Background
Policy makers in the United Kingdom, and elsewhere, have increasingly advocated the use of mobile-phones in the treatment of patients with long-term conditions, based on the presumption that they have the capability to improve both clinical care and self-management. However, in the field of mental health, little is currently understood about the acceptability of new technological systems or their integration (Daker White G, Rogers A: What is the potential for social networks and support to enhance future telehealth interventions for people with a diagnosis of schizophrenia? A critical interpretive synthesis. Submitted). In particular, the perception of mobile-phone based interventions in individuals with diagnoses of severe mental illness has not previously been sought. This paper outlines a qualitative evaluation of mobile-phone based assessment in patients with schizophrenia and related disorders.
Schizophrenia can be distressing and disabling with many individuals experiencing an episodic, lifelong course of fluctuating symptoms. Individuals for the most part live and manage their conditions in the community and there can be lengthy and inconsistent periods of time between clinical assessments. This may mean that symptom deterioration and relapse indicators are sometimes missed, and opportunities for promoting self-management lost. Mobile-phone based assessment can upload data in real-time, helping to facilitate earlier and more effective intervention. It could also be used to promote greater self-monitoring strategies increasing opportunities to directly modify behaviour and engage in informal support. The flow and frequency of reports back about a persons' condition could in turn enhance the potential for therapeutic alliance through better considered and informed decision making with clinicians, and increased levels of perceived control, autonomy and self-esteem in service users. Service user feedback advocates autonomy and feelings of control as key components of subjective recovery from severe mental illness. Additionally, a greater understanding of the self, empowerment, and collaborative care have been identified as factors influencing recovery from psychosis. Thus, the aims and utility of healthcare technology appear compatible with service user definitions of recovery. The extent to which this is likely to happen in practice is part of the rationale for carrying out the study reported in this article.
There are multiple technological options for delivering mobile-phone based assessment. Smartphone software applications can be purpose-made allowing for greater configurability and usability. Alternatively, text messages have the major advantage that they are not constrained by the make or model of the user's mobile phone. Mobile-phone technology is becoming increasingly widespread and affordable in individuals with mental illness, with one report showing that rates of use are similar to those of the general population. With regards to their effectiveness, small-scale text-based interventions in psychotic samples have shown a significant reduction in the severity of hallucinations and the number of acute inpatient admissions. Our research group has demonstrated high compliance and low drop-out rates to smartphone facilitated assessment in individuals with psychotic experiences. Analysis of quantitative feedback data also revealed that whilst smartphones outperform text based solutions in terms of data-point completion and length of entry times, patients' appraisals of both forms of technology are generally positive.
Early evaluations of mobile-phone based assessment attest to its efficacy. However, the question of which technology and how it is implemented are always more complex issues than is originally anticipated. Assumptions about an objects use and how patients' engage with technology in reality may not match preconceived ideas. Indeed, large trials of mobile interventions in physical disorders report high levels of non-participation and withdrawal suggesting that these technologies are often poorly integrated into clinical practice. Additionally, these problems appear to occur at all stages of implementation and integration, including at a service level. The complexities of a technology's expected value versus its actual use in practice, especially with regards to social relations, make a focus on the processes between users and context essential. These questions might be best addressed through qualitative design research.
Qualitative studies, in the realm of physical disease management, have suggested that patients can be ambivalent about healthcare technology, views mediated by the technologies place of use (i.e. home vs. public environments). Implementation is often obstructed by system design; uneven integration resulting from poor information transmission concerning the role of technological systems and their adoption; contextual relevancy; and uncertainties about novel software's adequacy and purpose. Furthermore, threats to independence, prior identities and established ways of self-managing, perceived technical competence, and how technology disrupts healthcare practices, were cited as reasons for non-participation or withdrawal from a recent trial for mobile-phone based intervention in the UK. Healthcare technologies have been found to positively impact on patients' sense of autonomy and participation in social activities, but can also greatly restrict behaviour. For example, in regards to the latter, technology that draws attention to an individual may make them feel uneasy and avoid public spaces.
Although single studies can be revealing, reviews allow new insights and reinterpretations of themes from across different clinical groups and software packages. A recent meta-synthesis identified several factors influencing how technology is integrated into the management of chronic conditions, including preventing individuals from recreating a normalized identity, the generation of new uncertainties, issues with technological dependence, problems with adapting to a technologically assisted life, and difficulties with actually using the devices. In analysis of 16 studies, Obstfelder and colleagues observed that successfully implemented medical software applications had clear benefits to the challenges faced by local services, and provided solutions to medical and political issues (e.g. targeting individuals in inaccessible geographical regions). A collaborative enterprise between promoters and users, and the presence of a clear organisational and technical arrangement within a service, were found to further facilitate successful adoption of technology. Thus, a multitude of factors may influence the accommodation of mobile health devices into domestic settings, and its ability to make the transition from the foreground to the background of peoples' lives. Integration and acceptance may be vital in determining mobile-phone technologies ability to assist with long-term disease management.
The aim of this study was to explore patients' understandings and perceptions of mobile-phone based clinical assessment for psychosis, and how it might be implemented into their everyday lives and clinical care. The contents represent the qualitative component of a mixed-methodology evaluation of both text and native Smartphone application administered assessments for psychosis. The quantitative part of the study explored differences in the acceptability and feasibility of the two forms of software, and can be found in a separate manuscript. To the best of the author's knowledge a qualitative exploration of mobile healthcare technologies has never previously been conducted in individuals with schizophrenia (Daker White G, Rogers A: What is the potential for social networks and support to enhance future telehealth interventions for people with a diagnosis of schizophrenia? A critical interpretive synthesis. Submitted).