Digital technology, including the internet, smartphones, and wearables, provides the possibility to bridge the mental health treatment gap by offering flexible and tailored approaches to mental health care that are more accessible and potentially less stigmatising than those currently available. However, the evidence base for digital mental health interventions, including demonstration of clinical effectiveness and cost-effectiveness in real-world settings, remains inadequate. The James Lind Alliance Priority Setting Partnership for digital technology in mental health care was established to identify research priorities that reflect the perspectives and unmet needs of people with lived experience of mental health problems and use of mental health services, their carers, and health-care practitioners. 644 participants contributed 1369 separate questions, which were reduced by qualitative thematic analysis into six overarching themes. Following removal of out-of-scope questions and a comprehensive search of existing evidence, 134 questions were verified as uncertainties suitable for research. These questions were then ranked online and in workshops by 628 participants to produce a shortlist of 26. The top ten research priorities, which were identified by consensus at a stakeholder workshop, should inform research policy and funding in this field. Identified priorities primarily relate to the safety and efficacy of digital technology interventions in comparison with face-to-face interventions, evidence of population reach, mechanisms of therapeutic change, and the ways in which the effectiveness of digital interventions in combination with human support might be optimised.

Regardless of geography or income, effective help for depression and anxiety only reaches a small proportion of those who might benefit from it. The scale of the problem suggests a role for effective, safe, anonymized public health–driven Web-based services such as Big White Wall (BWW), which offer immediate peer support at low cost. Using Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) methodology, the aim of this study was to determine the population reach, effectiveness, cost-effectiveness, and barriers and drivers to implementation of BWW compared with Web-based information compiled by UK’s National Health Service (NHS, NHS Choices Moodzone) in people with probable mild to moderate depression and anxiety disorder. A pragmatic, parallel-group, single-blind randomized controlled trial (RCT) is being conducted using a fully automated trial website in which eligible participants are randomized to receive either 6 months access to BWW or signposted to the NHS Moodzone site. The recruitment of 2200 people to the study will be facilitated by a public health engagement campaign involving general marketing and social media, primary care clinical champions, health care staff, large employers, and third sector groups. People will refer themselves to the study and will be eligible if they are older than 16 years, have probable mild to moderate depression or anxiety disorders, and have access to the Internet. The primary outcome will be the Warwick-Edinburgh Mental Well-Being Scale at 6 weeks. We will also explore the reach, maintenance, cost-effectiveness, and barriers and drivers to implementation and possible mechanisms of actions using a range of qualitative and quantitative methods. This will be the first fully digital trial of a direct to public online peer support program for common mental disorders. The potential advantages of adding this to current NHS mental health services and the challenges of designing a public health campaign and RCT of two digital interventions using a fully automated digital enrollment and data collection process are considered for people with depression and anxiety. International Standard Randomized Controlled Trial Number (ISRCTN): 12673428; http://www.controlled-trials.com/ISRCTN12673428/12673428 (Archived by WebCite at http://www.webcitation.org/6uw6ZJk5a)

BACKGROUND:Traditional evaluation methods are not keeping pace with rapid developments in mobile health. More flexible methodologies are needed to evaluate mHealth technologies, particularly simple, self-help tools. One approach is to combine a variety of methods and data to build a comprehensive picture of how a technology is used and its impact on users.OBJECTIVE:This paper aims to demonstrate how analytical data and user feedback can be triangulated to provide a proportionate and practical approach to the evaluation of a mental well-being smartphone app (In Hand).METHODS:A three-part process was used to collect data: (1) app analytics; (2) an online user survey and (3) interviews with users.FINDINGS:Analytics showed that >50% of user sessions counted as 'meaningful engagement'. User survey findings (n=108) revealed that In Hand was perceived to be helpful on several dimensions of mental well-being. Interviews (n=8) provided insight into how these self-reported positive effects were understood by users.CONCLUSIONS:This evaluation demonstrates how different methods can be combined to complete a real world, naturalistic evaluation of a self-help digital tool and provide insights into how and why an app is used and its impact on users' well-being.CLINICAL IMPLICATIONS:This triangulation approach to evaluation provides insight into how well-being apps are used and their perceived impact on users' mental well-being. This approach is useful for mental healthcare professionals and commissioners who wish to recommend simple digital tools to their patients and evaluate their uptake, use and benefits.

Background: Guidelines in the United Kingdom recommend that medication titration for attention deficit hyperactivity disorder (ADHD) should be completed within 4-6 weeks and include regular reviews. However, most clinicians think that weekly clinic contact is infeasible, and audits have shown that this timeline is rarely achieved. Thus, a more effective monitoring and review system is needed; remote monitoring technology (RMT) may be one way to improve current practice. However, little is known about whether patients with ADHD, their families, and clinicians would be interested in using RMT.Objective: To explore patients', parents', and health care professionals' views and attitudes toward using digital technology for remote monitoring during titration for ADHD.Methods: This was a qualitative study, and data were collected through 11 focus groups with adults and young people with ADHD, parents of children with ADHD, and health care professionals (N=59).Results: All participant groups were positive about using RMT in the treatment of ADHD, but they were also aware of barriers to its use, especially around access to technology and integrating RMT into clinical care. They identified that RMT had the most potential for use in the ongoing management and support of ADHD, rather than during the distinct titration period. Participants identified features of RMT that could improve the quality of consultations and support greater self-management.Conclusions: RMT has the potential to augment support and care for ADHD, but it needs to go beyond the titration period and offer more to patients and families than monitoring through outcome measures. Developing and evaluating an mHealth app that incorporates the key features identified by end users is required.

This chapter explores the use of multi-techniques for teenage HCI health research. Through four case studies we present information about adolescents as users of healthcare services and technologies, adolescent personal development and the human factors approaches through which teenagers have been involved in healthcare research projects. In each case study comprising of the design or evaluation of a new digital technology for supporting health or well-being, the techniques used by researchers to involve teenagers are explored and analysed. The case studies examine various aspects of technology design and use including but not limited to usability, acceptability and learnability. The penultimate section of the chapter presents a 'Schema for Multi-technique HCI Health Research with Teenagers' and provides the supporting case for a multi-method approach. The conclusions of the chapter reinforce the benefits that are specific to the implementation of multi-technique research with teenage participants. Consideration of the eight factors outlined in the 'Schema' within study designs should serve to unlock the potential of teenagers, ensuring reliable elicitation of their views and needs.

Networked Urban Screens offer new possibilities for public health education and awareness. An information video about Attention Deficit Hyperactivity Disorder (ADHD) was combined with a custom browser-based video game and successfully deployed on an existing research platform, Screens in the Wild (SitW). The SitW platform consists of 46-in. touchscreen or interactive displays, a camera, a microphone and a speaker, deployed at four urban locations in England. Details of the platform and software implementation of the multimedia content are presented. The game was based on a psychometric continuous performance test. In the gamified version of the test, players receive a score for correctly selected target stimuli, points being awarded in proportion to reaction time and penalties for missed or incorrect selections. High scores are shared between locations. Questions were embedded to probe self-awareness about ‘attention span’ in relation to playing the game, awareness of ADHD and Adult ADHD and increase in knowledge from the video. Results are presented on the level of public engagement with the game and video, deduced from play statistics, answers to the questions and scores obtained across the screen locations. Awareness of Adult ADHD specifically was similar to ADHD in general and knowledge increased overall for 93

Introduction: Attention Deficit-Hyperactivity Disorder (ADHD) is characterised by developmentally inappropriate and impairing levels of inattention, hyperactivity and impulsivity. ADHD affects between 3-5% of school aged children and young people in the UK, with an increased awareness that these symptoms typically continue into adulthood. NICE Guidance recommends medication for the treatment of severe ADHD. During the medication initiation and titration phase, NICE recommends that clinicians should maintain weekly contact with their patients, and monitor treatment response and adverse effects at each dose change. However, because of constraints on time and resources, routine monitoring of response to treatment and changes in symptoms over time currently falls short of NICE guidelines in many NHS Trusts. This results in treatment optimisation taking longer, causing delays in the alleviation of symptoms. Mobile phone technology offers the potential for more effective real-time monitoring to ensure treatment optimisation is reached in a timely way, without increasing the strain on clinic resources. Aims and objectives: The aim of the study, currently in progress, is to explore the barriers and facilitators to using mobile phone technology to assist in the careful monitoring and optimisation of treatment for ADHD. Methods: A user workshop was held in February 2014 with a number of children and adults with ADHD, parents of children with ADHD and NHS staff working in the field, to gain some preliminary insights into the needs of each user group. The findings from this workshop are being used to International Digital Health and Care Congress, The King’s Fund, London, September 10-12 2014. International Journal of Integrated Care – Volume 14, 01 November – URN:NBN:NL:UI:10-1-116554– http://www.ijic.org/ shape the focus groups (April–June 2014), which aim to gain a greater understanding of the needs of each stakeholder group. Data from the focus groups will be thematically analysed (June–August 2014) with the aim of developing overarching analytic categories to describe the barriers and facilitators to using mobile phone technology. To enhance the rigour of the analysis, more than one researcher will be involved in these tasks and regular checks of the coding, category refining and identifying overarching themes across the research team, including the patients and parents who form the study Reference Group. Results: The results of this study will inform the design, development and testing of a smartphone App. Critically, the results will enable a clearer understanding of the functions all stakeholders wish to see incorporated into the App and their design preferences. For example, the user workshop suggested that while prescribing practitioners are likely to be interested in receiving regular reports of symptoms and side effects which are easily integrated into electronic patient records (EPR), additional features such as appointment and medication reminders will increase the likelihood that patients and parents will use the App. The focus groups will enable a more thorough and systematic exploration of these issues with a wider sample of potential users, full results of which will be presented. Conclusions: Working with an industry partner, the results of this study will feed into the development and testing of a new App designed to monitor symptoms regularly and remotely, with the ultimate aim of ensuring clinician and patient usability and acceptability.

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental condition that is characterised by three core behaviours: inattention, hyperactivity and impulsivity. It is typically thought that around 3-5% of school aged children have ADHD, with lifetime persistence for the majority. A psychometric Continuous Performance Test (CPT) had recently been incorporated into an interactive smartphone application (App), Snappy App, to allow the measurement of the three ADHD symptom domains. Snappy App presents a sequence of letters of the alphabet in a pseudo-random manner with responses via the device's touch screen. Following a pilot test in the general population where the CPT showed sensitivity to ADHD-related symptoms (self-reported impulsive behaviour related to CPT measures), a new project was begun to convert the App into a game Attention Grabber based on the functionality of the test, focussing on the attention and impulsivity domains. The Screens in the Wild (SITW) platform is in the process of being employed for public engagement in awareness about ADHD through interactive technology. SITW has deployed a network of four public touch-screens in urban places. Each of the four nodes has a large (46 inch) display, a camera, a microphone and a speaker. The Snappy App web-app was translated for presentation on to the SITW platform. The browser-based App was redesigned, with the input of a commercial graphics design company, based on an initial proof-of-concept whereby the original App was reprogrammed to present sequences of graphical objects (fruit) and to introduce further engagement features including animations. A shortened video about Adult ADHD and a brief questionnaire were incorporated to form a stand-alone edutainment package. The earlier design and user testing of Snappy App is briefly described and details are then provided of the process of gamification to produce Attention Grabber. An evaluation process is described whereby awareness of ADHD and its related symptoms are to be probed. In general, finding out whether and how people engage with interactive screen technology can help in the design of future public engagement and health promotion activities. Ethical considerations are discussed, since public access to this kind of game could potentially raise health anxiety related to self-interpretation of game performance. This risk is balanced with the need to provide health information.

BACKGROUND:Supporting self-care is being explored across health care systems internationally as an approach to improving care for long term conditions in the context of ageing populations and economic constraint. UK health policy advocates a range of approaches to supporting self-care, including the application of generic self-management type programmes across conditions. Within mental health, the scope of self-care remains poorly conceptualised and the existing evidence base for supporting self-care is correspondingly disparate. This paper aims to inform the development of support for self-care in mental health by considering how generic self-care policy guidance is implemented in the context of services supporting people with severe, long term mental health problems.METHODS:A mixed method study was undertaken comprising standardised psychosocial measures, questionnaires about health service use and qualitative interviews with 120 new referrals to three contrasting community based initiatives supporting self-care for severe, long term mental health problems, repeated nine months later. A framework approach was taken to qualitative analysis, an exploratory statistical analysis sought to identify possible associations between a range of independent variables and self-care outcomes, and a narrative synthesis brought these analyses together.RESULTS:Participants reported improvement in self-care outcomes (e.g. greater empowerment; less use of Accident and Emergency services). These changes were not associated with level of engagement with self-care support. Level of engagement was associated with positive collaboration with support staff. Qualitative data described the value of different models of supporting self-care and considered challenges. Synthesis of analyses suggested that timing support for self-care, giving service users control over when and how they accessed support, quality of service user-staff relationships and decision making around medication are important issues in supporting self-care in mental health.CONCLUSIONS:Service delivery components - e.g. peer support groups, personal planning - advocated in generic self-care policy have value when implemented in a mental health context. Support for self-care in mental health should focus on core, mental health specific qualities; issues of control, enabling staff-service user relationships and shared decision making. The broad empirical basis of our research indicates the wider relevance of our findings across mental health settings.

Patient and public involvement in health research is increasingly well established internationally, but the impacts of involvement on the research process are hard to evaluate. We describe a process of qualitative data analysis in a mental health research project with a high level of mental health service user and carer involvement, and reflect critically on how we produced our findings. Team members not from research backgrounds sometimes challenged academic conventions, leading to complex findings that would otherwise have been missing. An essential component of how we coproduced knowledge involved retaining methodological flexibility so that nonconventional research voices in the team could situate and critique what was conventionally known. Deliberate and transparent reflection on how "who we are" informed the knowledge we produced was integral to our inquiry. We conclude that reflecting on knowledge (co)production is a useful tool for evaluating the impact of patient and public involvement on health research.

Self-care is an important approach to the management of long-term health conditions and in preventing ill-health by living a healthy lifestyle. The concept has been used to a limited extent in relation to mental health, but it overlaps with the related concepts of recovery, self-management and self-help. These related concepts all entail individuals having more choice and control over treatment and a greater role in recovery and maintaining their health and well-being. This paper reviews qualitative empirical research that provides information on the nature of self-care in mental health from the perspective of people experiencing mental health problems. Twenty qualitative studies were identified from a systematic search of the literature. The methods used in these studies were critically appraised and key themes across studies identified self-care behaviours and processes supporting self-care. The paper also highlights challenges to this approach in mental health and provides a conceptual framework of the relationships between self-care support, self-care behaviours and strategies, and well-being for the individual. It also highlights limitations in the current evidence base and identifies areas for future research.

Mental health education aims to develop values based practice to support practitioners in clinical decision-making. Values-based practice requires high levels of cultural competence achieved through service user participation in professional preparation. The degree of service user participation remains dependent on the values of programme providers.In this paper, we consider whether strategies to involve service users in mental health professional education can support the principles of values based practice. To do this, we have drawn on the findings from qualitative studies of educators' practices and their views regarding service user involvement. Values-based practice requires self-awareness of values impacting on decisions and knowledge derived from service users' personal accounts. The studies suggest that while opportunities exist for service users to present their accounts, few examples of service user involvement facilitated deeper examination of values underpinning decision-making. Enabling service users to influence values-based practice development requires more authentic participatory approaches. Educators valued the contribution of service users' experiential knowledge to the learning process, but there was less evidence of educators' values base that would model commitment to the empowerment of service users.

Mental health presents challenges to the concept of self care – mental health services have been especially reluctant to share responsibility with service users, and some service users are reluctant to engage with services that they feel are disempowering. This makes mental health a particularly useful case within which to explore the barriers and facilitators of effective implementation of self care policy. This study integrates qualitative and quantitative methodologies in a two-stage service mapping design together with a cohort study in order to investigate the implementation of self care initiatives in mental health care from a range of stakeholder perspectives. The study will address the following aims and objectives: (1) To identify the main barriers/ facilitators-– organisational, team, user & carer expectations, structures and processes of self care - to effective delivery of self care in NHS mental health organisations (in terms of improved outcomes for users of self care initiatives and their carers); (2) To identify learning about the implementation of self care from the mental health service experience that can be applied to other health service areas. Service user researchers and NHS managers will be integral members of the research team at all stages of the research process, and have been fully involved in the development of this proposal. The initial service mapping phase and cohort study will take place in three NHS Trust areas (Hampshire Partnership NHS Trust, Leeds Mental Health NHS Trust, South West London & St George’s Mental Health NHS Trust) selected as offering geographical and demographic contrast, as well as range of socio-economic and rural/ urban mix. The cohort study, with measures at baseline (referral) and 9 month follow-up, will investigate three self care initiatives (one in each trust area) selected as offering three contrasting interpretations and applications of self care. Participants in the cohort study will be 40 consecutive new referrals to each self care initiative, aged 18-65 and meeting the entry criteria of each initiative. Carers and support workers on the self care initiatives - with sampling centred on the service user sample - will also be interviewed as part of the study. As well as semi-structured interviews collecting qualitative data about expectations and experiences of self care, standard measures of clinical status (CORE-OM), satisfaction, empowerment, quality of life, mental health confidence, locus of control and experience of therapeutic relationship will be made of user participants, experience of care giving of carers, and experience of therapeutic relationship of support workers/ professionals. Concrete indicators of service use (9 months prior to and 9 months post referral) and engagement with the self care initiative will also be measured. A final national service mapping design, using an online, web based approach, will be applied to all 77 mental health Trusts in England (including PCTs that provide mental health services directly). The potential to generalise the findings of this study to people in other health service sectors undertaking self care will be explored firstly by triangulating our findings with existing published change management and self care literature, and secondly by comparison with the findings of SDO funded self care teams working in other areas. The potential to generalise findings to different groups of people with a mental health problem will be considered firstly by accurately describing the sample in each study site, and secondly by between site data comparison and a synthesis of data across sites.

The purpose of this article is to illustrate both the processes of data analysis and the methodological development involved in adopting the sequential use of two data analysis methods applied to the same data set. Understanding of the phenomena of interest was sought through examining both the content and the form of nurses' accounts of practice experiences. Initially, a method of thematic content analysis was applied to understand what the nurses said about their experiences. The core theme of nurses' change agency derived from this analysis was examined further through a method of narrative analysis. In the second analysis, the focus was shifted to how the nurses accounted for their experiences. The innovative use of iterative, sequential methods of analysis revealed greater complexity and depth of understanding of the phenomena than would have been achieved with one method alone.

BACKGROUNDGeneral practices in England have been encouraged to introduce Advanced Access, but there is no robust evidence that this is associated with improved access in ways that matter to patients.AIMTo compare priorities and experiences of patients consulting in practices which do or do not operate Advanced Access.DESIGN OF STUDYPatient questionnaire survey.SETTINGForty-seven practices in 12 primary care trust areas of England.METHODQuestionnaire administered when patients consulted.RESULTSOf 12,825 eligible patients, 10,821 (84%) responded. Most (70%) were consulting about a problem they had had for at least 'a few weeks'. Patients obtained their current appointment sooner in Advanced Access practices, but were less likely to have been able to book in advance. They could usually see a doctor more quickly than those in control practices, but were no more satisfied overall with the appointment system. The top priority for patients was to be seen on a day of choice rather than to be seen quickly, but different patient groups had different priorities. Patients in Advanced Access practices were no more or less likely to obtain an appointment that matched their priorities than those in control practices. Patients in both types of practice experienced problems making contact by telephone.CONCLUSIONPatients are seen more quickly in Advanced Access practices, but speed of access is less important to patients than choice of appointment; this may be because most consultations are about long-standing problems. Appointment systems need to be flexible to accommodate the different needs of different patient groups.

Combining research approaches, commonly referred to as 'mixed methods', has the potential to lead to greater insights than would be gained by one approach alone. The discussion in this paper draws on the personal experience of conducting interrelated studies that adopted different methods, underpinned by different methodological positions. In the conduct of the research, several roles were occupied by members of the research team and, together with the mixed methods, gave rise to a number of issues in the conduct and implementation of research. The particular tensions identified are likely to be transferable to other contexts. Key to working with mixed methods is the need for researchers to acknowledge the alternative conceptions of knowledge and reflect on their position in relation to the range of possibilities. It is suggested that continued conflation of particular concepts, i.e. method and paradigm, acts as a barrier to meaningful interdisciplinary working and true integration of insights gained from combined approaches.

Background Case studies from the US suggest that Advanced Access appointment systems lead to shorter delays for appointments, reduced workload, and increased continuity of care.Aim To determine whether implementation of Advanced Access in general practice is associated with the above benefits in the UK.Design of study Controlled before-and-after and simulated-patient study.Setting Twenty-four practices that had implemented Advanced Access and 24 that had not.Method Anonymous telephone calls were made monthly to request an appointment. Numbers of appointments and patients consulting were calculated from practice records. Continuity was determined from anonymised patient records.Results The wait for an appointment with any doctor was slightly shorter at Advanced Access practices than control practices (mean 1.00 day and 137 days respectively, adjusted difference -0.75; 95% confidence interval [CI] = -1.51 to 0.004 days). Advanced Access practices met the NHS Plan 48-hour access target on 71% of occasions and control practices on 60% of occasions (adjusted odds ratio 1.61; 95% CI = 0.78 to 3.31; P = 0.200). The number of appointments offered, and patients seen, increased at both Advanced Access and control practices over the period studied, with no evidence of differences between them. There was no difference between Advanced Access and control practices in continuity of care (adjusted difference 0.003; 95% CI = -0.07 to 0.07).Conclusion Advanced Access practices provided slightly shorter waits for an appointment compared with control practices, but performance against NHS access targets was considerably poorer than officially reported for both types of practice. Advanced Access practices did not have reduced workload or increased continuity of care.