Organizational readiness for implementing an internet-based cognitive behavioral therapy intervention for depression across community mental health services in albania and kosovo: Directed qualitative content analysis

Asmae Doukani, Arlinda Cerga Pashoja*, Naim Fanaj, Gentiana Qirjako, Andia Meksi, Sevim Mustafa, Christiaan Vis, Juliane Hug

*Corresponding author for this work

Research output: Contribution to JournalArticleAcademicpeer-review


Background: The use of digital mental health programs such as internet-based cognitive behavioral therapy (iCBT) holds promise in increasing the quality and access of mental health services. However very little research has been conducted in understanding the feasibility of implementing iCBT in Eastern Europe. Objective: The aim of this study was to qualitatively assess organizational readiness for implementing iCBT for depression within community mental health centers (CMHCs) across Albania and Kosovo. Methods: We used qualitative semistructured focus group discussions that were guided by Bryan Weiner's model of organizational readiness for implementing change. The questions broadly explored shared determination to implement change (change commitment) and shared belief in their collective capability to do so (change efficacy). Data were collected between November and December 2017. A range of health care professionals working in and in association with CMHCs were recruited from 3 CMHCs in Albania and 4 CMHCs in Kosovo, which were participating in a large multinational trial on the implementation of iCBT across 9 countries (Horizon 2020 ImpleMentAll project). Data were analyzed using a directed approach to qualitative content analysis, which used a combination of both inductive and deductive approaches. Results: Six focus group discussions involving 69 mental health care professionals were conducted. Participants from Kosovo (36/69, 52%) and Albania (33/69, 48%) were mostly females (48/69, 70%) and nurses (26/69, 38%), with an average age of 41.3 years. A directed qualitative content analysis revealed several barriers and facilitators potentially affecting the implementation of digital CBT interventions for depression in community mental health settings. While commitment for change was high, change efficacy was limited owing to a range of situational factors. Barriers impacting "change efficacy"included lack of clinical fit for iCBT, high stigma affecting help-seeking behaviors, lack of human resources, poor technological infrastructure, and high caseload. Facilitators included having a high interest and capability in receiving training for iCBT. For "change commitment,"participants largely expressed welcoming innovation and that iCBT could increase access to treatments for geographically isolated people and reduce the stigma associated with mental health care. Conclusions: In summary, participants perceived iCBT positively in relation to promoting innovation in mental health care, increasing access to services, and reducing stigma. However, a range of barriers was also highlighted in relation to accessing the target treatment population, a culture of mental health stigma, underdeveloped information and communications technology infrastructure, and limited appropriately trained health care workforce, which reduce organizational readiness for implementing iCBT for depression. Such barriers may be addressed through (1) a public-facing campaign that addresses mental health stigma, (2) service-level adjustments that permit staff with the time, resources, and clinical supervision to deliver iCBT, and (3) establishment of a suitable clinical training curriculum for health care professionals.

Original languageEnglish
Article numbere29280
Pages (from-to)1-14
Number of pages14
JournalJMIR Formative Research
Issue number11
Early online date31 Mar 2021
Publication statusPublished - Nov 2021

Bibliographical note

Funding Information:
Audio recordings of the interviews were then transcribed verbatim in Albanian and subsequently translated into English. The notes made in Kosovan were also translated to English. This study was approved by the Republic of Albania Ministry of Health Social Protection Ethics Committee on November 17, 2017, and the Republic of Kosovo Qeveria-Vlada Government on February 11, 2017. This project was funded by the European Union’s Horizon 2020 research and innovation program under grant agreement 733025 and received funding from the National Health and Medical Research Council European Union program by the Australian Government (1142363). Funding bodies had no influence on the design of this study. The trial registration number is NCT03652883.

Funding Information:
Qualitative focus group discussions (FGDs) were conducted with mental health care stakeholders involved on the ImpleMentAll study, a multinational trial funded by the European Union’s Horizon 2020 program. The project aimed to (1) develop and apply tailored implementation strategies for implementing evidence-based iCBT services for common mental disorders in routine mental health care through and (2) conduct a stepped wedge-cluster randomized trial to investigate the effectiveness of tailored implementation, when compared to implementation as usual (more information about the trial can be found in the trial protocol by Bührmann and colleagues [17]). Participants were recruited from 7 CMHCs across Albania (located in Tirana, Shkoder, and Korce) and Kosovo (Prizren, Gjilan, Prishtine, and Mitrovice). Focus groups were conducted prior to the commencement of the ImpleMentAll trial. A purposive sampling method was used for data collection to facilitate access to key informants (mental health care professionals working in and in association with CMHC) and maximum variations within an organization [18,19]) considering diversity across age, gender, job role, and the level of experience of working with people with depression [19]. FGDs were conducted in a meeting room within respective CMHCs.

Funding Information:
The authors thank and acknowledge the ImpleMentAll project for supporting this study. The authors also thank the CMHC leads who facilitated recruitment for the study.

Publisher Copyright:
© 2021 Asmae Doukani, Arlinda Cerga Pashoja, Naim Fanaj, Gentiana Qirjako, Andia Meksi, Sevim Mustafa, Christiaan Vis, Juliane Hug.


  • Albania and kosovo
  • Community mental health center
  • Content analysis
  • Digital mental health
  • E-mental health
  • Implementation science
  • Internet-based cognitive behavioral therapy
  • Organizational readiness for implementing change
  • Qualitative interviews


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