JMIR Publications

ABSTRACT

Background:

More than 135 million people worldwide live with acquired brain injury (ABI) and its many psychosocial sequelae. This growing global burden requires scalable rehabilitation services. Despite demonstrated potential to increase accessibility and scalability of psychosocial supports, digital health interventions are challenging to implement and sustain. The Nonadoption, Abandonment, Scale-Up, Spread and Sustainability (NASSS) framework can offer developers and researchers a comprehensive overview of considerations to implement, scale and sustain digital health interventions.

Objective:

This systematic review (1) identified published, peer-reviewed primary evidence of implementation outcomes, strategies or factors for web-based psychosocial interventions targeting either adults with ABI or their formal or informal caregivers; (2) evaluated and summarised this evidence; (3) synthesised qualitative and quantitative implementation data according to the NASSS framework; and (4) provided recommendations for future implementation. Results were compared with 3 hypotheses that (1) “complexity” (dynamic, unpredictable and poorly characterised factors) in most or all NASSS domains increases likelihood of implementation failure, (2) success is achievable but difficult with many “complicated” domains (containing multiple interacting factors), and (3) “simplicity” (straightforward, predictable and few factors) in most or all domains increases likelihood of success.

Methods:

From a comprehensive search of MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus, SpeechBITE and NeuroBITE, we reviewed primary implementation evidence from January 2008-June 2020. For web-based psychosocial interventions delivered via standard desktop, mobile, tablet, television and virtual reality devices to adults with ABI or their formal or informal caregivers, we extracted intervention characteristics, stakeholder involvement, implementation scope and outcomes, study design and quality, and implementation data. Implementation data were both narratively synthesised and descriptively quantified across all 7 domains (condition, technology, value proposition, adopters, organization, wider system, and their interaction over time) and all subdomains of the NASSS framework. Study quality and risk of bias were assessed using the 2018 Mixed-Methods Appraisal Tool.

Results:

We identified 60 peer-reviewed studies from 12 countries, including 5,723 adults with ABI, 1,920 carers and 50 healthcare staff. Findings aligned with all 3 hypotheses.

Conclusions:

Although studies were of poor methodological quality and insufficient number to statistically test relationships, results appeared consistent with recommendations to reduce complexity as much as possible to facilitate implementation. Although studies excluded individuals with a range of comorbidities and sociocultural challenges, such simplification of NASSS domain 1 may have been necessary to advance intervention value propositions (domain 3). However, to create equitable digital health solutions that can be successfully implemented in real-world settings, it is recommended that developers involve people with ABI, their close others, and healthcare staff in addressing complexities in domains 2-7 from the earliest intervention design stages. Clinical Trial: PROSPERO 2020 CRD42020186387; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020186387. The review was primarily funded by an Australian National Health and Medical Research Council Postgraduate (PhD) Scholarship Grant (GNT1191284).