Feasibility of online psychosocial interventions to promote mental health recovery and well-being

Abstract

Background:

Amid the increasing trend and huge impact of mental illness, psychosocial support (PSS) has been asserted to support individuals’ recovery. Unfortunately, about 80% of affected people cannot access care as needed. Meanwhile, digital technology has a considerable role in closing service gaps.

Aims:

This convergent parallel mixed methods study examines existing mental health service utilization, users’ needs for PSS, and feasibility of online PSS development.

Methods:

A cross-sectional interview survey was conducted using a semi-structured questionnaire at a super tertiary psychiatric hospital in Thailand from March to May 2023, with three groups of service users, having self-perceived conditions/diagnosis of schizophrenia (n = 100), mood disorders (n = 84), and others including alcohol and substance use, anxiety and personality disorders (n = 52). Four focus group discussions with three user groups (n = 16) and one multidisciplinary provider group (n = 7) were parallelly executed. Quantitative and qualitative data were convergently analyzed using descriptive and inferential statistics, and thematic and content analysis.

Results:

Critical shortcomings of PSS were indicated by 75.8% of user participants. Six common types of self-determined PSS were psychoeducational program, support group, skills training, counseling, supported employment, and complimentary therapy. While psychoeducational program was feasible, support group, and counseling were possibly featured within the ‘all-at-once’ online intervention development.

Conclusions:

PSS development based on users’ needs can promote clinical and personal recovery outcomes, and close the service gaps. Users with mood disorders have the potential for online interventions. Peer-provider formalization, co-production approach, community engagement, digital literacy, infrastructures, and equal access factors are crucial for sustainable development.

Keywords

online psychosocial intervention feasibility mental health recovery-oriented service well-being convergent parallel mixed-methods

Introduction

Mental health challenges

Mental health is an integral part of overall well-being, essential for facilitating social connection, effective functioning, coping, and flourishing in daily life. Despite its intrinsic value, mental health confronts a global crisis of an increasing number of people with mental illness, from 450 million in 2009 to 540 million in 2019 (World Health Organization [WHO], 2009, 2022a). Regarding 13% of the global prevalence, 82% of target people reside in low- and middle-income countries (LMICs). Alarmingly, 76% and 85% of people in LMICs do not receive treatments, and those who do receive them encounter poor service quality. Consequently, an inadequacy of services exacerbates functional impairments, cognitive decline, compromised physical health, and social and emotional coping challenges (Gamieldien et al., 2020; Rehm & Shield, 2019; WHO, 2021a). For instance, among adults aged 15 to 49 years with mental illness, the greatest portion of the burden was reported during years lived with disability, affecting key life milestones such as attaining education, starting a family, and maintaining work productivity (Hyman et al., 2016). The individual’s impact extends to broader societal and global impacts, including socioeconomic output loss and premature deaths (Talamonti et al., 2023; Weye et al., 2020). Therefore, well-defined psychosocial support (PSS) interventions are needed (Department for International Development, 2020).

Thailand’s mental health service situation

Thailand, an upper middle-income country located in Southeast Asia, mirrors the global situation of mental health service gaps. Whereas the number of Thai people with mental illness had increased from 1.3 million in 2015 to 2.3 million in 2021 (Thai PBS World, 2022), local evidence reported only 3.7% could access public health facilities (Kittirattanapaiboon et al., 2017). Recently, a survey showed the ratio of mental health professionals per population at 7.87:100,000 (WHO, 2022b), while COVID-19 caused service access distraction and accumulating unmet needs (DMH Data Center, 2022). Aligning with international concerns (WHO, 2021b), the growing prevalence of depression, anxiety, and alcohol and substance use disorders were mentioned (Jiang et al., 2021) along with funding shortages and inequitable access to services (Sinsub, 2021).

Online psychosocial interventions

PSS are crucial to support individuals’ recovery and well-being. They can be tailored to meet individuals’ needs and be able to provide by non-clinical providers for example, civil volunteers, caregivers, and peer support workers (Zaken, 2019). During the COVID-19, digital technology made major contributions to improving healthcare accessibility (Costa et al., 2021). About 70% of countries across six regions integrated telemedicine or teletherapy to narrow mental health service gaps (WHO, 2020), which online mental health services via mobile-based and video-communication demonstrated acceptability and feasibility (Hulsbosch et al., 2017; Ndlovu et al., 2023). The recovery-oriented service (ROS) approach was recommended for practice, which emphasized personal transformation and growth, focusing on attitude, values, skills, and life goals despite the challenges of mental illness or psychosis (Bejerholm & Roe, 2018; Slade et al., 2019). Furthermore, handling the social determinant of health, community-based approach, multisectoral collaboration, and technological integration are four pillars to address the unmet needs of mental health and psychosocial support (MHPSS) services, promote care quality, support personal recovery, and prove cost-effectiveness (Feijt et al., 2023; Fink-Samnick, 2021; Isaacs et al., 2019; Mueller-Stierlin et al., 2020). This study thus aimed to examine the current service utilization, self-determined PSS needs, and online PSS development feasibility based on the local context.

Methods

Procedure and ethics

This research obtained consent from all participants and adhered to the methods approved by two Institutional Review Boards: Mahidol University’s Committee for Research Ethics (COA no. 2022/179.1912) and Srithanya Hospital’s Ethics Committee (COA no. STY.COA009/2566). In compliance with the hospital’s EC, a third-party caregiver, companion, or coordinating nurse was required to sign as a ‘witness’ in each consent form. Throughout the procedure, the researcher ensured respect for individuals’ autonomy and dignity, without manipulation, and maintained balanced power relationships.

The convergent parallel mixed methods (Creswell, 2018) were designed to collect data during March to May 2023 at the outpatient department of a super-tertiary psychiatric hospital located in the central part of Thailand. A cross-sectional semi-structured interview survey was conducted in the hospital’s waiting room on weekdays from 8:30 a.m. to 3:30 p.m., with three service user groups. Four focus group discussions (FGDs) involving three user groups and one multidisciplinary provider group were organized, parallelly.

The studied population for the cross-sectional study (n = 24,056) comprised three groups from the total (N = 123,825) of 2021 hospital’s psychiatric outpatient users with schizophrenia (n = 10,213), mood disorders (n = 8,515), and others, including alcohol and substance use, anxiety, and personality disorders (n = 5,328) (Srithanya Hospital Department of Mental Health, 2022). A ‘cross-sectional survey in medical research with qualitative variables approach’ was used for sample size calculation, which required a margin error precision level of 5%, a confidence level of 95% (Z = 1.96), a population proportion of 0.19 (19.4%), and a standard normal variate of 5% type 1 error (p < .05) (Charan & Biswas, 2013). The calculated 236 samples were subsequently proportionated using quota sampling for the actual number of participants in each group (Moser & Stuart, 1953). Finally, 100, 84, and 52 users’ groups with schizophrenia, mood disorders, and other conditions were included. Besides, those participants who indicated having more PSS needs were numerically recorded for further FGD recruitment at the end of the interviews.

Regarding FGDs, a criterion purposive sampling was applied to the seven participants of each group (Cortini et al., 2019). Finally, 16 participants joined the FGDs, including 5, 6, and 5 from groups of schizophrenia, mood disorders, and other disorders, separately. Parallelly, the seven key informants from multidisciplinary providers were recruited based on their roles in treatment and rehabilitation criteria. They were a psychiatrist, psychiatric nurse, social worker, psychologist, occupational therapist, pharmacist, and nutritionist. All FGDs’ sessions were scheduled at the participants’ convenience and lasted approximately 90 minutes each.

Instruments

A semi-structured questionnaire of 14 questions was developed for interview surveys (Pattaraarcharchai, 2005) with the 11 dichotomous categorical closed-ended questions covering demographics, access behavior, self-perceived conditions/diagnosis, technological familiarity, and another two dichotomous categorical open-ended questions on existing service utilization and PSS needs identification. The last question was optional for the only record of the interested FGD participants.

Two sets of semi-structured open-ended guiding questions were constructed for users’ and providers’ FGDs. The topics centered around mental health services, self-determined PSS needs, and feasibility of online psychosocial intervention development. The operational definitions of recovery and PSS were provided in an information sheet attached to the consent form. Regarding qualitative data collection, the researcher was an integral part of the instrument, with audio recording requested throughout the process.

Convergent data analysis

The data were integrated from all sources for convergent analysis and synthesis. Quantitative data was processed using the IBM SPSS statistical software (version 27), after being transferred, managed, checked, cleaned, categorized via MS Excel, and imported into SPSS. Descriptive and inferential covering cross-tabulation, chi-square, and ANOVA were used for describing and comparison analysis with statistical significance considered at p < .5. The analysis encompassed demographics description, digital information technological devices and online platforms’ familiarity, MHPSS utilization, and self-determined PSS needs. An incorporated qualitative data from cross-sectional interviews were convergently and thematically analyzed.

The thematic and content analysis was applied for qualitative data from FGDs, following a six-step process: data familiarizing, initial coding, identifying sub-themes, themes reviewing, defining and naming of themes, and reporting (Braun & Clarke, 2006; Mayring, 2000). Quotes were employed to illustrate findings and interpretation, ensuring the informants’ voices and perspectives.

Results

Cross-sectional interview survey

Characteristics of the participants

From a total of 236 user-participants, females were observably predominated in a group of mood disorders (67.9%), which significantly differed (p = .018) from the groups of schizophrenia (49%), and other mental health conditions (48.1%). Age range and level of education were highly significantly different (p < .001). The schizophrenia group attributed older (40–49 years), the other disorders group was in between (30–39 years), and the mood disorders group was younger (18–29 years. Despite a university education being the commonly highest attainment (60.2%), the group of mood disorders stood out at 79.8%, when compared to the groups of schizophrenia (46%) and others (55.8%). Concerning employment, only 22.6% within the mood disorders group were unemployed, which significantly differed (p = .004) from those within groups of other disorders (30.8%) and schizophrenia (51%). Regarding residential types, even though most of the participants resided in a private house, the schizophrenia group reported the highest staying in residential centers significantly (p = .001). For service access patterns, the users with mood disorders performed higher self-access to service (61.9%), compared with the users with schizophrenia (39%), and the users with other conditions, which only 3.8% independently accessed service facilities (see Table 1).

Table 1.

Demographic profiles of three groups of participants.

Demographics	% Schizophrenia (n = 100)	% Mood disorders (n = 84)	% Other conditions (n = 52)	% Total (N = 236)	p-value
Biological sex					.018*
Male	51.0	32.1	51.9	44.5
Female	49.0	67.9	48.1	55.5
Age range (years old)					<.001
18–29	23.0	48.8	25.0	32.6
30–39	31.0	32.1	53.8	36.4
40–49	46.0	19.0	21.2	30.9
Marital status					.180
Single	73.0	71.4	57.7	69.1
Married/couple	19.0	25.0	34.6	24.6
Divorced/separate	8.0	3.6	7.7	6.4
Education level					<.001
Primary school	4.0	1.2	1.9	2.5
Secondary school	50.0	19.0	42.3	37.3
University	46.0	79.8	55.8	60.2
Employment status					.004*
Unemployed	51.0	22.6	30.8	36.4
Fulltime/paid salary	34.0	50.0	44.2	41.9
Part-time/freelance	9.0	13.1	17.3	12.3
Student	6.0	14.3	7.7	9.3
Type of residence					.001*
Private house	64.0	66.7	59.6	64.0
Rental room	24.0	19.0	34.6	24.6
Private unit/condo	3.0	14.3	3.8	7.2
Residential facility	9.0	0.0	1.9	4.2
Household member					.079
Living alone	16.0	22.6	21.2	19.5
Parents	44.0	39.3	30.8	39.4
Spouse/couple	19.0	22.6	40.4	25.0
Sibling/relative	12.0	7.1	1.9	8.1
Friend/others	9.0	8.3	5.8	8.1
Access behavior					.007*
Self-access	39.0	61.9	3.8	7.2
Accompanied	61.0	38.1	96.2	92.8

Statistically significant (p < .05); <.001 highly significant (less than .001%).

MHPSS utilization

MHPSS utilization among the three studied groups (Table 2) demonstrated ever-used and never-used services, and the PSS needs indicating. Overall, PSS utilization mainly appeared in the community rather than in the hospital. While medical services like visiting psychiatrists and receiving medication were met by over 90% overall and within groups, over 70% of other categorical PSS services were reported never used. Regarding hospital-based psychotherapy, 80.1% never used it significantly with only 10% of users with schizophrenia experiencing it. The interview data analysis convergently revealed that for those who had met psychotherapy, it typically occurred at the onset for only one time, with a few continuing sessions, and was categorized as a psychological intervention need. According to PSS used in the community, peer support was the most utilized informally in a community. Besides, the users’ group of mood disorders engaged more peer support than the other two groups, significantly. Regarding the self-determined PSS needs, 179 participants from the three studied groups (75.8%) indicated having more PSS needs to support their recovery and well-being, with statistically significant differences (p = .049).

Table 2.

Mental health services utilization and needs of PSS indicated by the participants.

MHPSS utilization by categories	% Schizophrenia (n = 100)		% Mood disorders (n = 84)		% Other conditions (n = 52)		% Total (N = 236)		p-value
Services provided and used in hospital setting
Visiting psychiatrist	n	%	n	%	n	%	n	%	.072
Never-used	8	8.0	3	3.6	0	0.0	11	4.7
Ever-used	92	92.0	81	96.4	52	100.0	225	95.3
Receiving medication	n	%	n	%	n	%	n	%	.161
Never-used	0	0.0	2	2.4	0	0.0	2	0.8
Ever-used	100	100.0	82	97.6	52	100.0	234	99.2
Psychotherapy	n	%	n	%	n	%	n	%	.004*
Never-used	90	90.0	62	73.8	37	71.2	189	80.1
Ever-used	10	10.0	22	26.2	15	28.8	47	19.9
Services provided and used either in hospital or community settings
Program training	n	%	n	%	n	%	n	%	.129
Never-used	74	74.0	72	85.7	42	80.8	188	79.7
Ever-used in hospital	8	8.0	3	3.6	6	11.5	17	7.2
Ever-used in community	18	18.0	9	10.7	4	7.7	31	13.1
Day activity	n	%	n	%	n	%	n	%	.338
Never-used	80	80.0	73	86.9	46	88.5	199	84.3
Ever-used in hospital	4	4.0	2	2.4	3	5.8	9	3.8
Ever-used in community	16	16.0	9	10.7	3	5.8	28	11.9
Vocational program	n	%	n	%	n	%	n	%	.101
Never-used	78	78.0	75	89.3	43	82.7	196	83.1
Ever-used in hospital	7	7.0	3	3.6	6	11.5	16	6.7
Ever-used in community	15	15.0	6	7.1	3	5.8	24	10.2
Supplementary therapy	n	%	n	%	n	%	n	%	.193
Never-used	79	79.0	73	86.9	48	92.3	200	84.7
Ever-used in hospital	5	5.0	2	2.4	2	3.8	9	3.8
Ever-used in community	16	16.0	9	10.7	2	3.8	27	11.4
Peer Support	n	%	n	%	n	%	n	%	.039*
Never-used	79	79.0	50	59.5	39	75.0	168	71.2
Ever-used in hospital	2	2.0	1	1.2	1	1.9	4	1.7
Ever-used in community	19	19.0	33	39.3	12	23.1	64	27.1
PSS needs indicated	n	%	n	%	n	%	n	%	.049*
No	31	31.0	13	15.5	13	25.0	57	24.2
Yes	69	69.0	71	84.5	39	75.0	179	75.8

Statistically significant (p < .05).

Users’ self-determined PSS needs

In Table 3, the psychoeducational program was indicated as the most and in common PSS need (50.8%) among all identified types, with no significant difference across all groups. However, support group, counseling, and supported employment were self-determined as needs with statistically significant differences. When comparing between groups, the users with mood disorders expressed higher needs for support group and counseling, whereas supported employment was lower needed. While the support group was categorized as peer support intervention, the counseling has emerged newly in the pre-determined PSS list. The qualitative data also complimentarily suggested that counseling could be provided by non-clinical providers, either as a standalone intervention or integrated into peer support intervention. The overlapping and extension between the pre-categorized and self-determined PSS needs were considered. The results suggested that skills training could be extended to day activity, and counseling could be added to support group of peer support intervention.

Table 3.

Users’ self-determined needs of PSS by categories.

Needed PSS	Total needed users (n = 179)		Schizophrenia (n = 69) % within group		Mood disorders (n = 71) % within group		Other conditions (n = 39) % within group		p-value
Needed PSS	n	%	n	%	n	%	n	%	p-value
Educational program	91	50.8	37	53.6	36	50.7	18	46.2	.757
Support group	55	30.7	12	17.4	28	39.4	15	38.5	.009*
Skills training	41	22.9	22	31.9	14	19.7	5	12.8	.055
Counseling	36	20.1	8	11.6	23	32.4	5	12.8	.004*
Supported employment	29	16.2	13	18.8	6	8.5	10	25.6	.048*
Supplementary therapy	11	6.1	3	4.3	6	8.5	2	5.1	.574

Statistically significant (p <. 05).

Other supporting context needs

Table 4, additional supportive contexts were addressed as considerable needs, including medical service improvement, rights protection, and housing support. The results showed 16.2% of the total user participants in the PSS needed group (n = 179) preferred medical service enhancements, revolving technological integration for appointment system, professionals’ attitudes and empathetic communication, and appropriate medications, stated as ‘good medicine’ or ‘good quality of medicine’. Social assistance and rights protection, which encompassed subsidizing basic living allowances and post-treatment assistance were pointed out as essential to support recovery and quality of life. Housing support was also raised by the participants with schizophrenia who were unhoused for their fundamental quality of life and in pursuit of social inclusion. Lastly, the need for understanding and empathy toward individuals living with mental illness was expressed by either the users within PSS need or no-need groups with 59.3% of the total respondents (n = 236) in a cross-sectional study.

Table 4.

Other supportive context needs identified by the participants.

Within the needed groups of users (n = 179)	Medical service improvement (n = 29)		Rights to access (n = 19)		Housing support (n = 6)		Understanding/empathy (n = 140 from 236)
	Number of respondents and % within each need						Number of respondents and % within need
	n	%	n	%	n	%	n	%
Schizophrenia	8	27.6	9	47.4	6	100.0	39	16.5
Mood disorders	10	34.5	8	42.1	0	0.0	72	30.5
Others	11	37.9	2	10.5	0	0.0	29	12.3
Total	29	16.2	19	10.6	6	3.4	140	59.3

Familiarity with technological devices and online platforms

Table 5 described high familiarity with communication devices with 92.8% overall, with a statistically significant difference (p = .002), and a highly significant difference (p < .001) for online platforms (90.3%) between groups. Notably, user-participants with mood disorders showed the highest use rate followed by those with other disorders and schizophrenia, respectively. The smartphone was the most commonly used device whereas the LINE application was the most favored platform for daily communication. A highly statistically significant difference was found in videoconferencing familiarity, in which groups of mood disorders showed distinction with 67.9% of the used rate, compared to other conditions (26.9%) and schizophrenia (24%).

Table 5.

Technological devices and online platforms’ familiarity of the participants.

Devices and platforms in daily using	Schizophrenia (n = 100) % Within group		Mood disorders (n = 84) % Within group		Other conditions (n = 52) % Within group		Total participants (N = 236) % Overall		p-value
Devices and platforms in daily using	Yes	No	Yes	No	Yes	No	Yes	No	p-value
Technological devices used	86.0	14.0	98.8	1.2	96.2	3.8	92.8	7.2	.002*
Online platforms used	82.0	18.0	97.6	2.4	94.2	5.8	90.3	9.7	<.001
Types of devices used	Yes	No	Yes	No	Yes	No	Yes	No
Smartphone	84.0	16.0	98.2	1.2	96.2	3.8	91.9	8.1	<.001
Tablet	19.0	81.0	46.4	53.6	17.3	82.7	28.4	71.6	<.001
Computer/laptop	31.0	69.0	75.0	25.0	38.5	61.5	48.3	51.7	<.001
Online platforms used	Yes	No	Yes	No	Yes	No	Yes	No
Line application	79.0	21.0	98.8	1.2	92.3	7.7	89.0	11.0	<.001
Video-conferencing	24.0	76.0	67.9	32.1	26.9	73.1	40.3	59.7	<.001
Facebook	69.0	31.0	94.0	6.0	86.5	13.5	81.8	18.2	<.001
TikTok	30.0	70.0	58.3	41.7	34.6	65.4	41.1	58.9	<.001
Instagram	23.0	77.0	75.0	25.0	42.3	57.7	45.8	54.2	<.001
Others	6.0	94.0	23.8	76.2	9.6	90.4	13.1	86.9	.001*

Statistically significant (p < .05); <.001 highly significant (less than .001%).

Focus group discussions

The analyzed qualitative data from FGDs convergently yielded the findings of existing mental health service situations, including unmet PSS needs, challenges of improvement, and feasibility of developing online PSS interventions. The focused topics enabled more insights and came out with five themes of the STARTs acronyms. Tables 6 to 10 exhibited each theme with its incorporated quotations.

Table 6.

STARTs: service gaps affirmation [S].

Theme S: Quotations		Informants
S1	‘Getting access to services is tough; there’s a long wait. But once they finally get in, things usually smooth out’.	Provider
S2	‘Only 154 psychiatric users could get vocational support last year, a very small fraction of the total’.	Provider
S3	‘I only had one appointment with a psychologist on my first visit. I wanted more, even willing to pay, but couldn’t get another appointment’.	Female user
S4	‘I’ve switched psychiatrists three times now. It feels like they don’t get what I’m going through. They just ask about my symptoms and hand me a prescription, without really listening to what I have to say’.	Male user
S5	‘It was hard to accept going to a psychiatric hospital. Like me, it took a long time to overcome the shame’.	Female user
S6	‘Media often make scary news about mental illness, making people fearful of psychiatric patients. Many don’t realize it’s treatable’.	Male user
S7	‘For four years, I couldn’t bring myself to tell my mother about my illness. When I had appointments, I had to leave home very early to avoid any conversations’.	Female user

Table 7.

STARTs: tailored PSS to fill the gaps [T].

Theme T: quotations		Informants
T1	‘Patients should be educated to recognize illness as the only aspect of lives when our hearts are sick and need recuperation. We are more than that and capable’.	Female user
T2	‘Education was very important, I think. If I had some knowledge and understanding about mental illness 2 years before, it should be easier for me to deal with it’.	Male user
T3	‘For me, I’d rather learn to manage my illness. However, it’s not only knowing what illness is for patients but also caregivers too, that they may need to be educated’.	Female user
T4	‘For me, I believe in the power of support group. Joining the support group connected me with others facing similar challenges. Sharing experiences fosters encouragement, empathy, and comfort in talking. It liberated me from reliance on psychiatric treatment’.	Female user
T5	‘While in the psychiatric ward, I informally received support from friends who had been admitted before. They offered advice on managing feelings and adjusting. We shared experiences and strategies for getting through’.	Male user
T6	‘I learned a lot from anonymous individuals who shared similar experiences on web forums while researching information about my condition. I would suggest having someone who has previous experience and can provide necessary information for mental health service access’.	Female user
T7	‘I highly recommend service programs provided by civil organizations which I’ve experienced when someone suggested me after discharging. They meant a lot to my knowledge of recovery and helped me to keep on track’.	Male user
T8	‘As I knew, a few NGOs like Thai Familylink Association and Living Recovery Center offer rehabilitation services in communities, but such organizations are limited nationwide’.	Provider
T9	‘Local government agencies are essential stakeholders in supporting community psychosocial services. NGOs play a role, but couldn’t financially survive in the long term unless supported by local fundings’.	Provider

Table 8.

STARTs: attitudes toward peer-provider [A].

Theme A: quotations		Informants
A1	‘It’s great if there was an experienced person to support along with our recovery. it’s not only for helping but also mutual sharing of friends on how we could live our lives’.	Female user
A2	‘I wonder if they should have trained before working to support others. . .’	Female user
A3	‘Peers should not provide counseling or communicate with families. Toxic conversations from peers might spread to other users, posing danger. . .Peer support might trigger issues for the peers themselves’.	Provider
A4	‘I’ve involved recovered users to assist at OPD, pairing them with current users needing shared treatment experiences. However, peers shouldn’t support those with different mental illnesses—symptom match is crucial’.	Provider
A5	‘Peer supporters must not involve treatments, like inquiring about medications or doctors. They should offer friendship and discuss improvement strategies only. Peer workers must operate under professional supervision, as they may have personal struggles requiring professional support’.	Provider

Table 9.

STARTs: recognition of online approaches [R].

Theme R: quotations		Informants
R1	‘I support the idea of development for online counseling. . .tele-counseling could reduce costs both traveling and fees to make service more accessible’.	Male user
R2	‘Video-conferencing is great! If people could access services without walking in psychiatric hospitals. It is a practical channel of choice for those who may still hesitate to go and get services at facilities’.	Female user
R3	‘I think programs like psychoeducation or illness management should be the best choice for online delivery. Patients could attend for learning through programs for gaining knowledge’.	Female user
R4	‘Online is good and should be integrated in service systems. Since COVID-19, I think everyone learned its necessity. The hospital’s psychiatric ward has also used LINE video call for inpatient-users’ visits during the pandemic instead of in-person visits, as I’ve seen before’.	Male user
R5	‘It is possible to develop and provide online psychotherapy or counseling, but challenges may include internet infrastructure, incurred costs and budgetary support, and affordability to obtain digital communication devices among patients’.	Provider

Table 10.

STARTs: technological potentials [Ts].

Theme Ts: quotations		Informants
Ts1	‘I think a teleconferencing program can be used together with some interventions, which might be needed along with an in-person approach’.	Provider
Ts2	‘I surely believe, there is no concern about the ability to use devices and online platforms among the patients since we have ever used and are already familiar with the Government’s wallet application’.	Female user
Ts3	‘It is possible to train for technological use. As I previously experienced in community outreach. Psychiatric patients could be able to employ devices when they’ve been trained by village volunteers.. . . Even they are at baby boomer age’.	Provider
Ts4	‘They have the potential to use technological devices and online platforms, but the challenges should be dealing with standards of devices, internet infrastructures, and affordability to acquire devices and access to service equally across the country’.	Provider
Ts5	‘I do not doubt that patients living in urban areas are familiar with technology, but I’m not sure about people who live in rural areas. They may have potentials, but may have less chance to access’.	Male user

Service gaps affirmation [S]

Table 6 confirmed MHPSS gaps and supported the interview survey’s results. While the high percentage of seeing psychiatrists with continuing psychiatric medicine prescriptions was shown, psychological counseling and vocational rehabilitation were expressed as inadequate to cover the needs, apart from the difficulty in accessing [S1–S3]. The communication practices of service providers represented a critical barrier to access and required improvement, particularly the shift from a clinical symptom-focused approach characterized by limited, one-way communication to empathetic, two-way interactions [S4]. Seeking treatment at psychiatric hospitals was often stigmatized, as it imparted a social stigma to individuals with psychiatric illnesses. Additionally, concealing their illness led to difficulties in obtaining appropriate care [S5–S7].

Tailored PSS to fill the gaps [T]

User participants identified common unmet needs of PSS, including psychoeducation, support group, and counseling. Psychoeducation was essentially required for the earliest awareness and better self-management of illness throughout one’s recovery journey. It was not only for people living with mental illness but also suggested for family caregivers [T1–T3]. The first-hand experience of living with mental illness was highly valuable to individuals with similar conditions, and sharing experiences could be effectively organized through support group or one-to-one peer service. These interventions served as a vital source of energy and practical tools for the daily lives of people living with mental illness [T4–T6]. Insights into feasibility also highlighted that civil service organizations (CSOs) could provide a good practice for delivering psychoeducation aimed at knowledge for recovery and support group, particularly those operating in a self-help style. Furthermore, effective collaborations with local governmental stakeholders would enhance sustainability [T7–T9] See quotes in Table 7.

Attitudes toward peer-provider [A]

Vital discussions addressed peer-provider roles and challenges of integrating peer interventions into mental health service systems (Table 8). User participants valued peer services for their empathetic sharing of recovery journeys, instilling hope, and strategies for managing struggles. However, concerns were raised about the qualifications and skills necessary to provide accurate information and effective counseling [A1–A2]. Multidisciplinary providers recognized the value of peer-to-peer support but hesitated to formalize peer practices. This hesitation stemmed from concerns about peers’ knowledge, skills, accountability, and ethical issues in service roles, as well as the faint safety margin associated with mental illness. Despite the international recognition of peer services, their suitability for local adoption remained uncertain. Compromising suggestions included defining clear roles and job descriptions for peer workers, ensuring avoiding treatment interference, and limiting the scope of work to tasks similar to volunteer activities. Additional suggestions involved restricting individual support to those with similar mental illness, confirming the recovery status of peer workers, and working under professionals’ supervision [A3–A5].

Recognition of online approaches [R]

Table 9 [R1–R5] represented both provider- and user-participants optimism about practicing tele-services despite some limitations. They strongly emphasized their value of service access improvement, especially in reducing stigma-related barriers and also minimizing travel costs through psychoeducation, counseling, and support group. Psychoeducation was mostly considered as suitable and feasible for online, whereas support group and counseling were possible. However, investment concerns on information and computer infrastructures were addressed to ensure the stability of online service platforms and the affordability of standard devices for individuals.

Technological potentials [Ts]

Corresponding quotes [Ts1–Ts5] in Table 10 confirmed the survey’s findings regarding the learning ability to use digital technology, even among older people or residents in remote areas. Video-conferencing showed potential for psychoeducation and counseling but may not be suitable for follow-up with psychiatrists or diagnostic sessions. Among user groups, those with mood disorders were more enthusiastic about having online services compared to the other two groups. Types and quality of devices, and ability to acquire and afford them were argued for equal accessibility.

Discussion

The interview revealed consistent results with previous research that females were more commonly diagnosed with affective disorders, while males were more frequently diagnosed with schizophrenia spectrum, which correlated with lower levels of education and inadequate health insurance coverage (Choi et al., 2012). The findings suggested females with mood disorders more frequently expressed self-determined PSS and were considered the most feasible users of online interventions, linked to education levels. Lower employment and higher living-in residential facility rates among users with schizophrenia also complied with prior findings. Interestingly, users in the group of others also declared unhoused and higher demand for supported employment than other PSS, when compared with another two groups. Besides, dependent living implication among users with other disorders was considered according to service access behaviors and other related studies’ suggestions (Barnett et al., 2022; Gutwinski et al., 2021; Strassnig et al., 2018).

Access to institution-based services showed high rates of visits to psychiatrists and receiving medication, exceeding 90%, whereas psychotherapy was notably low (19.9%). The community-based psychological interventions were widely acknowledged as filling this gap, particularly in LMICs (Jansen et al., 2015; Qureshi et al., 2021). Regarding peer support, users with mood disorders demonstrated the highest need, affirmed by FGDs’ findings. The findings aligned with other studies about peer support intervention, which promised effectiveness for people with mood disorders, other mental illnesses, and also caregivers either in individual-based or group-based interventions. Nonetheless, greater benefits for clinical and personal recovery outcomes for example, emotional/depressive symptoms, hope, and empowerment could be gained more than functional recovery and supportive contexts (Fortuna et al., 2022; Smit et al., 2023; Worrall et al., 2018). Tailoring PSS to specific groups, therefore may be required, resulting from varieties of illness characteristics, according to the findings. As study suggested that PSS interventions for adults with schizophrenia usually aim at improving functioning for daily living and quality of life, managing illness, and reducing relapse (McDonagh et al., 2022), the findings showed higher needs for skills training within the schizophrenia group, differently from the mood disorders group with support group and counseling preferred. However, other psychosocial interventions could be provided for people with schizophrenia, which were not limited only to expected functioning outcomes (Shikuri et al., 2022). Moreover, the revealed sub-categories of educational programs were consistent with other studies such as psychoeducation for users and caregivers (Chiu et al., 2013; Veltro et al., 2018), social skills, illness/self-management (Jensen et al., 2019; Lean et al., 2019), and stigma reduction (Goh et al., 2021).

As health equity is an important and well-known universal indicator of health service system performance, not only the availability of PSS should be addressed, but also equal access when in need was in concern (Satcher & Rachel, 2017), which was implied by participants’ need for social supportive contexts. Some other specific illness-related barriers included attitudes toward people living with mental illness, as reflected in the manners and communication of providers and general public. These barriers were critically addressed, aligning with previous findings that created shameful feelings when visiting psychiatric hospitals (Coombs et al., 2021). Consequently, they hesitated or avoided accessing mental health services (Knaak et al., 2017; Thornicroft et al., 2007; Vistorte et al., 2018). Similarly, reports found that stigma remains a significant factor influencing users’ access to in-person mental health services, thus online PSS together with a community-based approach was recommended to help improve mental healthcare access and reduce users’ costs (Semrau et al., 2023).

Online feasibility varies according to the demographic and illness characteristics of users as the results reflected differences in familiarity and preference for communication devices and platforms. While videoconferencing was most suitable for the ‘all-at-once’ tailored PSS, challenges such as the digital divide including standardization of devices and delivery, and digital infrastructures of areas coverage were considered for extensive implementation (Kozelka et al., 2023). Another suggestion contributed to this tailored PSS stated that hybrid interventions, combining in-person and online approaches were also potential (Pelletier et al., 2020). For further development, an outcome study of online PSS intervention was recommended before scaling up (Beentjes et al., 2018). Based on findings, the early stage of online PSS development should focus on people living with mood disorders, according to their demographics, characteristics, and familiarity with information technology profiles. Additionally, another study reported that online self-help platforms, which artificial intelligence-based chatbots offered potential solutions and effective evidence in particular younger individuals, and also beneficial for diverse conditions, as empirical from FGDs’ findings (Zhou et al., 2021). Differently, users with schizophrenia may face a digital literacy gap, especially among those with lower levels of education. From this insight, digital literacy could be considered as a kind of social determinant of health, necessary to shift toward digital service platforms (Ng et al., 2019). Additionally, empowering the service users’ community, enhancing the co-production of services between healthcare professionals and peer providers, political commitment and digital education for all stakeholders are keys recommended for community mental health equity in digital approaches (Kozelka et al., 2023). However, two major challenges from convergent findings, which related to provision are technological infrastructure investment and collaboration between health professionals and peer providers. Dealing with technological feasibility on the user side, the smartphone was considered more feasible than other devices in terms of ownership and its understandable features, supported by relevant studies (Kozelka et al., 2023; Ndlovu et al., 2023). Moreover, once an online platform has been developed and implemented, continuing studies to improve retention rate and user satisfaction are recommended (Beentjes et al., 2018; Zhou et al., 2021).

This study highlighted a co-production of PSS between healthcare practitioners and service users with first-hand experience of mental health recovery. The recovery college (RC) approach is gaining global traction for its effectiveness in filling mental health service gaps despite its under-recognized within systems globally (Aakerblom & Ness, 2021; Crowther et al., 2019; Davidson, 2016; Hayes et al., 2022, 2023). As same as reported by previous studies, the peer provider’s scope of roles and responsibilities was still unclear as well as questionable peer’s knowledge and communication skills from healthcare professionals’ perspectives. Then, the safety of peer-recipient concerns was a critical factor in the formalization and integration of peer service within mental health service systems. Amid these continuous concerns, nonetheless, positive effects on quality of life, mutual learning opportunities, and social inclusion facilitated by peer support workers were reported (Mikolajczak-Degrauwe et al., 2023; Smit et al., 2023). Addressing these peer service capacity concerns, evidence-based in-person or online peer support training with standard practice guidelines was suggested, and aligned with users’ and providers’ recommendations (Charles et al., 2021; Puschner et al., 2019). Lastly, to foster feasibility and sustainability, the involvement of local governmental authority and secured funding from national health insurance were focused, on which is feasible to implement based on FGDs’ insights and national policy considerations and contexts (Mahomed, 2020; Wannasewok et al., 2022; WHO, 2022b).

Limitations

User participants in this study may not represent rural users due to geographic and demographic differences, and super-tertiary characteristics of the hospital. Further cross-regional studies may be required to affirm equal service and access. Using quota sampling methods may offer an opportunity for misclassification, resulting from co-occurring among user-participants.

Conclusions

The online PSS intervention aiming at enhancing personal mental health recovery and well-being of people living with mental illness was found feasible to be developed in an urban-based setting in Thailand context. Psychoeducation, support group, and counseling were common self-determined unmet PSS needs, particularly among service users with mood disorders followed by those with other mental disorders and schizophrenia, respectively. Combining self-determined needs and technological feasibility, the early development stage of online PSS was recommended for users with mood disorders. While a well-defined scope of peer roles and capacity building were required. Further study on outcomes effectiveness was recommended before scaling up.

Footnotes

Acknowledgements

The authors are grateful to all participants for taking the time to share their valuable insights in the study. Special thank you to Srithanya Hospital for being in service of the research venue and coordination throughout the research process.

Authors’ note

The study was conducted as part of a larger project in partial fulfillment for the Degree of Doctor of Philosophy (Quality of Life Development for Persons with Disabilities), Ratchasuda Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, completed by Ms. Peanchanan Leah.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Peanchanan Leah

Wachara Riewpaiboon

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