A comprehensive, multi-level investigation of the implementation of a novel
digital substance misuse intervention, Breaking Free Online:
Conceptualising implementation processes within services using the MRC
framework and health psychology theory
Stephanie Dugdale
Research Associate, Breaking Free Group
© 2014 Breaking Free Online Limited. All rights reserved.
www.BreakingFreeGroup.com
Medical Research Council
(Craig et al., 2008)
Feasibility
Development
Evaluation
Implementation
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Breaking Free Online
•
Online treatment and recovery programme for substance use and co-morbid mental
health difficulties.
•
Centred on the Lifestyle Balance Model (Davies et al., 2015)
© 2016 Breaking Free Group. All rights reserved.
www.BreakingFreeGroup.com
•
Growing evidence base of both qualitative and quantitative research (Elison et al., 2013,
2014a, 2014b, 2015a, 2015b)
© 2015 Breaking Free Online Limited. All rights reserved.
www.BreakingFreeGroup.com
© 2015 Breaking Free Online Limited. All rights reserved.
www.BreakingFreeGroup.com
Aims and method
•
To investigate the initial implementation process and subsequent normalisation of BFO
within CRI.
•
Semi structured interviews were conducted with staff, peer mentors and service users.
•
Thematic analyses were conducted over three separate studies based on models derived
from health psychology and implementation science:
1) Implementation of Breaking Free Online using Roger's diffusion of innovation theory
2) The continued adoption of Breaking Free Online
3) Conceptualising the impact of peer mentoring on the ability of peer mentors to maintain their
recovery
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www.BreakingFreeGroup.com
Study 1:
Implementation of Breaking Free Online using Roger's diffusion of innovation theory
•
Introducing a novel digital innovation into an
existing healthcare structure can be seen as
‘disruptive’ (Edmondson et al., 2001).
•
This may affect adoption and uptake of the
innovation.
•
Diffusion of Innovations theory (Rogers, 1995,
2002, 2004) was used to conceptualise the
spread of BFO throughout CRI services.
© 2015 Breaking Free Online Limited. All rights reserved.
www.BreakingFreeGroup.com
Study 1:
Implementation of Breaking Free Online using Roger's diffusion of innovation theory
•
A lack of IT resources and competing demands on staff time were a barrier to
effective implementation of BFO.
•
Benefits of the programme included being able to interact with the clinical content
and the option to access the programme at home.
•
Participants realised the potential of BFO within CRI and believed that it fit with the
ethos of the company – continued adoption:
“Well, for things to change, people
need to change, mindsets need to
change, so it’s just getting over
those first hurdles”.
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“Within the next year I’d like to see us
with lots of volunteers and peer mentors
who have done the programme who
want to then facilitate every client
coming in”.
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Study 2:
The continued adoption of Breaking Free Online
•
Following the previous study, CRI now has a
nationwide licence to deliver BFO.
•
Diffusion can be seen to have occurred
throughout services on a macro organisational
level.
Coherence
Cognitive participation
Collective action
•
Need to investigate whether the programme
has become integrated as a normal part of
routine clinical practise: Normalisation Process
Theory (Murray et al., 2010).
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Reflexive monitoring
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Study 2:
The continued adoption of Breaking Free Online
•
Some services showed signs of taking ownership of the
programme. Staff also recognised the advantages of BFO
over ‘traditional’ group therapy, including the option to
use the programme as a means of self-help:
•
Several staff commented on their preference for group therapy, and thought that BFO
should be used in conjunction with these.
•
Peer mentors were often given the
responsibility of running BFO:
© 2015 Breaking Free Online Limited. All rights reserved.
“It’s about people
educating themselves,
and taking charge of
their own recovery.”
“A peer mentor's recovery journey will
be a lot more recent. So, I think it's vital
that peer mentors lead on this.”
www.BreakingFreeGroup.com
Study 3:
Conceptualising the impact of peer mentoring on the
ability of peer mentors to maintain their recovery
•
The Transtheoretical Model (Prochaska et al.,
1992) can conceptualise peer mentors’
recovery journeys through services and allow
identification of facilitators to recovery or
relapse.
© 2015 Breaking Free Online Limited. All rights reserved.
Precontemplation
Contemplation
Preparation
Relapse
Peer mentors were delivering BFO within CRI,
however some evidence suggested that this
role could actually lead to relapse (Colon et al.,
2010; Tober et al ., 2013)
Recovery
•
Action
Maintenance
Termination
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Study 3:
Conceptualising the impact of peer mentoring on the
ability of peer mentors to maintain their recovery
•
Through their new role, peer mentors were able to regain control over their behaviour and
develop into a ‘self’ distinct from their previous substance using identity.
•
This role facilitated maintenance of recovery by creating
opportunities to build recovery capital.
•
BFO was identified as one such form of recovery capital, which was used to remind peer
mentors of key psychosocial techniques that could be used to maintain their recovery.
“The life I had and the life
I've got now... they're
completely different”
“If I'm having a bad day, I can just go online and just do some work
on Breaking Free for a few hours, and I feel better afterwards. As
I said, it's one of the things that keeps me in recovery.”
© 2015 Breaking Free Online Limited. All rights reserved.
www.BreakingFreeGroup.com
Summary
•
The principal focus when designing an intervention should be establishing clinical
effectiveness – however, many valuable interventions are not instigated in ‘real-world’
settings.
•
Implementation analysis is therefore key, and health psychology theory may help
structure investigations around implementation.
•
Models such as diffusion of innovation and normalisation process theory may be of
particular use in understanding the spread of an intervention across services and the
normalisation of practice within services.
© 2015 Breaking Free Online Limited. All rights reserved.
www.BreakingFreeGroup.com
Next steps…
•
Once evidence surrounding implementation is gathered,
this can inform the development process.
Feasibility
•
Service users are currently on version 3 of the
programme and this is consistently updated with
evidence from these studies being used to improve
the user experience.
Development
Evaluation
Implementation
•
This evidence has also been used to guide research and future
studies, which will investigate how the programme is best utilised.
© 2015 Breaking Free Online Limited. All rights reserved.
www.BreakingFreeGroup.com
References
Colon, R. M., Deren, S., Guarino, H., Mino, M., & Kang, S.-Y. (2010). Challenges in recruiting and training drug treatment patients as peer
outreach workers: A perspective from the field. Substance Use & Misuse, 45(12), 1892-1908.
Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I., & Petticrew, M. (2008). Developing and evaluating complex interventions: the new
Medical Research Council guidance. BMJ, 337, a1655.
Davies, G., Elison, S., Ward, J., & Laudet, A. (2015). The role of lifestyle in perpetuating substance dependence: A new explanatory model, The
Lifestyle Balance Model. Substance Abuse, Treatment, Prevention and Policy, 10(2).
Edmondson, A. C., Bohmer, R. M., & Pisano, G. P. (2001). Disrupted routines: Team learning and new technology implementation in hospitals.
Administrative Science Quarterly, 46(4), 685-716.
Elison, S., Davies, G., & Ward, J. (2015a). An outcomes evaluation of computerised treatment for problem drinking using
Breaking Free Online Alcoholism Treatment Quarterly, 33(2), 185-196.
Elison, S., Davies, G., & Ward, J. (2015b). Sub-group analyses of a heterogeneous sample of service users accessing computerassisted therapy (CAT) for substance dependence using Breaking Free Online. Journal of Medical Internet Research, 2(2), e13.
Elison, S., Humphreys, L., Ward, J., & Davies, G. (2013). A pilot outcomes evaluation for computer assisted therapy for
substance misuse- An evaluation of Breaking Free Online. Journal of Substance Use, 19(4), 1-6.
Elison, S., Ward, J., Davies, G., Lidbetter, N., Dagley, M., & Hulme, D. (2014). An outcomes study of eTherapy for dual diagnosis
using Breaking Free Online. Advances in Dual Diagnosis, 7(2), 52-62.
Elison S, Ward J, Davies G, Moody M. (2014b). Implementation of computer-assisted therapy for substance misuse: A qualitative
study of Breaking Free Online using Roger's diffusion of innovation theory. Drugs and Alcohol Today, 14(4), 207-218.
Murray, E., Treweek, S., Pope, C., MacFarlane, A., Ballini, L., Dowrick, C., . . . O'Donnell, C. (2010). Normalisation process theory: a framework
for developing, evaluating and implementing complex interventions. BMC medicine, 8(1), 63.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American
Psychologist, 47(9), 1102-1114.
Rogers, E. (1995). Diffusion of innovations. Simon and Schuster.
Rogers, E. (2002). Diffusion of preventive innovations. Addictive Behaviors, 27(6), 989-993.
Rogers, E. (2004). A Prospective and Retrospective Look at the Diffusion Model. Journal of Health Communication, 9(sup1), 13-19.
Tober, G., Raistrick, D., Fiona Crosby, H., Sweetman, J., Unsworth, S., Suna, L., & Copello, A. (2013). Co-producing addiction aftercare. Drugs
and Alcohol Today, 13(4), 225-233.
© 2015 Breaking Free Online Limited. All rights reserved.
www.BreakingFreeGroup.com
Contact details
Stephanie Dugdale
Research Associate
Email: sdugdale@breakingfreegroup.com
Phone:
+44 (0) 161 834 4647
Website:
www.breakingfreegroup.com
© 2015 Breaking Free Online Limited. All rights reserved.
www.BreakingFreeGroup.com