An emerging framework for digital mental health design with Indigenous young people: a scoping review of the involvement of Indigenous young people in the design and evaluation of digital mental health interventions.

BACKGROUND: Indigenous young people worldwide possess unique protective factors that support wellbeing. However, they experience mental illness at higher rates than their non-indigenous counterparts. Digital mental health (dMH) resources can increase access to structured, timely, and culturally tailored mental health interventions by reducing structural and attitudinal barriers to accessing treatment. The involvement of Indigenous young people in dMH resource development is recommended, however, no guidelines exist on how this can best be facilitated. METHODS: A scoping review examining processes to involve Indigenous young people in developing or evaluating dMH interventions was conducted. Studies reported between 1990 and 2023 involving Indigenous young people aged 12-24 years, originating from Canada, the USA, New Zealand, and Australia, in the development or evaluation of dMH interventions were eligible for inclusion. Following a three-step search process, four electronic databases were searched. Data were extracted, synthesized, and described under three categories: dMH intervention attributes, study design, and alignment with research best practice. Best practice recommendations for Indigenous research and participatory design principles derived from the literature were identified and synthesised. Included studies were assessed against these recommendations. Consultation with two Senior Indigenous Research Officers ensured Indigenous worldviews informed analysis. RESULTS: Twenty-four studies describing eleven dMH interventions met inclusion criteria. Studies included formative, design, pilot, and efficacy studies. Overall, most included studies demonstrated a high degree of Indigenous governance, capacity building, and community benefit. All studies adapted their research processes to ensure that local community protocols were followed and most aligned these within an Indigenous research paradigm. Formal agreements regarding existing and created intellectual property and implementation evaluations were rare. Outcomes were the primary focus of reporting, with limited detailed descriptions of governance and decision-making processes or strategies for managing predictable tensions between co-design stakeholders. CONCLUSIONS: This study identified recommendations for undertaking participatory design with Indigenous young people and evaluated the current literature against these criteria. Common gaps were evident in the reporting of study processes. Consistent, in-depth reporting is needed to allow assessment of approaches for this hard-to-reach population. An emergent framework, informed by our findings, for guiding the involvement of Indigenous young people in the design and evaluation of dMH tools is presented. TRIAL REGISTRATION: Available via osf.io/2nkc6.

Feasibility and Acceptability of the Aboriginal and Islander Mental Health Initiative for Youth App: Nonrandomized Pilot With First Nations Young People.

BACKGROUND: Despite young First Nations Australians being typically healthy, happy, and connected to family and culture, high rates of emotional distress, suicide, and self-harm are also observed. Differing worldviews of service providers and First Nations young people regarding illness and treatment practices, language differences, culturally inappropriate service models, geographical remoteness, and stigma can all inhibit access to appropriate mental health support. Mental health treatments delivered digitally (digital mental health; dMH) offer flexible access to evidence-based, nonstigmatizing, low-cost treatment and early intervention on a broad scale. There is a rapidly growing use and acceptance of these technologies among young First Nations people. OBJECTIVE: The objective was to assess the feasibility, acceptability, and use of the newly developed Aboriginal and Islander Mental Health Initiative for Youth (AIMhi-Y) app and determine the feasibility of study procedures in preparation for future assessments of effectiveness. METHODS: This was a nonrandomized pre-post study using mixed methods. First Nations young people aged 12-25 years who provided consent (with parental consent where appropriate) and possessed the ability to navigate a simple app with basic English literacy were included. Researchers conducted one face-to-face 20-minute session with participants to introduce and orient them to the AIMhi-Y app. The app integrates culturally adapted low-intensity cognitive behavioral therapy (CBT), psychoeducation, and mindfulness-based activities. Participants received supportive text messages weekly throughout the 4-week intervention period and completed assessments of psychological distress, depression, anxiety, substance misuse, help-seeking, service use, and parent-rated strengths and difficulties at baseline and 4 weeks. Qualitative interviews and rating scales were completed at 4 weeks to gain feedback on subjective experience, look and style, content, overall rating, check-ins, and involvement in the study. App use data were collected. RESULTS: Thirty young people (17 males and 13 females) aged between 12 and 18 (mean 14.0, SD 1.55) years were assessed at baseline and 4 weeks. Repeated measures 2-tailed t tests showed improvements in well-being measures that were statistically and clinically significant for psychological distress (Kessler Psychological Distress Scale, 10-item) and depressive symptoms (Patient Health Questionnaire, 2-item). Participants spent on average 37 minutes in the app. The app was rated positively, with mean ratings of 4 out of 5 points (on scales of 1-5). Participants reported that they found the app easy to use, culturally relevant, and useful. The feasibility of the study was demonstrated with a 62% recruitment rate, a 90% retention rate, and high study acceptability ratings. CONCLUSIONS: This study supports earlier research suggesting that dMH apps that are appropriately designed with and for the target populations are a feasible and acceptable means of lowering symptoms for mental health disorders among First Nations youth.

The stay strong app as a self-management tool for first nations people with chronic kidney disease: a qualitative study.

BACKGROUND: The high burden of chronic kidney disease in First Nations peoples requires urgent attention. Empowering people to self-manage their own condition is key, along with promotion of traditional knowledge and empowerment of First Nations communities. This study explores the potential of a culturally responsive tool, already found to have high acceptability and feasibility among First Nations people, to support self-management for First Nations people with kidney failure. The Stay Strong app is a holistic wellbeing intervention. This study explores the suitability of the Stay Strong app to support self-management as shown by the readiness of participants to engage in goal setting. Data were collected during a clinical trial which followed adaption of research tools and procedures through collaboration between content and language experts, and community members with lived experience of kidney failure. METHODS: First Nations (i.e., Aboriginal and Torres Strait Islander) participants receiving haemodialysis in the Northern Territory (n = 156) entered a three-arm, waitlist, single-blind randomised controlled trial which provided collaborative goal setting using the Stay Strong app at baseline or at 3 months. Qualitative data gathered during delivery of the intervention were examined using both content and thematic analysis. RESULTS: Almost all participants (147, 94%) received a Stay Strong session: of these, 135 (92%) attended at least two sessions, and 83 (56%) set more than one wellbeing goal. Using a deductive approach to manifest content, 13 categories of goals were identified. The three most common were to: 'connect with family or other people', 'go bush/be outdoors' and 'go home/be on country'. Analysis of latent content identified three themes throughout the goals: 'social and emotional wellbeing', 'physical health' and 'cultural connection'. CONCLUSION: This study provides evidence of the suitability of the Stay Strong app for use as a chronic condition self-management tool. Participants set goals that addressed physical as well as social and emotional wellbeing needs, prioritising family, country, and cultural identity. The intervention aligns directly with self-management approaches that are holistic and prioritise individual empowerment. Implementation of self-management strategies into routine care remains a key challenge and further research is needed to establish drivers of success.

Determining Priorities in the Aboriginal and Islander Mental Health Initiative for Youth App Second Phase Participatory Design Project: Qualitative Study and Narrative Literature Review.

BACKGROUND: Digital mental health tools can promote access to culturally safe early intervention mental health services for Aboriginal and Torres Strait Islander young people. Participatory design methodology facilitates user engagement in the co-design of digital resources. However, several challenges have been identified that limit the methodological rigor of this approach. OBJECTIVE: This paper aims to present an in-depth account of the second phase of participatory design in the development of the Aboriginal and Islander Mental Health Initiative for Youth (AIMhi-Y) app. METHODS: A first idea storyboard, generated from a formative phase of the AIMhi-Y project, was refined through a series of youth co-design workshops and meetings. A narrative review of the literature, 6 service provider interviews, and engagement with an expert reference group also informed the design process. Generative design activities, storyboarding, discussions, and voting strategies were used. RESULTS: The participatory design process identified the app features preferred by young people and service providers and assessed their alignment with current recommendations from the scientific literature. Findings from the co-design process are presented across 9 app characteristic domains. Integration of findings into app design proved complex. Although most preferred features identified by young people were included to some degree, other inclusions were restricted by budget, time, and the need to integrate best practice recommendations. A process of prioritization was required. CONCLUSIONS: Participatory design is often cited in the development of digital mental health resources; however, methods are diverse and often lack detailed descriptions. This study reports the outcomes and strategies used to determine priorities in the second phase of the development of the AIMhi-Y app. We provide an example and the key learnings to inform others seeking to use participatory design with a similar cohort.

Involvement of Indigenous young people in the design and evaluation of digital mental health interventions: a scoping review protocol.

BACKGROUND: Indigenous young people worldwide are at greater risk of developing mental health concerns due to ongoing inequity and disadvantage. Digital mental health (dMH) interventions are identified as a potential approach to improving access to mental health treatment for Indigenous youth. Although involvement in the development and evaluation of dMH resources is widely recommended, there is limited evidence to guide engagement of Indigenous young people in these processes. This scoping review aims to examine the methods used to involve Indigenous young people in the development or evaluation of dMH interventions. METHODS: Articles published in English, involving Indigenous young people (aged 10-24 years) in the development or evaluation of dMH interventions, originating from Australia, New Zealand, Canada and the USA will be eligible for inclusion. PubMed, Scopus and EBSCOhost databases (Academic Search Premiere, Computer and Applied Science complete, CINAHL, MEDLINE, APA PsychArticles, Psychology and Behavioural Sciences collection, APA PsychInfo) will be searched to identify eligible articles (from January 1990 onwards). Infomit and Google Scholar (limited to 200 results) will be searched for grey literature. Two reviewers will independently screen citations, abstracts and full-text articles. Study methods, methodologies, dMH intervention details, participant information and engagement, and dissemination methods will be extracted, analysed (utilising content analysis), and qualitatively assessed for alignment with best practice ethical guidelines for undertaking Indigenous health research. A narrative summary of findings will be presented. Reporting will follow the Consolidated Criteria for Strengthening Reporting of Health Research involving Indigenous peoples (CONSIDER) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines. DISCUSSION: To date, there are no reviews which analyse engagement of Indigenous young people in the development and evaluation of dMH interventions. This review will appraise alignment of current practice with best practice guidelines to inform future research. It will highlight appropriate methods for the engagement of young people in study processes, providing guidance for health practitioners, policy makers, and researchers working in the field of Indigenous youth and dMH. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework ( osf.io/2nkc6 ).

Effectiveness of Wellbeing Intervention for Chronic Kidney Disease (WICKD): results of a randomised controlled trial.

BACKGROUND: End stage kidney disease (ESKD) is associated with many losses, subsequently impacting mental wellbeing. Few studies have investigated the efficacy of psychosocial interventions for people with ESKD and none exist for Indigenous people, a population in which the ESKD burden is especially high. METHODS: This three-arm, waitlist, single-blind randomised controlled trial examined efficacy of the Stay Strong App in improving psychological distress (Kessler distress scale; K10), depressive symptoms (adapted Patient Health Questionnaire; PHQ-9), quality of life (EuroQoL; EQ. 5D) and dialysis adherence among Indigenous Australians undergoing haemodialysis in central and northern Australia (Alice Springs and Darwin), with follow up over two 3-month periods. Effects of immediate AIMhi Stay Strong App treatment were compared with those from a contact control app (The Hep B Story) and treatment as usual (TAU). Control conditions received the Stay Strong intervention after 3 months. RESULTS: Primary analyses of the full sample (N = 156) showed statistically significant decreases in K10 and PHQ-9 scores at 3 months for the Hep B Story but not for the Stay Strong app or TAU. Restricting the sample to those with moderate to severe symptoms of distress or depression (K10 > =25 or PHQ-9 > =10) showed significant decreases in K10 and PHQ-9 scores for both Stay Strong and Hep B Story. No significant differences were observed for the EQ-5D or dialysis attendance. CONCLUSIONS: Findings suggest that talking to people about their wellbeing and providing information relevant to kidney health using culturally adapted, locally relevant apps improve the wellbeing of people on dialysis. Further research is required to replicate these findings and identify active intervention components. TRIAL REGISTRATION: ACTRN12617000249358 ; 17/02/2017.

Assessing the Impact of a Pharmacist-Managed Discharge Medication Reconciliation Pilot at a Community Hospital System.

INTRODUCTION: With unintended medication discrepancy rates ranging from 30% to 70%, a formal discharge medication reconciliation process must be developed. One strategy shown to reduce medication errors is a pharmacist medication review at discharge. The purpose of this study is to determine the impact of a pharmacist-driven discharge medication reconciliation program. METHODS: The intervention group included pharmacist-reviewed patients with a high risk of unplanned readmission score and had a discharge order signed during a 2-month period. The control group included eligible patients who were not reviewed by a pharmacist. The after-visit summaries for both groups were then reviewed for additional medication discrepancies. RESULTS: This study included 140 patients, with 70 patients in each group. A total of 176 discrepancies were identified in the intervention group and 235 were found in the control group. The median number of discrepancies per patient was not statistically different between groups (2 vs. 2, p-value = .196). There were 22 and 24 30-day hospital readmissions in the intervention and control groups, respectively (p-value = .857). CONCLUSIONS: More medication discrepancies were identified in the control group compared to pharmacist-reviewed patients. More robust studies including a pharmacist dedicated to discharge medication reconciliation should be conducted to identify the potential benefit.

Evaluation of a three-phase implementation program in enhancing e-mental health adoption within Indigenous primary healthcare organisations.

BACKGROUND: A three-phase implementation program was carried out to support Indigenous primary healthcare organisations in Australia to integrate e-mental health approaches into the day-to-day practice. The present study aimed to evaluate the process and the effectiveness of the program. METHODS: A concurrent triangulation design was employed to collect and compare quantitative and qualitative data from organisations that participated in the implementation program (case studies) to those that participated in training only (non-case studies). Quantitative methods, i.e., t-tests and descriptive statistics, were used to measure outcomes relating to the frequency of e-mental health usage and levels of organisational readiness. Qualitative data were analysed separately, using theoretical thematic analysis, to gain an in depth understanding of the implementation process. The findings were integrated and interpreted within the implementation science literature. RESULTS: The case studies evidenced greater use of e-mental health approaches than the non-case studies. They also demonstrated increased organisational readiness over the course of the implementation program. The program helped organisations to work and improve on essential aspects within the organisation so that they better supported e-mental health adoption. The key areas addressed were Information Technology resources and infrastructure, leadership and support, policy and protocols around e-mental health utilisation and its integration into practice. CONCLUSIONS: By addressing and improving essential aspects relating to e-mental health implementation, the program helped organisations to increase organisational readiness and enhance uptake of e-mental health approaches.

Drafting the Aboriginal and Islander Mental Health Initiative for Youth (AIMhi-Y) App: Results of a formative mixed methods study.

BACKGROUND: Culturally responsive, strengths-based early-intervention mental health treatment programs are considered most appropriate to influence the high rates of psychological distress and suicide experienced by Aboriginal and Torres Strait Islander youth. Few early intervention services effectively bridge the socio-cultural and geographic challenges of providing sufficient and culturally relevant services in rural and remote Australia. Mental Health apps provide an opportunity to bridge current gaps in service access if co-designed with Aboriginal and Torres Strait Islander youth to meet their needs. AIMS: This paper reports the results of the formative stage of the AIMhi-Y App development process which engaged Aboriginal and Torres Strait Islander youth in the co-design of the new culturally informed AIMhi-Y App. METHODS: Using a participatory design research approach, a series of co-design workshops were held across three sites with five groups of young people. Workshops explored concepts, understanding, language, acceptability of electronic mental health tools (e-mental health) and identified important characteristics of the presented applications and websites, chosen for relevance to this group. An additional peer supported online survey explored use of technology, help seeking and e-mental health design elements which contribute to acceptability. RESULTS: Forty-five, Aboriginal and Torres Strait Islander youth, aged 10-18 years, from three sites in the Northern Territory (NT) were involved in the workshops (n = 29). Although experiencing psychological distress, participants faced barriers to help seeking. Apps were perceived as a potential solution to overcome barriers by increasing mental health literacy, providing anonymity if desired, and linking young people with further help. Preferred app characteristics included a strength-based approach, mental health information, relatable content and a fun, appealing, easy to use interface which encouraged app progression. Findings informed the new AIMhi-Y App draft, which is a strengths-based early intervention wellbeing app for Aboriginal and Torres Strait Islander youth. CONCLUSIONS: Research findings highlight the need, feasibility and potential of these types of tools, from the perspective of Aboriginal and Torres Strait Islander youth.

Evaluation of Electronic Mental Health Implementation in Northern Territory Services Using the Integrated "Promoting Action on Research Implementation in Health Services" Framework: Qualitative Study.

BACKGROUND: Electronic mental health is a promising strategy to bridge the treatment gap in mental health care. Training workshops have been delivered to service providers working with Aboriginal and Torres Strait Islander people at a primary health care level to raise awareness and knowledge of electronic mental health approaches. OBJECTIVE: This study aimed to understand service providers' perspectives and experiences of electronic mental health adoption. More specifically, it aimed to use the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to further identify and understand how different factors facilitate or impede electronic mental health uptake within primary health care settings providing services to Aboriginal and Torres Strait Islander people. METHODS: Qualitative interviews were conducted with 57 service providers working with Aboriginal and Torres Strait Islander people, who had undergone electronic mental health training workshops. RESULTS: Several factors related to innovation (electronic mental health approach), recipients (service providers as an individual and as a team), and context (local, organizational, and external contexts) were found to influence electronic mental health uptake. Particularly, organizational readiness, in terms of information technology resources and infrastructure, policies, workforce and culture, and processes to mandate electronic mental health use, were found to be significant impediments to electronic mental health utilization. These findings led to the development of a three-phase implementation strategy that aims to enhance electronic mental health adoption by addressing organizational readiness before and post electronic mental health training. CONCLUSIONS: The i-PARIHS provides a useful determinant framework that deepens our understanding of how different factors impede or facilitate electronic mental health adoption in this setting. This insight was used to develop a practical and comprehensive implementation strategy to enhance the utilization of electronic mental health approaches within primary health care settings, involving three phases: pretraining consultations, training workshops, and post-training follow-up support.

Adapting wellbeing research tools for Aboriginal and Torres Strait Islander people with chronic kidney disease.

BACKGROUND: Chronic kidney disease is an increasingly common health problem for Aboriginal and Torres Strait Islander people. It is associated with multiple concurrent psychosocial stressors frequently resulting in negative impacts on emotional and social wellbeing. There is need for well-designed intervention studies to provide evidence of effective treatment for comorbid depression or other mental illness in this setting. Attention to early phase piloting and development work is recommended when testing complex interventions. This paper documents feasibility testing and adaptation of an existing culturally responsive brief wellbeing intervention, the Stay Strong App, and three commonly used wellbeing outcome measures, in preparation for a clinical trial testing effectiveness of the intervention. METHODS: The Stay Strong App, which has not been used in the setting of Chronic Kidney Disease before, is reviewed and adapted for people with comorbid wellbeing concerns through expert consensus between research team and an Expert Panel. The outcome measures (Kessler 10, Patient Health Questionnaire 9, and EuroQoL) are valid, reliable, and commonly used tools to assess various aspects of wellbeing, which have also not been used in this context before. Feasibility and acceptability are examined and developed through 3 stages: Pilot testing in a purposive sample of five haemodialysis patients and carers; translation of outcome measures through collaboration between the Aboriginal Interpreter Service, Aboriginal and Torres Strait Islander research officers and the research team; and conversion of translated outcome measures to electronic format. RESULTS: Research team and expert panel consensus led to adaptation of the Stay Strong App for renal patients through selective revision of words and images. Pilot testing identified challenges in delivery of the wellbeing measures leading to word changes and additional prompts, integration of audio translations in 11 local Indigenous languages within an interactive Outcome Measures App, and related research protocol changes. CONCLUSION: Modelling the complex intervention prior to full-scale testing provided important information about the design of both the outcome measures and the intervention. These changes are likely to better support success in conduct of the clinical trial and future implementation of the intervention in clinical settings.

Internal Medicine Residency Program Directors' Screening Practices and Perceptions About Recruitment Challenges.

PURPOSE: To examine internal medicine residency program directors' (PDs') screening practices and perceptions about current recruitment challenges. METHOD: In March-May 2017, the Association of Program Directors in Internal Medicine Survey Committee sent a survey to 373 Alliance for Academic Internal Medicine member residency programs. PDs rated the importance of 23 inclusion and 11 exclusion criteria for interview invitation decision making, provided United States Medical Licensing Examination (USMLE) cutoff scores for U.S. medical school and international medical graduates, and indicated changes in recruitment practices due to application inflation, including their ability to conduct holistic review and interest in potential solutions to address application inflation. Exploratory factor analysis was used to identify and confirm factors that were most important to interview invitation decision making. RESULTS: The response rate for eligible programs was 64% (233/363). USMLE Step 2 Clinical Knowledge scores were the criteria most frequently reported to be "very important" (131/233, 57%). Among respondents who reported any criteria as "very important," 155/222 (70%) identified a single most important (SMI) criterion. Non-USMLE criteria were frequently reported as an SMI criterion (68%). Concerning exclusion criteria, 157/231 (68%) reported they "absolutely would not invite" applicants with hints of unprofessional behavior. Of the 214/232 (92%) who reported an increase in applications, 138 (64%) adjusted recruitment practices. Respondents were most interested in limiting the number of applications per applicant (163/231, 71%), allowing applicants to indicate high interest in a subset of programs (151/229, 66%), and creating a national database of qualities of matched applicants for each program (121/228, 53%). CONCLUSIONS: PDs rely heavily on USMLE scores when making interview invitation decisions. However, collectively, non-USMLE criteria were more frequently reported as an SMI criterion. Most programs adjusted recruitment practices to respond to application volume. Several potential solutions to address application inflation garnered wide support.

Internal Medicine Residency Program Responses to the Increase of Residency Applications: Differences by Program Type and Characteristics.

BACKGROUND: Over the past decade, the number of residency applications has increased substantially, causing many residency programs to change their recruitment practices. OBJECTIVE: We determined how internal medicine (IM) residency programs have responded to increased applications by program type (community-based, community-based/university-affiliated, and university-based) and characteristics (percentage of international medical graduates, program size, and program director [PD] tenure). METHODS: The Association of Program Directors in Internal Medicine conducted a national survey of 363 IM PDs in 2017. Five questions assessed IM program responses to the increased number of residency applications in 3 areas: changes in recruitment strategies, impact on ability to perform holistic review, and interest in 5 potential solutions. We performed a subgroup analysis to measure differences by program type and characteristics. RESULTS: The response rate was 64% (233 of 363). There were no differences by program type or characteristics for experiencing an increase in the number of applicants, altering recruitment practices, or conducting holistic reviews. There were moderate differences in alterations of recruitment practices by program characteristics and moderate differences in interest in proposed solutions by program type. Community-based programs had the greatest interest in a program-specific statement (59%, P = .032) and the lowest percentage in a national database of matched applicants (44%, P = .034). CONCLUSIONS: IM residency programs are experiencing an increasing number of applications and are accommodating by adjusting recruitment practices in a variety of ways. A majority of IM PDs supported 4 of the 5 solutions, although the level of interest differed by program type.

The New Internal Medicine Subinternship Curriculum Guide: a Report from the Alliance for Academic Internal Medicine.

The internal medicine (IM) subinternship has been a long-established clinical experience in the final phase of medical school deemed by key stakeholders as a crucial rotation to prepare senior medical students for internship. Medical education has changed greatly since the first national curriculum for this course was developed in 2002 by the Clerkship Directors in Internal Medicine (CDIM). Most notably, competency-based medical education (CBME) has become a fixture in graduate medical education and has gradually expanded into medical school curricula. Still, residency program directors and empirical studies have identified gaps and inconsistencies in knowledge and skills among new interns. Recognizing these gaps, the Association of Program Directors in Internal Medicine (APDIM) surveyed its members in 2010 and identified four core skills essential for intern readiness. The Association of American Medical Colleges (AAMC) also published 13 core entrustable professional activities (EPAs) for entering residency to be expected of all medical school graduates. Results from the APDIM survey along with the widespread adoption of CBME informed this redesign of the IM subinternship curriculum. The authors provide an overview of this new guide developed by the Alliance for Academic Internal Medicine (AAIM) Medical Student-to-Resident Interface Committee (MSRIC).

Wellbeing intervention for chronic kidney disease (WICKD): a randomised controlled trial study protocol.

BACKGROUND: Incidence of end stage kidney disease (ESKD) for Indigenous Australians is especially high in remote and very remote areas of Australia (18 and 20 times the rate of comparable non-Indigenous people). Relocating away from family and country for treatment, adjusting to life with a chronic condition and time lost to dialysis cause grief and sadness which have immense impact on quality of life and challenges treatment adherence. We describe the first randomised controlled trial to address both chronic disease and mental health in Indigenous people with ESKD, which is the first to test the effectiveness of a culturally adapted e-mental health intervention in this population. It builds on an existing program of mental health research with demonstrated efficacy - the Aboriginal and Islander Mental Health Initiative (AIMhi) - to test the newly developed electronic motivational care planning (MCP) therapy - the AIMhi Stay Strong App. METHODS: This is a 3-arm, waitlist, single-blind randomised controlled trial testing the efficacy of the Stay Strong App in improving psychological distress, depressive symptoms, quality of life and treatment adherence among Indigenous clients undergoing haemodialysis for ESKD in Alice Springs and Darwin with follow up over two periods of 3 months (total of 6 months observation). The study compares the efficacy of MCP using the AIMhi Stay Strong App with two control groups (control app intervention and treatment as usual) on participant-reported psychological distress (the primary outcome) using the Kessler Distress Scale (K10); depressive symptoms using the adapted Patient Health Questionnaire (PHQ-9); quality of life using the EuroQoL instrument (EQ5D) and adherence to dialysis treatment planning through file audit. Participants are randomised to receive MCP either at baseline (early treatment) or after 3 months (delayed treatment). The study also examines the cost effectiveness of this therapy in this setting through examination of health care service utilisation across groups during the first 3 months. DISCUSSION: This project will contribute much needed evidence on the efficacy of an electronic wellbeing intervention for Indigenous people with ESKD - a group in which distress is likely to be unacceptably high, yet relatively untreated. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry; ACTRN12617000249358 ; Date registered: 17/02/2017.

E-Mental Health Innovations for Aboriginal and Torres Strait Islander Australians: A Qualitative Study of Implementation Needs in Health Services.

BACKGROUND: Electronic mental health (e-mental health) interventions offer effective, easily accessible, and cost effective treatment and support for mental illness and well-being concerns. However, e-mental health approaches have not been well utilized by health services to date and little is known about their implementation in practice, particularly in diverse contexts and communities. OBJECTIVE: This study aims to understand stakeholder perspectives on the requirements for implementing e-mental health approaches in regional and remote health services for Indigenous Australians. METHODS: Qualitative interviews were conducted with 32 managers, directors, chief executive officers (CEOs), and senior practitioners of mental health, well-being, alcohol and other drug and chronic disease services. RESULTS: The implementation of e-mental health approaches in this context is likely to be influenced by characteristics related to the adopter (practitioner skill and knowledge, client characteristics, communication barriers), the innovation (engaging and supportive approach, culturally appropriate design, evidence base, data capture, professional development opportunities), and organizational systems (innovation-systems fit, implementation planning, investment). CONCLUSIONS: There is potential for e-mental health approaches to address mental illness and poor social and emotional well-being amongst Indigenous people and to advance their quality of care. Health service stakeholders reported that e-mental health interventions are likely to be most effective when used to support or extend existing health services, including elements of client-driven and practitioner-supported use. Potential solutions to obstacles for integration of e-mental health approaches into practice were proposed including practitioner training, appropriate tool design using a consultative approach, internal organizational directives and support structures, adaptations to existing systems and policies, implementation planning and organizational and government investment.