Introduction
Even though the urban population is growing and expect to grow approximately 1.84% per year between 2015 and 2020, there is still 64% of the total global population in 2014. (World Health Organization, 2015). Therefore, access to healthcare services is essential and critical for rural residents. Research have shown people who live in rural areas may use less medical care than those living in urban areas (Grossman et al.,1994 ; Baldwin et al., 2010).The ability to access, organise, use, and disseminate information presents a major challenge in mental health care as the scope and depth of information increases exponentially. Yet, information is as vital to providers and consumers of rural mental health care as to those in any other specialty areas of health care. In addition, people living in rural areas already have greater barriers to access because of geographic and transportation factors, lack of specialisation nearby, and cultural considerations. However, by the development of innovations in information and communication technology (ICT), the prospect of mental health service delivery has been changed. This emerging field, often referred to as “E-health”, which includes key features, such as electronic, efficient, enhancing quality, evidence based, empowering, encouraging, education, enabling, extending ethics and equity (Eysenbach, 2001).
The objective of this paper focus on examining two technological innovations examples (ComputerLink and MoodGYM) in e-health within treatment and social support areas regard on how they improve the accessibility in rural areas and the potential barriers in the implementation. Firstly, both innovations will be explained and described. After that, the strengths and benefits associated with e-mental health initiatives will be presented with evidence-based literatures. Then , the concerns and barriers on implementing e-health will be identified and the implications of the literatures and the future development of e-health will be discussed at the end of this article.
Social Support (ComputerLink) (300)
One of the most salient social support theory that has been applied to the study of online support groups is the buffering effect model. Cobb(1976) first introduced the concept of the buffering model to explain how social support can protect a person against stress. The buffering effect model states that psychosocial stress will have negative effects on the health and well-being of those with little or no social support. Social support exists in e-health with several types of Web-based formats, including discussion groups, bulletin boards, chat rooms, blogs and social media and Computerlink (Ripich et al.,1992) is one of them. As early as the 1990s, researchers, such as Brennan and colleagues, implemented and evaluated ComputerLink as a method of support for informal caregiver of Alzheimer’s’ patients who work in remote locations(Brennan, 1996).ComputerLink has also been considered as an alternative to traditional caregiver support services, such as support groups and health education programs in remote/rural areas, and it is dealing with other health or social problems (Robinson, 1989; Christ & Siegel, 1990) ComputerLink consists of a multiplayer design, with several components. The Communication module is made up of a bulletin board (the Forum), an electronic mail section, and a Question and Answer are. The Decision Support module allows users to formulate decision strategies based on their own value system. The Information module contains an electronic encyclopedia with factual data about several diseases, caregiving problems, and resources (Ripich et al., 1992).
Evidence-based research of ComputerLink
In a pilot study that investigate the usage of ComputerLink by people with Acquired Immune Deficiency Syndrome (AIDS) used ComputerLink to maintain social contact with other users and to obtain self-care information (Brennan et al., 1991). In a large, randomised clinical trial was examining the feasibility of the ComputerLink on Alzheimer Disease (AD) caregivers, found 55 of the 22 subjects (68%) used the ComputerLink more than one time with the average log-on length of about 13 minutes and mainly spent time in using the Forum or Q&A sections of the communication pathway (Brennan et al., 1991). However, more than 85% of the participants were spouses of the person to whom they were providing care. Therefore, they might more eager to find out the information regards on how to care their spouse and close one (Bascom & Tolle,1995). A later study conducted by Bass et al(1998) investigated that whether caregivers in the experimental group had greater reductions in four types of care-related strain (Physical strain, emotional strain, relationship strain and activity restriction) by the end of the one year study. The statistic revealed that ComputerLink reduced all types of strain if the caregivers were spouse of the patients or under more stress. Participants spend more time on the communication function had a significant reduction on stains for caregivers who were initially more stressed and for non-spouse caregivers. More frequent use of the information function was related to significant decrease on strains among caregivers who lived alone with care receivers in the rural areas.
Treatment (MoodGYM) (300)
Interventions in E-mental health has been classified into 6 stages according to the treatment process. They are stage of the treatment (promotion, prevention, early intervention, active treatment, maintenance, and relapse prevention, type of relationship, and treatment or therapy modality.
Most of the interventions were provided as the primary therapy or adjunct to conventional in person therapy and were delivered to individuals or groups or both.
E-mental health interventions mostly mimicked traditional treatment approaches in that they often addressed the single disorders. For example, MoodGYM is an exemplary Web-based, interactive intervention that has been developed and evaluated in several randomised controlled trials (Bennett et al.,2010; Christensen et al., 2004; O’Kearney et al., 2006). MoodGYM is an automated self-help Cognitive Behavioural Therapy (CBT) program for depression with five modules and 29 exercises. It was originally developed by researchers at the Australian National University. The principal authors of the content were Professor Helen Christensen and Professor Kathy Griffiths. It can be completed without health professional involvement, as an adjunct to treatment by a General Practitioner (GP) or mental health practitioner or, in the case of school students in the classroom under the broad supervision of a teacher. MoodGYM is freely available to the public and has been translated into several languages. Its purpose is to enhance coping skills in relation to depression, and it includes assessments, workbooks, games online exercise, and feedback. MoodGYM is freely available to the public and has been translated into several languages.
Evidence-based research of MoodGYM
Griffiths and Christensen (2007) has investigated the potential utility of MoodGYM in rural regions and found that it was effective on reducing depressive symptoms and stigmatising attitudes to depression and in improving depression literacy.
Strengths and Benefits of e-mental health initiatives (1000)
Strengths of e-mental health initiatives has been suggested in the literature that include improved accessibility, reduced costs, flexibility in terms of standardisation and personalisation, interactivity, and consumer engagement. E-health technologies are also considered to be particularly promising for rural and remote populations. They are also promising for subpopulations that have other barriers to access (attitudinal, financial, or temporal) or that avoid treatment because of stigma. For instance, by using internet-based social support, individuals can share their perspective freely while preserving their anonymity.
Improved accessibility (250)
One of the clear advantage of the new technologies is the potential for universal access to information and services to assist in meeting the huge need for mental health services in our community. The expansion of technology and the ever increasing computer literacy in Australia could assist in addressing some critical issues of relevance to certain disadvantaged groups, particularly those living in rural and remote areas. The new technologies can facilitate greater access to mental health services and other forms of social support for all Australians (Christensen et al., 2002).Either ComputerLink and MoodGYM, both of them can be access by using internet, which means no matter where the household is. They can connect to MoodGYM or using ComputerLink if they have computer. This also assure that people who live in remote/rural area can also access to the mental health support or intervention anywhere, even in school or workplace. Another advantage for using technology to access health care is some people may have some types of barriers which make them cannot reach to the mental health institutes, for instance, having Dementia or AD. They cannot access to the mental health care by themselves. If people do not want others to know they need mental health care or afraid being labelled as a person with mental health problem. They can use online bulletin or forum such as ComputerLink to acquire the information they need. Another benefit from using ComputerLink and MoodGYM is people can save their time for transportation and the money to travel to the mental health institutes. The Internet has the advantage of being inherently self paced and available twenty four hours a day, seven days a week. The sender and receiver do not have to online simultaneously in order to retrieve the information they need.
Reduced Costs (250)
Operating cost
Mental illness is a major cause of disability and burden in the world. Many individuals with mental health problems do not receive help. Therefore, the cost of current services may be reduced if technology could be used to decrease the burden of routine procedures and processes
Since the internet based intervention or social support do not require many people to monitor or provide the service. The operating cost will be much lower than the conventional practice since there is no equipment or staff require. For example, MoodGYM can be completed without any mental health professional involved and ComputerLink only need few psychologist to answer the questions occasionally. Also, the programme is running online, therefore, no actual institutions need to be present and it saved the operating cost including rent and utility bills. Another benefit from using internet-based intervention is the ability of the new technology to reach the large numbers of population that need help simultaneously. It provides a relatively cheap , alternative and complementary, targeted program could help manage service delivery and health costs.Web-based preventative programs such as MoodGYM, aimed at educating consumers, alerting them to possible symptoms and offering a degree of treatment to prevent the development of mental health symptoms, may decrease the need for more expensive medical treatment (Christensen et al., 2002). Another example, The communication section of ComputerLink is capable for many people share their experience and retrieve the information they need at the same time without any staffs or professional involved. Also, MoodGYM can be completed by many people in need at the same time.
Since part of the intervention can be done by people without any help. Therapist can save some more time to focus each patient and answer as many people as possible. It makes therapist more efficient and they can optimise their time since they can deal with a lot more patients in the same period of time when it compare to use conventional practice.
The internet is able to offer individually tailored help that may not be achievable in the timeframe provided in normal service delivery. Customisation refers to the development of individually targeted help that is provided to people on the basis of need. Technology also can evoke people’s individual needs and provide specific help in response to that need. This alternative health delivery medium is unique in its ability to deliver tailored information and advice at low cost. The technology facilitating customisation is developing rapidly and is changing traditional approaches to the delivery of mental health services. The technology could be especially useful in the delivery of mental health prevention programs, particularly to young people, who are adept at using internet technology. The internet also provides the opportunity to deliver up to date and relevant mental health information.
Can be developed according to the best research and design evidence
Internet technologies make the task of storing and locating information easier, for example , through the use of distributed networks and powerful search capacity.
Can be designed for virtually any mental health issue or topic
Interactivity and Consumer engagement (250)
The growth of Internet technology represents a fundamental paradigm shift in health delivery, and has the capacity to dramatically alter the relationship between the health expert and the consumer. It is generally accepted that an increased access by the community to knowledge, once the preserve of experts, empowers that community. The Internet makes possible the widespread dissemination of accurate mental health information. It leads to a more informed and educated community. This especially desirable in the arena of mental health because an increased generalised mental health literacy may improve the health outcomes for the entire society. The technology may empower the consumer in another way as well: it extends the possibilities as to who can be involved in the delivery of mental health preventive strategies. Not only does the technology facilitate the integration of health services into the community sector, it also facilitates the development of partnership between members of the community and health professional sectors. This means that the internet technologies may increase the capacity of the broader community to be involved in the development of mental health services.
Through consumer empowerment
Can improve continuity of care (for example ,can be integrated within a set of services across the service continuum)
Concerns and Limitations (1000)
(100 per each point)
Some concerns and barriers are associated with using e-mental health. There are concerns that e-mental health will replace important and needed conventional services; divert attention away from improvements to or funding for conventional services; and be costly to develop, deploy, and evaluate since the growing potential and interest of e-mental health (Ougrin, 2009).
Another issue raised in the literature is related to the financial interests of developers and researchers, which may produce a risk of publication bias (Emmelkamp, 2005).
Others have highlighted the limited evidence base for interventions, lack of quality control and care standards, and slow uptake by or reluctance among health care professionals.
The quality of information on the Internet is one of major concern to consumers, governments and professional bodies internationally. There were concerns that information maybe inaccurate and even dangerous; that the information is often not referenced, that it is sometimes not possible to tell if a website is endorsed or sponsored by a particular group, nor to know what effect a developer’s potential conflicts of interest may have on the quality of the information.
Therapeutic relationship which referred to the relationship between professionals and patients (Alexander & Coffey,1997). This relationship is essential for delivering treatment because it is central to the practice of psychiatry being used as a means to engage patients who may not agree that they need treatment or deliver complex treatment programmes (McCabe & Priebe, 2004). Some researcher may question about the ability of professionals to establish therapeutic relationships online and the feasibility of online treatment for certain population groups (Kiropoulos et al., 2008). has been Sucala et al (2012)
Will technological phobia, whereby professionals or older adults (aged over 55) may be unfamiliar with technology and anxious about its use in professional care. However, research has indicated that older adult (over 55 years olds) have shown a greater interest than younger adult on learning computer and use computer to get the information online (Dyck & Smither, 1994). Also, research found that after 1.5 hour training , participants who average aged was 68 years old with little prior computer experience were able to participate successfully in the network. This may imply the credibility to the assertion that older adults can be taught to use computers (Brennan et al., 1991).
Concerns have also been expressed about the potential to further marginalise individuals who have physical, financial, or cognitive barriers in terms of access to conventional services.
Although,
Some are concerned that the availability of e-mental health services may lead some individuals to postpone seeking needed conventional care or that some will receive inappropriate or harmful care when where is insufficient quality control over content.
Ethical and liability concerns have been cited too. For example, when participants are from outside the regulatory jurisdiction, ethical responsibilities cannot be met
The issue of the nature of legal liability for treatment or information disseminated over the Internet is a critical issue in the development of policy on e-mental health. Some of the participants considered that the resistance to the use of the Internet for providing treatment and disseminating information can be explained in part by the profession’s fear of liability. In particular, there was concern that information offered over the Internet maybe misconstrued or used in an inappropriate way.
Other concerns are that participants cannot be reliably identified and that privacy cannot be guaranteed for typed or recorded communications. (anonymous also brought uncertainty when deliver the treatment) .
The perception that privacy is protected is crucial to the uptake and utilisation for e-mental health services. Concerns about privacy frequently focused on the issue of personal health records. There is an underlying between the need for access to health records and the need for security of those records. The new technologies raise important questions in relation to access to patient records: who should have access to what records. Moreover, the new technology raises important questions of authentication. While in the traditional doctor/relationship it is easy for each party to verify the identity of the other, this is not the case with internet based consultations or records access.
Discussion (200)
The purpose of this review was to synthesise and describe what is currently known on the topic of technology innovation on rural/remote population/area. This review also indicated that e-mental health initiatives is not perfect even though there is evidence from randomised controlled trials that internet delivered treatment and prevention for certain disorders is effective (Winzelberg et al., 2000). However, there are still some issues to tackle before expand the technologies innovation widely.
Most of the literature reviewed only described one single interventions in isolation. One very important question that has been given limited attention is how e-mental health interventions might best be situated in relation to an array of related services for a broad population. Also, there are several questions needed to be addressed in the future. First of all, most of the research focused on the effect e-mental health initiatives on common mental disorder such as depression (Coyle et al., 2007) and eating disorder(Winzelberg et al., 2000). Therefore, more research of e-mental health initiatives impact on psychotic disorder should be conducted. Secondly,a more systematic and informed approach is required to realise the potential of the Internet to contribute to better mental health services, prevention and improved community awareness. However, at present, lack of systematic suggestions for government on how to manage and implement e-mental health initiatives in political level is scared (Lal., & Adair, 2014). Lastly , extending to which intervention have or can be applied in cross-cultural and international context is the next step for e-mental health initiatives research to make internet benefit the most population in the very soon future with the lower cost.