J Telemed Telecare OnlineFirst, published on October 29, 2015 as doi:10.1177/1357633X15613236

RESEARCH/Original Article

Use of mobile technology in a community mental health setting

Journal of Telemedicine and Telecare 0(0) 1–6 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X15613236 jtt.sagepub.com

Gretl Glick1, Benjamin Druss1, Jamie Pina2, Cathy Lally1 and Mark Conde1

Abstract Introduction: mHealth holds promise in transforming care for people with serious mental illness (SMI) and other disadvantaged populations. However, information about the rates of smartphone ownership and usage of mobile health apps among people with SMI is limited. The objective of this research is to examine the current ownership, usage patterns, and existing barriers to mobile health interventions for people with SMI treated in a public sector community mental health setting and to compare the findings with national usage patterns from the general population. Methods: A survey was conducted to determine rates of ownership of smartphone devices among people with SMI. Surveys were administered to 100 patients with SMI at an outpatient psychiatric clinic. Results were compared with respondents to the 2012 Pew Survey of mobile phone usage. Results: A total of 85% of participants reported that they owned a cell phone; of those, 37% reported that they owned a smartphone, as compared with 53% of respondents to the Pew Survey and 44% of socioeconomically disadvantaged respondents to the Pew Survey. Discussion: While cell phone ownership is common among people with SMI, their adoption of smartphone technology lags behind that of the general population primarily due to cost barriers. Efforts to use mHealth in these populations need to recognize current mobile ownership patterns while planning for anticipated expansion of new technologies to poor populations as cost barriers are reduced in the coming years. Keywords Mental health, mobile health, mHealth, community mental health centers, smartphones Date received: 17 August 2015; Date accepted: 30 September 2015

Introduction Mobile technology is increasingly used to deliver primary health interventions. Mobile devices may particularly hold promise in transforming the delivery of health interventions. For poor and disadvantaged populations, these interventions hold the potential to help narrow the digital divide and reduce health disparities.1 People with serious mental illness (SMI) may be a particularly important target of these interventions.2 Individuals with SMI die approximately 10 years earlier than the general population3 due, in part, to poor medical care and limited self-management of medical conditions. mHealth holds the potential to improve self-management and engagement in care4 as a step towards reducing these disparities.5 Mobile technologies hold promise in expanding access to care and improving existing health interventions.6 As cellular infrastructure improves and smartphones rapidly decrease in cost, there is an opportunity to expand mental health services beyond the traditional clinical office space and broadly distribute information and resources.7,8

Mental health interventions delivered on mobile devices may have several advantages, including increased symptom monitoring and assessment, behavioral analytics, psycho-social education, increased medication adherence, skills training, enhanced communication with providers and access to resources, and tracking of treatment progress. However, uptake of these interventions in populations with mHealth has been slower in mental health settings than in general medical settings.9 One reason for the slow uptake of mHealth interventions among individuals with SMI may be due to the low rates of ownership of devices in which to implement these

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Center for Behavioral Health Policy Studies, Emory University, USA Center for the Advancement of Health IT, RTI International, USA

Corresponding author: Gretl Glick MPH, Emory University, Rollins School of Public Health, Center for Behavioral Health Policy Studies, 1518 Clifton Road, NE, Room 648, Atlanta, GA 30322, USA. Email: [email protected]

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interventions. Mental illness has been shown to be a risk factor for poverty, which may contribute to barriers to purchasing mobile devices.10 The few studies to date looking at the rates of mobile phone ownership and mHealth app usage among people with SMI have suggested a pattern of increasing usage of mobile technologies in this population. A 2012 survey found that 72% of individuals with SMI own a mobile device.4 Given the rapidly changing mHealth landscape, it is critical to update these estimates and to benchmark them against national patterns of mobile technology use. The aim of this study was to examine the current ownership, usage patterns, and existing barriers of mobile phone ownership for people with SMI treated in public sector community mental health settings.

criteria were an inability to provide informed consent based on a validated screener.

Data analysis Findings were compared to the Pew Research Center’s Internet and American Life Project’s Health Tracking Survey 2012, a national telephone survey of mobile health usage amongst the general US population. Frequency distributions were used to describe ownership, usage, and demographics. Logistic regression analysis was used to examine the relationship between mobile device ownership and age, income, and health status. Frequency distributions were used to describe barriers to smartphone ownership and interest in mobile mental health services.

Results Methods Design A survey was conducted to determine the rates of ownership of smartphone devices among people with SMI, as well as to identify any potential barriers such as affordability challenges. All surveys were conducted at a large public sector community mental health center (CMHC) in Atlanta, GA. Surveys were administered to a convenience sample of 100 patients with SMI at Grady’s mental outpatient clinic. The study was reviewed and approved by Emory’s Institutional Review Board as human subjects research (IRB#00062439); additionally, this research was submitted to Grady Healthcare Research Oversight Committee for review and approval (ROC#00062439). Trained research interviewers distributed the Pew Mobile Health 2012 survey of mobile health information technology to people diagnosed with SMI. Participants answered questions about their ownership and usage of mobile phones, smartphones, and current usage of health apps on mobile devices. Participants self-reported current mental health diagnoses, medical diagnoses, income level, education level, and demographic information. Additionally, enrolled participants answered questions regarding barriers to mobile device ownership (including affordability, lack of interest, lack of necessity), and interest in potential mobile health app services and specific functionality (medication reminders, appointment reminders, communication with providers, and information about existing mental health services).

Recruitment and eligibility Participants were approached in the waiting room of the CMHC and compensated for their time and effort. Eligibility criteria included the presence of an SMI diagnosis, as defined by the DSM-IV, including bipolar disorder, schizophrenia, schizoaffective disorder, major depression, obsessive compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). The only exclusion

The final sample included 100 participants with a mean age of 47 (SD ¼ 10.73); 62.6% were male, 85.0% were African-American, and 4.0% were Caucasian; 2.2% were identified as Hispanic. 78% had a high school diploma or less years of education; 70.1% reported having an annual income of less than $5,000 and 12.4% reported having an income between $5,001–$10,000; 29.2% were diagnosed with schizophrenia or schizoaffective disorder, 33.3% with bipolar disorder, and 52.1% with major depressive disorder. 42.1% were diagnosed with hypertension, 23.2% with hyperlipidemia, and 18.9% with diabetes. Table 1 shows the respondent’s demographic information, and medical and mental health diagnosis. Respondents reported varying levels of health and wellness; 8.0% described their health as excellent, 43.0% as good, 36.0% as only fair, and 13.0% described their health as poor. Within the past 12 months, 20.2% of survey respondents had faced a medical emergency, 39.4% had gone to the ER or been hospitalized unexpectedly, and 42.6% had experienced a significant change in physical health. Cell phone ownership was common among survey respondents. 85% of participants reported that they owned a cell phone; of those, 36% reported that they owned a smartphone. 40.4% of respondents paid for their mobile service using a month-to-month plan, 40.4% indicated being covered by a government subsidized plan, and 7.4% responded as having a contract plan for mobile services. 75.5% reported that they used their mobile on a daily basis, 6.1% on a weekly basis, and 9.2% on a monthly basis or less. Texting was common among survey respondents, with 77% reporting that they used texting on a regular basis. Among respondents who did not own a cell phone, 14% cited affordability as a barrier to ownership, followed by 8% who cited a lack of necessity.

Mobile health 36% of survey participants with SMI reported having looked for health or medical information online using

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Table 1. SMI safety net and Pew Mobile Health 2012 survey respondents: demographics.

Survey responses

SMI safety net survey responses

Pew Mobile Health 2012 low income (under $20,000/yr) respondents

Pew Mobile Health survey 2012

Age Mean Median

47 51

50 50

53 53

Gender Male Female

63% 37%

41% 59%

49% 51%

Ethnicity Not Hispanic or Latino Hispanic or Latino Unreported

80% 2% 17%

94% 3%

79% 14%

a

a

Race White Black (Born in the US) Black (other) Alaskan Native More than one race Unreported Refused to answer

4% 85% 3% 1% 3% 2% 1%

57% 29%

75% 19%

a

a

a

a

4%

3%

a

a

a

a

Annual Income $0–$5,000 $5,001–$10,000 $10,001–$15,000 Greater than $15,000 Don’t know Refused to Answer

70% 12% 3% 5% 5% 4%

a

a

a

10% (Less than $10k) 10% ($10–20k) 80% (More than $20k)

Years of Education Completed 12 years or less 12 to 16 years 16þ years

81% 14% 5%

61% 25% 13%

44% 36% 27%

Mental Health Diagnosis Schizophrenia Bipolar Disorder Major Depression OCD PTSD Other

29% 33% 52% 6% 19% 8%

a

a

a

a

a

a

a

a

a

a

a

a

Chronic Disease Diagnosis Diabetes Hypertension Asthma Heart Disease Cancer Hyperlipidemia Other chronic condition NA

19% 42% 14% 6% 2% 23% 19% 24%

36% 20% 12% 3% 2%

11% 25% 13% 7% 3%

a

a

a a a a

a

16%

a

a

a

Data not available.

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Table 2. SMI safety net survey respondents: mobile device ownership and usage patterns.

Survey responses

SMI safety net survey responses

Pew Mobile Health 2012 low income (under $20,000/yr) respondents

Pew Mobile Health 2012 respondents

Cell Phone Ownership Yes No

85% 15%

78% 22%

85% 15%

Smartphone Ownership Yes No Uncertain

37% 52% 8%

44% 56%

53% 47%

Payment Plan Month to Month Government Plan Contract Plan Pre-paid Card

40% 40% 7% 2%

a

a

a

a

a

a

a

a

Functions Used Text Internet/Email

77% 48%

78% 52%

80% 50%

Frequency of Use Daily Use Weekly Use Monthly Use Less than Monthly Use

76% 6% 5% 4%

a

a

a

a

a

a

a

a

a

Interest in Mobile Services a Reminders about appointments or medications 79% a Regular check-ins with provider 40% a Information about health services 57% Currently Receive Texts or Update about Health and Medical Issues from Provider Yes 34% 9% No 64% 91%

a a a

9% 91%

Health Apps on Smartphone Yes No

15% 75%

7% 93%

19% 81%

Types of Health Apps Used Exercise Tracker Diet & Nutrition Weight Menstrual Tracking Blood Pressure WebMD Pregnancy Blood Sugar Tracking Medication Management Mood Sleep Other

13% 4% 5% 1% 5% 8% 1% 2% 3% 3% 6% 9%

21% 23% 10% 17% 10% 6%

38% 31% 12% 7% 5% 4% 3% 2% 2%

a

1% a a

a

a

a

a

14%

a

Data not available.

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their mobile device. This is lower than the general US adult population, 52% of whom reported using their smartphones to gather health information in 2012.11 Among smartphone owners, 15% of respondents with SMI reported having downloaded and used a health app on their smartphone. This is similar to the general population, where 19% of smartphone users reported using health apps to manage their personal health in 201211. Survey respondents reported exercise, sleep, and the WebMD app among the most commonly used health apps on their mobile devices; 13.4% of survey respondents reported tracking the amount and duration of exercise. 8.2% reported using WebMD on their mobile device, 6.2% reported using sleep apps, 5.2% reported using blood pressure tracking apps, and 3.1% reported using apps for medication management. Comparatively, Pew Research reported in 2012 that exercise, diet, and weight apps were among the most popular health apps in the general population. 78.5% of participants reported an interest in receiving reminders about appointments or medications on their mobile device; 57.0% wanted to receive information about health services, and 39.8% reported an interest in having regular check-ins with their provider on their mobile device. 60.6% of survey respondents were interested in receiving text messages on their mobile device to better manage their health, 48.9% in receiving phone calls, and 28.7% in receiving emails. A logistic regression model did not show age, income, or education to be a significant predictor of owning a smartphone among this population.

Discussion The study found overall rates of cell phone ownership was relatively high but that smartphone ownership generally lagged behind the general population. Among survey respondents, 85% of people with SMI reported owning a cell phone and used it on a regular basis for a variety of functions. This is on par with mobile phone ownership in the general US adult population, with 85% reporting cell phone ownership in 2012,11 as well as a survey of adults with SMI reporting ownership rates of 81%.4 In contrast, the findings in this study showed a 16% lower rate of smartphone ownership than found in the general population, with 37% of participants with SMI reporting owning a smartphone. The study’s findings also indicate future potential to use smartphone-based technologies. Ownership of mobile devices, particularly smartphones, is rapidly increasing; while the rate of smartphone ownership among people with SMI continues to lag behind the general population, this study has demonstrated that the gap in ownership is quickly decreasing relative to previous studies.4 Affordability was the primary barrier cited by the population, but these barriers are quickly decreasing as smartphones and data plans are becoming less expensive. Mobile devices can be used to reduce some of the

potential barriers to accessing and sustaining clinical behavioral therapies. This may result in a decrease in the number of visits or duration of therapy, thereby also reducing costs associated with mental healthcare. Additionally, mobile devices can extend the benefits of therapeutic visits beyond the clinical space. Finally, mobile devices can reduce transportation barriers, often cited as a challenge to full and continued participation in behavioral therapy interventions.12 This is of particular relevance to people with SMI, as certain studies have indicated that the rate of attendance can be as low as one in every two sessions scheduled.13 Our research showed a high level of interest among people with SMI in using their smartphones to better manage their personal health, providing further support for mental health interventions to be delivered using mobile platforms. Numerous benefits may be derived through delivery of mobile health interventions for people with SMI, including enhanced skills-training opportunities in real-world settings, continuous, on-going support from clinical providers, improved medication management, enhanced potential for treatment plan compliance, and additional tools for self-monitoring mental health symptoms.14 Additionally, a growing number of interventions are being developed focusing on providing support for general wellbeing, health, and overall wellness for people with SMI. These tools center on empowering patients to make well-informed decisions, but also provide feedback that assists consumers in making healthy lifestyle choices. Several limitations to this research should be noted. The study was conducted in a single CMHC. Additionally, all data was self-reported by survey respondents; many other studies commonly use selfreporting methods among this population. Finally, the research team did not note how many potential respondents were approached and refused participation. Further research is needed to ascertain generalizability to other mental health populations. In conclusion, the study shows increasing penetration of mobile device and smartphone technologies among low-income individuals with SMI. Smartphone technology has the potential to increase access to both behavioral and medical healthcare, make treatment options more interactive, enhance patient engagement and provider communication, and may improve the reach of evidencebased interventions. Research on the efficacy of mHealth interventions for behavioral and medical health is still at an early stage and could benefit from rigorous testing. New interventions should be thoughtfully developed and evaluated for use in clinical practice. As the behavioral health field continues to rapidly adopt new technologies that increase access and improve quality of care, it will be critical to evaluate the efficacy, usability, and acceptance of mHealth interventions. Mobile applications will need to incorporate user-centered design principles, federal regulatory privacy standards, and harness the potential of mobile technologies in delivering innovative and effective care to people with SMI.

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Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: National Institute of Mental Health (10.13039/100000025 0000018517).

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Use of mobile technology in a community mental health setting.

mHealth holds promise in transforming care for people with serious mental illness (SMI) and other disadvantaged populations. However, information abou...
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