance given that GPs offered interventions in the pre-test consultation as part of the routine care.

Conclusion The monitoring of mental health symptoms with a mobile phone application appears to increase emotional selfawareness over time, but this may not translate to improved mental health outcomes. However, the use of the mobiletype system was related to improved depression, anxiety and stress outcomes over the trial in all groups.

As many participants in both groups received an active intervention as a part of routine medical care, there is a need for further investigations with an adequate control to comprehensively assess the effect of mobiletype on mental health outcomes. However, this study highlights the possible benefits of mobile mood and behavioural monitoring in young people, and how this can be integrated into clinical care to encourage meaningful clinicianclient interaction. Therefore, the role of mobile monitoring as an adjunct to face-to-face treatment in youth health warrants further research.

Study 3: Online physical activity intervention in conjunction with counselling Study rationale Mailey and colleagues (2010) conducted a RCT investigating an internet-delivered physical activity intervention as an adjunct to mental health counselling for students of a university in the Midwest of the United States. This was informed by research indicating that physical activity is a useful adjuvant to traditional treatment methods and the high use of the internet in the university-aged population. Forty-seven participants with a mean age of 25 years (aged 18-52 years old) were randomised to the intervention (n=24) or control (n=23) group over a ten-week trial.

Intervention participants were given access to an online program where they set exercise goals and were able to 10

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monitor their progress. They were also provided with a pedometer that tracked and prompted activity. All participants received face-to-face mental health counselling throughout the trial.

Review of findings on technology as an adjunct treatment There was a significant main effect for time in both groups for physical activity (F (1,40) = 4.20, p = .04) and selfefficacy (F (2,40) = 6.40, p = .004) but not for anxiety and depression outcomes (F (2,40) = 0.81, p = .45). There was a significant group by time interaction effect for physical activity (F (1,40) = 3.19, p = .08) with a larger increase in physical activity in the intervention condition (d = 0.68) and only a small change in the control condition (d = 0.05). There was no significant group by time effect for the other outcome measures. However, in the intervention group, increases in physical activity were associated with moderate decreases in depression (r = 0.44), with no such significant correlation in the control group.

Risk of bias Overall, this RCT was deemed methodologically flawed, with all risk of bias criteria marked as “unclear”. Also of concern, was the lack of objective diagnostic information apart from a report that participants had a “mental health problem”. There were no baseline depression and anxiety measures reported, casting doubt on the clinical relevance of this population, especially as mean post-intervention depression and anxiety scores were only in the mild range. Furthermore, with the large range of ages investigated–with no report of the standard deviation from the mean–the applicability of this sample to our target demographic is also unclear.

Conclusion Results suggest that an internet-delivered physical activity intervention promotes physical activity in university students with mild to moderate mental health problems. This increase in physical activity can subsequently be beneficial to reducing mental health symptoms, especially related to depression. However, RCTs of a high quality are required to investigate this effect further. Further research should also consider non-university and populations of a higher illness severity to comprehensively assess the benefit of this adjunctive tool.

DISCUSSION The results of the present review highlight that there is insufficient evidence to identify which technologies are best for the engagement of young people in, and as an adjunct to, face-to-face clinical treatment, despite their potential as demonstrated in the included studies. Given young people’s use of the vast array of technologies available today, there is a clear need to build on this preliminary evidence, and much remains to be learned about the benefits of integrating technology and youth health services.

While in no way conclusive, studies under the first aim offer some ideas on how technology may be used in practice. For example, the study by Furber and colleagues (2011) helps to illustrate that SMS can be used to schedule care and facilitate low-level interaction between clinician and client. Even in the crisis-driven environment of youth mental health outreach, there were little issues with duty of care or with the inappropriate use of mobile messaging. This indicates that concerns reported by clinicians and executive leaders over the dangers of technology (Ward et al. 2008) may be exaggerated, and that the benefits of technology endorsed by young people may more accurately reflect the role technology may have to play in treatment, with the benefits outweighing the risks (Blanchard 2008). Furthermore, the second included study demonstrates how technology can be integrated into a primary care setting to facilitate the stepped-care process. While mental health concerns are common in primary care, GPs often do not adequately screen for them due to a perceived lack of time (Berger-Jenkins et al. 2011). As young people often seek help with family doctors (Sawyer et al. 2000) and this may be their only professional source of help-seeking (Rickwood et al. 2005), it is crucial that screening is streamlined to relieve some pressure on overburdened providers. As Gardner and colleagues (2010) demonstrate, electronic screening in primary care may be one such tool to engage young people in the treatment they need without straining resources.

When considering the treatment literature in our second aim and with the huge variety of self-care technologies available, how these technologies integrate into treatment is in urgent need of further investigation. While the study by Sethi and colleagues (2003) is a promising start, high quality and high power replications of this RCT are required. Considering the relatively wide literature into online-only CBT interventions (Andersson & Hedman 2013; Cuijpers et al. 2009) and the finding that adjunctive online-FTF CBT may be more beneficial than online CBT 11

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alone, it is surprising that this relationship has not been a specific focus of testing. Furthermore, when considering the amount of technologies aimed at increasing physical activity (smartphone integrated applications and exercise tracking hardware, for example) there is a surprising lack of quality research linking the benefits of physical activity with mental health outcomes. While flawed, the study by Mailey and colleagues (2003) indicates that technologies may be a viable addition to an adjunctive physical activityâ&#x20AC;&#x201C;mental health treatment plan in young people. This relationship however needs testing with more rigorously conducted RCTs. Despite the lack of conclusive evidence, the rationale to trial the integration of tech-interventions in youth mental health is strong. No studies in the present review reported any significant iatrogenic effects of the use of technology in practice, only benefits in therapist-client communication, treatment scheduling, and initial identification and engagement of clients, as well as reduced mental health symptoms. Considering the preliminary evidence and the potential for technology described here, as well as the frequency of youth engagement with technology, attempting to promote the use of technology in practice to explore its benefits is warranted.

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Systematic review: Strategies for increasing ICT uptake in healthcare professionals Despite the expectation that technology will become crucial tool in clinical practice (Gagnon et al. 2012), healthcare organisations are still lagging behind in information communication technology (ICT) use (Yarbrough and Smith 2007). Technology has the potential to engage clients, supplement treatment, enhance the clinicianpatient relationship, and improve efficiency (Chaudry et al. 2006; Hawn 2009), yet it remains underused in health settings (Berner, Detmer & Simborg 2005). This may be because implementation strategies often result in poor uptake (Hile 2003) and many health care professionals are still inadequately trained for ICT (Ward et al. 2008).

This underuse of technology extends to youth health care professionals. Given the rationale for the use of technology in the engagement and treatment of young people described earlier in this report, it is unfortunate that youth service providers rarely use ICTs for such purposes. In a survey of the workplace technology use, only 8.6 percent of Australian youth health care professionals reported direct client engagement through technology (Blanchard 2008). This is perhaps due to a lack of confidence in the ICT use, particularly creative technologies, and clinicians’ perceived need for training in skills for tech-facilitated youth engagement (Blanchard et al. 2008).

Furthermore, youth workers often cite their clients’ economic vulnerability, lack of access and low literacy as barriers to technology use, even though young people themselves do not report these concerns (Metcalf et al.

2008).

Despite poor tech-facilitated engagement with young people, youth health care professionals do report a desire to incorporate client-centred technological tools into their future practice (Blanchard 2011). This included SMS reminders, videoconferencing, record management, and online counselling. However, organisational policy barring access to clinically relevant websites, lack of formal ICT training, and lack of awareness of evidence based technology services hindered the integration of technology and practice. There is also a prevailing attitude in young people that educators, parents and youth workers do not understand how young people use technology and are not in a credible position to guide its use (Inspire International Research Institute 2010). Indeed, it appears that older generations use the internet in different ways to young people. Compared to young people, adults’ technology use is less dynamic, less integrated into all aspects of everyday life, and they are less positive about social networking (Kubiatko 2013), and while young people are active, experiential learners, older people often struggle to master new technologies (Carroll et al. 2002).

If healthcare professionals are to innovate in the integration of technology and practice, it is crucial to “bridge the digital divide” between young people’s and professionals’ technology use. To be a credible source of technological guidance, healthcare professionals must be supported to better understand technology engagement and how technology use can promote and improve their clients’ mental health and wellbeing. Therefore, evidencebased interventions must be developed to enhance health workers’ understanding and uptake of technology. At present, there has been no systematic review of all levels of evidence with the aim of exploring ICT uptake intervention strategies in health care settings. Therefore, the final aim of the present review was to gain a comprehensive summary of the effectiveness of a range of interventions to increase ICT uptake in health care professionals through a systematic review of the literature. To wholly address our aim, we considered all levels of evidence–apart from case studies–to garner as much rich and varied data as possible.

METHODS Studies with qualitative, quantitative or mixed-methods approaches with an aim and intervention to increase ICT adoption in healthcare professionals were considered, whether they were with or without a comparison or control condition.

Participants Participants were all healthcare professionals, including supervised clinicians in training, in any health or mental health service. This included psychologists, GPs, specialists, nurses and allied health professionals.

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Interventions We included any intervention with a clearly described strategy to increase ICT uptake in healthcare professionals.

Adoption of any new technology was considered (for example, email use, SMS, decision support tools and so on), except for telephone use. The study was excluded if it simply evaluated the new ICT service, or if the intervention did not extend beyond the basic provision of the new ICT. Outcome measures No single outcome measure was necessary for inclusion in this review. However, a number of outcomes (as defined by the EPOC categorisation of outcome categories) were identified a priori to be of particular interest to our research aim. This included any objective or subjective measure of ICT resource use in clinicians and any reported differences between intervention and comparison conditions in ICT resource use. Secondary outcomes of interest were clinician attitudes, knowledge and skills related to technology and any reported measure of health care providersâ&#x20AC;&#x2122; or consumersâ&#x20AC;&#x2122; satisfaction. Patient outcomes, for example, physical or psychological treatment outcomes and treatment adherence, and quality of care outcomes were also considered. Finally, any qualitative data on clinician perspectives on barriers and facilitators to ICT uptake were considered as complementary information.

Search strategy The search strategy was developed for a MEDLINE database sample (reported in detail in Appendix A) for studies published in English from January 2000 to August 2012. Health care professional terms, technology terms, and Cochrane recommended evidence filters were the three search sets used for the core search strategy.

The MEDLINE strategy was then translated for use in the other search databases, which were the Cumulative Index of Nursing and Allied Health Literature (CINAHL), EMBASE, Educational Resources Information Center (ERIC), PreMEDLINE, PsycINFO, Web of Science and All EBM (including Cochrane Database of Systematic Reviews). Following the initial search we followed up and included any other relevant studies from the reference lists of the studies retrieved in the original search strategy.

Data collection All papers were initially screened on the basis of their title and abstract. Papers at this stage were included if they contained both technology terms and reference to a health service or professionals. The remaining studies were then screened according to the inclusion criteria, described above, also on the basis of the title and abstract.

Consensus meetings were held with the three raters (AP, KV, HS) at this stage to clarify any inconsistencies in ratings. The final stage of screening was completed on the basis of an assessment the full-text article. Again, consensus meetings were held between three raters (AP, KV, AM) to reduce inconsistencies in inclusion/exclusion decisions.

The methodological quality of the studies was assessed using the Cochrane Effective Practice and Organisation of Care Review Group (EPOC) criteria, the assessment of multiple systematic reviews (AMSTAR) tool (Shea et al.

2009) and specific criteria for qualitative and interrupted time series methodology (Cesario, Morin & Santa-Donato 2001; Ramsay et al. 2003). Controlled trials and case series with quantitative outcomes measures were assessed using the EPOC criteria, the included systematic review with the AMSTAR tool, and the ITS and qualitative studies with their corresponding scoring system. Mixed methods studies were assessed using a combination of the EPOC criteria and the qualitative scoring system. The full description of the assessment criteria can be found in Appendix C.

RESULTS Description of studies A flowchart detailing the number of references screened, included and excluded is presented in Figure 2, and the characteristics of the included studies are described in Appendix D. Of 11,165 references retrieved from the original search, 24 met the inclusion criteria for the review. These 24 studies were comprised of twelve case series, eight RCTs, two non-randomised controlled trials, one interrupted-time series (Simon & Soumeri 2005) and one systematic review (Gagnon et al. 2009). Of the case series, seven used only quantitative methods, five were purely qualitative, and one had a mixed-methods approach.

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Figure 2. PRISMA Diagram of Systematic Review Screening Process

Most of the primary studies investigated ICT uptake in general practice physicians (n=1F), but others focussed on hospital physician (n=6) and nurse (n=2) samples. Participants in one study were various hospital clinicians, including both physicians and nurses. Of note, only one study by Koivunen and colleaguesâ&#x20AC;&#x2122; (2008) focussed on mental health service providers, namely psychiatric nurses.

Most studies aimed to promote uptake of a single-purpose ICT: online evidence based-medicine search databases (n=7), clinical decision/intervention support systems (n=4), online health information and resource portals (n=3), continued professional development portals (n=2), patient referral system (n=1), patient triage email system (n=1) and online physician audit and feedback (n=1). Four studies promoted the use of a multi-purpose ICT system, including combined electronic health record and clinical decision support systems (n=2), electronic health record and referral system (n=1) and an integrated electronic health record, evidence based search, and inter-physician messaging system (n=1).

Types of interventions for increasing ICT uptake The most common intervention aimed to promote IT uptake by educating clinicians, with all but three primary research studies utilising an educational intervention. Educational uptake strategies included professional development lectures, hands-on workshops and tutorials in person (n=13) and online (n=3), one-on-one outreach training (n=3) and the distribution of written educational materials (n=11). A single educational uptake strategy may have incorporated any or all of these elements. Education was the sole intervention in 13 studies (Cabell et al. 2001; Cheng 2003; Magrabi et al. 2005; Magrabi et al. 2007; Magrabi et al. 2008; Strayer et al. 2006, Tomnay et al. 2007; Toth-Pal et al. 2008; Vedel et al., 2012; Bradley et al. 2002; Koivunen et al. 2008; Perrochia et al.

2005; Zheng et al. 2005) and was part of a multifaceted intervention in seven others (Alexander et al. 2011; Dornan et al. 2002; Dykes et al. 2007; Homa et al. 2008; Jerome et al. 2008; Simon & Soumeri 2005; Waldorff et al. 2009).

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Educational interventions, even of the same type, were heterogeneous across studies, with training time–if adequately described at all–ranging from 30 minutes to three hours in duration. The distribution of written educational materials also varied, with some studies investigating the effect of information disseminated at the clinician population level (Jerome et al. 2008; Tomnay et al. 2007; Waldorff et al. 2009) while others distributed personalised feedback on individual clinician work performance (Simon & Soumeri 2005).

Alerts and reminders Six studies made use of system alerts and reminders to prompt ICT use (Dornan et al. 2002; Haynes et al. 2006; Homa et al. 2008; Jerome et al. 2008; Sadasivam et al. 2011; Waldorff et al. 2009). It was the sole intervention in one study (Haynes et al.) where intervention clinicians were prompted to use an online evidence search database with tailored alerts and search strategy suggestions. The effect of the intervention was assessed by comparing the system use of physicians assigned to the “full serve” active reminder system to those assigned to a passive “self-serve” system with no such reminders. Alert interventions were more commonly used in conjunction with another intervention type, for example with an educational intervention (Dornan et al.; Homa et al.; Jerome et al.; Waldorff et al.) or a financial intervention (Sadasivam et al.). Alerts were often in themselves tech-facilitated, that is, through the target software itself (Haynes et al.) or by email (Dornan et al., Jerome et al.) but they were also by phone (Homa et al. Sadasivam et al.) or even by mail (Waldorff et al.).

Financial intervention Sadasivam and colleagues’ was the only study to outline a financial intervention. To promote GP access to an online referral portal for patient smoking cessation, participants were offered a $150 incentive for trial completion.

This intervention was complemented with a telephone reminder intervention to prompt use. The effect of this multifaceted intervention on GP system logons and the number of patient referrals was assessed.

Participatory design intervention One study (Alexander et al. 2012) used participatory design as a component of its multifaceted intervention strategy. Six clinical nurse specialists were actively involved in the two-step iterative design process of a new health information technology application, complemented with a three-hour training intervention. The effect of this participatory design and training process was assessed in terms of nurse attitudes in terms of opinions of the usefulness, ease-of-use, and clinical relevance of the new system.

Organisational intervention Finally, three studies described an organisational intervention (Dykes et al. 2007; Katz et al. 2003; Simon and Soumeri 2005). Katz and colleagues’ (2003) was the only study to use this as its sole intervention. In that study, the medical practice’s communication protocol was altered, thus mandating that health care providers in the intervention group use a triage-based email system to contact their patients and colleagues. Providers in the control group, although contactable through email, were not encouraged to use it and were not directly affected by the policy change. Organisational interventions were used as part of a multifaceted intervention in an investigation of a hospital-level transition to digital provider order entry (Dykes et al.) and in a quality assurance program where physicians were encouraged to access an online audit through written statements from their superiors (Simon and Soumeri).

Risk of bias of included studies The methodological quality of all the selected studies, according to their relevant rating criteria, is summarised in detail in Appendix F. Overall, only six studies were of a high quality, five were of moderate quality, and the remaining 13 were of low quality.

Quantitative methodology assessed with EPOC Criteria: RCTs, NRCTs and case series Of the 18 included RCTs, NRCTs and case series that had quantitative outcomes measures, only three had low risk of bias (high quality; Cabell et al. 2001; Haynes et al. 2006; Waldorff et al. 2009). Three were rated as having a moderate risk of bias (Bradley et al. 2002; Cheng 2003; Perocchia et al. 2005) and the remaining 12 had a high risk of bias (low quality; Dykes et al.; Katz et al.; Magrabi et al., 2007; Tomnay et al.). Only four studies adequately described their randomisation sequence (Cabell et al. 2001; Cheng 2003; Haynes et al.; Waldorff et al.) and just two adequately described allocation to intervention or control groups (Haynes et al.; Bradley et al.).

Other quantitative methodological quality assessments: ITS and systematic review The single interrupted time series (Simon & Soumeri 2005) was rated as having good methodological quality according to the criteria outlined by Ramsay (2003). Five quality criteria were rated as “met”, one as “unclear”, 16

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and another “not met”. The one included systematic review (Gagnon et al. 2009) was also of high methodological quality according to the AMSTAR tool, with nine criteria met and the final criterion considered not applicable, as there were no meta-analyses performed.

Evaluation of qualitative level of evidence Evaluation indicated that one qualitative study was of a high-level and well-constructed (Vedel et al. 2012), two were of at a moderate level and were fairly well constructed (Koivunen et al. 2008; Toth-Pal et al. 2008), and one was of a low-level, and was poorly constructed (Zheng et al. 2005). Apart from Vedel and colleagues’, studies were particularly poor at providing enough detail to confirm the validity of the analysis as they provided little raw data. All studies were also noticeably lacking in descriptive vividness and procedural rigour.

Effect of interventions on primary outcome measures Subjective or objective ICT uptake outcome measures were reported in 18 of 23 the reviewed primary research papers. Of these, a low ICT uptake was reported in eight studies, moderate uptake in two, and good uptake in eight. The effect of an uptake intervention relative to no intervention or according to a pre and post-intervention comparison of ICT resource use was only reported in ten of 23 studies. Seven of these reported a significant positive effect of the intervention, whereas three reported no effect.

Details of the 18 studies with resource use outcomes measures are outlined below in terms of uptake success, type of intervention and intervention effect (if applicable).

Education Intervention Nine of 13 studies featuring a standalone educational intervention reported on ICT resource use outcomes (Cabell et al. 2001; Cheng 2003; Magrabi et al. 2005; Magrabi et al. 2007; Magrabi et al. 2008; Strayer et al. 2006; Tomnay et al. 2007; Toth-Pal et al. 2008; Vedel et al. 2012). Of these, five reported good uptake of ICT resources, two moderate, and two poor. Only four of these were controlled trials (two C-RCTs: Cabell et al.; Magrabi et al.

2007; one RCT: Cheng; and one NRCT Tomnay et al.) allowing for the any investigation of intervention effect.

Results on the effectiveness of standalone educational interventions compared to no intervention or standard practice were mixed and limited. The ICT resources investigated in these comparisons were pertaining only to the usage of online informational resources, such as online evidence databases, with no data on any other type of ICT tool. However, there was some evidence of educational interventions successfully promoting clinician use of such resources. For example, Cheng reported that participants who attended a three-hour training workshop followed by a hands-on practice session were 2.6 times more likely to use the Cochrane Library (36.1 percent versus 17.9 percent, 95 percent CI 1.743-3.868) and 5.6 times more likely to use Medline (82 percent versus 46 percent, 95 percent CI 3.766-8.362) compared to those who did not receive any intervention. Similarly, Cabell and colleagues reported that logons to the target online evidence database was over two times higher in the intervention group when compared to control (4.4 versus 2.1; p<.001), with intervention participants searching more often (2.4 versus 0.8 hours of searching; p<.001) and accessing over two times as many full-text papers (2.6 versus one; p=.0005). Discordantly, Magrabi and colleagues (2007) found that advanced online training had no effect on mean number of online evidence database searches.

Beyond online evidence databases, exposing GPs to an educational resource website address was found to significantly increase website access and the use of online evidence-based chlamydia resources for patients, such as partner letters (p<.001) and informational brochures (p<.001), over time. There was no such significant change in the non-exposed group (Tomnay et al. 2007).

Alert and reminder intervention There was only one study that utilised a standalone reminder intervention to promote uptake of a specialised online evidence search database (Haynes et al. 2006). Intervention participants were given access to a “fullserve” version of the database that prompted use with tailored search tips and messages while control participants were given access to a passive “self-serve” system with no such alerts. Significantly more intervention participants used the database (12.6 percent difference; 95 percent CI = 1.8, 22.9) and their mean logins per month increased at a significantly higher rate relative to control (intervention login rate rose nine percent while the controls’ fell seven percent). Despite this, there was no significant difference between groups on searching time, access to specific databases (for example, The Cochrane Library and Ovid) and full-text retrieval.

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Organisational intervention One study implemented an organisational intervention as its sole uptake strategy (Katz et al. 2003). In this low quality RCT, primary care physicians in the intervention group were encouraged to inform their patients to contact them via a triage-based email system, while control physicians had no access to the triage account. This new mechanism for patient contact resulted in a trend of increased email volume over time that was significantly greater in the invention group compared to control (p<.001, adj. IRR = 3.6; 95% CI 2.1 to 6.2). There was no such significant effect for phone communication (adj. IRR = 1.2).

Multifaceted interventions Most studies with combined educational and reminder interventions reported poor uptake (Dornan et al. 2002; Jerome et al. 2008; Waldorff et al. 2009) while one reported moderate uptake success (Homa et al. 2008). For example, in one study that aimed to increase use of computerised continued professional development (CPD) software through an invitation to a training workshop and email reminders, only 30 of 439 physicians (7 percent) used the service (Dornan et al.). Another similar intervention to promote use of an online CPD program also resulted in poor uptake (only 4.7 percent of GPs logged on), however intervention GPs who received written educational materials as well as letter reminders were eight times more likely to logon compared to controls who only received educational materials (OR=8.0, 95 percent CI: 1.03-66.1; p=0.047; NNT=22.2; Waldorff et al.). A non-randomised controlled trial (NRCT) also reported varied effects of the intervention on physician internet use for clinical resources: there was a significant difference between intervention and control in terms of monthly use rate (p=.04), patient referral to online resources (p=.03), and Medline use (p=.001) but no difference on daily use and access to general clinical resources, guidelines and the medical practice website. Finally, Jerome and colleagues (2008) reported that there was no change in the number of physicians using an EMR system before and after an intervention with hands-on demonstrations, email reminders, and the distribution of written educational materials (11 percent use in each time period).

Both studies with an educational and organisational combined intervention reported poor uptake, with device use lower than expected in one crossover RCT (Dykes et al. 2007) despite training workshops and a hospital-level change to computerised patient assessment. Similarly, only 33 percent of physicians in an ITS (Simon & Soumeri 2005) accessed an individualised online audit of work performance despite educational training, the distribution of written materials, and corporate encouragement, with no significant effect of the intervention on audit access.

Sadasivam and colleagues (2011) reported very poor uptake after a financial-reminder combined intervention strategy. Even though GPs were given written and telephone reminders as well as a US$150 incentive to use an online patient referral portal for smoking cessation, only six GPs from 400 target general medical practices logged on to the service, with only one GP referring a patient.

Finally, Alexander and colleagues (2012) did not report any resource use outcome measures so the effect of their educational-participatory design intervention could not be ascertained. Only pre and post-trial comparisons of clinician ICT attitudes were reported.

Active versus passive intervention strategies for ICT uptake Of the 18 studies that outlined data on post-intervention ICT use, implementation strategies where clinicians were required–or received an incentive–to be actively engaged in the intervention were 16 times more likely to show uptake over time that was categorised as “good” compared to those who only received a passive intervention (OR=16.0, 95 percent CI=1.32 – 193.6; p=.03). In the ten studies that compared intervention and control ICT usage rates, there was a higher percentage of active versus passive interventions with a significant positive intervention effect (100 percent verus 40 percent), but this effect significant was not significant (p=0.11).

Patient outcomes Two studies reported on patient outcomes (Katz et al. 2003; Simon & Soumeri 2005), with both reporting no discernable effect of the ICT uptake intervention on patient health behaviour and symptoms. Katz and colleagues reported that there was no significant difference between groups over time in patient appointment attendance behaviour when comparing the online communication system to control (adj. IRR=1.2, 95 percent CI, 0.9-1.6), as measured by the number “no-shows” per 100 scheduled visits, logged on the medical centre database. Similarly, Simon and Soumeri found no effect of the intervention on patients’ first-line anti-hypertensive prescription filling and glycaemic monitoring behaviours and treatment outcomes (mean blood sugar level and blood pressure over time). This null effect remained when considering individual clinician access to their online audit, indicating that the online intervention had no effect on patient outcomes.

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Quality of care Five studies reported on quality of care outcomes (Dykes et al. 2007; Magrabi et al. 2005; Magrabi et al. 2007; Tomnay et al. 2007; Haynes et al. 2006). These included a comparison of assessment documentation completeness between an electronic and paper form (Dykes et al.), and the impact of the use of online evidence databases and information websites on clinician reported (Magrabi et al.; Magrabi et al.; Haynes et al. 2006) and objectively measured (Tomnay et al.) adherence to evidence-based guidelines.

Three of five studies reported a significant intervention effect. Dykes and colleagues reported that documentation completion rates were significantly higher when clinician used an electronic tool for some assessment types (fall prevention, pressure ulcer prevention, pain management, aspiration prevention, malnutrition prevention, and DVT/VTE prevention, all p<.001; and suicide prevention assessment p<.05) but not others (tobacco, alcohol abuse and violence prevention) when compared to the paper-based control. Tomnay and colleagues reported that there was significant increase in guideline adherent GP use of patient educational materials (p<.01) after being exposed to an informational website address, with no significant change among GPs that were not exposed.

Finally, Magrabi and colleagues (2007) reported that those GPs which frequently used the target online evidence search database were more likely to report benefits to quality of care than clinicians who performed less than six searches (Ď&#x2021;2= 4.8, d.f. = 1, p= 05).

In the other two studies, there was no significant difference between groups in a clinician reported quality of care (Haynes et al. 2006) or there was not enough information to form any conclusions on the effect of the intervention on quality of care outcomes (Magrabi et al., 2005). Also of note, all but one of these studies (Haynes et al.) was rated as having a low methodological quality.

EFFECT OF INTERVENTION ON SECONDARY OUTCOMES Clinician ICT attitudes Eight studies reported on the effect of ICT uptake intervention on clinician attitudes to technology. Of these, six found a positive effect and two found no effect on ICT attitudes, either in pre/post intervention comparisons or in comparison to control.

Clinician ICT skills and knowledge Five studies reported on the effect of the uptake intervention on the ICT skills and knowledge of clinicians. These skills ranged from the ability to perform evidence based searches, knowledge of technology-facilitated smoking cessation counselling and knowledge of using the internet for health information. Two studies reported that an active education intervention was successful at improving evidence-based search skills compared to a no education control. Similarly, Perrochia and colleagues found that healthcare professionals reported higher confidence in their ability to use the internet for health information after a training workshop. Strayer and colleagues, however, found that there was no significant difference in physician knowledge of the target ICT tool before and after being engaged in a short training session. On the whole, the current evidence indicated that active education interventions are often successful at enhancing the ICT skills of healthcare professionals, particularly for building online evidence search skills.

Clinician satisfaction Eight studies reported data on self-reported clinician satisfaction, using either an ordinal survey measure (Dykes et al. 2007; Magrabi et al. 2005; Katz et al. 2003; Tomnay et al.; Cheng 2003; Haynes et al. 2006) or a qualitative measure (Dornan et al 2002.; Zheng et al 2005.). In combination, results are mixed, inconclusive and sometimes contradictory. Three RCTs reported a significant intervention effect, with higher satisfaction in the intervention group with the target ICT (Dykes et al., p<.008; Katz et al., p=.03; Cheng, OR=9.52-15.0 on various measures) compared to control. Katz and colleagues also reported, however, that there was no significant difference between groups on clinician satisfaction with communication with patients and colleagues (p=.25). Similarly, Haynes and colleagues reported no significant difference between groups on satisfaction with the useability of the target ICT on a seven-point Likert scale (difference = 0.38, 95% CI = -1.07, 0.31). The remaining quantitative studies were case series, and therefore did not provide enough information to identify an intervention effect on satisfaction outcomes. Overall, no conclusions can be made about the relative effectiveness of intervention or ICT types for clinician satisfaction.

Qualitative indications of clinician satisfaction were mixed and lacking any rich description. One study did not go beyond describing that there were â&#x20AC;&#x153;positive and negative reactionsâ&#x20AC;? to the target ICT (Dornan et al. 2002) and the 19

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other described both high and low satisfaction with the ICT, but did not outline which was the predominant viewpoint (Zheng et al. 2005). While the latter information is potentially useful for identifying barriers and facilitators to ICT uptake in general, it is not useful for delineating the link between uptake strategy type and provider satisfaction.

Patient satisfaction Only one study reported on the effect of ICT uptake on patient satisfaction outcome measures (Katz et al. 2003).

There was no significant group differences in self-reported satisfaction with quality of care or satisfaction with communication and relationship with providers (73.6 percent of intervention versus 70.7 percent of control; p=.29) despite a significant increase in patient-provider email communication in the intervention group. While this indicates that an organisational change to ICT communication policy has no effect on patient satisfaction, the survey measure was marred by a low (62.3 percent) and biased response (responders were significantly more likely to be older and female). Furthermore, as this study was of a low methodological quality–and specifically, patients’ “random” group allocation was particularly susceptible to contamination–it is difficult to make any sound conclusions about the effect of an organisational uptake intervention, let alone the effect of ICT uptake in general, on patient satisfaction.

Barriers and facilitators to uptake Descriptions of barriers and facilitators to ICT uptake were found across a range of studies, but were particularly emphasised in the qualitative publications. The barriers and facilitators described in the nine relevant studies are summarised in Figures 3 and 4.

Figure 3. Barriers to ICT uptake in healthcare professionals

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Figure 4. Facilitators to ICT uptake in healthcare professionals

The most commonly reported barriers were technical problems or impracticality (n=6) and lack of clinical relevance (n=4) of the target technology, and lack of clinician time (n=5) or IT skills (n=5). Accordingly, commonly reported facilitators were functionality and ease of use (n=3) and clinical relevance (n=4) of the target ICT, clinician IT experience (n=4) and positive attitudes to ICT use (n=3). Four studies described that a positive impact on the patient-clinician relationship was also important for successful ICT implementation. Organisational level factors were also described, including workplace ICT culture and policy (n=2) and availability of resources (n=2).

DISCUSSION AND CONCLUSION The research on interventions to promote the integration of ICT and clinical practice is very limited. Although this review aimed to capture all levels of research literature, a wide range of healthcare settings, professionals, and ICT applications, we only found 24 eligible studies, where only seven were of a high methodological quality.

Studies included in this review focused mainly on the adherence to evidence-based guidelines in general practice and hospital settings, with a focus on physical, and not mental health. Only one, poor quality study facilitated direct engagement with clients (Katz et al. 2003). Therefore, it appears that information retrieval systems, such as online evidence search databases, are some of the first systems to penetrate the clinical space, with the integration of dynamic, interactive clinical tools relatively lacking investigation. Furthermore, there is particular need to develop the literature to support the design and implementation of strategies to increase ICT uptake in healthcare professionals beyond physicians in the hospital and general practice setting.

Despite the lack of included studies, results from our screening process indicated that research exploring ICT in healthcare in general is not scarce, with almost 1,000 articles remaining even after two phases of screening. The further full-text screening revealed however that the literature was characterised by cross-sectional research on existing clinician IT attitudes and use (for example, Smith, Darling & Searles 2011; Meyer et al. 2009), outcome evaluations of existing systems (for example, Stewart et al. 2010) or feasibility analyses of future systems (for example, Stahl and Dixon 2010; Vollmar et al. 2009), with little of specific relevance to our aim. This indicates that while ICT uptake is being explored in healthcare settings, the implementation process itself is rarely thoroughly documented or evaluated, thus limiting implementation innovation in healthcare.

When uptake strategies were adequately described and thus eligible for inclusion in this review, results that outlined the intervention effect on ICT uptake were mixed, and again, limited. Only 18 studies included some index of ICT resource use, and objective, rather than self-report, measures were rare. Measures of actual ICT uptake were mixed, with only eight reporting good uptake. The possibility for the isolation of the intervention effect was even scarcer, with only 10 studies having some kind of comparison group (of these, eight were RCTs).

Among these ten studies, results tended toward a positive intervention effect, with seven reporting a positive

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impact. However, with the wide variety of intervention types in all study designs, no conclusions about the effectiveness of one type of intervention to increase uptake relative to another could be drawn.

Overall, the paucity of research in this area, the heterogeneity in study design, intervention types, target technologies, health disciplines and outcome measures, as well as the poor methodological quality of included studies, precludes our ability to draw any robust conclusions on the best interventions for the uptake of ICTs in health care professionals. Even though many studies implemented an educational intervention, they too presented a great heterogeneity in delivery modality, duration, clinician engagement, and frequency. With other patient, clinician, and quality of care outcomes also rarely measured, it is also very difficult to determine the effect of ICT uptake on secondary outcomes. These results are consistent with the conclusions of the included systematic review of experimental research (Gagnon et al. 2009).

Despite the complexity of ICT uptake interventions in healthcare, the relative success of active versus passive interventions in the reviewed articles has a clear implication for ICT uptake across healthcare settings. Our results indicated active interventions of any type were 16 times more likely to be met with uptake success, implying that engagement of health care professionals in the uptake intervention was a key precursor to intervention effect. No prior professional development research has investigated intervention engagement specific to ICT uptake, so this is a novel finding. However, this result is in line with a recent review of the continuing professional development literature that indicated that didactic, passive techniques and the provision of printed materials alone were found to have little or no impact on learning outcomes in healthcare professionals (Bluestone et al. 2013). Similarly, another systematic review by Bloom (2005) indicated that interactive professional development techniques such as audit and feedback, outreach education, and reminders were the most effective at simultaneously changing physician care and patient outcomes, while guideline changes and passive education techniques had little to no effect. Of note, two included studies of the present review (Sadasivam et al. 2011; Simon et al.) that utilised a reminder or an audit or feedback strategy reported little to no effect on outcome measuresâ&#x20AC;&#x201C;in contrast with the findings of Bloom. The results of Haynes and colleagues (2006), however, support Bloomâ&#x20AC;&#x2122;s indication of the benefit of reminder interventions. The efficacy of these particular active interventions therefore needs to be explored further in the context of ICT uptake. However, overall, the present results taken together with past professional development research indicates that strategies to increase ICT use should be constructed with sufficient incentives to promote clinician motivation to attend professional development sessions. Then on, professional development sessions should be substantial, repetitive, and interactive and provide feedback so to meaningfully engage professionals over time.

Tackling the complexity of ICT uptake in healthcare settings Considering the mixed results of the present review, it is important to acknowledge the reality of ICT uptake in healthcare settings: it will always be heterogeneous. With the diversity of healthcare providers, consumers, settings, and organisations as well as the ever-expanding variety of available technologies, it is clear that no one ICT uptake intervention strategy will be universally appropriate. Therefore, the complex, inconclusive results of the present review are not surprising, but do serve to emphasise that the promotion of ICT uptake in health care professionals is a multi-level, multifactorial phenomenon, and should be treated as such. This is concordant with a number of authors who identified described a multi-level description of clinician ICT acceptance, from the organisational level to characteristics of the technology itself (Yarborough & Smith 2008; Gagnon et al. 2012).

Uptake interventions, therefore, should be tailored to any given healthcare environment.

We have developed a logic model of ICT uptake to inform the design and development of uptake strategies, as well as to guide their evaluation upon implementation (Figure 4). Descriptions of the barriers and facilitators to ICT uptake informed this multi-factorial model of the integration of ICTs and healthcare. While this review did not aim to comprehensively collate descriptions of all factors related to service providersâ&#x20AC;&#x2122; uptake of technologies, our results taken together with a previous mixed-methods systematic review on the subject (Gagnon et al. 2012) were used to attempt fully describe the phenomenon.

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Figure 4. Multi-factorial model of ICT uptake in healthcare professionals

This model aims to represent the summation of the potential factors presented in this review that may influence ICT uptake. It emphasises the need to identify key issues at the clinician, organisational, technology and patient level to help to design more tailored uptake interventions. The descriptions of barriers and facilitators extracted in the present review indicate that intervention strategies should ideally tackle barriers and enhance facilitators of ICT use at the technology, clinician and organisational level. That is, the technology itself should be easy to use, practical and clinically relevant, and should build upon the therapeutic relationship, wherever possible.

Implementation strategies should also recognise the skill-level and opinions of clinicians and adjust uptake strategies accordingly, in order to moderate the effect of ICT inexperience and negative attitudes to ICT. On a larger scale, organisational policy should reflect the aims of the uptake intervention and embrace ICT use, and it should be assured that the proper technological resources and support are available in the workplace.

Implications for future research It is clear that high quality research, particularly randomised controlled trials, are required to fully assess the effects of ICT uptake interventions in a variety of healthcare settings. Even in the included studies, outcomes, moderators, and mediators of ICT uptake were rarely rigorously measured. Firstly, future investigations should aim to objectively measure ICT resource use, as this was rarely done in the present literature. Furthermore, as evidence on the effect of ICT uptake on quality of care, and patient health outcomes is particularly lacking (only two studies reported on patient outcomes), this should be considered with further investigation. While there was evidence from the present review to indicate that active education interventions are successful at increasing online evidence search skills, more research is required to ascertain the best methods to promote both generalised, basic ICT skills and knowledge of specialised ICT platforms. Additionally, the qualitative data on the various reported barriers and facilitatorsâ&#x20AC;&#x201C;including clinician ICT attitudes and skills, organisational setting, and technology ease of useâ&#x20AC;&#x201C;should be supplemented with quantitative research to determine the relative mediating and moderating effect of these factors.

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The views of young people and youth service providers on putting technology into practice The apparent lack of high quality investigation into technological tools in engaging and treating young people indicated that focus group consultations with both young people and clinicians would be the next step in assisting the establishment of best practice in this field. It was particularly apparent that gathering rich, qualitative data on young people’s opinions on strategies to engage them in ongoing treatment using technology was required. To our knowledge, only one study at present has explored young people’s opinions generally on ongoing engagement strategies to maintain treatment attendance, let alone specific to technological tools (French et al.

2003). Considering the potential damaging effects of treatment non-attendance (Baydar, Reid & Webster-Stratton 2003), it is clear that such research should be conducted. Consultation with both young clients and clinicians may also indicate which technologies, of the many available, are already used in the mental health treatment process, and the degree to which they are used. This may help identify technologies that are in particular need to evaluation or further rigorous exploration in the research, or could identify potential tools for more widespread use in the future.

Focus group consultations were also conducted with the aim to supplement the ICT uptake literature with a focus on youth mental health services. As the review in the present report revealed that ICT uptake in healthcare professionals must be tackled with a tailored multi-factorial, multi-level approach, focus group discussion with clinicians was required to establish barriers and facilitators to technology use in practice. Considering the collaborative care approach often employed in youth mental health, it was also crucial to consult young clients on potential professional development strategies, as they too, would be a key partner in the integration of technology and mental health treatment.

METHOD Ethical approval was obtained for this research from the Human Research Ethics Committee of Melbourne Health.

Participants Clinician participants were 14 youth health service providers from the Orygen Youth Health Clinical Program (OYHCP; n=8) or headspace (n=6). The sample was comprised of mostly females (three males) and had a mean age of 35.07 years (SD = 9.41; range = 25-53). Clinicians included clinical psychologists, occupational therapists, nurses, and a vocational worker. The average length of experience of working in their profession was 6.46 years (SD = 5.52 years; range 1-19) and the average number of years working with young people was 5.50 years (SD = 5.67; range = 1-19).

Participating young people were either from the headspace Youth National Reference Group (hY NRG) or OYHCP’s Platform Group of youth representatives. The hY NRG participants were ten females and six males with a mean age of 20.88 years (SD = 2.99; range 16-25). The Platform sample comprised five former or current OYHCP clients (three females, two males) with a mean age of 22.5 years (SD = 2.65; range = 19-25).

Setting Clinician and client participants were recruited from OYHCP and headspace between 3 May 2013 and 9 June 2013. The Orygen Youth Health Clinical Program (OYHCP) is a specialised youth mental health clinical service for young people aged 15 to 25 years in the western and northwestern areas of Melbourne, Australia. headspace is a specialist youth health service that offers enhanced primary care services for health, mental health, vocational and substance use problems for young people aged 12 to 25 years across Australia (Purcell et al. 2012).

Data collection Focus groups were conducted in order to facilitate discussion on perceptions of and experience with the integration of technology and face-to-face clinical treatment with young people. In accordance with our research aims, three core questions were posed in all focus groups. These were to probe discussion on 1) technology for youth treatment engagement, 2) technology as a complementary intervention and finally, 3) the adoption of 24

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technology by youth health service providers. Additional prompts were employed as required to stimulate discussion. The full discussion schedule with the three research questions are outlined in Appendix G. A member of senior research staff who was a qualified psychologist with experience in facilitating focus group discussion conducted all focus groups. The two face-to-face focus group discussions lasted between 81 and 86 minutes (mean of 83.5 minutes) and the online focus group was live from 8-24 May 2013.

Procedure Clinicians were invited to participate via email using the OYHCP service-wide email list or via the headspace Collaborative Learning Network online discussion board. Follow-up emails were also sent to headspace centre managers to encourage staff participation. Participant inclusion was on a first-response basis, and once 20 clinicians expressed interest, recruitment was closed. Interested clinicians were emailed with the details of the time and location of the focus group, to which 14 attended. All provided informed consent prior to the discussion and were reimbursed for their time.

Participating young people from the hY NRG were invited via email to take part in an online focus group by the headspace Youth Participation Officer, with 16 members choosing to take part. The focus group was conducted in a closed Facebook discussion group that was only accessible to hY NRG members, the researchers and the Youth Participation Officer. All in the hY NRG sample provided informed consent prior to participation.

Eight young people from the Platform Group were invited to participate in a face-to-face focus group by the Platform Youth Participation Coordinator. Of those invited, five agreed to take part, with informed consent obtained prior to the commencement of the focus group. Two researchers and the Youth Participation Coordinator were present to facilitate discussion and take notes. In accordance with OYHCP procedures, participants were reimbursed for their time.

Analysis Face-to-face focus groups were audio recorded and then transcribed verbatim by an external contractor. For the online focus group, the comment data saved from the Facebook discussion was used as a record for analysis.

Data from the focus groups was then analysed using Interpretative Phenomenological Analysis (IPA) to extract rich experiential data related to the three research aims. The IPA was conducted according to the staged process outlined by Smith and Osborn (2003) supplemented with the focus-group specific protocol outlined by Palmer and colleagues (2010). This involved one researcher (AM) engaging in the conscious and systematic interpretation of participants’ descriptions of their own experience and opinions of the integration of technology and treatment— either as a youth health care consumer or provider.

IPA is an iterative, four-stage process. The first stage was completed without any computer software while stages two to four were aided with the qualitative analysis software, NVivo 10. The first stage of analysis involved repeatedly reading the full text of the focus group records while making note of any observation of interest. The aim of this stage is to be fully immersed in participants’ description and develop a high familiarity with the content of the focus group discussions (Smith 2004). In stage two of the IPA common emerging themes that highlighted the conceptual essence of the response while remaining true to the verbatim word choice of participants were identified and labelled. When a new theme was identified, previously analysed discussions were re-interpreted to remain consistent between groups. In the third stage, themes were interpreted in terms of their relationship to one another and were arranged hierarchically. Finally, in stage four, a final summary table of themes that were consistently endorsed across both groups and participants was produced.

RESULTS OPINIONS ON TECHNOLOGY AND YOUTH HEALTH SERVICES Young people and clinicians endorsed that as technology use is pervasive—especially in young people–it has a central role to play in the future of youth health service provision. Most young people were positive about using technology as a tool to coordinate their care. One Platform youth representative, for example, expressed that as they were always connected, it was only natural that healthcare should connect with them that way.

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“I am always on Facebook, Google, Tumblr, or pretty much everything. Gmail, Hotmail, Yahoo….

All that. If you have got healthcare staring at you right in the face… well yeah, I think that would be great.”

– Platform youth representative Another young person extended this thought, expressing that technology was key for coordinating their everyday activities. As it has such a central mediating role, they expressed that using technology to connect with young people not only was wise, but essential for “getting through” to and engaging with young people in treatment.

“Technology is part of life now. If you don't work healthcare into something that's such a huge part of your life, it doesn't work. Like, technology is how I get through my day and I am sure it’s the same with a lot of other people my age. And having health professionals in where I am looking all day... It gets through to me better.”

– Platform youth representative This perspective was reflected in the clinician focus group, with all clinicians perceiving that the trends of technology use in young people was to guide service provision in the future. That is, as young people were always using it, to remain engaging, technology should be an integrated component of a youth friendly health service. As one clinician put it: “I don't think the sector has a choice. Young people… They are more and more inclined to use technology. So we will have to change.”

– Clinician

PERSPECTIVES ON CLIENT AND CLINICIAN ENGAGEMENT It was clear that the young people were highly engaged with technology, using its various platforms to communicate with their peers and coordinate their daily routines. However, individual preference for mode of clinician contact was not homogenous. Differing individual resources, backgrounds, and opinions, as well as patterns of use for specific technologies, influenced each individual young person’s preference. Indeed, the strongest overarching theme was that the best way to contact young people using technology was with a clientcentred, tailored approach.

Clinicians agreed that, in their experience, that consulting young people on their preferred mode of contact was beneficial for increasing engagement.

“I often ask the client as well if they would prefer—if they would like reminder calls or text messages, which I think is always important… So I like that flexibility and that client centred approach, to be able to find out what's going to suit the client best and what's going to help them engage in the service and come to appointments.”

– Clinician Clinicians and young people also believed that the consideration of client preferences was crucial as techfacilitated contact may not suit an individual client due to different levels of access, geographical location, or cultural and linguistic background. Without a tailored approach, they explained, contact through technology may well result in poor engagement, specifically in economically vulnerable, rural, and culturally and linguistically diverse young people.

“I think it's also important to actually find out - we know young people are obviously using technology but not everybody is accessing it as regularly as others. So I think we need to really also be mindful of that and find out "is this person using Internet often? Does this person have access to it? Do they have a smartphone? Like, what phone are they using?" All those kind of things; we need to remember those questions, too.”

– Clinician “It’s beneficial, depending if you are within the zone. So, for me, I work in the outskirts of Melbourne. So my internet reception is mostly in question. So half the day, I don’t have decent reception and the other half I do. So if I am in the city, it’s great, but if I have a contact outside…”

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– Platform youth representative “I think the only problem we sometimes face is people with English as their second language; that can be a bit of a barrier. You know, text messages, people get overwhelmed and confused by those, some people. So that's actually been counterproductive. So in that case, do it by a phone call, when we can.”

– Clinician This was perhaps the most prominent and important theme garnered from the discussion on engagement. Young people were eager to be consulted on their contact preferences, and clinicians described clinical experience increasing client engagement with this approach. The variety of young people’s backgrounds, circumstances, and preferred technologies indicated that a discussion around contact method is crucial for optimal youth engagement.

Still, there was some consensus in all focus groups on the most appropriate mode of contact in given situations, and importantly, which technologies should be avoided when engaging with young people with technology. While not universally endorsed, these themes should be considered when engaging with clients in youth health services.

TELEPHONE PROVIDES THE “PERSONAL” TOUCH FOR INITIAL CONTACT While most participants in the Platform and hY NRG focus group were positive about communicating with their clinicians using technology, this did not appear to apply in the initial stages of treatment engagement. Indeed, the preference expressed by most participants for contact prior to their first appointment was through a personal telephone call from their clinician. Young people described telephone calls as “more personal”, “friendly and welcoming” and “comforting” than SMS, email, or other forms of tech-facilitated contact. They explained that having this personalised contact and hearing their clinician’s voice alleviated some of the anxiety associated with their first appointment.

“Yes I do believe first appointments need a phone call confirmation to make sure the young person is comfortable with the first appointment as it can be nerve-racking.”

– hY NRG member “I like calls because they are more personal and clients would be able to hear who they’d be speaking too [sic] [if it is their first appointment] and hear their tone which I think would be comforting knowing a bit more about what the session would be like.”

– hY NRG member “It seems really cold if you go to an area and it’s like–it’s just like a machine. You think, ‘Do I rock up?’”

“Yeah, it is always more welcoming to hear a human voice.”

– Platform youth representatives Clinicians, too, acknowledged the benefit of telephone for easing anxieties with attending appointments, especially in the early treatment stages. They expressed that a telephone call helped to develop the clinicianclient connection, and thus has the potential to increase client comfort and engagement.

“Maybe in the early stages, when young people are first engaging with the service; especially if they have spoken to you maybe over the phone… It can help to engage them further. They have that connection with someone; they know you understand them and they feel more comfortable to come in.”

– Clinician

SMS FOR ONGOING CONTACT: CONVENIENT AND NON-INTRUSIVE However, when it came to ongoing contact, SMS was largely the preference for contact between sessions. This was especially true for SMS reminders. Several young participants were already being contacted by their clinicians or reception staff through SMS, and were satisfied with the service.

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“I generally get texts to remind me of appointments and it works really well.”

– hY NRG member “I would get texts from headspace about my appointments and that was great–it was nonintrusive, it was private and I always forget things!”

– hY NRG member “I really like the SMS system that is happening at my headspace and my local GP practice. I forget a lot of think like appointments but with classes and work I’m not allowed to answer my phone, I’m much more likely to answer an email or SMS!” – hY NRG member Like two of the above participants, most young people cited convenience and flexibility as the main advantage of SMS as a means of contacting them, as they “always” had their phone with them. SMS was seen as good fit to their busy lifestyles, with easy, reliable, contact and reminders at work, school, or where they were otherwise inaccessible by telephone.

“If I got a call for an appointment while driving it would be far better if they did a call then SMS’d you the app[ointment] time and date.”

– hY NRG member “I like reminders, actually, SMS, because I am always on my phone and it’s good to have just an SMS reminder in case I forgot to put it in my calendar or something; letting you know that it’s coming up.”

– Platform youth representative “Text definitely works best for me. I think email is too unreliable and I also find calling a bit annoying. If it’s during business hours then people are often at school/work/uni and can’t answer the phone and if it’s after then it’s intrusive.”

– hY NRG member This “annoyance” with telephone calls appeared to be embedded in a sense of intrusion experienced by young people when they received calls from their mental health service providers. Text messages, in contrast, were perceived to be far less invasive in the everyday lives of these clients.

“It is just that you are busy. You have got things going on. You don’t want to have a phone call with someone. Obviously, you see the Orygen number and you don’t know who it’s going to be and you sometimes ignore it, if you don’t want to talk to anybody. So a text message–‘just confirming your appointment’–would be much better than having to ignore a phone call because you can’t be bothered to.”

– Platform youth representative Clinicians were also aware that telephone calls were perceived as intrusive by their clients, and in some settings– such as in a crisis outreach team–this was a significant, potentially damaging, barrier to engagement. Here, two clinicians discuss that they believed that as their calls were often “screened”, SMS is a useful tool for making some contact in crisis outreach, beyond just appointment reminders.

“I think the other thing–I've used it not just for appointments. I worked on the crisis team at Orygen and if somebody wouldn't respond to phone calls and we were worried about their risks, they might respond to text. So you can have a little, you know, check-in if they're okay, ‘Can you just let me know that you are safe, even if you don't want to talk at the moment?’ So it's not just appointments. And it is not ideal but I guess it's better than no contact whatsoever.”

“I think a lot of young people screen their calls these days…”

“Or will not answer a blocked number at all.”

– Clinicians

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The partial anonymity of SMS provided protection going the other way too, with clinicians describing that clients often used SMS to seek help from them in the moment.

“Often we will come in at 9 o’clock and there’s a message from 2am that they’ve sent you: ‘I really want to talk to you about this or that’ the next day. So I guess it’s a way of communicating in that moment, they have sent it and they can sort of forget about it.”

“I think, also it protects their anonymity a little bit as well, if they have been anxious about contacting the service. It can be less intrusive.”

– Clinicians Clinicians and young people both emphasised, however, that clear boundaries must be set for such situations to manage client expectations. Out-of-hours contact was seen as a potential risk to duty of care, especially at times of crisis where asynchronous communication may go unnoticed. The provision of the appropriate information on reply expectations, office hours, and crisis support, were seen as a way to manage this risk.

SOCIAL MEDIA: DON’T BRING MY MENTAL HEALTH INTO MY “PERSONAL SPACE” In relation to engagement through social media, the main theme that emerged was the overwhelming negative attitude towards personal patient-clinician contact on social media platforms. Almost universally, participants described their social media profiles as their “personal space” and denied it as a means of patient-clinician contact, and were keen to keep their mental health out of their social media profiles.

“Most of these services–I don’t know about you guys, but you don’t really talk in detail with friends, a lot of friends don’t even know about me. So it’s already separate. So the idea of integrating it with something that you are already separated with… It’s very compartmentalised, like: life, and mental health.”

– Platform youth representative Young people often explained their concerns with social media contact in terms of confidentiality. This was partially entrenched in a perceived loss of control over the rate and content of the disclosure of their personal information to their clinician.

“Social media I think not so much; there could be a ton of issues there in relation to how much information the client wants you to see for instance and just that for many, that's their personal space! ” “I think it would be anxiety inducing to me to think of personal contact being made through the more popular social mediums–Facebook, Twitter et cetera. They're just not as private as people think they are.”

– hY NRG member Clinicians also acknowledged that potential breaches of client confidentiality were barrier to social media contact, and similarly advocated keeping personal health and social media separate. Mirroring the young person’s concern over uncontrolled client disclosure, one clinician expressed.

“I think it's their place to have fun, isn't it, Facebook? You don't want to be reminded about your mental health issues on your Facebook. Would you?... I think we take people at face value. So what they tell us is subject to how much they trust us and how much rapport you have got. And Facebook is the rest of their life that they may not tell you all about. So by looking and talking on that, you are kind of breaching into what they have kept from you... There's a reason why they have kept that from you at that time.”

– Clinician The young people’s fears of breach of confidentiality on social networking sites also extended to a fear of sharing their personal information with peers, which was ultimately linked to the fear of being stigmatised due to their mental health problems. As discussed in the Platform focus group:

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“What do you think about health professionals contacting you via social media, Facebook or…”

“Mmm, yeah, I don't think so.”

(Laughs) “No. I suppose if they know that the person–other people could see that the person contacting you is from mental health or–there's a lot of stigma.”

“Yeah, you wouldn't want that.”

“A lot of my friends don't know there's anything up…”

(Mostly agreed) “And they see it online and go, ‘Ooh, you know, that's what happened to her’.”

– Platform youth representative

THE ROLE OF SOCIAL MEDIA IN ENGAGEMENT The use of social media in the mental health sector was not entirely denied. Participants in all focus groups acknowledged the potential of social media as a mental health and wellbeing promotional tool by mental health organisations, as a means for youth participation in organisational development, and as source of health information.

“I think the online medium is vitally important to where health service provision goes and that there must be positive health based and help-seeking information/messages/discussion on social media.”

– hY NRG member “I think having a presence and having doing a campaign, I think it’s really sensible to do it…

Also, a lot of social media is used for advisory committees as well. So just encouraging young people to want to be part of that is really integral for social media.”

– Clinician focus group In short, both young people and clinicians were positive about youth engagement through social media at a universal, impersonal level, but not for any kind of personal communication or ongoing treatment coordination.

“Along with everyone else, I think [social media] is only effective to give out information and promote along with giving a better understanding of a service and broader issues rather than personal client-worker relations.”

– hY NRG member “I think it’s different whether you are talking about as an individual service provider or if you are doing a health promotion campaign… But not for individuals. At a personal level.”

(Clinicians mostly agree) – Clinicians

PERSPECTIVES ON ONLINE CLINICIAN PROFILES Another emergent theme was that young people were largely positive about public profiles–modelled on social networking profiles–that contained introductory information on clinicians. Young participants saw online service provider profiles as a potential tool to alleviate anxiety and build a trusting therapeutic relationship, before the first appointment even occurred. As one young participant explained, it helped to “humanise” their clinician.

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“Where they are from, kind of thing. Maybe even likes and interests. I don't know, it just makes them seem more human than just a professional telling you what to do. It's always nice to have a human being helping you along.”

– Platform youth representative Online profiles also helped to inform the client on what to expect, increasing comfort with and demystifying the service, which led to increased engagement.

“I always like a bit of background about the woman I am about to tell my entire life story to.”

“Especially when you don’t really know the service. Like, I was new so I had no idea what the hell this was. So when I got referred, I was like, ‘Why am I here? Are they going to put me inside?’”

“I think if you knew more about them, then you would be more inclined to go and see somebody, as opposed to someone else, I think.”

– Platform youth representatives Clinicians, too, were open to this idea, acknowledging that as such freely available information on themselves was beneficial to reducing patient anxiety, and was a way of building a trusting clinician-client relationship, they were happy to have their information online, as long as it was in a professional format.

“As a health professional, would you feel comfortable or okay with young people looking at your online profiles, if you did have a professional profile? Is that okay, do you think, before they come and see you?”

“Yeah, I think that's their right; kind of a bit of information about what you do.”

“If it was professional.”

“I think it's helpful to have less anxiety about what to expect and what the person is going to look like; if they look friendly or not and all that sort of…”

“From my experience, they are certainly less inclined to be looking at you and those qualifications, credential type things but more, ‘What's this place like? What are they likely to want to do?’ and that sort of thing… A bit like, you know, being able to see your restaurant on Urbanspoon or something, ‘Oh, that looks nice. That looks’–you know. It is not a clinical–you know, it is not so awful. They can actually see some things warm and inviting and–that made a difference.”

– Clinicians

TECHNOLOGY AS AN ADJUNCT TREATMENT TOOL Both young people and clinicians were generally positive about using technology as an adjunct to more traditional treatment methods. Indeed, participants in all focus groups indicated they had already used technology as a complement to their face-to-face clinical services. In most cases, this was for client-initiated self-care and not yet formally integrated into treatment plans.

One such example of the informal use of technology as an adjunct to treatment was with online support groups. A number of young people indicated they had found informal support from peers on online discussion forums.

“When I was very ill, I was on my computer and the computer became my life. And it was kind of almost like a ‘kill or cure’ thing for me. I was lucky because I found support groups online… I was on Tumblr a lot and you kind of develop a network of Tumblr friends. There's a lot of support there. Because no one actually knows what you look like, kind of thing, there's no judgment based on–it's all just about your mental health.

– Platform youth representative

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Young people also discussed their past experiences with online forums specific to their disorder, for example Wrong Planet for autism spectrum disorders and schizophrenia.com for psychosis. They explained that these online communities were a helpful source of both mental health information and informal support from peers: “Wrong Planet was also a good site. It has stuff to do with both the autistic community and it’s also got a section for people with mental health issues as well… Forums and discussions and stuff like that.”

“I like schizophrenia.com. That was good for me. They have got forums for different countries and stuff, in different languages … I found they have got a lot of scientific research studies and everything on there, that you can read and find out more things about your illness.”

– Platform youth representatives

SMARTPHONES AND APPS IN TREATMENT Young people also indicated that they had already found smartphone and tablet apps as a useful adjunct to their services, with one Platform participant explaining, ‘I spend most of my time on apps’. Discussed technologies included ‘Recovery Record’ for eating disorder tracking and management, fitness, sleep, menstruation and mood tracking apps, and educational resource apps to coordinate their education. Clinicians also mentioned similar apps, mentioning the same sleep and mood tracking apps, as well as a medication record and reminder system.

As one hY NRG member described, such technologies can give clients a sense of independence, enhancing their ability to take control of their own mental health and wellbeing between appointments: “I also think that having apps or something online would give people a sense that they are able to do something to help themselves between appointments too rather than feeling completely dependent on their appointments with psychologists etc.”

– hY NRG member Clinicians, too, expressed satisfaction with the use of self-care apps as well as mobile reminder systems in treatment, describing such technologies as “empowering”, as “they are not needing to be reminded, they are reminding themselves”. Furthermore, the information generated with tracking technologies out-of-session was seen to create opportunities for psychoeducation and clinician-client discussion in session.

“I think using them to help with goals or, for instance, Sleep Cycle to capture some data is a good way to spark more discussion and for young people to be open about their goals and what's going ok for them. They also get more control over helping themselves and knowing some tools they can use to do that which is important.”

– Clinician Technology-based tracking was also seen simply as more convenient, being perceived as less cumbersome than their paper-based counterparts, especially for young people who often had their phone with them. These systems therefore, were able to produce a more comprehensive, integrated record for tracing outcome measures over time, providing rich data for the benefit of both clinician and client.

“I have used the sleep apps and the healthy eating apps and the mood rating apps with clients because they have all got their iPhones in sessions and they can rate their mood, rather on paper. Nobody carries around paper anymore but they can write their mood every day on their phone and it tracks on a graph for them and it is sleep as well.”

– Clinician

TECHNOLOGY ENABLING CLIENT-CLINICIAN DISCUSSION AND COLLABORATION Clinicians also described, from their experience, that technology had already been a useful tool for sharing and collaboration between themselves and clients. For example, one clinician explained that a handheld device had been useful tool for the client to engage them, then allowing them to easily share materials that they could then explore together.

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“I had a client who was really into chakras. So he was able to pull out his iPad and show me all this stuff he had been reading. And that was quite an important engagement session, kind of looking back. Particularly with delusions and things like that, when you are trying to help people challenge or explore, being able to look up UFOs or whatever or them bringing stuff to you, and being able to show you.”

– Clinician Email was seen as another useful tool for the patient-client collaboration. Clinicians reported that email’s potential to share resources immediately allowed for content sharing that was easy to do, and extended beyond the faceto-face session. Combined with SMS, this allowed for brief interactions that developed a framework for a timeefficient collaboration between sessions.

“But particularly with sending resources, if I have a session with someone and then I think, ‘Oh, there's this great manual that I would love to send you, rather than have to wait until next week’, just emailing the links through and then texting them and they're like, “I'm reading it now”… I think all those things help. Or you can't see them that day but you can go, "Look, I will send this through. Have a read. We will talk about it next session," or things like that.”

– Clinician This was found particularly useful in some settings, for example, for the vocational consultant.

“I actually email my clients but my role is a little bit different. I find that's really helpful, particularly if they are working, so they can get back to me in their own time… But just for my sort of role because I am a vocational consultant, sending resumés back and forward, I couldn't do that unless I could contact them in that way.”

– Clinician

CONTINUITY OF CARE Despite not yet being formally integrated treatment plans, young people expressed that these ICT tools had the benefit of providing a better treatment management and a stronger sense of continuity of care, providing low-level support between appointments.

“What do you think would make you more likely to use an app as part of your treatment?”

“Having one. Having an app to use…”

“More stability. I also think that having apps or something online would give people a sense that they are able to do something to help themselves between appointments too rather than feeling completely dependent on their appointments with psychologists.”

– hY NRG member “I think it is important to have something to work on between sessions and with apps, online interventions and emails, its almost like a keep track tool to ensure things are kept on track as oppose to waiting for each session and relying on each session to actively work on oneself, be it working on self esteem or working on strategies for an issue.”

– hY NRG member With its potential for ongoing, lower-level support, young people also suggested that technology might be able to extend care beyond discharge, where they believed that there was an increased need for support: “Even when you are out of Orygen, there's still support kind of in the background, online, and you are still talking to other people who have been through Orygen and it doesn't completely disconnect you from all the services. I think it's good to have that background support and just keep going for as long as you need it, really.”

- Platform Youth Representative

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“Whether that might be a bit more cost effective in a way; where we look at saying, ‘Is there some way of keeping a connection?’ And online might be useful then, if it is not possible to still do face‑to‑face stuff.”

“Yeah, definitely.”

“That makes more sense. Keep some kind of support…”

— Three Platform Representatives Therefore, self-guided or moderated online therapeutic modalities, they suggested, may be a useful tool beyond discharge, providing a continued, lower-level tenure of care to help them transition into, and maintain, mental health. This opinion was reflected in the clinician focus groups, with the clinicians expressing that technology, while not a crisis-management tool, was appropriate as a means of providing ongoing support for relapse prevention upon conclusion of a face-to-face care plan. That is, they described online support as a potential “part of an ending process” and for “interim support” to help “tide them over until… they get ten sessions a year”.

TECHNOLOGY MUST HAVE A CLEAR BENEFIT FOR TREATMENT While both young people and clinicians were positive about the use of technology as a supplement to treatment, many participants emphasised that any addition of technology into face-to-face practice should have a clear rationale and a clear benefit to the client’s treatment plan. Adjunct technological interventions would not be received well if they were ‘for the sake of it’, but rather should have a clear clinical benefit and be followed up throughout treatment.

“I think not entering the use of technology for the sake of technology, rather than as a tool to drive therapy forward, or using something because it's available in technology form rather than because it's the best path forward. So I guess integrating the technology into treatment…”

Putting it in the treatment plan, maybe, and following up on it; not just putting it out there and forgetting about it. Coming back and asking the question and revisiting the whole idea.

– Clinicians “What do you think would make you more likely to use an app as part of your treatment?”

“Seeing that it’s followed up; not something that you go home and work on and then it’s just completely ignored. See that is affecting something, rather than just mundane homework that is not worthy at all.”

“If it's something that is beneficial to you and so forth, then you are more inclined to use it; compared to something that you brush off.”

– Platform youth representatives Like their thoughts on tailored communication methods, clinicians and young people indicated that technology provided opportunities for a targeted, client-centred, and thus more effective, treatment intervention. One hY NRG member believed that a hands-on walkthrough of a technology and a discussion between and clinician was the best way to establish whether a technology would “fit” the young person: “The professional should work through the app/program with the young person first about how to use it and how it could complement but be responsive to the young person–there are still many who exist who just would not do it or be comfortable with it.”

– hY NRG member Extending this thought of tailored technologies, some young people discussed that targeted, rather than general, apps would be the most useful tools for young people. Here, they discussed how general apps were far more likely to be neglected than a targeted e-tool, due a lack of personal relevance.

“I have a feeling it's not going to be one app. There has to be a series of the same app that has to be slightly tailored to slightly different areas and conditions because someone who is 34

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suffering depression isn't going to be the same person as someone suffering bipolar… You have no choice but to tailor it that way. If you generalise it too much, then no one will feel that it's personalised to them and then they will just disregard it.”

“Yeah, even with the case managers, you are assigned to a case manager depending on your illness and stuff. So it makes sense that you have it tailored towards that. It's kind of ironic that you would have tailored services and yet a generic app for all.”

– Platform youth representatives Indeed, one clinician reported experience with making use of the multitude of tools technology offers to allow for a more tailored and effective interaction with patients according to their needs, for example, with those with “low literacy, high visual literacy”.

“The iPhones are for other things, like photographic and getting them to do stuff because a lot of the kids that I work with, they have very low literacy, high visual literacy, don't like writing things down much, but they have a different kind of way of learning. And I find it very interactive, very helpful and engaging. So when we do sleep hygiene, they will photograph their room and bring it in, if I haven't had the chance to go to their house, and we will talk about it through things and they can photograph things. Instead of a rating scale… They can photograph something about their mood that day and then bring it in; we can talk about it.”

– Clinician On the whole, all clinicians and young people agreed that the integration of technology and treatment should begin with a discussion between client and clinician on how any given tool would be beneficial to treatment, and whether or not they would like to use it. Such a conversation, they expressed, would increase motivation to use technology meaningfully in treatment. Furthermore, in considering the vast array of available technological tools to recommend, they should be cognisant about which ones would best suit the client’s individual needs and treatment plan.

TECHNOLOGY MUST NOT REPLACE FACE-TO-FACE TREATMENT One important theme that arose from the discussion was the overwhelming opinion that technology should not be considered a replacement to face-to-face treatment. This theme was common to all focus groups, both with young people and clinicians.

“I think you have to be cautious, though, that it doesn't overshadow and replace face-to-face, especially given how powerful the therapeutic relationship can be with a young person. I think it can be a great complement to face-to-face therapy but I think it needs to be a balance; I don't think it should be the one and only thing that we use.”

– Clinician “So long as it’s only in addition to appointments, not as a replacement for or at the expense of face to face consultation.”

“I agree… I believe it would be a great idea as long as they complement therapy as opposed to replacing them.”

– hY NRG members Overall, technology was viewed as a useful complementary tool to face-to-face treatment, but not as a standalone intervention.

ICT UPTAKE IN YOUTH SERVICE PROVIDERS When prompted to discuss their opinions on future technology uptake in clinicians, both young people and clinicians identified several factors that would facilitate successful implementation of technology into clinical practice. Themes related to key facilitators included 1) the pre-existing uptake readiness of youth mental health

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clinicians, 2) readily available resources, 3) policy that embraces technology use, 4) evidence-based resources, and 5) training, potentially led by young people.

First and foremost, the clinician sample appeared to be uptake ready. They expressed they were motivated to integrate technology and practice–seeing its benefits, especially in a youth mental health setting–and were prepared for behavioural change. As one clinician explained, while technology use in practice was not as yet universal in youth mental health, this particular group of healthcare professionals was already primed for the uptake of technology: “I don't think it would be across the board, but I think by growing our familiarity and their use, I think the take-up would be pretty quick here, in the youth mental health services I would say, so that it could come across the board.”

– Clinician Clinicians believed that a move towards integrated technology in practice was unavoidable, as technology in everyday life seen to be increasingly ubiquitous and normalised.

“As new people come into the workforce as well, they are from the Generation Y, who are up to date with all the apps and it's part of their life as well as the client's life. So it would just seem normal to, you know, they have grown up with smartphones and see it normal to carry it onto work.”

– Clinician Another factor clinicians identified as a promoter of ICT uptake was having the appropriate resources readily available in the service environment. It was suggested that easily available, shared hardware, such as iPads, for use in-session would enhance possibilities for staff collaboration and shared learning, thus increasing ICT uptake.

“I wonder if every agency, ideally speaking, had an iPad, with all these apps actually on the desktop, that could be shared around amongst the clinicians and therefore amongst their clients. Maybe kept at reception, for example. So that the clinicians could play around with it and talk about it in the staff meeting and have a play with it; and actually bring it into a session with a young person and say, ‘These are the options; what do you think?’ ‘You think this one, this one, this one.’”

– Clinician One clinician also explained that easily available technologies in-session with a client had the potential to streamline the sharing process (described in detail above) by removing any potential barriers to client access and allowing immediate collaboration.

“I think also to have iPads or something in session, so that you can look at sites together; particularly she's talking about if there's some online CBT or you want to go through something online with someone or do it together there and then you can send it to them, that would be great.”

– Clinician However, current technology use was described as either through resources already available to either clinician or patient (be they for personal or professional use), rather than having dedicated resources for the interaction between the two. A lack of resources, therefore, was seen as a barrier to uptake. Clinicians also suggested that if resources were available, it would facilitate their ability to ‘try it themselves’ and build their ICT-skills in less structured, self-guided exploration. This environment would then potentially promote collaborative learning between colleagues, as well as with clients.

Clinicians expressed that in order for technology to be successfully integrated into treatment, organisational policy should also embrace its use, and at present, policy was a barrier to technology use in practice. Clinicians expressed frustration that current policy did not reflect the potential benefits of technology and the needs of young people.

“But I think it's actually absurd that within Orygen we don't have promotion and effective use of email; but it's because of policy reasons that that exists at the moment. But I have had 36

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experience in a university counselling service where email is a central part of the communication and I think it's really effective.”

“It is funny because I have clinicians come in to me and say, ‘I know you email, so can you email this client and just remind them to come in, because I can't from mine?’ And I'm like, ‘Okay’. It seems a bit sad that you can't.

– Clinicians That is, while clinicians were reporting benefits of technology, their workplaces often forbade use. Clinicians reported trying to circumvent policy guidelines, but found that “absurd” barriers often prevented the direct interaction with their clients through technology. While acknowledging the risks that accompanied the integration of technology and practice, youth service providers appeared to believe that a outright ban was a detriment to client engagement and treatment.

All focus group samples emphasised that the implementation of technology into clinical practice must come with guidelines for client-clinician communication through technology. Both groups expressed some concern about the ambiguity of duty of care protocols in the online space, the over-availability of clinicians with 24/7 technology access and the potential for confidentiality breaches that accompanies widespread technology use. Some clinicians reported already experiencing some of these issues while using technology and practice.

This did not negate their hope for technology integration, however, they just expressed that clear, succinct guidelines for communication and clinician duty of care in the technological age were required to clarify grey areas. Such clearcut protocols were said to enhance confidence in technology use, and thus facilitate technology integration.

Young people and clinicians agreed that use would be promoted if there were clear evidence-based resources from trusted sources on which technologies were beneficial and which posed potential harms. Clinicians were currently reluctant to recommend the very online support spaces that the young people endorsed as useful, due to fear of unintended harm.

“I didn't realise how much is out there that is unhelpful.”

“Yeah, the pro-ana sites.”

“And forums.”

(Mostly agreed).

“Self-harming…”

“Self-harming and Tumblr.”

— Clinicians Young people also acknowledged the risks of social networking sites and online support groups, but insisted that as they also offered useful support, they should not be disregarded. As one Platform youth representative explained, rather than discouraging access to those sites, being directed to a recovery-focused online space would be more beneficial.

“Well, I spent a lot of time on Tumblr and I found there were a lot of trigger things on there which you have to watch for. But then there's also a lot of very cool people as well. So if you just stick to the people who are more into recovery, than the bad stuff, then, yeah, it's good. But you have got to watch… I think you have to be directed in the right places online.”

– Platform youth representative However, clinicians expressed that they would feel more confident in exploring online support as an adjunct to treatment if research could identify those that were most beneficial. Young people mirrored this opinion, expressing that resources that guided them to helpful, recovery-focused online spaces would be more beneficial than leaving them to explore the vast unknown of the online space.

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This suggestion of evidence-based resources and recommendations extended to apps, with participants in all groups expressing that concise resources such as factsheets or a type of technology “clearinghouse” would facilitate technology uptake by enhancing confidence in use and reducing personal trial-and-error.

“It would be great for us if national office would say, ‘Look, these are the apps that we kind of have done some research background on and have tested/trialled and maybe even workshopped with a few young people’, and then kind of roll that out in some way. That would make sense to me.”

“And then maybe get some feedback.”

“And links to the e-therapy and online sites. I think that should also be included as well. But if we have this resource list that's developed, it can be shared across services.”

“And maybe included in training or similar/like information on eheadspace or lots of other etherapy interventions because there's way more out there than people realise, I guess. So more information... Between them and face-to-face, I guess, in conjunction with all the information on how to use apps and stuff.”

– Clinicians

CLINICIANS ON THE NEED FOR EVIDENCE-BASED RESOURCES ON INTEGRATING TECHNOLOGY AND PRACTICE Finally, both clinicians and young people suggested that the best way to integrate technology into practice was to provide ongoing training and professional development to clinicians. Despite expressing that they are ready to adopt ICTs in practice, it also appears that there is still a need for IT education and support. Indeed, our young participants expressed that clinicians obviously needed to keep up to date with “the ever changing nature of technology” at the pace of their young clients. One young participant went so far as to describe that as her health care providers were “older” they had “no idea how to use the computer”, and so were in need of support.

Clinicians also recognised this need to bridge the “digital disconnect”.

“Internet sites and things change all the time and apps get changed or updated all the time as well. So you keep checking. So we are missing links to things; we have to keep checking if they work, if they have changed.”

– Clinician Webinars, interactive forums, and more traditional forms of professional development, such as the presentation of case studies, were mentioned as possible mediums for clinician training. Another recurring theme in all focus groups, however, was the idea of youth-led clinician training. Young people were perceived as the most frequent and up-to-date users of technology and so were the technological “experts”. Therefore, both clinicians and young people said it made sense for youth participation in technology implementation: “Basic social media training would be good, plus possibly a session where young people talk to them about how they want to communicate with health professionals through technology; overviews of some of the tried and tested apps with some guides on how they might be use them with young people. Young people should be part of the development of any training. ” – hY NRG member “Maybe include a session about how far you can go with technology and the do's and don'ts of using technology with young people. ” – Platform youth representative “I think having young people involved in the training and sort of explaining what ‘log’ means or what… Like those kind of things would be good, if you had young people involved in the training.”

– Clinician

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Training with feedback and support was also mentioned as a facilitator to technology uptake in clinicians. This included ongoing updates on the most current technologies, feedback from organisational-level trials of technology integration, and ongoing IT support and troubleshooting. Crucially, clinicians endorsed that they believed that such ongoing professional development should be become a compulsory part of continuing education, rather than optional: “As we move forward, it’s almost like a compulsory thing that you do as mental health clinicians, that is part of what we learn, like drug and alcohol. It’s kind of like a package that you have to do in the future.”

– Clinician Policy requirements, clinicians described, would help encourage uptake in those sub-groups of clinicians that were lagging behind in technology use. While youth health service providers were largely described as early adopters of technologies, policy requirements would help promote use in those who “steer clear” from technology.

Another, similar element that was endorsed by clinicians was the request that they had paid time for exploration.

“I reckon the best way to explore some of these apps, as a lot of people said, is just to try them yourself and take your time to do that. So one thing that would be really nice is to have some paid time to actually just do some investigation and exploration. That would be helpful, I think.”

– Clinician Overall, clinicians believed that the best intervention to increase ICT uptake amongst themselves and their colleagues was an engaging, interactive strategy that allowed clinicians to explore technologies themselves and learn from one another but also provided them with access to evidence based resources and expert trainers–such as young people–to guide use.

DISCUSSION Results from the three focus groups build on the results from the systematic review in the current report that technology can be a beneficial addition to youth clinical services. As young people and clinicians are already communicating with technology, they are already informally using technology as an adjunct to treatment, and clinicians are motivated to use technology in practice, it appears that youth health is primed to be formally integrated with technology. Indeed, it appears that the use of technology as a therapeutic tool has grown since a previous consultation with a similar sample of clinicians (Blanchard et al. 2012). While the current clinician sample may have been biased due to self-selection, it appears there is at least a passionate and motivated group of early-adopters that can champion the integration of technology and more traditional treatment services in youth mental health. According to technology implementation and diffusion of innovation theory, the leadership of early adopters is a significant factor in the acceptance and efficiency of the use of technology in practice over time (Ward et al. 2008; Rogers 2003). However, for widespread technology uptake in practice, further investment still needs to be made in training service providers to understand young people’s technology use and the various strategies that can be applied to improve and promote youth mental health and wellbeing (Blanchard et al.).

The first clear implication of the focus group results is that when communicating with young people through technology, it is important to first consult with the individual client on their preferences. While young people were generally positive about using technology to interact with their clinician or reception staff, opinions and reliable modes of contact differed for each given individual. This implies that the most engaging form of contact is the one that is come to through a shared collaboration between clinician and client. This too applies to technological tools as an adjunct to the treatment. The views expressed by both young people and clinicians that technology must have a clear rationale for any given client’s treatment plan indicates that the perceived benefit of an e-tool in treatment is a key precursor to successful technology-treatment integration. Collaborative care and shareddecision making strategies to determine which technologies are best suited to the given treatment situation are thus advised to guide this process, and may also increase client understanding and perceived benefits of a technological tool.

The finding that young people would not like to be personally contacted on social networking sites is consistent with past research and has clear indications for the engagement of young people in this space. Young people see 39

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their social networking profiles as their private space (Mitchell & Ybarra 2009) where they craft their “ideal digital self” through which they communicate socially (Satchel, Zic & Singh 2005). It is therefore unsurprising that an uninvited discussion of personal mental health concerns would not be well-received in these spaces, likely due to fear of stigma, reported both in the present study and in the past literature (Eisenberg et al. 2009). However, young people and clinicians both strongly believed that targeted or universal mental health promotion and prevention messages on social media were a powerful tool. It is clear, then, that such depersonalised engagement in social media may continue, as long as it does not venture into young people’s personal space.

It is also clear that there is a demand from both clinicians and young people for evidence-based resources to guide technology use in practice. This is unsurprising, as the vast majority of technologies already used by participants are unevaluated in the research literature, as demonstrated by the lack of evidence garnered from our review. There is a clear need to evaluate technologies to determine their feasibility, acceptability and effectiveness, not only to outline their standalone benefit, but to build an evidence base to inform the integration of technology and practice. The recent development of the Mobile Application Rating Scale (MARS), that provides practitioners and researchers with a tool to objectively and reliably assess the quality of mobile apps, may help alleviate this concern (Stoyanov et al. 2014). However, it is clear from the present research that randomisedcontrolled trials to evaluate technologies’ efficacy followed by good translational science is required to support youth service providers’ in technology uptake and for evidence-based service innovation.

Beyond evaluation of existing mental health technologies, the results of the present report also highlight that online platforms are an underused, and potentially beneficial, tool for interim support and relapse prevention in youth mental health. Although past research has demonstrated the potential mental health benefits of online support groups (Barak 2007), our review indicates that as yet, there has been no evaluation on how this may be integrated into face-to-face youth services. Indeed, it appears from both past research (Mission Australia 2013; Burns et al. 2013) and the present results that young people are already comfortable seeking peer support online, on large social networks such as Tumblr, or through health information forums. Furthermore, opinions expressed by both young people and clinicians in the focus groups demonstrate that such an online support platform may have particular benefits in providing lower-level, continuous support between face-to-face sessions, or as relapse prevention upon discharge from a face-to-face service. How online support services–either peer or clinician moderated–could be developed by and integrated into youth health services, and how this may influence clinical outcomes, is therefore a potential avenue for future research.

In terms of the uptake of technology, the present study also highlighted that inflexible organisational policy was a barrier to adopting technology in practice. While youth health leaders have previously expressed positive attitudes towards technological innovation (Blanchard 2008), health service policy is still hindering use. This implies that while individual attitudes promote technological innovation, health service guideline change is required to reflect these attitudes. In the risk-averse environment of youth mental health, it is essential to balance the needs and safety of young people with the potential benefits of technology in treatment. Systematic banning of email or social networking however, as reported in the present study, is not the way to do this. Indeed, considering the emerging evidence for the feasibility and benefits of the integration of technology and practice as outlined in the present systematic review, it may be that the risk is oft overestimated. Rather than considering the risk of technology in treatment, perhaps service providers should consider the risk of the lack of service innovation, especially when considering young people’s engagement with technology and their relative lack of engagement in mental health services, and adjust policy accordingly. As the evidence benefit of these technologies is ever increasing, it is crucial that a more nuanced health service organisational policy is developed to harness technology’s potential in practice.

Finally, clinicians endorsed that any intervention to increase technology uptake in practice should seek to actively engage health care providers in interactive, hands-on training. Tools for increasing clinician engagement in training included having resources readily available for “trying them out” and collaborative learning, policymandated modules in professional development programs, youth-led training, and paid-time for technology exploration. These findings further support the quantitative evidence from our systematic review that active interventions are indeed more successful at increasing ICT uptake in health care professionals in the past.

Therefore, one strong recommendation of this review is that static, didactic training techniques should be replaced with interactive, youth-led professional development programs to integrate technology and youth mental health practice.

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Appendices Appendix A: Systematic review search strategy A search strategy was developed as detailed below for the Medline database example. Three search sets were used for the core strategy; 1. Health professional terms 2. Technology terms 3. Cochrane handbook recommended evidence filter (or the equivalent in each database) The Medline strategy was translated into the other databases with the resulting references as described below. All references were imported into Endnote and deduplicated for the screening process.

Databases accessed

Evidence Source All EBM (Ovid) *

Period 2000 â&#x20AC;&#x201C; Current issue

Date of Search th 27 August 2012

CINAHL (Ovid)

2000 - Current

18 August 2012

EMBASE

2000 - 2012 Week 34

27 August 2012

ERIC Medline (Ovid) PreMedline (Ovid)

2000 - Current

th

2140

th

4968

th

22

th

3022

th

16

18 August 2012

2000 - August Week 3 2012 August 27, 2012

# hits Q4 741

27 August 2012 27 August 2012 rd

PsycInfo

2000 - Current

23

WoS

Since publication

20 August 2012

Aug 2012

th

2002 11

TOTAL 12,876 unduplicated *including The Cochrane Database of Systematic Reviews, DARE, CENTRAL, NHSEED, HTA and ACP Journal Club

Search undertaken in Medline** 1 2 3

4

5 6 7

"Health Personnel"/ "Professional Practice"/ physician's practice patterns/ (psychologist* or psychiatrist* or psychotherap* or counsellor*).ti,ab.

"Communication"/ "Physician-Patient Relations"/ *"Attitude of Health Personnel"/

30

((mobile or cell*) adj phone*).ti,ab.

31

(ipad or android*).ti,ab.

32

exp Cellular Phone/

33

internet/

34

(ict or information communication technolog$).ti,ab.

35

(remote communication$ or remote consultation$).ti,ab.

36

Information Services/

8

or/1-7

37

(ehealth or e-health).ti,ab.

9

telecare.ti,ab.

38

(digital divide or information poverty).ti,ab.

10

exp Online Systems/

39

(internet or email or www or world wide web or virtual or web site or website).ti,ab.

11

Interactive health communication.ti,ab.

40

(e-learning or elearning or telecommunicat$).ti,ab.

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12

Communication aid*.ti,ab.

41

exp Medical Informatics Applications/

13

exp social environment/

42

Reminder Systems/

14

facebook.ti,ab.

43

(computerised reminder$ or computerised reminder$).ti,ab.

15

Short messaging service*.ti,ab.

44

or/9-43

16

Electronic communication*.ti,ab.

45

randomized controlled trial.pt.

17

virtual world*.ti,ab.

46

controlled clinical trial.pt.

18

interactive health.ti,ab.

47

randomized.ab.

19

Information technolog*.ti,ab.

48

placebo.ab.

20

Myspace.ti,ab.

49

drug therapy.fs.

21

exp Correspondence as Topic/

50

randomly.ab.

22

((Virtual or on-line or online) adj clinic*).ti,ab.

51

trial.ab.

23

exp Therapy, Computer-Assisted/

52

groups.ab.

24

*"Information Dissemination"/

53

"Randomized Controlled Trials as Topic"/

25

*"Information Storage and Retrieval"/

54

or/45-53

26

exp Telemedicine/

55

exp animals/ not humans.sh.

27

(telemedicine or telehealth).ti,ab.

56

54 not 55

28

exp computer communication networks/

57

and/8,44,56

29

Computers, Handheld/

58

limit 57 to yr="2000 -Current"

** Adapted for use in other databases

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Appendix B: NHMRC levels of evidence hierarchy

Appendix C: Risk of bias assessment criteria Suggested risk of bias criteria for EPOC reviews – RCTs, NRCTs, Pre/post designs Risk of bias for studies with a separate control group Randomised controlled trials (RCTs) Non-randomised contolled trials (NRCTs) Controlled before-after (CBA) studies Nine standard criteria are suggested for all RCTs, NRCTs and CBA studies. Further information can be obtained from the Cochrane handbook section on risk of bias.

Was the allocation sequence adequately generated?

Score “Yes” if a random component in the sequence generation process is described (eg Referring to a random number table). Score ”No” when a non-random method is used (eg performed by date of admission). NRCTs and CBA studies should be scored “No”. Score “unclear” if not specified in the paper.

Was the allocation adequately concealed?

Score “Yes” if the unit of allocation was by institution, team or professional and allocation was performed on all units at the start of the study; or if the unit of allocation was by patient or episode of care and there was some form of centralised randomisation scheme, an on-site computer system or sealed opaque envelopes were used.

CBA studies should be scored “No”. Score “unclear” if not specified in the paper.

Were baseline outcome measurements similar?1,2 Score “Yes” if performance or patient outcomes were measured prior to the intervention, and no important differences were present across study groups. In RCTs, score “Yes” if imbalanced but appropriate adjusted analysis was performed (for example, analysis of covariance). Score “No” if important differences were present and not adjusted for in analysis. If RCTs have no baseline measure of outcome, score “Unclear”.

Were baseline characteristics similar?

Score “Yes” if baseline characteristics of the study and control providers are reported and similar. Score “Unclear” if it is not clear in the paper (e.g. characteristics are mentioned in text but no data were presented). Score “No” if there is no report of characteristics in text or tables or if there are differences between control and intervention providers. Note that in some cases imbalance in patient characteristics may be due to recruitment bias whereby the provider was responsible for recruiting patients into the trial.

Were incomplete outcome data adequately addressed?

Score “Yes” if missing outcome measures were unlikely to bias the results (e.g. the proportion of missing data was similar in the intervention and control groups or the proportion of missing data was less than the effect size i.e. unlikely to overturn the study result). Score “No” if missing outcome data was likely to bias the results. Score “Unclear” if not specified in the paper (Do not assume 100% follow up unless stated explicitly).

Was knowledge of the allocated interventions adequately prevented during the study?

Score “Yes” if the authors state explicitly that the primary outcome variables were assessed blindly, or the outcomes are objective, e.g. length of hospital stay. Primary outcomes are those variables that correspond to the primary hypothesis or question as defined by the authors. Score “No” if the outcomes were not assessed blindly.

Score “unclear” if not specified in the paper.

Was the study adequately protected against contamination?

Score “Yes” if allocation was by community, institution or practice and it is unlikely that the control group received the intervention. Score “No” if it is likely that the control group received the intervention (e.g. if patients rather than professionals were randomised). Score “unclear” if professionals were allocated within a clinic or practice and it is

1

If some primary outcomes were imbalanced at baseline, assessed blindly or affected by missing data and others were not, each primary outcome can be scored separately.

2

If “UNCLEAR” or “No”, but there is sufficient data in the paper to do an adjusted analysis (e.g. Baseline adjustment analysis or Intention to treat analysis) the criteria should be re scored as “Yes”.

possible that communication between intervention and control professionals could have occurred (e.g. physicians within practices were allocated to intervention or control) Was the study free from selective outcome reporting?

Score “Yes” if there is no evidence that outcomes were selectively reported (e.g. all relevant outcomes in the methods section are reported in the results section). Score “No” if some important outcomes are subsequently omitted from the results. Score “unclear” if not specified in the paper.

Was the study free from other risks of bias?

Score “Yes” if there is no evidence of other risk of biases Quality Appraisal of Qualitative Literature

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Interrupted time series risk of bias criteria

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AMSTAR tool

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Appendix D: Summary of results â&#x20AC;&#x201C; strategies to increase clinician uptake of ICT in practice

Study

Sample

Clinical Setting

Type of technology to be adopted Customised HIT1 application for patient data entry and retrieval, referrals, and other information

Uptake strategy

Effect of intervention on outcome measures

Alexander et al. (2012), case series

N=6, clinical nurse specialists

Diabetes education in small medical practices, USA

Bradley et al.

(2002), CRCT2

N=10, medical residents, intervention (N=5) and control (N=5)

Cabell et al.

(2011), C-RCT

Cheng (2003), RCT3

Quality rating Low

All participants were actively involved in the design of the new system in a 2-step iterative process, and then had three 1hour training sessions.

Staff attitudes towards use of HIT in the workplace improved post-trial compared to pre-trial, in regards to opinions on usefulness, relevance and ease-of-use (no results of significance tests reported). No other outcome measures were compared pre- and post-intervention and there was no direct or indirect measure of use of the system throughout the trial, so no conclusions on the effect of the intervention on uptake can be drawn.

Neonatal intensive care unit, USA

Online evidence search databases

All participants attended a lecture on forming good clinical questions and clinical decision-making. Over the course of one month, intervention group received additional instruction from medical librarian about how to use search databases along with written educational materials. Control participants received no further training.

Compared to pre-intervention self-report, both groups elevated online search databases (eg. Medline) in their rankings of preferred information sources, but the intervention group's ranking increased by a higher mean rank compared to control (1.4 vs. 0.6; p-value not reported). Satisfaction with personal searching skills improved in both groups, but the control group's satisfaction improved slightly more than the intervention group (0.6 vs. 0.8; no p-value reported). Confidence in ability to find appropriate search terms grew slightly more in the intervention group compared to control (0.8 vs. 0.2) as did perceived ability to formulate effective search strategies, where the control group's rated ability actually decreased (0.4 vs. -0.8; no p-values reported). As no usage data was reported the effect of the intervention on uptake is unclear.

Modera te

N=48, medical residents, intervention (N=24) and control (N=24)

General internal medicine service at university teaching hospital, USA

Online evidence search databases

All participants had 30-minute, weekly sessions on online resources and search techniques. Intervention received additional training involving a 1-hour session with medical librarian and three 30-minute sessions with chief resident on search strategies, along with written educational materials. Control participants received no further training.

The intervention appeared to have a significant positive effect on uptake. The median logons per person was 2 times higher in intervention group (2.1 vs. 4.4; p<.001). The median total abstracts viewed was 3 times higher (5.8 vs. 17.7; p=.001) and median total full text articles was 2.6 times higher (1 vs. 2.6, p=0.005) in the intervention vs. the control group. Hours spent searching was 3 times longer in the intervention vs. control group (2.4 vs. .8 hours; p<.001).

High

N=800 hospital

Public hospital, Hong Kong

Online evidence search databases

Intervention participants received a 3hour training workshop followed by a

The intervention appeared to be successful at increasing ICT4 uptake. Intervention clinicians were 2.6 x more likely than control

High

clinicians, intervention (N=400) and control (N=400)

Dornan et al.

(2002), case series

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N=439, endocrinology consultants

hands-on practice session. This training involved case studies, role-playing, instruction of search techniques, and practice conducting searches. Control received no training.

Hospitals throughout the UK

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"PC Diary": a professional development platform that facilitates learning and behaviour change in practice

All participants were offered 1 year's access to the program, invited to a training workshop, sent email updates and tips for use, and were provided with continued online support.

to use Cochrane (95% CI = 1.743-3.868) and 5.6 x more likely to use Medline (95% CI = 3.766-8.362), which were covered in the workshops. There was no difference in use of sources not covered in workshops (OR=.68, 95% CI 0.408-1.133).

Intervention clinicians were also significantly more likely to be satisfied with the online databases, problem solving and the information obtained from their searches compared to controls (OR=9.517, 6.5, and 14.976 and NNT= 3, 4, 3 respectively).

Training also increased perceived and actual knowledge of databases and search technique (Pearson Chi-square=139.528, df=5, p=.000) and significantly affected attitudes to online databases, with controls more likely to perceive that online searches were time-consuming and burdensome compared to intervention clinicians (p=.000). Intervention clinicians were also more efficient in their search times (21 mins vs. 35 mins in control group; p=.0000).

Engagement with the intervention and subsequent uptake was poor. Only 95 (22%) consultants registered for the program, with only 60 (14%) attending training. Of the registered participants, 89 (94%) returned a self-reported use questionnaire and 87 described their use. 10 (11%) decided not to use it, 18 (21%) planned to use it but never set it up on their computer, 29 (33%) set it up but did not use it, 21 (24%) set it up but used it infrequently, 6 (7%) used it twice per month or more and 3 (3%) used it once per week or more on average. Qualitative analysis revealed that lack of time, IT inexperience, technical problems, and lack of resources were barriers to use.

Low

Dykes et al.

(2007), crossover RCT

N=79, nurses

Two patient care units in one hospital, USA

PDA or tablet PC for tailored patient assessment, provider order entry, and discharge and results information

Gagnon et al.

(2011), systematic review

10 studies (9 RCT and 1 ITS of ICT uptake interventions in health professionals

Hospitals (5), GPs (3) and an academic medical centre (1) in the USA (4), Canada (3), Australia (1) and Hong Kong (1)

Various ICT systems: Evidence databases (8) online feedback, or triage email system

Haynes et al.

(2006), C-RCT

N=203, general practice /internal medicine physicians, intervention (N=98) and control (N=105)

General practices and hospitals, Canada

McMaster PLUS: Online evidence search database

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All participants received preimplementation education involving 30 minutes of hands-on training for either paper and tech-based form along with written educational materials. "Unit champions" were paid a stipend to attend a one-hour training session on new devices and provided ongoing support throughout the trial. For the first six weeks of the trial, nurses were randomised to either a device (n=40) or paper (n=39). At crossover, those randomised to the device used the paper form and those using the paper form used a device for the remaining six weeks.

Eight studies evaluated "professional" interventions (IT education training/materials/walk-throughs or professional feedback), 1 a financial intervention (fees for use), and 1 organisational intervention (policy-driven provision of access)

The intervention appeared to be unsuccessful at promoting ICT uptake. Device use was lower than expected: the wireless devices were used only 63.5% of the time expected and the paper module approximately 33% more of the time expected based on the randomisation pattern. However, device use significantly improved clinical outcomes and clinician satisfaction: documentation completion was significantly higher between the electronic tools and the paper tools, eg. for suicide prevention assessment (p<.05), and satisfaction was greater with the electronic devices compared to the paper form (p<.008).

Low

Results from reviewed studies were mixed and indicated that few studies were successful in promoting clinician ICT uptake. 3 reported a significant positive effect of the intervention on ICT uptake. One study showed a positive impact, but only 6-months post-intervention. Due to these mixed results, no conclusions were drawn about the effectiveness of one type of intervention over another.

High

Intervention clinicians given "Full-Serve Version" of program that included tailored alerts, ratings from other physicians, and synonym prompts to promote use of the system. Control participants assigned to "Self-Serve" system that still could search the evidence database but it was a passive, non-tailored system.

The intervention was successful at increasing ICT uptake.

Significantly more intervention participants (87.8%) than control participants (75.2%) used the service (12.6% difference, 95% CI 1.8, 22.9). Adjusted for baseline differences, mean logins per month, per user grew at a significantly higher rate in the intervention group (from 1.66 to 1.84 logins) compared to control, (decline from 2.05 to 1.46 logins; 0.77 difference, 95% CI 0.43, 1.11). The average duration of PLUS usage increased by 4.2 minutes per participant, per month for the experimental group compared to 1.1 minutes for the control group, but these differences were not significant (95% CI -8.57, 14.79).

Frequency of access to Ovid, StatRef, full-text articles and The Cochrane Collaboration revealed no significant differences between groups. A comparison of intervention to control revealed that the intervention did not appear to have changed clinician attitudes: both groups believed the system to be useful

High

(Likert rating difference -0.31, 95% CI -1.04, 0.43), provided access to desired information (70.8% of intervention vs. 71.5% of control, p=0.803) and ease of finding information (Likert rating difference -0.38, 95% CI -1.07, 0.31).

Homa, Schifferdecker & Reed (2008), NRCT

N=352 primary care physicians, intervention (N=64) and control (N=288)

Primary care medical practices, USA

Internet usage in clinical practice (use of evidence search databases, finding patient information, and clinical decision making)

All practices were given two computers and internet access. Intervention clinicians, up to 3 from each practice, received 4-part training: 2 workshops, follow-up phone call, and a site visit.

Training was with medical librarians and offered information on how to access Web-resources, hands-on learning, and information on how to integrate the internet into practice. Comparison clinicians received no training.

The intervention had a significant positive effect on ICT uptake according to some use outcome measures, but not others. Selfreported frequency of online resource use was higher in the intervention group in terms of monthly use rate (p=.040), patient referral to online resources (p=.025) and Medline use (p=.001).

However there was no between-group difference postintervention on daily use, online clinical resource use, and access to online practice guidelines and medical organisation website. The intervention appeared to have a significant effect on IT knowledge: there was a significant group x time interaction effect for knowledge of online resources, eg. familiarity with Medline (p<.001), online practice guidelines (p<.001) and patient-oriented health information websites (p<.001), and online skills eg. Ability to narrow search results (p=.008) and develop search strategies (p=.002), favouring the intervention group. No such significant effect was found for ability to use 'AND' and 'OR' terms to widen/narrow searches.

Low

Jerome et al.

(2007), case series

N=137 attending and resident physicians

Adult primary care centre in University medical centre, USA

Electronic medical record system with inter-clinic secure messaging system and online evidence search database

Medical librarian advertised system to hospital clinicians through periodic emails, flyers, posters, and hands-on demonstrations with "approximately 15" physicians during clinic hours.

The intervention had little effect on ICT uptake and uptake was low. There was no significant difference in the proportion of physicians using the electronic service before and after the intervention (11% utilisation in each time period, p=1.0). Of the 48 participants (only 35% of the sample) who returned a selfreport survey, only 63% reported awareness of the uptake promotion materials and only 40% reported using the service.

Low

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Katz et al.

(2003), RCT

N=94, primary care physicians, intervention (N=50) and control (N=48).

2 university affiliated primary care centres, USA

Triage based email communication system between patients and physicians

Intervention physicians were encouraged to give patients a card during clinical visits with a study-specific email address, and directions on how to use the system.

Control group had no access to triage account, but all participants could be emailed at their personal email address, listed on their business cards.

The intervention had a significant effect on ICT use. Trend of increased email volume over time was significantly greater in the intervention vs. control group (p<.001, IRR adjusted for physician type and clinic=3.6, 95% CI 2.1 to 6.2). However there was no such significant effect for phone communication (adj. IRR Int. vs. Control = 1.2, 95% CI 0.9-1.4). There was no significant difference in patient "no show rate", satisfaction with communication and quality of care between groups over time. In terms of attitudes to email, the intervention group was less "bothered" with (p<.03) and perceived more benefits of (p=.012) email communication and were more positive about using email to address urgent patient questions (p=.05). However, there was no significant difference between groups on "liking" email communication.

Low

Koivunen et al.

(2008), qualitative case series

N=89, registered and practical nurses

9 wards in 2 psychiatric hospitals, Finland

"Mieli.Net portal", used by physicians to educate patients with psychosis with patient-centred, tailored information, peer support and clinician advice.

Nurses can also use the device for educational purposes

IT skills and attitudes were assessed, and basic IT training was provided as required. Computer and internet access was provided for 6 wards where equipment was limited Manuals for portal use was provided for all wards.

Researchers informed nurses of potential benefits of uptake, intended to motivate portal use, in information sessions and discussions. There was access to practical support throughout the study period, with two portal support representatives per ward.

Qualitative content analysis revealed facilitators and barriers to clinician uptake at the organisational, technology and individual level. Examples of facilitators included sufficient and functional computers, sufficient time, portal promotion and education (organisational), portal functionality, ease of use and relevance (technology level), high motivation to use IT and for new actions, (individual attitudes) and sufficient IT skills and increased experience (individual capacity). Conversely, barriers to uptake included lack of computers, internet access, staff resources, education, time, finances and uptake policy (organisational), technological problems, discomfort of website name, and inertness of portal content (technology level), negative attitudes to computers and negative attitudes and poor commitment to new action (individual attitudes) and computer inexperience (individual capacity). In terms of the effect of the intervention on uptake, as no use outcome measures were reported, no conclusions can be drawn about the success of this uptake strategy.

Modera te (QII)

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Magrabi et al.

(2005), case series

N=132, general practitioners

General medical practices with existing computer and internet access, Australia

"QuickClinical", GPspecific online evidence search database

All GPs were provided QuickClinical system at the organisational level and were "asked to use" it in their routine care over a 4-week period, using a personal username and password. Online help manual and help desk support was available throughout the study period.

ICT uptake was relatively low. While 85% of participants used the system at least once, with 8.7 mean searches per active participant (overall mean = 7.9, median = 4) . However, 51% used it five times or less and 15.6% of participants used the system only once. Only 17.1% of the sample conducted 16 or more searches. Use by female participants was significantly higher than males (p=.004). No conclusions could be drawn on the effect of the intervention on uptake due to the lack of a control group. While most believed that the system had the potential to improve patient care (82.7%) and enabled better evidence-based care (58%), only 25.6% of GPs had direct experience of the system positively impacting patient care.

Low

Magrabi et al.

(2007), C-RCT

N=227, general practitioners, intervention (N=63) and control (N=164).

General medical practices with existing computer and internet access, Australia

"QuickClinical", GPspecific online evidence search database

All participants were provided with QuickClinical system at the organisational level and were "asked to use" it in their practice, with the aid of an online help manual and help desk support. A subset of participants (intervention group) was given advanced online training that provided guidance for search strategies to answer clinical questions.

The uptake strategy was not successful at increasing ICT uptake. While 85% of participants used the system -- with a mean of 8.7 searches per active participant -- most active participants used the system only once. The data also appeared to be skewed, with some outlier clinicians using the system far more than others, raising the mean. The advanced training in search skills did not promote ICT use compared to control (mean number of searches were 8.98 vs. 9.77; p=.65). It was suggested that this was because of the simple interface of the system and the high level of computer skills in the sample (83.4% rated their skills as good to excellent). Females were more likely to use the system compared to males (p=.008) even though they worked fewer hours per week (p=.001). One attitude measure was associated with use: if the clinician believed system impacted on patient care they were more likely to use it (p=.001).

Low

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Magrabi et al.

(2008), case series

N=140, general practitioners

General practices with existing computer and internet access, Australia

"QuickClinical", GPspecific online evidence search database

All participants were given personal access to and "asked to use" QuickClinical system over a 12 month period in their routine practice. Also offered an online tutorial (which 59 GPs completed). An online manual for use was provided throughout the trial.

Perrocchia et al. (2005), case series

N = 256, various healthcare professionals

Hospital, comprehensive cancer centre and "several community based organisations", USA

"CancerInfoNet.org" , Online cancer information portal with links to external online sources

All participants engaged in 1-hour workshop on health information seeking strategies (eg. hands-on demonstrations, search scenarios, how to assess accuracy and credibility of information).

Workshop was itself led by a participant (or "champion") who previously engaged in 3-hour train-the-trainer session.

Sadasivam et al. (2011), case series

400 general medical practices, unknown total N, GPs

General medical practices, USA

"ReferASmoker.org" , e-referral portal for patient smoking cessation

All practices sent information on portal, and invitation to be included in trial. If chosen for inclusion, they were mailed a $150 incentive for trial completion. 25 included practices were mailed instructions on how to access and register for the site. All enrolled participants were contacted by telephone to prompt system use.

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Only the use of those who completed the online tutorial (N=59) was reported. Even in those who completed the tutorial, ICT uptake was not high or sustained. Trained participants conducted an average of 39.14 searches over the study period (3.26 searches per month). 9 participants did not use the system after first two months of the trial, and average use decreased significantly from this time point (from 10.8 to 4.4 searches, then continuing to decrease to 0.4 searches/month at TP 10) Posthoc analyses indicated that "high use" was not associated with gender, years of GP experience, or information seeking behaviour, but those characterised as "low use" were more likely to be aged 45 years and older (p=.03). However, due to the lack of control and absence of data on the participants that did not complete the tutorial, no conclusions can be drawn about the success of the intervention on ICT uptake.

Only post-intervention, self-report attitude data was reported, categorised by profession. Most (89.6-100%) planned to use the internet to find cancer information, would use cancer information services (85.7 - 100%) and would refer patients to cancer information services (97.4 - 100%). Most reported, that due to learning about the internet that they were more comfortable using the internet to find cancer info (52.4%-92%) and learned about new websites (76.2 - 96.1%). However, conclusions on the effect of the intervention on uptake cannot be drawn due to a lack usage data and control.

Uptake of the referral portal was very poor. Of original 400 practices, only 7 accessed the system. In these practices, only 6 GPs from 5 practices registered with the system, with only 5 logging on. Initially, no clinicians referred patients, and after encouragement by telephone, only 1 GP used it to refer 2 patients. Lack of training, study champions, and motivation and poor practical relevance were proposed as uptake barriers by the authors, but there was no data to support these claims.

Low

Modera te

Low

Simon et al.

(2005), ITS5

N = 12, primary care internal medicine residents

Multi-site primary care internal medicine group, USA

Online audit and feedback to physicians. Aimed to improve evidence-based practice in hypertension and diabetes treatment

Strayer et al.

(2006), pre/post intervention case series

N = 23, faculty and resident physicians

Department of Family Medicine in university health system, USA

Handheld computer smoking intervention tool (HCSIT), assists clinicians with smoking cessation counselling with best practice guidelines, drug information and recommendations

Tomnay et al.

(2007).

NRCT6

N = 499, GPs, exposed (N = 109) and unexposed (N = 380)

General practices, Australia

Website with access to chlamydia resources to distribute to patients (eg. patient partner notification letters, treatment guidelines, brochures, etc.)

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All participants' superiors (residency program directors) formally encouraged participants to access their audit on the internet verbally, in personal letters and by distributing written educational materials. This encouragement presented the project as an opportunity for quality improvement and professional development. The primary author also personally and verbally encouraged access.

All participants engaged in a 30-minute training session about how to use the system, were given access for a 4-month trial, and were asked to use it in routine care to assist with smoking cessation counselling.

2 pathology laboratories "serving half of GPs" in the study included the website URL at the bottom of a positive result for chlamydia. Post-intervention surveys assessed those who were exposed to (used a target lab and diagnosed a patient with chlamydia) and those who were not exposed (did not use a target lab or did not diagnose a patient with chlamydia) to the website URL

Access to the online audit was poor, and there was no reported effect of the intervention on uptake. Only 4 of 12 residents accessed their websites. Website access also appeared to have no discernable effect on clinical outcomes: access to online audit had no effect on participants' guideline adherent care and patients' long-term glucose control, β-blocker or a diuretic prescription, and other clinical outcomes.

High

Due to hardware failures, only 14 of 22 participants' usage data could be logged. Of those 14, there was an average of 10.7 uses per physician over the 4-month study period. 20 of 22 respondents (91%) reported using the software. Overall, participants found the HCSIT tool easy to use, well organised and fast enough to suit a clinical encounter. There was no significant difference in attitudes in a pre/post test comparison (mean increase = 0.44, p=.16) but there was a significant difference in of physician comfort with the system in a consultation (t = 3.87, p=.001). No significant mean differences were found for physician knowledge in a pre/post intervention comparison (p=.584). As use data was not collected prior to the intervention, the effect of the intervention on uptake is unclear.

The intervention appeared to be successful at increasing ICT uptake. Of 109 exposed GPs, 40 (37%) reported seeing the URL and 34 (32%) indicated that they used the website. Logs of use indicated that 59 of 109 positive pathology results resulted in access to the website (54%, 95% CI 45 - 64%). The intervention also appeared to have an effect on clinical practice, as in the exposed group, there was a significant increase in the use of printable partner letters (p=0.0009) and brochures (p=0.003) but there was no corresponding change in the non-exposed group (p=0.45 and 0.78, respectively).

Low

Low

Toth-Pal et al.

(2008), qualitative and case series

N = 5, GPs

General practice, Sweden

CDSS7 for use in the diagnosis and management of chronic heart failure with probability calculations, recommendations, and general

At the beginning of the 11-month trial, all participants were exposed to a 1.5-hour introductory demonstration of the CDSS, given access to the system, and involved in individual hands-on training. After this session they were "encouraged to use" the system in routine clinical care.

Results indicated that CDSS uptake was low: log-files indicated that it was used on 38 occasions, but many log-clusters were made in the same time-period, indicating they were used in the same decision-making situation, so use was better estimated to be 0 - 4 uses per GP. Qualitative profiling indicated low use was associated with limited computer skills, stress with learning new computer tasks, and the following attitudes: perception of being forced to uptake ICT system, perceived lack of confidence, and lack of clinical relevance, professionalism and practicality of the system. High use was qualitatively associated with regular computer use outside of work, seeking out opportunities to improve computer skills and learn new information from the internet, and the following attitudes: belief that a computer is an important tool and can facilitate knowledge, clinical guidelines are essential, and that it is acceptable and professional to seek guidance with ICT when a patient is present.

Modera te (QII)

Vedel et al.

(2012), qualitative case series

N = 31, healthcare professionals

Two family medicine groups, Canada

"Da Vinci System", CDSS to support clinicians with the complexity of multimorbidity in patients

Two three hour, voluntary training sessions offered to all potential users.

Physicians received six study credits as a part of a "maintenance of competency" program. Other professionals received 6 hours of training during normal work hours. Individual one-on-one coaching available on request.

ICT uptake was strong, as 27 (87%) of participants used the system. Post-hoc qualitative analysis grouped these participants into early adopters (21), late adopters (6), and laggards. 26 continued to use the system, and 1 discontinued use. Themes associated with sustained use included user IT skills, expected ease of use and usefulness, and a positive "societal trend" amongst co-workers. Laggards were characterised by a lack of basic IT skills and perceived usefulness, and the following attitudes: concerns about negative impact on doctor-patient relationship and resident training and concerns about system sustainability and data entry. Due to the lack of control, it is unclear whether the intervention strategy was successful at promoting uptake.

High (QI)

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Waldorff et al.

(2009), C-RCT

N = 339 GPs, intervention (N=168) and control (N=171)

General practices, Denmark

Electronic continuing education program, aims to improve adherence to best practice dementia guidelines

Zheng et al.

(2005), qualitative case series

Unknown total N, 41 internal medicine residents used system

Ambulatory primary care clinic in urban teaching hospital, USA

CDSS with "just in time" reminders for clinicians at the point-of-care consistent with evidence-based guidelines and according to patient's admin, lab and clinical records, which are all stored in a single database

1. HIT – Health information technology 2. C-RCT – Cluster randomised controlled trial 3. RCT – Randomised controlled trial 4. ICT – Information and communications technology 5. ITS – Interrupted time series 6. NRCT – Non-randomised controlled trial 7. CDSS – Clinical decision support system

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All GPs had free access to the program from the Danish College of GPs website, and it was advertised in their weekly journal. All members were sent one email about the system. Intervention participants went sent 3 reminder letters over a 3-month period. These letters were intended to remind GPs to use the system, test their knowledge so to engage them with the system, and offered IT support. Control GPs were sent no further reminders.

System implementation completed 3 months prior to study and all individuals were given training. Use of the system was strongly recommended but not mandatory.

Although use was low, use was significantly higher in the intervention group. A total of 15 GPs (4.7%) GPs had at least one logon to the system, 12 from the intervention group (7.5%) and 3 (1.9%) from the control group. Intervention GPs were 8 times more likely to logon compared to controls (OR=8.0, 95% CI: 1.03 - 66.1; p=.047; NNT = 22.2). So while only a small proportion of GPs used the system and the effect of the intervention was not strong, it did significantly increase the probability of a GP logon to the system. However, as there were no significant group differences on secondary outcomes (relogons and median slides viewed) it is unclear whether this increased use was meaningful.

41 participants used the system over the trial period. Post-hoc qualitative analyses grouped residents into "light", "moderate" and "heavy" users. These groups made up 41.46, 36.59 and 21.95% of users, respectively. Themes associated with uptake were clinician attitudes that the CDSS had a positive impact on medical practice, was easy to use, and was time efficient.

Themes of barriers to uptake included attitudes that the CDSS was a static system as it did not feedback and generated the same reminders every time, it involved too much data entry that took too much time, it was relevant to their role and they believed "nurses should do it", and that it disrupted the patientphysician relationship. As the total N was not provided, no direct measures of use were reported, and there was a lack of control, the success of the intervention on increasing uptake is unclear.

High

Low (QIII)

Appendix F: Risk of bias of included studies â&#x20AC;&#x201C; strategies for clinician ICT review RCTs, C-RCTs, NRCTs, Pre/Post Designs and Case Series

Included Interrupted Time Series’ Risk of Bias

Included Qualitative Studies’ Risk of Bias

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Included Systematic Reviewâ&#x20AC;&#x2122;s Risk of Bias

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Appendix G: Focus group discussion schedules Focus groups discussion schedule – young people AIM 1: Engagement Do you think it’s a good idea for health professionals (e.g., doctors, psychologists, counsellors, nurses, social workers etc) to use email, SMS or social media to setup and confirm appointments with young people?

Have there been times when your health professional(s) have contacted you via email, SMS or social media?

Were there times this worked well? Were there times when this did not work well?

What do you think about health professionals contacting you via social media? Do you want to be contacted this way?

Why/why not?

What do you think about using social media as a way for you to learn more about your health professionals, prior to meeting them for the first time? Do you think this would find this helpful? Why? Why not?

Would you feel more engaged with health services (e.g., would you be more likely to attend appointments or see a health professional) if you were contacted via your preferred method?

Do you think it makes a difference to how engaged you feel with a service if you are contacted by your clinician versus reception staff? Why/why not?

What do you think of the way health professionals currently communicate with young people? How would you change it?

AIM 2: Complementary interventions What do you think about the idea of mental health professionals referring young people to online interventions or apps to use in, and/or between, appointments?

Do you want your health professionals to use online interventions in conjunction with face-to-face therapy?

Can you give examples of when you used an online intervention or app as part of treatment?

Were there times this worked well? Were there times when this did not work well?

Are there any particular online programs or apps that you would recommend health professionals use?

What would make you more likely to use an online intervention as part of therapy?

What do you think health professionals need to say or do to support/encourage young people to use apps or online programs as part of therapy?

AIM 3: Adoption/Uptake What kind of training do you think health professionals need to get them to use technology in their practice with young people?

What are some of ‘do’ and ‘don’ts’ of using technology with young people?

What are some pros of using technology with young people? What are some cons?

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Focus groups discussion schedule – clinicians

AIM 1: Engagement Do you think it’s a good idea, as a health professional, to use email, SMS or social media to setup and confirm appointments with young people?

Can you give examples of when you have used email, SMS or social media to contact a young person either before your first appointment or between appointments?

Were there times this worked well? Were there times when this did not work well?

How do you think young people would prefer to be contacted by their health professional(s) about their appointments? (e.g., text message, email, phone call or social media)?

Do you think young people would like to be contacted via social media? Why? Why not?

What do you think about using social media as a way for young people to learn more about you, as their health professional, prior to meeting them for the first time? Do you think young people would find this helpful? Why? Why not?

Do you think young people would feel more engaged with health services (e.g., more likely to attend appointments) if they were contacted via their preferred method?

Do you think it makes a difference to engagement if young people are contacted via their clinician versus reception staff?

What do you think of the way you currently communicate with young people? How would you change it?

AIM 2: Complementary interventions What do you think about the idea of referring young people to online interventions or apps to use in and/or between, appointments?

Can you give examples of when you referred a young person to an online intervention or app to use between your appointments?

Were there times this worked well? Were there times when this did not work well?

How did you use online interventions or apps with young people?

Are there any particular online programs or apps that you would recommend?

Do you think young people want to use online interventions in conjunction with therapy?

What would make you more likely to recommend an online intervention?

What would make young people more likely to use online interventions that you recommend? What would you need to say or do?

AIM 3: Adoption/Uptake What kind of training or education would you need to increase your use of technology in youth mental health services?

What are some of ‘do’ and ‘don’ts’ of using technology with young people?

What assistance should clinicians receive to integrate technology into their practice with young people?

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What cautions or warning should clinicians receive if they are using technology in their practice?

What are some pros of using technology with young people? What are some cons?

Have you, or any of your colleagues, been particularly good at using technology in practice?

What skills do you think you or others would need to enable better integration of technology?

Where do you see the sector heading in terms of integrating technology and/or online interventions in clinical practice?

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