Digital Health Implementation Strategies Coproduced With Adults With Acquired Brain Injury, Their Close Others, and Clinicians: Mixed Methods Study With Collaborative Autoethnography and Network Analysis

Abstract

Background: Acquired brain injuries (ABIs), such as stroke and traumatic brain injury, commonly cause cognitive-communication disorders, in which underlying cognitive difficulties also impair communication. As communication is an exchange with others, close others such as family and friends also experience the impact of cognitive-communication impairment. It is therefore an internationally recommended best practice for speech-language pathologists to provide communication support to both people with ABI and the people who communicate with them. Current research also identifies a need for neurorehabilitation professionals to support digital communication, such as social media use, after ABI. However, with >135 million people worldwide affected by ABI, alternate and supplementary service delivery models are needed to meet these communication needs. The "Social Brain Toolkit" is a novel suite of 3 interventions to deliver communication rehabilitation via the internet. However, digital health implementation is complex, and minimal guidance exists for ABI.

Objective: This study aimed to support the implementation of the Social Brain Toolkit by coproducing implementation knowledge with people with ABI, people who communicate with people with ABI, clinicians, and leaders in digital health implementation.

Methods: A maximum variation sample (N=35) of individuals with living experience of ABI, close others, clinicians, and digital health implementation leaders participated in an explanatory sequential mixed methods design. Stakeholders quantitatively prioritized 4 of the 7 theoretical domains of the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework as being the most important for Social Brain Toolkit implementation. Qualitative interview and focus group data collection focused on these 4 domains. Data were deductively analyzed against the NASSS framework with stakeholder coauthors to determine implementation considerations and strategies. A collaborative autoethnography of the research was conducted. Interrelationships between considerations and strategies were identified through a post hoc network analysis.

Results: Across the 4 prioritized domains of "condition," "technology," "value proposition," and "adopters," 48 digital health implementation considerations and 52 tailored developer and clinician implementation strategies were generated. Benefits and challenges of coproduction were identified. The post hoc network analysis revealed 172 unique relationships between the identified implementation considerations and strategies, with user and persona testing and responsive design identified as the potentially most impactful strategies.

Conclusions: People with ABI, close others, clinicians, and digital health leaders coproduced new knowledge of digital health implementation considerations for adults with ABI and the people who communicate with them, as well as tailored implementation strategies. Complexity-informed network analyses offered a data-driven method to identify the 2 most potentially impactful strategies. Although the study was limited by a focus on 4 NASSS domains and the underrepresentation of certain demographics, the wealth of actionable implementation knowledge produced supports future coproduction of implementation research with mutually beneficial outcomes for stakeholders and researchers.

International registered report identifier (irrid): RR2-10.2196/35080.

Keywords: brain injury; caregivers; complexity; delivery of health care; digital health; implementation science; internet interventions; mobile phone; psychosocial; psychosocial interventions; stroke; traumatic brain injury.

Figure 1

Comprehensive comparison of each tool in the Social Brain Toolkit with previously released communication partner training programs, "TBI Express" and "TBIconneCT". Program images and visual supports are included to improve accessibility. TBI Express and TBIconneCT cover images Copyright 2010, 2019, the Australasian Society for the Study of Brain Impairment [30,31], used with express permission of the copyright holder. Additionally, convers-ABI-lity, interact-ABI-lity, and social-ABI-lity logos Copyright 2020, author Melissa Miao for the Social Brain Toolkit.

Figure 2

Examples of how additional implicit and explicit relationships (between right and center boxes) were identified during post hoc network analysis beyond the original targeted relationships reported in Table 2 (between left and center boxes). As indicated by arrow direction, additional relationships can occur between any strategy or consideration, in either direction.

Figure 3

Network visualization of 172 unique, directional relationships between the 100 implementation considerations and strategies identified in the 4 prioritized domains. Each consideration and strategy is indicated as a “node,” represented by a circle, with each directional relationship shown as an “edge,” indicated by a curved arrow. The size of each node reflects its total outgoing relationships, with larger nodes indicating a larger number of outgoing relationships, and vice versa.