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Lupine Publishers | Applying Innovation Diffusion Theory to Determine Motivating Attributes for Successful Implementation of Internet-Based Interventions for Evidence Based Medicine: a Developing Country Context

 Lupine Publishers | Scholarly Journal Of Psychology And Behavioral Sciences

Abstract

Current healthcare outcomes depend on the adoption of valid and latest research evidence and practicing evidence-based medicine (EBM). EBM is the process of adaptation of the finest available scientific research evidence into routine clinical practice. However, literature reports gap between actual and required clinical practice. This gap will not be bridged by just updating physicians about EBM. Therefore, it is required to study the motivational factors in a context to use technology in routine clinical practice as things behave differently under varying constraints. This study aimed to address this gap by investigating motivating factors to promote EBM, focusing mainly on developing country context. Innovation diffusion theory will be used to provide the basic or theoretical support for the research as this theory states that the adoption of any innovation is itself facilitated by its certain characteristics. Cross-sectional quantitative methodology will be used for this research. SPSS and SEM will be used to analyze data and validation of the tested research model. The innovation diffusion theory may provide constructive and practical insights into the factors for the successful implementation of EBM, as well as it will provide a guideline for those who try to adopt the bestevidences into their clinical practice.

Keywords: Innovation diffusion theory; Evidence based medicine; EBM; DOI Diffusion of innovation

Introduction

The innovation is a new idea that is observed by the individual. Evidence-based medicine is an innovation in the clinical decisionmaking process, which promises to improve health care delivery [1]. But at the same time, practicing EBM is a paradigm shift that is changing the conventional way of the clinical decision-making process [2]. Acceptance of any change or innovation in conventional clinical practices is always very hard, and multiple factors play their part in the adoption procedure [3]. The characteristics of innovation play a significant role in defining its rate of adoption [4]. For an innovation to be adopted, it must be perceived as offering relative advantage, i.e., simple, compatible, observable and testable. Roger proposes one of the theoretical approaches addressing the diffusion of innovation (DOI). DOI model is supportive at describing the acceptance of explicit clinical events, mostly when determining which components will need additional effort if diffusion is to ensure [4]. Literature showed applications of DOI in health departments as well [5-7]. Becker and Mohr worked to identify organizational characteristics linked with the diffusion process among the health department [6]. One study found that demographic features age, gender, education level, urban and rural areas had a great impact on the time for adoption of innovation. It was noted that the initial adopters of innovations different by age, education and used information-seeking approaches as compared to their jurisdictions who are varied by rurality [7,8]. Graduated younger people who had a higher standing in their graduating class and belonged to urban areas were ready to adopt less risky interventions. In comparison, older people in countryside areas who had a normal standing in their graduating class, and they established their leadership roles were ready to take more risks, but they adopt less conventional innovations. It is also evident in literature that large health departments easily adopt innovations than small health departments. The accessibility of funds and human resources are the reasons which are supporting this finding [8,9].

The effective implementation of EBM in the healthcare sector, a better understanding of the motivating factors is required in detail. Relation and association of factors with each other are also very important as the context is very special, and physicians have autonomous authority in the clinical decision-making process. Context and users of technology matter a lot because things behave differently under varying constraints. It is evident from literature that the primary characteristics of the innovations have been conflicting as these are inherent in the innovation. These primary characteristics are not dependent on the perceived characteristics of the intended users. Augury of the potential user’s behavior depends on their perception about the primary traits as different users may perceive the primary characteristics of the innovation in a different way, which can cause different behavior of the users. This is the origin of the problem of using the primary characteristics of innovation.
Innovation Diffusion Theory (IDT) is used for this research work because IDT is considered relevant and useful to researchers conducting studies of information systems innovations in healthcare organizations. The IDT theory tries to explain the diffusion of new ideas, attitudes, opinions, and behaviors all over a community. The IDT is an important constituent of the upgrading health services worldwide, yet the literature illustrates that it is not always an easy theory to relate empirically [10]. IDT identifies five factors that influence the diffusion and adoption of an innovative idea or strategy. The IDT offers a theoretical framework globally to accept information technology. The role of ethnical background plays an important part in the adoption of new ideas/technology as it addresses that how, why, and what adoption rate of new technology can relate with different social backgrounds and settings [11]. IDT not only addresses the adoption of information technology only, but it also addresses other diffusion processes through the society, such as the acceptance of new technology products such as services, style of music, fashion, food, ideas, or political candidates [11-13].
This study builds upon what is known from past research on the diffusion and research conducted by Jenine K. Harris [8], which described the significance to comprehend how health personnel perceives the relative advantage, simplicity, compatibility, and testability of evidence-based decision making. Specifically, this research examined the effect of IDT factors, which can play a great motivational role for the physicians to adopt the new way of the clinical decision-making process. Results are based on their perceptions and experience of practicing EBM. Rogers identified five (05) elements of a new or substitute clinical behavior that can help in determining the adoption of a new activity such as EBM. These are relative advantage, compatibility, complexity, trialability, and observability [14]. Definitions of all these four elements are given in Table 1 along with the hypothesized relations. All these variables are discussed below.

 

Independent variables

Relative advantage: The social prestige, satisfaction and convenience, clinicians are some important factors for measuring the degree of relative advantage. Relative advantage can also be measured in economic terms for a new clinical activity [3]. Objective advantage of innovation is less important as compared to clinician’s perception of the advantages of innovation. Clinicians, patients, and the healthcare system together decide the best-evidence practice implementation. For instance, if a new clinical activity changes the power distribution balance in professional groups in a negative way, then the innovation cannot be successfully applied. On the other hand, if the proposed activity generates more revenue and benefits the clinicians without disturbing the balance of power distribution, then innovation will be readily accepted and adopted.
Therefore, it is hypothesized that
H1: Relative advantage of EBM has a noteworthy positive effect on the usage intention for EBM adoption.

Compatibility: It is necessary for successful adoption of an innovation that it must tackle an issue that is perceived as problematic by the clinicians. For instance, a new clinical activity or procedure will be adopted fast if it helps clinicians to detect cancer or other life-threatening illness at very early stages [15]. It is a strong medical belief that early detection of a disease is beneficial for the patients. Accordingly, clinical activity or procedure offering this capacity will be adopted quickly. The rapid adoption of mammography screening [16,17] and testing for prostate cancer are a few real-life examples. Though literature also has some controversial debates about the therapy mentioned above effectiveness.

Therefore, it is hypothesized that
H2: Compatibility of EBM has a significant positive effect on the usage intention for EBM adoption.

Complexity/Simplicity: Literature proves that the probability of adoption for a clinical procedure increases when the procedure is simple, easy, and well defined. For example, the rate of change in drug regimen for patients by clinicians is high and the reason behind this phenomenon is that it is easy to adopt. While some precautionary activities as detecting and handling patients with harmful alcohol consumption [18] have not been adopted quickly, though reported potential health gain in literature. This may be due to the complexity of these activities. All preventions at the primary level are vulnerable due to the patient’s resistance and their lack of accuracy in self-reporting risk behaviors. Additionally, inadequate expertise in the consulting skills of clinicians necessary to achieve change may be the other reason.

Therefore, it is hypothesized that
H3: Complexity/simplicity of EBM has a significant positive effect usage intention for EBM adoption.

Trialability: According to Rogers, “trialability” is the degree of modification of an innovation. In other words, the capability to test an intervention in medicine on a limited basis allows clinicians to explore the implementation of the procedure, its acceptability, and the possible outcomes. Rogers claims that the ability to undertake limited cost-benefit experiments of an intervention endorses trust and confidence that the evidence is not only, but its implementation is logistically promising as well.
Therefore, it is hypothesized that
H4: Trialability of EBM has a significant positive effect on the usage intention for EBM adoption.

Observability: Observability means the idea of innovation is visible to others. The visibility of innovation’s results motivates colleagues to discuss that particular innovation. Discussions on the method or innovation by the influential physician will further enhance the adoption rate. More clinicians will tend to adopt the change in their clinical behavior if the role model practitioner is more influential and charismatic. New techniques are often adopted very quickly in the surgery department because of a common belief that there are disadvantages in being “left behind” by not adopting new technology.
Therefore, it is hypothesized that
H5: Observability of EBM has a significant positive effect on the usage intention for EBM adoption.

Dependent variable

UI: In IS research, the system usage intention is a vital construct. Self-reported usage is the only aspect of UI addressed by most of the researchers in quantitative studies. These studies adapted self-reported usage to operationalize the actual system usage, in the absence of usage metrics. In technology acceptance studies intentions leads towards behavior [19]. The reason behind this is high values of correlation reported in the literature for the relation of intention and behavior. This research framework focused on the use of UI as a dependent variable because the use of UI as a dependent variable has literature support relative advantage and compatibility equivalent to PEOU and PU constructs. Under conditions of incomplete volitional control, the intention cannot act as a sufficient predictor of the behavior [20]. Diagrammatic representation of the research framework along with dependent and independent variables is given as Figure 1.

 

Methodology

Sampling

A simple random sampling method was used to collect data. Random numbers were generated through the computer after having access to the staff records of the physicians in the selected hospitals. The self-administered questionnaire used as a data collection tool. A description of the questionnaire is provided in the next section (Figure 2). A total of 350 questionnaires were distributed, and 290 responses were returned. Thus, the response rate was 82.85%. Total of twenty responses was discarded due to the same reply, missing responses or left blank and thus the usable response rate was 77.1% of the 270 respondents, 61.1% were female doctors (Mean age= 38.3 years, SD= 10.7) and 38.9% were male doctors (Mean age= 40.1 years, SD= 9.83).

 

Data collection tool

A structured close-ended questionnaire was used. At the beginning of the questionnaire definition of evidence-based medicine was provided to have a better understanding of the concept. Demographic questions (were age, gender, organization, and working experience) were included at the beginning of the questionnaire. It was requested to the participants to give feedback by thinking that practice evidence-based medicine will be a requirement in the future for their routine clinical practice. The standard variable for innovation diffusion theory (technical compatibility, simplicity, relative advantage, and intentions) was used in the current research model. The variables derived from other related studies on the extension of the IDT (Trialability and Observability) were also included to have a deeper understanding of the phenomenon. Seven (07) points Likert scale (1=strongly disagree, 7=strongly agree) was used to code the responses. English was the language of the questionnaire. All the constructs were measured through the validated items confirmed by the literature.

Results and Discussion

 

Data screening was performed to identify missing data. The expectation-maximization technique was applied by using little’s MCAR test, and it was found that the missing data was less than 10 percent, and it is missing completely at random. Missing data were handled by using the mean substitution imputation method. Skewness and kurtosis were checked to detect data normality at a univariate level while Kolmogorov Smirnov and Shapiro Wilks tests were performed to check multivariate normality. Results suggested that the data was normally distributed both at univariate and multivariate level. The linear regression method by using the Mahalanobis distance test was performed to detect the presence of outliers. Results revealed that the presence of the few outliers; it was, decided to retain all the cases, as there was insufficient evidence to suggest that these outliers were not part of the entire population (Hair et al. 2006). Construct reliability for each construct is calculated with alpha value and tabulated in Table 2 all values are within an acceptable range. After basic data screening process factor analysis is performed.

Factor analysis (FA)

FA is a multivariate regression analysis statistical method used to analyze the correlation structure between different variables/constructs. In FA, after identifying latent dimensions of the constructs, data reduction was performed. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) are two steps in FA. The data is explored in EFA, while hypothesis is tested in CFA [21]. For the current analysis, the researcher performed both steps of factor analysis. EFA: There are two main steps in EFA, which are extraction and rotation processes. The extraction process identifies the underlying factors or constructs, while the rotation process yields an easy presentation of a factor loading pattern. In the current analysis, the researcher used the orthogonal rotation method for factor loading. Before performing factor analysis, we must check the suitability of current research data for sample adequacy. For this purpose, we performed KMO and Bartlett’s Test.

Kaiser-Meyer Olkin (KMO) and Bartlett’s Test

For the current research study, the value of the KMO test is 0.853, which shows the confidence about sample size adequacy to proceed for further steps of factor analysis. The result for Bartlett’s test can be interpreted on the value of significance. The value of significance is .000 confirmed that the analysis could continue by using factor analysis as tabulated in Table 3. Furthermore, for exploratory factor analysis (EFA), the principal components analysis (PCA) and orthogonal model with varimax rotation method were applied. The result of principal component analysis also confirms the presence of 6 factors explaining the total variance of the components as shown in Table 4. The results recommended the deletion of the item SP4 of Complexity/ Simplicity construct, as it was highly cross loaded on another latent factor, OB (observability). The graphical presentation of latent constructs based on eigenvalues in EFA is shown in the scree plot (Figure 3). Scree plot plots all the eigenvalues in their decreasing order, where eigenvalues on the vertical axis and factors on the horizontal axis. The scree plot confirms the choice of 6 components.

 

Confirmatory factor analysis (CFA)

CFA consists of the measurement and structural model. The measurement model used to evaluate the model validity and reliability. The reliability includes Cronbach’s alpha, while validity includes discriminant validity. Whereas structural model is used to test the relationship between constructs. The result for discriminant validity is shown in Table 5. The off-diagonal values represents correlation squared while diagonal values represent AVE In order to meet the criteria for discriminant validity, it is required that the AVE square root for each construct should be greater than the interconstruct correlation as tabulated in Table 6. It is also found that the inter-construct correlation value was not above the square-root of the AVE, so the model satisfies the discriminant validity criterion. In Table 7, the fit indexes for both measurement and structural model are given. Hypothesis testing is done by using the structural model. It is noted that four out of five hypotheses are supported either at .001 (***) or .05 level of p-value; only one hypothesis BIßOB is rejected. Path diagram showing all the hypothesis is presented in Figure 4. The most probable reason for the insignificant hypothesis between observability and usage intention was that the software and information system had less observability by physicians, hence less rate of adoption as compare to hardware innovation [22]. Consequently, the more potential user can see the innovation, the more likely he will adopt it.

This study has following limitations:
a) Cross-sectional self-reported data limit this study.
b) Only one healthcare system, which might not reflect the factors for the successful diffusion of EBM in other health care settings.
c) Using an anonymous survey for data collection.
d) The small sample sizes.

Conclusion

Evidence-based medicine holds promise in improving health care quality and efficacy by improving the clinical decision-making process. So far, health care is decades behind other industries to adoption and use of information technology (IT). Though, stakeholders in the health care sector have highlighted the urgent need to adopt IT systems. This research work advocates that the resources presently accessible to practice EBM are unlikely to attain full diffusion in the preferred time frames. Regardless of the existing resources, the factors influencing adoption patterns are also unlikely to change absent significant incentives that have a positive impact on the new paradigm of clinical practice. Already a lot of time elapsed between the introduction of sustainable EBM technologies and today. There is growing recognition that the EBM diffusion process is multidimensional and that no single dimension will effectively address all the barriers and challenges to EBM adoption by physicians. Future research that draws on cross-national comparisons of government programs and their effect on diffusion factors could help shape policy maker’s attempts to accelerate EBM adoption among health providers. It would be informative to have in-depth information on how physicians and other providers react to the government-introduced standards.

 

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Lupine Publishers | Juvenile Delinquency and It’s Psychological Implication-a Case Study of Pakistan

 Lupine Publishers | Scholarly Journal Of Psychology And Behavioral Sciences

Abstract

According to common law-the legal dispensation system used in most countries across the world, including Pakistan-two fundamental components are required to prove the commission of a crime: firstly, actus reus and secondly mens rea. In general, the first of these two-the actus reus-is the physical act (or omission) of committing the crime. The second-mens rea-is the necessary intent to prove that the alleged perpetrator wanted to commit the crime. Besides, these demonstrate potential psychological impacts over the societies across the world, which is focused on this study. The study adopts qualitative means to examine the psychological implications of Juvenile delinquency in Pakistan and provide insightful understanding for the readers.

Keywords:Juvenile; Psychological implication; Pakistan; Legal developments

Introduction

Human nature a complex topic since the earlier ages. Factors, conditions, circumstances, helping in the evolution of human nature. The different persons are acting differently in the same situation, making us wonder. The DNA composition of every man making us all perplexed. The same number of chromosomes millions of genes and genetic codes all contributing to the evolution and development of human psychology. Youngs, children, minors have always been the apple of the eye of the legislature. From the base of fundamental rights having a special place in principles of the policy of the supreme law of the land. “Doli incapax” the Latin term referring to the limelight fact inability of young to do the crime [1]. However, the question arises in societies like Pakistan, where we see young offenders involved in all sorts of crimes. Dealing with them, the legislature in Pakistan had to provide an act Juvenile Justice System Act, 2018 [2]. So now the hypothesis we can give is that the adolescent delinquency is mainly depending on the psychology of the offender. Factors contributing to it are Age, Social Status, Abusive Culture, Inequality and Partiality, Social Circle, Poor Education System, Social Factors, Economic Factors. The present study examines the juvenile delinquency and its psychological implication as a general and taking Pakistan as a case study. It presents the background and introduction of the subject matter in section one, provides an in-depth discussion in section two and concludes the discussion in section three with proactive findings with some appropriate suggestions.

Discussion

Keeping in focus the psychology is the heart of every juvenile case, so, following special procedure is introduced by the legislature in Juvenile Justice System Act, 2018:

a) Report about juvenile psychology/ economic and social status by the probation officer.
b) Trial to be concluded in four months to prevent them from the agony.
c) No trial with adults.
d) No arrest or detention in jail.
e) Special committee to formulate a reformative judgement in a case where needed.
f) No fetters or capital punishment.
g) The expense of litigation with medical treatment by the state.
h) Immunity of publication of name and facts of juvenile.

Furthermore, the height of delight is that the punishment awarded under this act will never act as conviction in case of jobs and future life of juvenile. It means an act done in the rage of hormones will not become repent/regret in future. Legislature wanted to secure the future of juveniles, but to the contrary, it is giving dirty minds of societies to get their work done without getting their hands dirty. The hands of the juvenile are tainted with the filth of crime; their minds are tortured with the agony of offences and trials; however, they are getting away easily. The upcoming decades will lead us to see the fact that all crimes will be done by juveniles making it impossible to track the real offenders as juveniles are never to be tortured for retraction of confession. Latest amendment sections 82 and 83 in Pakistan Penal Code, 1860, giving immunity to juvenile again the very nature was to safeguard the psychology of juveniles [3]. However, the honey of immunity and the general exception is attracting the thugs of society to attack the delicate minds and incorporate them with microchips of crimes, infecting their minds and softness.

 

According to a Society for the Protection of the Rights of the Child (SPARC) report [4], published in 2012, in Pakistan 1500 to 2000, juveniles were imprisoned. This figure, however, excludes thousands of under trial juveniles whose numbers are unknown. Figure 1 presents an overview of the Juvenile detention facilities as provided by the governments of various provinces of Pakistan-it provides that Sindh province tops in the provision of such facilities, i.e. four centres; Punjab provinces adhere two centres; Khaybar Pakhtunkhwa (KPK) demonstrates one facilitation centre which is not functional; while Baluchistan province does not have any such facility [5].

Conclusion

Greater care is to be taken while dealing in such cases; penalties/ punishments/ reformations are to be awarded, keeping in view psychology of juvenile along with other factors of the case. Every case is to be dealt with individually keeping the facts in mind the future of juvenile can help us to determine the future of Pakistan.

 

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Lupine Publishers | A Review of Telepsychology and Mental Health Mobile Apps in Advanced Countries: Opportunities for Ghana’s Mental Health Care

 Lupine Publishers | Scholarly Journal Of Psychology And Behavioral Sciences

Abstract

Sustainable development denotes the development of nations in ways that are not restrictive for future generations in their efforts to meet their own needs. Without healthy human beings, sustainable development cannot be successfully carried out or assessed as a goal. For this reason, health, which forms the third arm of sustainable development goals have received much attention across nations. In Ghana, however, the aspect of health which has not received as much attention lies in the area of mental health. This paper addresses how mental health care and access in Ghana can be improved through the use of applied science and technology. Specifically, recommendations are made about the prospects that telepsychology and mental health mobile apps hold for applications in Ghana. This concept is introduced in the paper by reviewing telemental health practices and the use of mobile mental health apps in more advanced countries like the United States and Britain. The paper addresses how these two concepts can be introduced in Ghana, and guided by the experiences of other African countries, the potential associated challenges of implementation are also discussed. The paper ends with recommendations on how to overcome these challenges and makes note of the impossibility of fully achieving sustainable development goals for health when Ghana’s mental health care system remains in such dire states.

Keywords:Sustainable development; Ghana; Mental health; Telepsychology; Mental health mobile apps

Introduction

In September 2015, 194 countries adopted the sustainable development goals spearheaded by the United Nations. These 17 goals officially came into effect in January 2016 with the ultimate aim of a higher quality of life for all (“The Sustainable Development Agenda,” n.d.). Sustainable development can be defined as development that meets the needs of the present without compromising the ability of future generations to meet their own needs. Sustainable development implies development and growth in conscious ways that do not cause havoc for future generations. Human beings are the central reason for the need for sustainable development and at the same time, without humans, the agenda for sustainable development cannot be realized. Health and wellbeing comprise the third arm of the United Nations’ sustainable development goals.
The goals of sustainable development cannot be achieved when there is a high prevalence of encumbering illnesses (Von Schirnding & Mulholland [1]). Health is a significant contributor to, and an indicator of, sustainable development and its wide-reaching impact on people, societies, countries, economies and such goals as the sustainable development goals have corralled attention to this integral area. In doing so, there is an aspect of health that has not gained as much attention as the physical health related issues in Ghana and this lies in the area of mental health. Mental health can be defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community (“WHO | Mental health: a state of well-being”, 2017). It comprises an individual’s psychological, emotional, and social being with impacts on the way one thinks, feels and acts. The state of an individual’s mental health affects how stress is handled, how relationships are managed, and the decisions that one makes. Just like physical health, mental health is important in every phase of life, from childhood to adulthood. In childhood for example, mental health plays a role in the bond between parents and their children. It helps set a solid foundation for life. During adolescence, mental health plays an integral role in the way the adolescent develops a sense of morality, and in adulthood, mental health plays a significant role in the way work, family and intimate relationships develop and evolve. In a pandemic such is currently being experienced with the coronavirus, its associated distresses of grief, social isolation, fear, panic and pre-existing mental health conditions mandate the pursuit of mental health can be ameliorative.
Problems with mental health can come in mild, moderate or severe forms. They can impact how one deals with mandatory social isolation or social distancing during a pandemic. They can impact a child’s understanding of social cues, for example, as can be the case with Autism Spectrum Disorders. Issues with mental health can influence the way the student is able to take in, process and understand information as can be the case with learning disorders. In the case of the new mother, problems with mental health can impact the way she is able take care of her child as can be the case with post-partum depression. Early detection and intervention tend to yield better outcomes for individuals with mental health disorders. In Ghana, however, access to mental health care and mental health professionals are severely lacking. According to the World Health Organization’s situational analysis report on Ghana, there is a mental health treatment gap of 98% in Ghana, meaning that only 2 out of every 100 Ghanaians with mental health issues will get the care they need. Advancements in technology have played a crucial role in the evolution of health care treatment and prevention. From electronic medical record keeping systems to portable diagnostic devices, health care systems are making use of technological advancements that bring about more efficiency. Diagnostic devices are being produced to be more sensitive in ways that can lead to early diagnosis and now, because of technology, healthcare devices are being made in sophisticated ways that allow for transfer and use in countries and areas that do not have easy access to such mechanisms. The impact that technology has had on medical science has been enormous and continues to evolve daily. In the field of psychology, technology has had impacts although not as great as that of the field of medicine. During a pandemic such as the world is currently facing with the coronavirus, many occupational fields, not just medical or psychological are turning to technology to provide care and services. Ghana can explore ways that technology can positively influence mental health care and access. This paper explores a few of these ways.

Methodology

The methodology for this research paper involved a review of the telepsychology practices and mobile mental health app use in advanced countries, particularly the United States and the United Kingdom. The APA and BPS telepsychology guidelines were reviewed in addition to the United Kingdom’s National Health Service digital library for mobile mental health apps and the APA’s mobile mental health app evaluation model. These countries were selected based on the major advances they have made with regard to regulating the use of telepsychology practice and mobile mental health apps. A literature review was also conducted on the application of telepsychology and mental health mobile apps in other African countries. This review was conducted mainly to balance the opportunities of telepsychology and mobile mental health apps observed in the advanced countries like the United States and United Kingdom with the potential real-life implementation challenges that have been discovered in similar cultural contexts.

Review of Telepsychology and Mental Health Mobile Apps

The trends of telepsychology and mental health mobile apps in more advanced countries can serve as learning opportunities for Ghana’s mental health system. The following sub-sections discusses some of these opportunities and makes suggestions for implementation [2-4].

Telepsychology and mental health care access

Telepsychology can be defined as the provision of psychological services using telecommunication technologies. Psychological services provided with such a modality can be in lieu of or in addition to traditional therapy or treatment. With telecommunication mechanisms like e-mail, texting, mobile apps and videoconferencing, mental health services can be provided without the need for inperson interactions. Telepsychology presents as a unique option for patients who are not ambulatory or for people and families who are unable to travel to the psychologist’s office to access services. For individuals whose diagnoses (such as agoraphobia or the fear of social situations) prevent them from leaving the house to get to the psychologist, telepsychology presents as an opportunity to begin the process of treatment that would eventually help them overcome their fear and potentially transfer to in-person treatment. The practice of some form of telepsychology or online counseling is not a novel concept in Ghana or abroad. Telepsychology has been around since the launch of the internet in 1972 (Alleman [2]). Currently, psychologists worldwide perform or have performed some sort of online counseling or telepsychology. In 2008, a survey conducted by the American Psychological Association revealed that 87 percent of psychologists provide mental health care services via telepsychology (American Psychological Association, 2009). The prevalence of this practice has led to the formulation of practice guidelines in some developed countries like the United States, Britain, and Canada. Mental health care access is an area in Ghana’s mental health care system that requires major development. With the exception of the popular, major psychiatric hospitals in the country, it can be difficult for the average Ghanaian to know where to go to in order to seek mental health care especially one that is not located in a psychiatric hospital. In recent years, the Ministry of Health has made provisions to allow for the placement of clinical psychologists in its hospitals. However, mental health care access continues to be a problem because of location, insufficient numbers of clinical psychologists and stigma among other reasons. Today, one is more likely to gain access to a clinical psychologist in the nation’s capital of Greater Accra than in any of the other regions of Ghana. This problem is worsened by reported estimates from Osei [3], the former Chief Psychiatrist of the Accra Psychiatric Hospital of a doctor-patient ratio of 1:1.7 million in the mental health sector (Awaf [4]). Stigma can be a deterrent when it comes to seeking mental health care even among people who have relatively easy access to these services. With clinical psychology facilities sometimes being housed in places like the Accra Psychiatric Hospital, individuals may be afraid to seek out these services for fear of being perceived as ‘mad’. In cases like these, the practice of telepsychology holds the potential for ameliorating such problems by abbreviating the distance between the prospective patient and psychologist, for allowing easy access to psychologists and for reducing the potential stigma of accessing the psychologist in a setting that could potentially be stigmatizing.

Development of telepsychology guidelines and opportunities for ghana

In 2013, the American Psychological Association (APA) released their guidelines for the practice of telepsychology. Prior to that in September 2009, the British Psychological Society (BPS) released its second edition of regulations concerning the provision of psychological services via the internet and other nondirect means (Professional Practice Board [5]). The formation of these guidelines was a response to the increasing rate of the use of telecommunication strategies among its psychologists. While the APA and BPS recognized the potential for telepsychology to increase access to psychological services, it also recognized the need for the formal regulation of tele psychological practices because of the potential challenges it presented. It is possible for Ghana to take a cue from these guidelines in order to pre-empt any potential challenges, and to keep itself from being reactive when tele psychological services rise to the capacities experienced in more developed countries. The formulation of such a guideline for Ghana’s psychologists will also serve as a mechanism to permit the use of such a service delivery mechanism as a solution to Ghana’s mental health care access problems [6]. For the APA (and BPS), core issues identified in their guidelines for telepsychology include the competence of the psychologist in providing tele psychological services and the importance of the need for the psychologist to be well-versed in the use of the telecommunication technologies as well as the awareness of the potential impact of such a modality on clients/patients, supervisees and other relevant stakeholders (“Guidelines for the Practice of Telepsychology”, 2013). There is a vast array of choices when it comes to telecommunication technologies today and it is important for the psychologist using such modalities to be knowledgeable about their chosen systems of communication especially where issues of privacy and confidentiality are concerned. Given the sensitivity of information that is shared in the client-psychologist relationship, the potential fears of stigma as well as the consequences of client-psychologist privileged information becoming public knowledge, it is important for the psychologist to be thoroughly knowledgeable about their telecommunication mechanisms and its privacy/confidentiality limitations in order to select systems that provide the most privacy/ confidentiality possible and to communicate any such limitations to the patient/client as sanctioned by psychological practice.

The upholding of the standards of care in the delivery of telepsychology services was also an important issue in the development of the APA and BPS telepsychology guidelines. By these, the guidelines reinforced the importance of translating the same ethical and professional practices of in-person services to telepsychology. While telecommunication technologies have the potential of connecting the patient to the psychologist, it also has the potential of creating a disconnect in the patient-psychologist therapeutic relationship. The patient/client who ‘sees’ the psychologist via a telecommunication device may not feel as close to the psychologist as the patient/client who does so face-to-face or in-person. In the patient- psychologist relationship, trust and the feeling of safety are important, and these tend to be more easily developed through in-person interactions.

For this reason, the APA and BPS telepsychology guidelines advise that psychologists choose telecommunication systems that do not negatively impact the development of a good patientpsychologist therapeutic relationship. In the spirit of upholding the ethical and professional standards of practice, it is also important that the psychologist assesses the effectiveness of telepsychology modalities to meet the needs of the client. While mental health care access can be a problem, telepsychology should be an option which not only connects the patient to the psychologist but which also does so in a way that ensures the patient is receiving optimal ethical and professional standards of care. Ethical and professional standards of care cannot be sacrificed on the altar of mental health care access. Sometimes, the severity of a mental health issue is such that an in-person service is required, and treatment cannot ethically be provided via the practice of telepsychology.

An area of focus that the APA guidelines concentrated on and which might potentially require some significant adaptation for Ghana as compared to the other identified core areas lies in the area of psychological testing. Psychological testing is equivalent to the laboratory testing that is performed in the medical sciences in that it is also needed for aiding in diagnoses formation and the assessment of the current functioning of the patient. While there are online psychological testing options, most tests are designed for in- person interactions allowing for the observed behaviors of patients/clients during the testing process to serve as important information in the testing process. For example, if a cognitive test is being conducted on a child who ends up scoring above average, it is also important to note if the child was attentive during the testing process or if the child had difficulty staying seated. It is important to note if the child was able to follow social cues or the child answered questions while staring out a window without making eye contact with the psychologist. While testing via videoconferencing can provide such information, it can be difficult to ascertain what part the videoconferencing in itself contributes to the behaviors witnessed in the patient/client during the testing process. Psychological testing in Ghana already possesses issues given the fact that the available testing tools are designed for a foreign population. This can create issues regarding validity and reliability of tests results for the Ghanaian cultural context without the additional variable of a telecommunication system of testing. Still, with the goal of the maintenance of ethical and professional standards of practice, guidelines can be formulated that ensures integrity of practice and the provision of appropriate care while trying to solve the problem of mental health care access.

Mobile apps and mental health care access

Mobile applications serve as mechanisms through which the problem of mental health care access can also be solved or improved upon. A mobile application or mobile app is an application software that is designed to run on mobile devices such as smart phones or tablets. With advances in technology, it is more common now to find individuals using smart phones which come with the capability of having apps such as those for emails, social media, messaging, shopping, gaming, and other areas of interest. Today, some smart phones have already built-in mobile apps that are geared towards health. Some apps for example allow people to track their food and water intake, physical activity and even stress levels. There are mental health apps (also known as mHealth apps) too that, for example, provide support for teenagers struggling with depression like the Code Blue app and apps that guide people through breathing exercises for stress management like the Breathe2Relax app. Some of these mental health apps are also interactive, combining therapeutic techniques with real life experts like the Lantern app. Other apps that can be used in addition to real life treatment include mobile applications such as the PTSD Coach, Self-Help for Anxiety Management (SAM) and Optimism apps which allow people to track their symptoms over time while providing psychological tools (“Top 10 Mental Health Apps”).
As already discussed, the problem of mental health care access in Ghana is impacted by the lack of clinical psychologists in the country, the physical distance between the patient and psychologist as well as the inability of people to know where and how to contact a psychologist, especially one that is not located in a psychiatric hospital setting. While accessing mental health services in a psychiatric hospital setting is not a problem in itself, there can be a hesitancy to access services in such locations because of the potential stigma of being perceived as ‘mad.’ Mobile applications have been used as a bridge to mental health care access problems in countries like the United States and Britain. mHealth apps can be designed where people in Ghana have a way of accessing available clinical psychologists and facilities by location and specialty. These apps can have built in the ability of also getting in touch with or communicating with a psychologist to begin treatment. Such an app also has the potential of regulating professional psychology practice in the country if the app only includes psychologists and facilities in the country which are actively licensed. When a psychologist or facility ceases to maintain active licensure, measures can be put in place to withdraw inclusion in the app or deactivate visibility and access to such psychologists and facilities. With such an app approved by the Ghana Psychological Council, psychologists will want to ensure active licensure of themselves and their facilities while potential patients are assured of getting access to qualified and approved professionals and facilities. Such an app which provides information on the psychologist, location and specialty will also serve as important data for developing the profession in the country. For example, if the app indicates the need for more psychologists who work with geriatric populations, geriatric training programs can be developed to cater for the mental health needs of such a population in the country. In mental health treatment, clinicians sometimes make use of group therapy to help support individuals who struggle through the same symptoms or problems. For example, group therapy can be used with individuals struggling with substance use, individuals who have gone through grief and loss, and individuals who struggle with depression and anxiety. This group treatment modality allows individuals to receive support from others who experience the same problems they go through and whom can empathize with their struggle. It also presents with opportunities for these individuals to hold each other accountable to treatment goals and to have a sense of purpose through their ability to contribute to the lives of others like themselves who are hurting thus raising self-esteem. There are apps that Ghana can adapt or develop that provide the platform to offer group therapy with a trained therapist. Such an app can be helpful for communal support through mental health struggles without some of the potential reservation and risks to confidentiality that the typical face-to-face group therapy presents.

In the traditional face-to-face group therapy setting, there are times when an individual or groups of individuals may not be as open or as vocal in ways that allow them to contribute to and benefit from group treatment. When the option of such an app is available, this can allow those who would likely be more hesitant and withdrawn to be more vocal and open. In addition to the group therapy module, mental health mobile apps present as a good opportunity for complementing in-person treatment or the practice of telepsychology. mHealth apps can provide supportive services to patients and clients between sessions that help facilitate treatment. The individual who is seeing a psychologist for anxiety related problems, for example, can have an app that provides resources for coping such as breathing exercises.

According to Henderson et al. [7] , one factor that affects the seeking out of mental health services includes lack of knowledge to identify features of mental illnesses. It is possible for people with mental health problems to experience difficulties that they either do not understand or which they brush aside. Sometimes the responsibilities of daily life can prevent one from attending to mental health problems until symptoms reach a point where they become severe enough to require psychiatric hospitalization or attempts are made to commit suicide. There is a great need for Ghanaians to be educated on mental health and through psychoeducation, convey the importance of seeking help while normalizing mental health help seeking behaviours to that of physical health seeking behaviors. When people are made to conceptualize seeking mental health help the same way they would seek medical help, fears associated with mental health stigma can be reduced and we could possibly see a decline in suicide behaviors. Mental health apps that are geared towards psychoeducation can be useful in Ghana’s fight for mental health education, access, and care. Such mental health apps can include screening for mental health issues which would have the potential for making on the spot referral recommendation when applicable. For example, an individual experiencing symptom of depression can take a questionnaire on the mHealth app that indicates their level of depression (whether mild, moderate, or severe) and makes recommendations to see a psychologist.

Development of mhealth apps and opportunities for ghana

The American Psychological Association has developed an app evaluation model in response to the increasing use of mHealth technologies. This decision to develop the evaluation model was also a response to questions received from mental health care professionals concerning the efficacy and risks of these mobile mental health apps. It appears the expanding use of mobile mental health apps was such that the development of the evaluation model was a better alternative to running every available app through an approval process and advertising those as APA-approved. In contrast to the stance taken by the American Psychological Association, the United Kingdom’s National Health Service has included in its digital library, a list of mhealth apps with indications of which apps have been approved and which apps are in the process of being tested by NHS. There are legitimate concerns regarding the increasing number of mHealth apps and the associated tendency for people to self-diagnose or use such mechanisms in lieu of the necessary professional care. The increased access to the internet in general has come with the tendency for people to look up the symptoms they experience -whether physical or behavioral- in order to figure out what is wrong with them. The enormous and varied number of mHealth apps only provides more avenues for potential selfdiagnoses and misuse.
It is for this reason that Ghana’s Psychological Council could combine the strategies used by both the APA and UK’s NHS to formulate an evaluation model that is used to recommend apps for the public. With such a mechanism in place, mHealth apps can be reviewed and regulated by the appropriate professional national body from the very onset. Also, mHealth app developers can begin the app development process keeping in mind that the final product would have to go through an approval process before being used by the public. The Ghana Psychological Council or Association bodies can themselves develop approved apps for its professionals and countrymen and women as well. The apps that are locally developed would have to be suited to the Ghanaian context and take into consideration some of the cultural and unique expressions of mental health problems among Ghanaians, for example, the commonality of somatization of some mental health problems.

Finding and Recommendation

Telepsychology and mental health mobile apps hold unique opportunities for improving mental health care and access in Ghana when adopted. Like most opportunities, these two concepts present with challenges that will be discussed in the sections to follow with recommendations on how to overcome these obstacles in order to improve mental health care and access. When mental health care and access is improved upon, the nation’s sustainable development goals for health can make gains towards a more complete picture of fulfillment. Ghana’s sustainable development goals for health cannot be entirely met if its mental health care problems persist.

Human health resources

Telepsychology and mobile apps provide potential solutions to mental health care problems in Ghana, but certain issues currently impede its implementation. These issues are not unlike the issues discovered in an analysis of tele mental health in South Africa (Jefee-Bahloul et al., [8] ). Just like in South Africa, Ghana does not have sufficient human health resources. As already discussed, there aren’t enough mental health professionals to meet the current demand in the nation. For this reason, there is the need for mental health or psychology training up to the highest level possible in the country. There is also the need for the profession to be properly supported by the government in order to keep from deterring other professional aspirants from the field of mental health care or psychology.

Infrastructure

An obvious potential limitation also lies in the requirements of technical and administrative support that the proposed technology mechanisms require. The use of telepsychology mandates adequate bandwidths that might not be available or which may be too expensive to acquire. Also, while messaging apps like WhatsApp and Skype can be used for telepsychology, these also require adequate amounts of data which could be relatively expensive when used at the levels that would be required for appropriate treatment. Again, should the problem of expense be addressed, another potential problem arises in the requirement of stable network connectivity which is not always the case in Ghana.

Political will

Until the year 2012 when Ghana’s mental health bill was passed, the country operated under a mental health law that was put into effect in 1972. Although Ghana made tremendous strides with the passing of the 2012 mental health act, five years later, the Legislative Instruments which will serve to assist the implementation of the bill is yet to be passed (Boateng [5]). Improvement in mental health care and access through recommendations of modalities like telepsychology and the use of mental health mobile apps would also only be more successful with government or political backing. Without support from Ghana’s government to improve upon mental health care, Ghana will likely continue to lag behind when it comes to attaining the advances that have been seen in the more developed countries with mental health care practice [9-11].

Conclusion

Sustainable development is development that meets the needs of the present without compromising the ability of future generations to meet their own needs. The health of human beings plays a central role in the fulfillment of sustainable development goals both as enactors and indicators of sustainable development. Health forms the third arm of the United Nation’s sustainable development goals and has received great attention given its implications not just on sustainable development goals but to the lives of families, societies and economies. In meeting sustainable development goals for health, mental health has not received as much attention although it holds just as much significance in attaining sustainable development goals for health. Mental health can have just as significant an impact on families, societies and economies. An individual with a healthy body but an unhealthy mind can be just as incapable of functioning as an individual with a healthy mind but an unhealthy body. Telepsychology and mobile mental health apps present as great opportunities for mitigating mental health care access problems in Ghana. During and outside of pandemic realities, these technologies can serve as means of connecting the potential patient to the psychologist, discovering options for mental health care, regulating the practice of psychotherapy in the country, and providing psychoeducation and complementary resources to treatment. With continuing growth in Ghana’s telecommunication technologies and support for the work of mental health professionals, the discussed challenges can be overcome and Ghana can make its way toward greater mental health care access, and ultimately, the achievement of its sustainable development goals for health.

 

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