Discussion
schizophrenia, psychosis
EVENTS
This study utilised a thematic analysis approach to construct themes relevant for understanding implementation behaviours within the EMPOWER feasibility trial from the perspectives of patients, mental health staff and one carer. From the results of the analysis, two key themes were identified that appear relevant to understand the mechanisms underpinning the relatively high implementation behaviour observed within the EMPOWER trial and will likely be of interest to researchers looking to develop digital interventions for people who experience psychosis, and in particular, those who have recently experienced a relapse.EMPOWER was a complex intervention which blended multiple components. All three key main EMPOWER components (clinical triage, self-monitoring and self-management with peer support worker support) appeared to be important and were appraised positively by patients, mental health staff and the one carer we spoke with. While some participants found the intervention difficult to use at first, patient-participants generally expressed confidence in using the mobile phone-based intervention components. This is noteworthy because some had never used a smartphone before, and there was concern expressed before the EMPOWER trial that older and digitally excluded people may struggle to use an app-based intervention [Initially, implementation by patient participants appeared driven by what the intervention afforded them (such as social connection). However, sustained implementation appeared driven by patients perceiving that the app was creating positive change in their life such as increased confidence in self-managing. The themes constructed in this analysis helped develop a theoretical account for why these implementation behaviours occurred. The first key concept was affordances. EMPOWER affordances can be described as offerings which may or may not be in line with how participants (patients, staff, and carers) envision how and why they will interact with the intervention [Patients reported that taking part in the intervention afforded them increased access to information about psychosis generally through conversations with peer workers or wellbeing messages as well as direct support from clinical trial staff during crisis events. Previous research has indicated that people diagnosed with schizophrenia perceive that digital interventions can afford them another source of support [While affordances helped explain early implementation, sustained implementation appeared driven by patients, carers and mental health staff perceiving positive change. This was distinguished from affordances because these themes described experiences beyond EMPOWER offering people something but rather extended to people noticing a positive change within their daily lives. If participants noticed a positive change from using EMPOWER – they continued to do so. However, participants who had stopped noticing positive change or who never found the intervention helpful dropped off. This “perceived positive change processes” theme is very similar to the theme of perceived effectiveness noted by Steare and colleagues in their qualitative evaluation of a digital self-management psychosis app [EMPOWER was designed with an assumption that patients would share data with mental health staff who support them to reduce inherent uncertainties within EWS based relapse prevention. While there were rare examples in the interviews of patients sharing data with mental health staff to develop a shared understanding of wellbeing, typically mental health staff opted to use the fact the patient was part of the study to open conversations rather than relying on data to understand how a patient was doing. This appeared to be a positive change process for mental health staff. Staff not feeling comfortable using data generated by digital interventions is a common implementation barrier [