Извадок UNDERSTANDING THE HEALTH CONTEXT FOR IMPLEMENTATION OF A NEW DIGITAL PSYCHOSOCIAL INTERVENTION FOR IMPROVEMENT OF THE MENTAL HEALTH IN NORTH MACEDONIA

РАЗБИРАЊЕ НА ЗДРАВСТВЕНИОТ КОНТЕКСТ ЗА ИМПЛЕМЕНТАЦИЈА НА НОВА ДИГИТАЛНА ПСИХОСОЦИЈАЛНА ИНТЕРВЕНЦИЈА ЗА ПОДОБРУВАЊЕ НА МЕНТАЛНОТО ЗДРАВЈЕ ВО СЕВЕРНА МАКЕДОНИЈА Ljubisha Novotni1, Silvana Markovskа-Simoska2, Biljana Blazhevska-Stoilkovska3, Milos Milutinovic1, Stojan Bajraktarov1, Antoni Novotni1, Nikolina Jovanovic4, Mome Spasovski5 1 University Clinic for Psychiatry; Ss. Cyril and Methodius University in Skopje Faculty of Medicine, Republic of North Macedonia 2 Macedonian Academy of Sciences and Arts, Skopje, North Macedonia 3 Ss. Cyril and Methodius University in Skopje, Faculty of Psychology, Republic of North Macedonia 4 Queen Mary University of London, United Kingdom 5 Ss. Cyril and Methodius University in Skopje, Faculty of Medicine, Institute of Social Medicine, Republic of North Macedonia


UNDERSTANDING THE HEALTH CONTEXT FOR IMPLEMENTA-TION OF A NEW DIGITAL PSYCHOSOCIAL INTERVENTION FOR IMPROVEMENT OF THE MENTAL HEALTH IN NORTH MACEDONIA
The aim of this study was to identify the contextual attributes in North Macedonia and their characteristics relevant to the implementation of a new digital intervention to improve mental health, called DIALOG+. This research is the first of its kind in North Macedonia due to the analysis of contextual attributes that may affect the effectiveness of the intervention and its acceptability in various settings of mental health care. Some of the data processed in this paper were provided and analyzed by the National Mental Health Strategy 2018-2025 and other relevant accompanying documents from the World Health Organization and action plans, as well as through interviews with stakeholders (patients, carers, clinicians and policy makers) for their opinion before introducing the DIALOG + intervention and the report on the assessment of the situation in the centers where the implementation of the intervention should have started. The collected data were then mapped to a framework developed by the Ottawa Implementation Group, which included 14 contextual attributes. The results are summarized in 2 subgroups, and are presented as facilitators and barriers to implementation, specific to the mental health system in North Macedonia. The characteristics of DIALOG + (widely applicable psychosocial intervention) are in accordance with modern assumptions for psychosocial rehabilitation of patients with psychosis. Hence, we can conclude that it is a useful tool for professionals in monitoring and achieving the true vision and mission of these institutions. It will help patients reintegrate into society, become more independent and use their full potential in the pursuit of healthy and functional living.

Introduction
People with severe mental illness within psychotic disorders, such as schizophrenia, schizoaffective disorder, and bipolar disorder, can have a wide range of symptoms. These disorders can include hearing voices, delusions, suspicion, withdrawal from family and friends, mood fluctuations 1 . In North Macedonia, but also in other countries, stigma, discrimination and violation of human rights of people with psychotic disorders are very common. These psychotic spectrum disorders usually last for decades and pose a major health, social and economic burden to patients, families, carers and society at large. Otherwise, life expectancy is 15-20 years shorter than that of the general population due to insufficiently diagnosed physical illnesses, poor access to health care and more frequent suicides 1 .
In our country, most of the patients with psychotic disorders are mainly treated in psychiatric hospitals where the treatment is largely focused on psychopharmacotherapy and antipsychotic drugs, and the psychosocial needs of the patients are often secondary. The approach in the Community Mental Health Centers, which are seven in total and were established with the last reform of the mental health system which began in 2000, in cooperation with the World Health Organization (WHO), is completely different. In these centers, the psychosocial treatment is included in the individual treatment plans of each patient, as a complementary part, together with the basic psychopharmacological treatment.
This reform in our country is on a positive path, approaching the orga-nized health systems in high-income countries that provide a combination of care, including medication and psychosocial interventions, which helps people affected by psychosis to lead a productive life and integrate into the society. However, low-and middle-income countries have neither sufficient funding nor sufficient staff to fully reform the mental health system and provide such specialized services to all patients with severe mental disorders as those mentioned in systems that are predominantly oriented to providing services through community mental health services 2 . One way to accelerate health care reform and improvement for this group of patients would be to implement effective, low-cost psychosocial interventions, which make existing routine clinical examinations more therapeutic.
When introducing such new specialized treatments in the community, contextual factors must be taken into account when assessing whether an intervention is effective or not and whether it leads to improvement in clinical practice 3 . Context is defined as a factor that is separate from the actual intervention itself (both from the patients receiving the intervention and the clinicians delivering it), but which may still contribute to the success of the intervention 4,5 . Adapting interventions to local contexts is an essential part of pragmatic research; unfortunately, implementation science cannot explicitly consider how local contextual factors affect the success of implementation 6 . This leads to the implementation of interventions being successful in one context but failing in another 4 . To increase the likelihood of successful implementation, researchers need to assess and explicitly address contextual barriers and/or promote facilitators and reduce barriers to implementation 7 .

Description of the new digital intervention DIALOG+ for improving mental health
The IMPULSE project (Implementation of an effective intervention for patients with psychotic disorders in low-and middle-income countries in Southeast Europe) aims to apply and evaluate the effectiveness of a new digital psychosocial intervention in patients with psychosis in five countries in Southeast Europe (North Macedonia, Serbia, Montenegro, Bosnia and Herzegovina and Kosovo). The intervention, called DIALOG+, is designed to increase the therapeutic efficacy of routine clinical appointments to improve the mental health of people with psychotic spectrum disorders and thus improve the quality of life for patients. The basic elements of DIALOG+ are structured interviews using a tablet computer, which assesses patients' satisfaction in 11 areas of their lives (mental and physical health, work, leisure activities, residence, partner/family, friends, safety, medication, practical help and satisfaction from the sessions). Then, with the help of the clinician, the patient selects from 1 to 3 areas that will be further examined/resolved during the control examination, through the approach of solution-based therapy in 4 steps (understanding the problem, looking forward, research and agreement). At the end of the session, an agreement is made on the activities that need to be completed between the sessions 8 . Therefore, this new digital psychosocial intervention is a solution-focused therapy and patient-centered communication, characterized by positive reinforcement. It can be performed by psychiatrists, psychologists and mental health nurses who need to be educated on how to perform the intervention. The interaction between the clinician and the patient during the DIALOG+ session is characterized by positive reinforcement, patient-oriented communication and great patient involvement. More details about the IMPULSE protocol were previously published 9 .
The aim of this study is to identify the contextual attributes in North Macedonia and their characteristics relevant to the implementation of a new digital psychosocial intervention to improve mental health, called DI-ALOG+. This research is the first of its kind in North Macedonia due to the analysis of contextual attributes that may affect the effectiveness of the intervention and its acceptability in various settings of mental health care.

Material and methods
Some of the data processed in this paper are provided and analyzed by the National Mental Health Strategy 2018-2025 10 and other relevant accompanying documents from the World Health Organization and action plans, as well as through interviews with stakeholders (patients, carers, clinicians and policy makers) for their opinion before the introduction of the DIALOG+ intervention and the report on the assessment of the situation in the centers where the implementation of the intervention should have started. The collected data were then mapped to the framework developed by the Ottawa Imple-mentation Group, which included 14 contextual attributes. 11 The results are summarized in 2 subgroups, as facilitators and barriers to implementation, specific to the mental health system in North Macedonia.
The paper of Squires 11 describes the contextual attributes and their characteristics according to which we analyzed and described the conditions of the context, i.e. the barriers and facilitators for the application of the new psychosocial intervention DIALOG+ in North Macedonia. In total, this paper describes 62 unique features of context. They are grouped into 14 broader attributes. The number of features in each of them varies and that number is not the same. To better understand these attributes and their characteristics, we will first give a brief description of each of them, and then present our results obtained from the interviews and the report from the visits to the places where the DIALOG+ intervention should be applied.

Access to resources -This does
not necessarily mean the proximity of such resources, but only their accessibility or availability in the broadest sense (e.g. physical space). 12. Evaluation -Evaluation involves the systematic collection of information about the activities, features, and results of programs, services, policies, or processes in order to evaluate program/ process, improve effectiveness, and/or inform future and development decisions. It includes 4 features: general evaluation, organizational evaluation, audit and patient evaluation.

Regulatory and Legislative
Standards -The 2 characteristics of law and standard of practice or care are usually beyond the control of healthcare organizations.

Social influences -This code with
1 characteristic of social influences is a general level of social knowledge and attitude towards a certain clinical behavior or procedure, such as the case with the stigma of mental illness.

Analysis of data from available documents (state of mental health in North Macedonia)
In North Macedonia, the Law on Mental Health was adopted on October 13, 2005 12 . Article 7 in the second chapter clearly states that persons with mental disorders have the right to be protected from any form of harassment, humiliation and discrimination. Article 9 specifies that every person with a mental disorder has the right to undergo an optimal rehabilitation/ program that will improve his or her mental health status.
According to the National Mental Health Strategy 2018-2025 10 , prepared by the Ministry of Health, the current mental health system is characterized by insufficient psychosocial outpatient services that are applied only in community mental health centers, few alternatives to hospital treatment, lack of programs for promotion, prevention and rehabilitation, lack of family involvement and social support, and lack of support and opportunities for people with mental illness to live and join the community. An organized mental health system indicates slow development and significant mental health challenges.
The health care of people with mental health problems is performed at all three levels -in the primary, secondary and tertiary health care. Mental health care in primary health care is the responsibility of selected physicians and they serve as "gatekeepers"; they detect the problem and refer patients to higher levels of health care. Given that the best effect is achieved when drug therapy is combined with other forms of treatment, such as individual and group psychotherapy, occupational therapy, rehabilitation and psychosocial support of the individual and/or the whole family as well as other forms, it is necessary to develop and foster a combined approach to mental health. In North Macedonia, in addition to psychopharmacological therapy, the following psychotherapeutic interventions for treatment of schizophrenia are recommended: a) psychoanalytic psychotherapy; b) cognitive-behavioral therapy (CBT); c) psychoeducation; d) rehabilitation (social skills training).
The National Health Insurance Fund includes several psychosocial/psychotherapeutic interventions in the list of mental health care services that are delivered free of charge to all state institutions. In theory, and as stated in the national guidelines, they are offered as regular services, and their implementation should be performed as an outpatient service. However, there is a large gap in practice, for two reasons: either there are few certified professionals or some types of psychotherapy are not covered by the fund and are therefore not available to all patients.
The process of opening the Community Mental Health Centers on the whole territory is relatively slow and there is still a lack of programs and activities for social rehabilitation and reintegration of people with mental illness. DIALOG+ intervention is one of the measures to improve mental health services. Based on the assessment of the factual situation with mental health, the review of which is given above, we will try in this paper to present the facts according to which psychosocial support would be improved, especially in patients with psychosis and bipolar disorder.

Analysis of interview data
Secondary data analysis was performed using data collected prior to the application of DIALOG+. The findings from this data were coded on the basis of context attributes developed by Squires 11 .
To assess the understanding of the context, we conducted several interviews to find out the opinion of the participants in each of the groups. The new digital intervention was first presented to all groups, followed by focus group interviews. A transcript was made of the recorded data which was then processed. The groups were as follows: • group of patients -15 (8 male and 7 female), • group of clinicians -12 (4 male and 8 female) (7 psychiatrists, 1 psychologist, 2 nurses, 1 social worker and 1 special educator), • group of carers -6 (6 females), • group of policy makers -6 (6 females).
During the interviews, the intervention was explained to the respondents, and then they were asked about the benefits, facilitators or barriers to its application. The results for each of the groups are given below.
The obtained data are explained in detail, but also graphically shown in Table 1 for easier monitoring of the results.

Group of patients
Patients said that the use of technology (in the form of computer tablets) during the examination would be more optimal, more pleasant and they would have the information in front of them while talking. According to them, if the family would be involved to some extent, it would be good for the implementation of the intervention itself, but also for the activities between the sessions. Family members would be a kind of facilitator of change in the patients and therefore it would be best to do psychoeducation of all family members of patients with mental illness so that they would know how to recognize the deterioration of the condition and accordingly seek help in time. For that purpose, the patients themselves think that they should have guides and directions that they would receive from the family doctors for this intervention anЗd in that way they would be informed even before they come for the examination and they would be properly prepared for that.

They also think more frequent sessions, greater availability of doctors and greater media representation as facilitators would help in better implementation of the intervention.
Training and education of medical staff would also be of great benefit to the implementation of the intervention.
They regard the culture of living and the stigma surrounding mental ill-ness, as well as religious affiliation as barriers in the implementation of the intervention. Then, they think that the time for conversation should be longer than now, if digital intervention is applied. It means that the time period given now in "My appointment" for one examination would not be enough in case of application of DIALOG+; therefore the time period is considered as a barrier in the implementation of the intervention.
Regarding the activities and tasks that are given to them between two sessions, they believe that our country does not offer enough activities.
For example, there are no support groups, no jobs for this type of patients, etc.

Group of clinicians
Patients also think that there is a shortage of medical staff, so that would be another major barrier to implementing the intervention. Some of them also see the professional training of the staff as a barrier, because they think that only psychiatrists would have the appropriate skills and are reserved for nurses or other staff. Also, some patients are afraid that the doctor-patient relationship will be lost if too much time and attention is paid to technology.
Clinicians assessed technology, computer program objectification, questionnaire structuring of the session, measurability of assessment, and continuity of assessment as one of the many advantages of applying this intervention. For them, the preparation and education of professionals is crucial, as well as the involvement of nurses who can apply the interven-tion while patients wait in the waiting room. According to them, it is an easy tool to learn and to work with especially younger colleagues. The involvement of family members is also important. The choice of the patient is important (demography), etc. It's the patient's choice. A barrier would be the lack of staff because the intervention is applied one by one. Due to that, there would be a lack of time and space. Clinicians also see a financial problem -as the examination would cost more, and those from other cities would have to pay more for the trip. According to them, there is a need for reorganization of the psychiatric service and greater involvement of social services, psychoeducation of the family and its involvement, as well as a multidisciplinary approach.

Group of carers
They think that they need psychoeducation. Then, financial help is needed, and maybe a patronage service that will visit them at home. The culture of behavior is also important to them. The lack of small groups, as well as patients, share the opinion that the state needs to support small groups to support these patients, either for socializing or for work. Involvement of the intervention in the first stages of the disease, and not in the more advanced stage, would lead to a faster improvement of the condition.

Group of policy makers
According to them, the benefit of implementation would be that it guarantees the same approach to all clinicians. Digital documentation would be a greater value and advantage. It is important to inform both clinicians and patients of the existence of such an intervention. They suggest having guides for "My appointment" entry and approaching world standards of psychiatry. To make changes and during the studies to introduce the students to the new way of examination and the doctor's approach to the patient. According to them, the useful thing is that the software is free and available. In that way, there would be a need to open daycare centers and homes for support or residential homes (which is one of the future tasks of the mental health strategy). Barriers to implementation would be the limited activities that the doctor can help with. Reliability of information received from patients. (Nurses have said the same thing and suggested another scale for a more objective simultaneous assessment by them and by the clinicians).
• Resistance to innovations in practice by clinicians.
• The time required for the examination.

On-site condition assessment analysis
In analyzing the data obtained from the on-site assessment carried out during the visit by a responsible person in charge of Queen Mary University of London, we obtained the following attributes and their corresponding characteristics:

Discussion
The idea of this paper was to analyze the attributes of the context in North Macedonia regarding the implementation of a new digital instrument/ mental health intervention that can be used in everyday practice and to change the doctor-patient communication. The difference in the application of this intervention is that the quality of life of the patient is developed and seen.
Patients have the right to be actively involved in the design of their treat- ment plan, along with its implementation. They also have the right to participate in the recovery and resocialization planning process, while respecting their needs and abilities. The health system of North Macedonia is obliged to follow these principles. DIALOG+ directly addresses these requirements by offering client-centered treatment and active patient involvement through a "four-step approach". Because it is a time-saving intervention, DIALOG+ has a great potential to help overcome problems (e.g., lack of time, work overload, etc.) resulting from the low ratio of mental health professionals/residents.
All countries have community mental health centers, but they generally do not operate independently of hospitals. In addition, the hospital-based approach is still dominant, especially given the existence of many hospitals specializing in the treatment of psychiatric disorders. The characteristics of DIALOG+ (widely applicable psychosocial intervention) are in line with modern assumptions about the psychosocial rehabilitation of patients with psychosis. Hence, it can be a useful tool for professionals in monitoring and realizing the true vision and mission of these institutions. It will help patients reintegrate into society, become more independent and use their full potential in the pursuit of healthy and functional living.
First, it empowers patients in the community in terms of their satisfaction with life and social functioning. Second, it promotes and encourages the involvement of carers and other community members in the process of psychosocial reintegration of these patients.
In a study conducted in the United Kingdom, Spain, the Netherlands, Sweden, and Switzerland 14 DIALOG+ proved to be an effective psychosocial intervention. If DIALOG+ proves to be an effective intervention (i.e., if it proves beneficial for patients in low-and middle-income communities), it is likely to be recognized and approved by national health insurance funds in low-and middle-income countries.
Contextual implementation facilitators that emerged from our analysis are the following: • the use of technology and data storage on tablets • involvement of other clinicians in the intervention (for e.g., nurses).
Contextual implementation barriers that will need to be bridged are the following: • culture of living and stigma The basic skills of someone who would work with DIALOG+ should be patience and trust, confidentiality. There is a structure to the interview, and if we stick to the structure, then we will really take the time to ask questions to people who have problems and who have come to discuss their problems. In particular, it does not matter if the ranking will be 2 or 4 at the moment and then it will be 3. It does not matter at all, but it is important to conduct a conversation and find a solution that will be considered. Therefore, this therapy is aimed at finding a solution. The clinician will suggest an activity; the patient will have to suggest an activity. We, of course, will not be able to solve all the problems, but if we stick to this structure, we will be able to have more domains that people can talk about.
The most important thing is that clinicians put all life segments in the direction of diagnosing, treating and monitoring the whole process. DIA-LOG+ will monitor all these 11 segments of life that are related and if a smaller part is solved, the remaining cubes will be like a domino effect. Therefore, this domino effect in most cases would have a positive outcome for both patients and clinicians who will learn a more comprehensive approach. Therapists will be upgraded in their domain, and patients will gain that trust and respect in order to get the most out of this. This intervention ensures that the 11 domains of life and treatment are constantly addressed and that patients' attitudes and priorities are always taken into account 15 . This is likely to increase awareness of patients' attitudes and their changes over time, resulting in care that reduces unmet needs and increases patients' quality of life and satisfaction with treatment 16 . Some authors expect and suggest that patients' quality of life may improve even when symptoms do not show significant changes 17,18 .
If applied at the secondary level, an information campaign will be required. The directors, i.e. the management of the health institution, will have to lobby for the workers and their employees to use that tool more often. Training of other medical professionals, logistical support (tablet service) will also be required. Patients would prefer this intervention take place in the outpatient services of the community, than in the hospital conditions and because of the stigma not to be seen, but also because of the faster and closer availability of Mental Health Centre. tal disorders" (SCI-HCO-07-2017) funding call.