Systematic review: eHealth potential under-used
Last week (21 February 2018) saw the publication of an important review of eHealth in treatment of Offenders in Forensic mental Health.
The authors, Hanneke Kip, Yvonne H. A. Bouman, Saskia M. Kelders and Lisette J. E. W. C. van Gemert-Pijnen, undertook a systematic review of 50 international studies in which electronic health was used for a wide range of treatment purposes including virtual reality, web-based interventions, and videoconferencing. The results confirmed the benefits of technology, for example, the acquisition of unique information about offenders, effectiveness, and tailoring to specific characteristics, but indicated that these are not fully taken advantage of.
The review acknowledges the difficulties and challenges of forensic mental health treatment. The authors acknowledge, for example, that meta-analyses on interventions targeting batterers, juvenile offenders, and relapse prevention of offenders found low overall effectiveness on clinical measures which they attribute to a number of issues including:
- The low motivation of many forensic psychiatric outpatients for their, often compulsory, treatment.
- Very many service users have complex needs which need simultaneous and co-ordinated responses.
- Many are often disproportionately poor, unemployed, and have lower literacy rates, which might affect their capability of being engaged in and adhering to interventions.
- Despite this range of needs and additional barriers, many providers offer only a “one-size-fits-all” approach.
The benefits of eHealth
The authors argue that eHealth has several characteristics that could be of added value for forensic mental health.
First of all, the content, way of communicating and design of technology, can be tailored to subgroups or individual users, based on their characteristics, needs, or context. This tailoring or personalization of eHealth interventions creates a better fit between the technology and the individual user and consequently addresses the complexity and diversity of the forensic mental health domain. Tailoring has been proven to enhance user engagement and effectiveness of multiple eHealth interventions.
Another way to account for the complexity of the target group is by the use of existing protocols, guidelines, and evidence-based theories in interventions, which is advised for forensic and also general mental health. However, research finds that many existing in-person interventions for forensic mental health care are not theory-based, or treatment integrity by therapists is not always satisfactory. Technology offers the possibility to deliver interventions based on theory and guidelines to patients in a standardized way to increase effectiveness, while still being able to tailor its content to individual patients. Consequently, eHealth can standardize care and interventions by incorporating existing guidelines.
eHealth has several characteristics that can increase the motivation of forensic psychiatric patients in managing their own care. If patients are motivated, they are more likely to have higher adherence to an intervention, meaning that they use it in the intended way and obtain positive treatment outcomes compared with disengaged and unmotivated patients. Patient engagement can be achieved by using innovative, state-of-the-art technologies that appeal to the patient, like serious gaming, wearable technology, or VR. Many of these new technologies do not primarily rely on conscious cognitive reflection, but mainly create experiences, which suits the lower literacy and education of the average forensic psychiatric patient. The way an intervention is designed can contribute to adherence as well, for example, via the application of principles from persuasive design.
Finally, tailoring of a technology can positively impact adherence since it increases the fit with a patient’s needs and wishes and can increase the perceived personal relevance of an intervention, which has a positive influence on patient motivation.
The 50 studies of eHealth technologies used in the treatment of forensic psychiatric patients covered a broad range of technologies that were studied using different research methods, ranging from Randomised Controlled Trials to exploratory qualitative studies.
The opinions of patients and therapists towards eHealth were positive, access to care was increased, the technology fitted the patient, interventions were—or were expected to be—effective and efficient, technology was said to increase fidelity of treatment, and offered new possibilities and information.
Disadvantages were that not everyone was enthusiastic about and able to use technology, there were concerns about privacy, in-person contact could decrease, technology could have unintended negative consequences, not every study found strong proof of effectiveness and efficiency, technology could contain errors, and many settings did not have regulations or protocols for eHealth.
The researchers conclude that eHealth has a lot of potential and much has been achieved at this point in time, but there are also many opportunities that are not used. Important advantages of technology were related to technology being able to deal with the complex nature of the forensic psychiatric population. Technology can take the low literacy and education level of forensic psychiatric patients into account by not relying primarily on language and cognitive reflection; it can create real-life, interactive situations in which skills can be trained, or information on reactions can be gathered via physiological measures which can be integrated in treatment.
However, most of these types of technologies are not thoroughly studied, so more studies on technologies such as VR or wearables that monitor arousal are required to determine whether they actually have added value for forensic psychiatric patients.
When looking at the use of technology in practice, many studies reported positive attitudes of both patients and care providers. A positive attitude increases the motivation to actually use a technology in the intended way. However, none of the studies paid attention to matters related to the use of technology such as engagement and adherence, despite the knowledge that treatment motivation and completion is low in forensic psychiatric patients.
Research into the manner in which technology is used by patients and suitable methods to increase their engagement and adherence is required to gain more insight into how and why technology can motivate forensic patients. One key issue raised as effective in engaging patients in several studies is tailoring interventions as a way to overcome the current predominant “one-size-fits-all” approach in forensic mental health by increasing the fit between the technology and the user.
The researchers, unsurprisingly conclude by calling for more research to be conducted on the interrelationships between technology and treatment motivation, and ways to increase engagement and adherence such as tailoring need to be identified.
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