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‘SMS’ for mental health – Feasibility and acceptability of using text messages for mental health promotion among young women from urban low income settings in India
Asian Journal of Psychiatry 11 (2014) 59–64
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Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
‘SMS’ for mental health – Feasibility and acceptability of using text messages for mental health promotion among young women from urban low income settings in India Prabha S. Chandra a,*, H.R. Sowmya a, Seema Mehrotra b, Mona Duggal c a
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bangalore, India Policy Center for Biomedical Research, Translational Health Science and Technology Institute, (Under DBT, GoI) National Institute of Immunology, Aruna Asaf Ali Marg, New Delhi 110067, India
b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 May 2014 Accepted 11 June 2014
Objective: The current study assesses the acceptability and feasibility of mobile text messages for promoting positive mental health and as a helpline among young women in urban slums of Bangalore. Methodology: Forty girls in the age range of 16–18 years from urban slums received messages every day for a month. They could call or message back or give a ‘missed call’ to the same number whenever they had emotional problems or felt like talking to a counselor. The received responses in the form of return texts, missed calls and return phone calls were recorded. Feedback about the feasibility and acceptability of the mobile messages was collected after a month. Results: 25 out of 40 (62.5%) participants called back, asking for mental health services and to say they felt good about the messages. 23 of 40 (57.5%) messaged back regarding their feelings. 62% reported that they felt supported with the mental health messages. Male family members of nearly half of the participants called back to check the authenticity of the source. Most women did not face any problems because of the messages. Conclusion: This pilot qualitative study indicates that mobile text messages are a feasible and culturally acceptable method for mental health promotion and prevention among young women from urban slums in India. Issues such as consent from the woman and family, ensuring confidentiality and providing authentic and reliable support services, need to be taken into account before attempting to scale up such a service, particularly in vulnerable groups. ß 2014 Elsevier B.V. All rights reserved.
Keywords: Mental health promotion Mobile phone Gender India mHealth
1. Introduction Mobile health (or mHealth) is defined as ‘‘the use of mobile and wireless technologies to support the achievement of health objectives’’. This approach includes diagnostic and treatment support, remote monitoring/data collection, education services and tools to improve communication and training for healthcare workers (WHO, 2011). Mobile technologies for mental health have been gaining ground in several countries across the world. Personalized text
* Corresponding author at: National Institute of Mental Health and Neurosciences, Bangalore 560029, India. Tel.: +91 80 26995272; mobile: +91 9880383057. E-mail addresses: [email protected], [email protected] (P.S. Chandra). http://dx.doi.org/10.1016/j.ajp.2014.06.008 1876-2018/ß 2014 Elsevier B.V. All rights reserved.
messaging has been used to manage appointments among youth with mental illness, to record mood state in bipolar disorder, in assessment of schizophrenic patients, to prevent relapse in alcohol use disorder, support patients with bulimia nervosa, evaluate mood among patients with depression, communicate medication changes and provide expressions of support (Furber et al., 2011; Spaniel et al., 2008; Granholm et al., 2012; Bopp et al., 2010; Moore et al., 2012; Agyapong et al., 2013; Ma¨kela et al., 2010). Personalized text messages have also been used for substance cessation (Free et al., 2009; Rodgers et al., 2005). Mobile health has also been used widely in physical health for education, monitoring or management of health related issues such as medications, reminders for appointments, self monitoring symptoms and promoting health related information’s among people (Buhi et al., 2013; Cole-Lewis and Kershaw, 2010; Fjeldsoe et al., 2009; Krishna et al., 2009; Sharma et al., 2011; Shet and De Costa, 2011).
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According to a recent survey conducted in the US, 78% of adolescents use mobile phones. The preferred way of communication is text messaging compared to voice calls, social sites, e-mail and even face to face talking. This survey also reports that compared with boys, frequency of receiving and sending text message is comparatively high in girls (Madden et al., 2013). A literature review by Joyce and Weibelzahl (2006) has discussed several barriers among youth in seeking help from counseling services related to fear, privacy, shame, guilt, embarrassment, lack of trust in others, the feeling that one should be able to cope on one’s own and not knowing what support is available or how to get it. However, in youth outreach services, young adults find the use of mobile phone and text messages a safe and practical way of maintaining contact and coordinating meetings with mental health professionals (Furber et al., 2011). Youth have also found it acceptable to have data about their daily activities, behaviors and attitudes collected through an automated text system (Garcia et al., 2014). India already has several mHealth pilot programs in place and is working to integrate mHealth into its health care systems (Ganapathy and Ravindra, 2008). These include maternal and child health services, tuberculosis treatment services and anti retroviral therapy adherence programs. Many studies in India, have reported mobile phone communication as an effective and acceptable tool in management of diseases such as Type-2 diabetes, tuberculosis, epilepsy and HIV for both patients and health care providers (Ramachandran et al., 2013; Elangovan and Arulchelvan, 2013; Bigelow et al., 2013; Shetty et al., 2011; Bali and Singh, 2007; Gautham et al., 2014). Based on current research in India, it appears that text messages are the most preferred mode of communication (Priyaa et al., 2013; Prasad and Anand, 2012). Text messages rather than pamphlets are preferred for educational information related to oral health, prevention of communicable and non-communicable diseases such as HIV/AIDS, tuberculosis and addressing sexual risk behaviors (Sharma et al., 2011; Deglise et al., 2012; Schneider et al., 2012). Researchers have shown that adherence to treatments for HIV, diabetes and tuberculosis has improved with sending regular text messages and SMSs reminders to patients (Elangovan and Arulchelvan, 2013; Shetty et al., 2011; Rodrigues et al., 2012; Manoharan et al., 2012; Sidney et al., 2012). Bali and Singh (2007) in their study in a rural area of northern India, found that people used their mobile phones for seeking medical consultations and help was sought mainly for skin, respiratory, mental health and sexual problems. Aggarwal (2012) in his recent review has discussed how mobile technologies are a valuable method for mental health interventions in South Asian counties. The wide usage and cultural acceptability of mobile phones can be harnessed for enhancing mental health literacy and ensuring help seeking in these countries. In specific situations mobile phones may have an added advantage, such as among women who are often denied access to mental health care in patriarchal societies and in remote areas where mental health services are not available (Farooqi, 2006). Mobile phones can also be a useful way of seeking information in situations where stigma can prevent information and help seeking, among those who are psychologically disturbed (Gulliver et al., 2010). In low and middle income countries, smart phones are still not affordable by the large majority and there is a need to rely on text messaging using a basic handset as a means of communication. While using mobile phones may be an acceptable way of addressing mental health in young women, ethical issues in the use of mHealth in the South Asian context, such as confidentiality of the text messages, the need to inform the user to delete the
messages, consent issues and the privacy of minors who may seek counseling without parental consent also need to be addressed (McGee, 2011). Issues such as the need for caller identification so that those at the receiving end are assured of a legitimate service and concerns related to its use among adolescents less than 18 years old are other issues that need to be examined. There have been recommendations that before mHealth is used widely, there is a need for more qualitative studies among users. The questions that need to be addressed include – how comfortable do users feel about discussing mental health issues using text messages, how does one communicate in low literacy situations, what barriers might need to be overcome while using text messages for mental health, what are the confidentiality concerns and what is the nature of content that is most acceptable? Understandably, the answers to these questions might be different for men and women, for different age groups and for different clinical conditions. Research from India has shown high rates of mental health problems and suicidal behavior in youth population (Pillai et al., 2009; Sidhartha and Jena, 2006). A study conducted among rural and urban young people from Goa, India, indicated that rates of suicidal behavior were higher among girls than boys. Gender discrimination from the society and from parents, physical violence, sexual abuse/violence and psychological distress were factors that were found related to increasing suicidal behavior among young people (Pillai et al., 2009). Many young people do not seek help for mental health problems due to various personal and structural barriers such as: fear of stigma associated with mental health disorders (e.g., it is seen as a weakness); concerns about confidentiality; lack of knowledge about services; the idea that symptoms of psychological distress reflect only a temporary age crisis; and lack of appropriate responses from both peers and adults. Many of these barriers relate to limited mental health literacy. There is extensive need to improve awareness, to plan interventions to improve recognition and enable help-seeking for mental health problems. While studies from India indicate that mHealth is feasible and acceptable in illness management, not much is known about its utility in mental health interventions. There is also a lack of data on what youth feel about mHealth interventions. This paper is an offshoot of a larger study entitled – mental health of girls growing up (MOGGU – flower bud) which focused on various low cost interventions in order to promote mental health and enable early help seeking among young women living in low income urban settings. The main objective of the study was to assess feasibility and acceptability of using mobile phone text messages as a means of sending information on positive mental health and providing a helpline service to young women in low income settings.
2. Methodology As a first step, focus group discussions were conducted with 26 girls (eight in three groups) and 20 mothers (six in three groups), to understand the issues and concerns of young women between the ages of 16 and 19 years, living in urban slums. Feasible and low cost mental health interventions were also discussed and most group participants, including mothers felt that the mobile phone was a friendly and acceptable tool for interventions. Based on the findings from the focus group discussions, the current study was initiated. Forty girls from low-income families who were attending the same college located in an urban slum gave consent for the study. Consent of a parent or guardian was also taken if the girl was below 18 years of age. All the young women gave consent for receiving mobile messages and a
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majority took permission from their parents. None of the participants reported a previously diagnosed psychiatric illness. Participants were in the age range of 16–18 years and were doing their pre-university education. The inclusion criteria were – (a) girls in the age group of 16–18 years, (b) girls who had access to a mobile phone (either own phone or sharing a phone with family or friends) and (c) girls who could read basic English. Participants were informed that they would receive a message every day for a month. They were also informed that they could call back, message or give a ‘missed call’ to the same number whenever they felt sad, angry or depressed or when they felt like talking to a counselor. The women received a message every day. Messages alternated between a positive mental health tip or helpline information. The helpline message asked them to message or call back if they felt like talking to someone when emotionally upset. Messages were sent during afternoons (12 pm–2 pm). Messages were sent and phone calls received only by female researchers. Both researchers and the participants used basic handsets. The messages were sent in the vernacular language (Kannada) using the English script.
Table 2 SMS for mental health – feed back form. 1
How did you feel about the positive messages
2
How did you feel about the helpline messages
3
How did you feel about the distress messages
4
Any problems faced because of the messages? How satisfied were you when you sent a message back or someone called back? How can we make this more effective? What helped you more?
5
6
3. Selection of messages Quotes and brief phrases on positive well-being were sought from two mental health experts and two young women from the community. Nearly 50 such messages were compiled, following which, the research team chose fifteen messages which seemed most appropriate for age, gender and socio-cultural background. The messages were either inspirational or focused on handling emotions. These were then translated into Kannada (the local language) using the English script (Table 1). The messages were sent over a month. All the responses received in the form of return messages, missed calls and return phone calls were recorded. After a gap of 1 month, the researchers contacted the participants for feedback about the feasibility and acceptability of the mobile messages using a feedback questionnaire (Table 2). They were also asked if they faced any problems due to the messages (such as family members objecting) and what they felt about the timing and content of the messages. 4. Results The mean age of the participants was 16.8 (SD 1.68) years and they were all studying in the 11th and 12th year in a pre university college. Seventy percent of them were from nuclear families and 30% from joint families. All of them belonged to low income families and lived in urban slums. Most of their parents worked as casual laborers.
Table 1 Some examples of the translated messages are. Every failure is a lesson – learn well. Every success is a mirror – care well Nothing is interesting when you are not interested Nothing is good or bad, but thinking makes it so Learning and trying to handle difficult times in a calm manner is a sign of growth Patience is bitter, but its result is sweeter. Have patience Whenever you feel that you failed, say these words – I have not failed. My success has just got postponed Forgive what you can’t forget. Forget what you can’t forgive Your mind is your great friend if you control it. But your mind is your greatest enemy if it controls you. Helpline Message: ‘‘Bejaru/dukka, kopa athva athanka anisutideya? Athva MOGGU counselor jothe mathanada bekadalli dayavittu call/missed call/MSG madi – (Research mobile no)’’. ‘‘Feeling sad, angry or anxious or just want to talk to a MOGGU counselor – please call/give a missed call/MSG – (Research mobile no)’’. MOGGU Team NIMHANS’’
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7 8
9 10
11 12 13
14
How often should it be sent so that you don’t feel awkward or disturbed, yet feel good? How can we make this more useful for young women? Is there any specific time you would like the messages to be sent? If Yes, What time of the day? What should we do if the girl does not have her own phone? Did you share these messages with others? Any other suggestions? – language, type of messages, helpline, response, should it be only positive mental health messages or helpline? How did you feel when you were receiving positive/ helpline messages?
Neither good nor bad Liked receiving the messages Did not like it Liked some and not others Felt someone cared Felt intrusion into my life and privacy You felt like calling back Felt that someone is there to help Felt like messaging back You felt like calling back Felt that someone is there to help Felt like messaging Family members objected Was stigmatizing Not at all Little Very much
Positive messages Helpline messages Every day Once in 2 days Once in a week
Yes/No
Morning/afternoon/ evenings
Yes/No
16/40 (40%) of them owned a mobile phone and 24/40 (60%) of them shared a mobile phone with their family members. During the 1 month period, 25/40 (62.5%) of the participants called back, asking for mental health services, to confirm who was sending the message and to say they felt good about the messages. 23/40 (57.5%) of them messaged back and texted messages such as: – ‘‘thank u’’, ‘‘Kopa (Anger)’’, ‘‘Bejaru (Sad)’’, ‘‘call me’’, ‘‘I am happy’’, ‘‘I am not having any feelings or anger; my life is going on happy - no tension’’, ‘‘I feel free and fresh’’, ‘‘OK – I am referring this number to my friends’’. Family members (usually brothers and fathers) of 18 (47.5%) of the participants called back to check who was sending messages, even though the consent of the parents had been sought earlier. Most of them felt reassured when the research group explained the study. The research team was able to contact 37 of the 40 participants from the group after a gap of 1 month. Based on the responses in the feedback form, 23 (62%) of the participants reported that they liked to receive the messages and 6 (16.2%) reported they felt that someone was there to care for them. When receiving messages, 19 (51.4%) of the girls reported that they felt very happy, 8 (21.6%) reported that they would like to receive more messages while 3 (8%) faced family objections for receiving messages.
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4.1. Messaging preferences Forty percent of participants reported that they would like to receive these kind of messages every day, 35% (13) wanted them once in 2 days and 24% (9) preferred to receive a message once a week. 78.4% (29) felt that messages should be sent at a particular time of the day with 90% (31) reporting that evenings were the best time to receive the mental health messages. 4.2. Content of the messages Data from the feedback form indicated that 62% (23) of the girls preferred the helpline messages over positive mood lifting messages. When receiving a helpline message, 62% (23) of the participants reported feeling that someone was available to help them, 27% (10) felt like sending a return message and 11% (4) felt like calling back. 32.4% (12) felt very satisfied when they got a response to their calls or messages. 65% (24) of the participants felt that they needed to share these received messages with their friends and family. 4.3. Suggestions to make it more effective Participants felt that messages should be accompanied by awareness programs on mental health and they wanted more messages. Girls who did not have their own phone suggested that we could a call a friend or family member or provide the same messages in a printed format by post. 5. Discussion This preliminary study has provided important information in understanding messaging preferences to inform development of mobile goal-directed behavioral interventions among young women from low income settings. Based on feedback received from the girls, it appeared that most of our subjects did not face any major problems from their family members during the study, even though individual phone ownership was less and most of them shared their phones with their families. This group is particularly important due to the high rates of mental health problems, poor mental health literacy and poor access to mental health services (Farooqi, 2006). Research has also shown that in countries such as India, interpersonal support from people within the community is often preferred over visits to physicians, especially psychiatrists (Kermode et al., 2009b) Majority of the young women in our study liked receiving the positive mental health messages. However, they preferred the helpline message to the positive messages and a large number accessed this helpline through return text messages or calls especially when they were upset or angry. The participants reported feeling that someone was there to help them when receiving a helpline message, which encouraged them to call or text back if they were going through difficult emotions such as anger, sadness or anxiety. Message framing impacts intervention outcomes and research has shown that overall tone and structure of the message can have an impact on receptivity in an intervention, as each point of contact is an opportunity to engage the end user (Muench et al., 2014). These findings have important implications for future mHealth interventions in mental health settings. Being able to text back or call someone, appeared to make the subjects feel better. This is likely to be linked to a sense of perceived support. Research has shown that positive interactions and emotional support are associated with improvements in distress for women (CIHI, 2012). Just having someone available for discussing their problems seems to be an important function that mHealth texting
interventions may be able to achieve in the context of mental health, especially in hard to reach populations. A quarter of the family members (all males) called the research team to verify where the text messages were coming from and were reassured when they learnt that it was from an authentic source. This was despite the fact that informed consent was taken from the subjects and family members. Issues of confidentiality and adverse consequences of mHealth interventions with adolescents, in medical conditions where stigma is high and among women in patriarchal societies are some concerns that have been raised in the context of mHealth in the South Asian context (Aggarwal, 2012). The perceived authenticity and credibility of the intervention provider by the community is also important. If there is a call back facility, the gender of the intervention provider maybe another point that needs discussion in the South Asian context. In the preparatory stage of our study, we had several focus group discussions with young women from the community and with their mothers. The latter strongly felt that there was a need for mental health interventions in their daughters. The mothers had endorsed the advantage of using mobile text messages as an easy way of delivering mental health messages. It appears that preparing the community for mHealth interventions and getting their approval may minimize adverse consequences. However, more research is needed to assess issues related to confidentiality and how young women in situations where there is considerable gender disadvantage will be able to use return messages without facing problems in the family. It has become increasingly evident that successful interventions require the approval of communities where the research is being conducted (Wells et al., 2004; Smikowski et al., 2009). Community participation can increase ownership over research and provide valuable leads into limitations and suggestions for minimizing adverse consequences (Smith and Romero, 2010). Previous limited research with mobile interventions among youth in the context of mental health has shown that personalized text messaging has engaged youth with mental illness around appointment logistics, mood evaluations, medication changes, clinician referrals, and expressions of support (Furber et al., 2011). Our study emphasizes that texting (which is a low cost method of communication) maybe a feasible and acceptable method of communicating about mental health with vulnerable sections of society in the South Asian context and in countries where more advanced mobile technologies like smart phones may not be accessible to the more disadvantaged. Our study had some limitations. First, only girls from a single college were selected. The sample size was small and was not powered to assess the impact of the intervention on outcomes like utilization of mental health services or mental health literacy. It needs replication with larger samples of young women before being considered for scaling up. Second, while all ethical safeguards were considered and consent taken, we received several enquiries from the men in the family about the authenticity of the intervention. Particularly in some societies where gender disadvantage is marked, more enquiry and discussion is needed on ethical concerns related to confidentiality so as to minimize the risk that the intervention puts on women within their families. Lastly, the team used a basic mobile handset to deliver intervention which can only be used for texting in the English script (even if the text uses vernacular words) and may hence be used only by those who can read and write English. This is a major limitation of the use and there is a need to collaborate with mobile companies to incorporate local languages in a basic mobile phone. Helpline messages may have been preferred over positive messages partly due to the conversational quality and opportunity for self disclosure. Further studies can examine whether building in an interactive element in the positive messages (e.g., providing
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an option to choose the nature of message through a prompt, based on one’s felt need) may add to their receptivity and utility. 6. Conclusions This pilot qualitative study indicates that mobile text messages (positive mental health messages or helpline) are a feasible method for mental health promotion and prevention. It appears to be a culturally acceptable method at least among young women from low income urban areas. Issues such as preparing the community, taking consent from the woman and family, gender sensitivity, discussing confidentiality and providing authentic and reliable support services when help or further information is sought, need to be taken into account before attempting to scale up such a service particularly in vulnerable groups. Conflicts of interest There are no conflicts of interest. Acknowledgment Department of Health Research (DHR) Ministry of Health and Family welfare, Government of India, for supporting and funding the study. Grant Number: DHR/Plan scheme/GIA/11/2012/dated 31/3/2012. References Aggarwal, N.K., 2012. Applying mobile technologies to mental health service delivery in South Asia. Asian J. Psychiatry 5, 225–230, PMID: 22981050. Agyapong, V.I., Milnes, J., McLoughlin, D.M., Farren, C.K., 2013. Perception of patients with alcohol use disorder and comorbid depression about the usefulness of supportive text messages. Technol. Health Care 21 (1), 31–39, http:// dx.doi.org/10.3233/THC-120707, PMID: 23358057. Bali, S., Singh, A.J., 2007. Mobile phone consultation for community health care in rural north India. J. Telemed. Telecare 13 (8), 421–424, PMID: 18078555. Bigelow, J., Singh, V., Singh, M., 2013. Medication adherence in patients with epilepsy after a single neurologist visit in rural India. Epilepsy Behav. 29 (2), 412–415, PMID: 24090776. Bopp, J.M., Miklowitz, D.J., Goodwin, G.M., Stevens, W., Rendell, J.M., Geddes, J.R., 2010. The longitudinal course of bipolar disorder as revealed through weekly text messaging: a feasibility study. Bipolar Disord. 12 (3), 327–334, http:// dx.doi.org/10.1111/j.1399-5618.2010.00807.x, PMID: 20565440. Buhi, E.R., Trudnak, T.E., Martinasek, M.P., et al., 2013. Mobile phone-based behavioural interventions for health: a systematic review. Health Educ. J. 72 (5), 564–583, http://dx.doi.org/10.1177/0017896912452071. Canadian Institute for Health Information (CIHI), 2012. The Role of Social Support in Reducing Psychological Distress. Available at: https://secure.cihi.ca/free_products/AiB_ReducingPsychological%20DistressEN-web.pdf. Cole-Lewis, H., Kershaw, T., 2010. Text messaging as a tool for behaviour change in disease prevention and management. Epidemiol. Rev. 32 (1), 56–69, PMID: 20354039. Deglise, C., Suggs, L.S., Odermatt, P., 2012. SMS for disease control in developing countries: a systematic review of mobile health applications. J. Telemed. Telecare 18 (5), 273–281, PMID: 22826375. Elangovan, R., Arulchelvan, S., 2013. A study on the role of mobile phone communication in tuberculosis DOTS treatment. Indian J. Commun. Med. 38 (4), 229– 233, PMID: 24302824. Farooqi, Y.N., 2006. Traditional healing practices sought by Muslim psychiatric patients in Lahore, Pakistan. Int. J. Disabil. Dev. Educ. 53 (4), 401–415, http:// dx.doi.org/10.1080/10349120601008530. Fjeldsoe, B.S., Marshall, A.L., Miller, Y.D., 2009. Behavior change interventions delivered by mobile telephone short-message service. Am. J. Prev. Med. 36, 165–173, PMID: 19135907. Free, C., Whittaker, R., Knight, R., et al., 2009. Txt2stop: a pilot randomised controlled trial of mobile phone-based smoking cessation support. Tob. Control 18 (2), 88–91, PMID: 19318534. Furber, G.V., Crago, A.E., et al., 2011. How adolescents use SMS (short message service) to micro-coordinate contact with youth mental health outreach services. J. Adolesc. Health 48, 113–115, PMID: 21185535. Ganapathy, K., Ravindra, A., 2008. M-Health: a potential tool for health care delivery in India. In: Making: the eHealth connection, Global Partnerships, Local Solutions Conference, Bellagio, Italy, July 13–August 8, In: http://www.ehealthconnection.org/files/conf-materials/mHealth_A%20potential%20tool%20in%20India_0.pdf.
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Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
‘SMS’ for mental health – Feasibility and acceptability of using text messages for mental health promotion among young women from urban low income settings in India Prabha S. Chandra a,*, H.R. Sowmya a, Seema Mehrotra b, Mona Duggal c a
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bangalore, India Policy Center for Biomedical Research, Translational Health Science and Technology Institute, (Under DBT, GoI) National Institute of Immunology, Aruna Asaf Ali Marg, New Delhi 110067, India
b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 May 2014 Accepted 11 June 2014
Objective: The current study assesses the acceptability and feasibility of mobile text messages for promoting positive mental health and as a helpline among young women in urban slums of Bangalore. Methodology: Forty girls in the age range of 16–18 years from urban slums received messages every day for a month. They could call or message back or give a ‘missed call’ to the same number whenever they had emotional problems or felt like talking to a counselor. The received responses in the form of return texts, missed calls and return phone calls were recorded. Feedback about the feasibility and acceptability of the mobile messages was collected after a month. Results: 25 out of 40 (62.5%) participants called back, asking for mental health services and to say they felt good about the messages. 23 of 40 (57.5%) messaged back regarding their feelings. 62% reported that they felt supported with the mental health messages. Male family members of nearly half of the participants called back to check the authenticity of the source. Most women did not face any problems because of the messages. Conclusion: This pilot qualitative study indicates that mobile text messages are a feasible and culturally acceptable method for mental health promotion and prevention among young women from urban slums in India. Issues such as consent from the woman and family, ensuring confidentiality and providing authentic and reliable support services, need to be taken into account before attempting to scale up such a service, particularly in vulnerable groups. ß 2014 Elsevier B.V. All rights reserved.
Keywords: Mental health promotion Mobile phone Gender India mHealth
1. Introduction Mobile health (or mHealth) is defined as ‘‘the use of mobile and wireless technologies to support the achievement of health objectives’’. This approach includes diagnostic and treatment support, remote monitoring/data collection, education services and tools to improve communication and training for healthcare workers (WHO, 2011). Mobile technologies for mental health have been gaining ground in several countries across the world. Personalized text
* Corresponding author at: National Institute of Mental Health and Neurosciences, Bangalore 560029, India. Tel.: +91 80 26995272; mobile: +91 9880383057. E-mail addresses: [email protected], [email protected] (P.S. Chandra). http://dx.doi.org/10.1016/j.ajp.2014.06.008 1876-2018/ß 2014 Elsevier B.V. All rights reserved.
messaging has been used to manage appointments among youth with mental illness, to record mood state in bipolar disorder, in assessment of schizophrenic patients, to prevent relapse in alcohol use disorder, support patients with bulimia nervosa, evaluate mood among patients with depression, communicate medication changes and provide expressions of support (Furber et al., 2011; Spaniel et al., 2008; Granholm et al., 2012; Bopp et al., 2010; Moore et al., 2012; Agyapong et al., 2013; Ma¨kela et al., 2010). Personalized text messages have also been used for substance cessation (Free et al., 2009; Rodgers et al., 2005). Mobile health has also been used widely in physical health for education, monitoring or management of health related issues such as medications, reminders for appointments, self monitoring symptoms and promoting health related information’s among people (Buhi et al., 2013; Cole-Lewis and Kershaw, 2010; Fjeldsoe et al., 2009; Krishna et al., 2009; Sharma et al., 2011; Shet and De Costa, 2011).
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According to a recent survey conducted in the US, 78% of adolescents use mobile phones. The preferred way of communication is text messaging compared to voice calls, social sites, e-mail and even face to face talking. This survey also reports that compared with boys, frequency of receiving and sending text message is comparatively high in girls (Madden et al., 2013). A literature review by Joyce and Weibelzahl (2006) has discussed several barriers among youth in seeking help from counseling services related to fear, privacy, shame, guilt, embarrassment, lack of trust in others, the feeling that one should be able to cope on one’s own and not knowing what support is available or how to get it. However, in youth outreach services, young adults find the use of mobile phone and text messages a safe and practical way of maintaining contact and coordinating meetings with mental health professionals (Furber et al., 2011). Youth have also found it acceptable to have data about their daily activities, behaviors and attitudes collected through an automated text system (Garcia et al., 2014). India already has several mHealth pilot programs in place and is working to integrate mHealth into its health care systems (Ganapathy and Ravindra, 2008). These include maternal and child health services, tuberculosis treatment services and anti retroviral therapy adherence programs. Many studies in India, have reported mobile phone communication as an effective and acceptable tool in management of diseases such as Type-2 diabetes, tuberculosis, epilepsy and HIV for both patients and health care providers (Ramachandran et al., 2013; Elangovan and Arulchelvan, 2013; Bigelow et al., 2013; Shetty et al., 2011; Bali and Singh, 2007; Gautham et al., 2014). Based on current research in India, it appears that text messages are the most preferred mode of communication (Priyaa et al., 2013; Prasad and Anand, 2012). Text messages rather than pamphlets are preferred for educational information related to oral health, prevention of communicable and non-communicable diseases such as HIV/AIDS, tuberculosis and addressing sexual risk behaviors (Sharma et al., 2011; Deglise et al., 2012; Schneider et al., 2012). Researchers have shown that adherence to treatments for HIV, diabetes and tuberculosis has improved with sending regular text messages and SMSs reminders to patients (Elangovan and Arulchelvan, 2013; Shetty et al., 2011; Rodrigues et al., 2012; Manoharan et al., 2012; Sidney et al., 2012). Bali and Singh (2007) in their study in a rural area of northern India, found that people used their mobile phones for seeking medical consultations and help was sought mainly for skin, respiratory, mental health and sexual problems. Aggarwal (2012) in his recent review has discussed how mobile technologies are a valuable method for mental health interventions in South Asian counties. The wide usage and cultural acceptability of mobile phones can be harnessed for enhancing mental health literacy and ensuring help seeking in these countries. In specific situations mobile phones may have an added advantage, such as among women who are often denied access to mental health care in patriarchal societies and in remote areas where mental health services are not available (Farooqi, 2006). Mobile phones can also be a useful way of seeking information in situations where stigma can prevent information and help seeking, among those who are psychologically disturbed (Gulliver et al., 2010). In low and middle income countries, smart phones are still not affordable by the large majority and there is a need to rely on text messaging using a basic handset as a means of communication. While using mobile phones may be an acceptable way of addressing mental health in young women, ethical issues in the use of mHealth in the South Asian context, such as confidentiality of the text messages, the need to inform the user to delete the
messages, consent issues and the privacy of minors who may seek counseling without parental consent also need to be addressed (McGee, 2011). Issues such as the need for caller identification so that those at the receiving end are assured of a legitimate service and concerns related to its use among adolescents less than 18 years old are other issues that need to be examined. There have been recommendations that before mHealth is used widely, there is a need for more qualitative studies among users. The questions that need to be addressed include – how comfortable do users feel about discussing mental health issues using text messages, how does one communicate in low literacy situations, what barriers might need to be overcome while using text messages for mental health, what are the confidentiality concerns and what is the nature of content that is most acceptable? Understandably, the answers to these questions might be different for men and women, for different age groups and for different clinical conditions. Research from India has shown high rates of mental health problems and suicidal behavior in youth population (Pillai et al., 2009; Sidhartha and Jena, 2006). A study conducted among rural and urban young people from Goa, India, indicated that rates of suicidal behavior were higher among girls than boys. Gender discrimination from the society and from parents, physical violence, sexual abuse/violence and psychological distress were factors that were found related to increasing suicidal behavior among young people (Pillai et al., 2009). Many young people do not seek help for mental health problems due to various personal and structural barriers such as: fear of stigma associated with mental health disorders (e.g., it is seen as a weakness); concerns about confidentiality; lack of knowledge about services; the idea that symptoms of psychological distress reflect only a temporary age crisis; and lack of appropriate responses from both peers and adults. Many of these barriers relate to limited mental health literacy. There is extensive need to improve awareness, to plan interventions to improve recognition and enable help-seeking for mental health problems. While studies from India indicate that mHealth is feasible and acceptable in illness management, not much is known about its utility in mental health interventions. There is also a lack of data on what youth feel about mHealth interventions. This paper is an offshoot of a larger study entitled – mental health of girls growing up (MOGGU – flower bud) which focused on various low cost interventions in order to promote mental health and enable early help seeking among young women living in low income urban settings. The main objective of the study was to assess feasibility and acceptability of using mobile phone text messages as a means of sending information on positive mental health and providing a helpline service to young women in low income settings.
2. Methodology As a first step, focus group discussions were conducted with 26 girls (eight in three groups) and 20 mothers (six in three groups), to understand the issues and concerns of young women between the ages of 16 and 19 years, living in urban slums. Feasible and low cost mental health interventions were also discussed and most group participants, including mothers felt that the mobile phone was a friendly and acceptable tool for interventions. Based on the findings from the focus group discussions, the current study was initiated. Forty girls from low-income families who were attending the same college located in an urban slum gave consent for the study. Consent of a parent or guardian was also taken if the girl was below 18 years of age. All the young women gave consent for receiving mobile messages and a
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majority took permission from their parents. None of the participants reported a previously diagnosed psychiatric illness. Participants were in the age range of 16–18 years and were doing their pre-university education. The inclusion criteria were – (a) girls in the age group of 16–18 years, (b) girls who had access to a mobile phone (either own phone or sharing a phone with family or friends) and (c) girls who could read basic English. Participants were informed that they would receive a message every day for a month. They were also informed that they could call back, message or give a ‘missed call’ to the same number whenever they felt sad, angry or depressed or when they felt like talking to a counselor. The women received a message every day. Messages alternated between a positive mental health tip or helpline information. The helpline message asked them to message or call back if they felt like talking to someone when emotionally upset. Messages were sent during afternoons (12 pm–2 pm). Messages were sent and phone calls received only by female researchers. Both researchers and the participants used basic handsets. The messages were sent in the vernacular language (Kannada) using the English script.
Table 2 SMS for mental health – feed back form. 1
How did you feel about the positive messages
2
How did you feel about the helpline messages
3
How did you feel about the distress messages
4
Any problems faced because of the messages? How satisfied were you when you sent a message back or someone called back? How can we make this more effective? What helped you more?
5
6
3. Selection of messages Quotes and brief phrases on positive well-being were sought from two mental health experts and two young women from the community. Nearly 50 such messages were compiled, following which, the research team chose fifteen messages which seemed most appropriate for age, gender and socio-cultural background. The messages were either inspirational or focused on handling emotions. These were then translated into Kannada (the local language) using the English script (Table 1). The messages were sent over a month. All the responses received in the form of return messages, missed calls and return phone calls were recorded. After a gap of 1 month, the researchers contacted the participants for feedback about the feasibility and acceptability of the mobile messages using a feedback questionnaire (Table 2). They were also asked if they faced any problems due to the messages (such as family members objecting) and what they felt about the timing and content of the messages. 4. Results The mean age of the participants was 16.8 (SD 1.68) years and they were all studying in the 11th and 12th year in a pre university college. Seventy percent of them were from nuclear families and 30% from joint families. All of them belonged to low income families and lived in urban slums. Most of their parents worked as casual laborers.
Table 1 Some examples of the translated messages are. Every failure is a lesson – learn well. Every success is a mirror – care well Nothing is interesting when you are not interested Nothing is good or bad, but thinking makes it so Learning and trying to handle difficult times in a calm manner is a sign of growth Patience is bitter, but its result is sweeter. Have patience Whenever you feel that you failed, say these words – I have not failed. My success has just got postponed Forgive what you can’t forget. Forget what you can’t forgive Your mind is your great friend if you control it. But your mind is your greatest enemy if it controls you. Helpline Message: ‘‘Bejaru/dukka, kopa athva athanka anisutideya? Athva MOGGU counselor jothe mathanada bekadalli dayavittu call/missed call/MSG madi – (Research mobile no)’’. ‘‘Feeling sad, angry or anxious or just want to talk to a MOGGU counselor – please call/give a missed call/MSG – (Research mobile no)’’. MOGGU Team NIMHANS’’
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7 8
9 10
11 12 13
14
How often should it be sent so that you don’t feel awkward or disturbed, yet feel good? How can we make this more useful for young women? Is there any specific time you would like the messages to be sent? If Yes, What time of the day? What should we do if the girl does not have her own phone? Did you share these messages with others? Any other suggestions? – language, type of messages, helpline, response, should it be only positive mental health messages or helpline? How did you feel when you were receiving positive/ helpline messages?
Neither good nor bad Liked receiving the messages Did not like it Liked some and not others Felt someone cared Felt intrusion into my life and privacy You felt like calling back Felt that someone is there to help Felt like messaging back You felt like calling back Felt that someone is there to help Felt like messaging Family members objected Was stigmatizing Not at all Little Very much
Positive messages Helpline messages Every day Once in 2 days Once in a week
Yes/No
Morning/afternoon/ evenings
Yes/No
16/40 (40%) of them owned a mobile phone and 24/40 (60%) of them shared a mobile phone with their family members. During the 1 month period, 25/40 (62.5%) of the participants called back, asking for mental health services, to confirm who was sending the message and to say they felt good about the messages. 23/40 (57.5%) of them messaged back and texted messages such as: – ‘‘thank u’’, ‘‘Kopa (Anger)’’, ‘‘Bejaru (Sad)’’, ‘‘call me’’, ‘‘I am happy’’, ‘‘I am not having any feelings or anger; my life is going on happy - no tension’’, ‘‘I feel free and fresh’’, ‘‘OK – I am referring this number to my friends’’. Family members (usually brothers and fathers) of 18 (47.5%) of the participants called back to check who was sending messages, even though the consent of the parents had been sought earlier. Most of them felt reassured when the research group explained the study. The research team was able to contact 37 of the 40 participants from the group after a gap of 1 month. Based on the responses in the feedback form, 23 (62%) of the participants reported that they liked to receive the messages and 6 (16.2%) reported they felt that someone was there to care for them. When receiving messages, 19 (51.4%) of the girls reported that they felt very happy, 8 (21.6%) reported that they would like to receive more messages while 3 (8%) faced family objections for receiving messages.
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4.1. Messaging preferences Forty percent of participants reported that they would like to receive these kind of messages every day, 35% (13) wanted them once in 2 days and 24% (9) preferred to receive a message once a week. 78.4% (29) felt that messages should be sent at a particular time of the day with 90% (31) reporting that evenings were the best time to receive the mental health messages. 4.2. Content of the messages Data from the feedback form indicated that 62% (23) of the girls preferred the helpline messages over positive mood lifting messages. When receiving a helpline message, 62% (23) of the participants reported feeling that someone was available to help them, 27% (10) felt like sending a return message and 11% (4) felt like calling back. 32.4% (12) felt very satisfied when they got a response to their calls or messages. 65% (24) of the participants felt that they needed to share these received messages with their friends and family. 4.3. Suggestions to make it more effective Participants felt that messages should be accompanied by awareness programs on mental health and they wanted more messages. Girls who did not have their own phone suggested that we could a call a friend or family member or provide the same messages in a printed format by post. 5. Discussion This preliminary study has provided important information in understanding messaging preferences to inform development of mobile goal-directed behavioral interventions among young women from low income settings. Based on feedback received from the girls, it appeared that most of our subjects did not face any major problems from their family members during the study, even though individual phone ownership was less and most of them shared their phones with their families. This group is particularly important due to the high rates of mental health problems, poor mental health literacy and poor access to mental health services (Farooqi, 2006). Research has also shown that in countries such as India, interpersonal support from people within the community is often preferred over visits to physicians, especially psychiatrists (Kermode et al., 2009b) Majority of the young women in our study liked receiving the positive mental health messages. However, they preferred the helpline message to the positive messages and a large number accessed this helpline through return text messages or calls especially when they were upset or angry. The participants reported feeling that someone was there to help them when receiving a helpline message, which encouraged them to call or text back if they were going through difficult emotions such as anger, sadness or anxiety. Message framing impacts intervention outcomes and research has shown that overall tone and structure of the message can have an impact on receptivity in an intervention, as each point of contact is an opportunity to engage the end user (Muench et al., 2014). These findings have important implications for future mHealth interventions in mental health settings. Being able to text back or call someone, appeared to make the subjects feel better. This is likely to be linked to a sense of perceived support. Research has shown that positive interactions and emotional support are associated with improvements in distress for women (CIHI, 2012). Just having someone available for discussing their problems seems to be an important function that mHealth texting
interventions may be able to achieve in the context of mental health, especially in hard to reach populations. A quarter of the family members (all males) called the research team to verify where the text messages were coming from and were reassured when they learnt that it was from an authentic source. This was despite the fact that informed consent was taken from the subjects and family members. Issues of confidentiality and adverse consequences of mHealth interventions with adolescents, in medical conditions where stigma is high and among women in patriarchal societies are some concerns that have been raised in the context of mHealth in the South Asian context (Aggarwal, 2012). The perceived authenticity and credibility of the intervention provider by the community is also important. If there is a call back facility, the gender of the intervention provider maybe another point that needs discussion in the South Asian context. In the preparatory stage of our study, we had several focus group discussions with young women from the community and with their mothers. The latter strongly felt that there was a need for mental health interventions in their daughters. The mothers had endorsed the advantage of using mobile text messages as an easy way of delivering mental health messages. It appears that preparing the community for mHealth interventions and getting their approval may minimize adverse consequences. However, more research is needed to assess issues related to confidentiality and how young women in situations where there is considerable gender disadvantage will be able to use return messages without facing problems in the family. It has become increasingly evident that successful interventions require the approval of communities where the research is being conducted (Wells et al., 2004; Smikowski et al., 2009). Community participation can increase ownership over research and provide valuable leads into limitations and suggestions for minimizing adverse consequences (Smith and Romero, 2010). Previous limited research with mobile interventions among youth in the context of mental health has shown that personalized text messaging has engaged youth with mental illness around appointment logistics, mood evaluations, medication changes, clinician referrals, and expressions of support (Furber et al., 2011). Our study emphasizes that texting (which is a low cost method of communication) maybe a feasible and acceptable method of communicating about mental health with vulnerable sections of society in the South Asian context and in countries where more advanced mobile technologies like smart phones may not be accessible to the more disadvantaged. Our study had some limitations. First, only girls from a single college were selected. The sample size was small and was not powered to assess the impact of the intervention on outcomes like utilization of mental health services or mental health literacy. It needs replication with larger samples of young women before being considered for scaling up. Second, while all ethical safeguards were considered and consent taken, we received several enquiries from the men in the family about the authenticity of the intervention. Particularly in some societies where gender disadvantage is marked, more enquiry and discussion is needed on ethical concerns related to confidentiality so as to minimize the risk that the intervention puts on women within their families. Lastly, the team used a basic mobile handset to deliver intervention which can only be used for texting in the English script (even if the text uses vernacular words) and may hence be used only by those who can read and write English. This is a major limitation of the use and there is a need to collaborate with mobile companies to incorporate local languages in a basic mobile phone. Helpline messages may have been preferred over positive messages partly due to the conversational quality and opportunity for self disclosure. Further studies can examine whether building in an interactive element in the positive messages (e.g., providing
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an option to choose the nature of message through a prompt, based on one’s felt need) may add to their receptivity and utility. 6. Conclusions This pilot qualitative study indicates that mobile text messages (positive mental health messages or helpline) are a feasible method for mental health promotion and prevention. It appears to be a culturally acceptable method at least among young women from low income urban areas. Issues such as preparing the community, taking consent from the woman and family, gender sensitivity, discussing confidentiality and providing authentic and reliable support services when help or further information is sought, need to be taken into account before attempting to scale up such a service particularly in vulnerable groups. Conflicts of interest There are no conflicts of interest. Acknowledgment Department of Health Research (DHR) Ministry of Health and Family welfare, Government of India, for supporting and funding the study. Grant Number: DHR/Plan scheme/GIA/11/2012/dated 31/3/2012. References Aggarwal, N.K., 2012. Applying mobile technologies to mental health service delivery in South Asia. Asian J. Psychiatry 5, 225–230, PMID: 22981050. Agyapong, V.I., Milnes, J., McLoughlin, D.M., Farren, C.K., 2013. Perception of patients with alcohol use disorder and comorbid depression about the usefulness of supportive text messages. Technol. Health Care 21 (1), 31–39, http:// dx.doi.org/10.3233/THC-120707, PMID: 23358057. Bali, S., Singh, A.J., 2007. Mobile phone consultation for community health care in rural north India. J. Telemed. Telecare 13 (8), 421–424, PMID: 18078555. Bigelow, J., Singh, V., Singh, M., 2013. Medication adherence in patients with epilepsy after a single neurologist visit in rural India. Epilepsy Behav. 29 (2), 412–415, PMID: 24090776. Bopp, J.M., Miklowitz, D.J., Goodwin, G.M., Stevens, W., Rendell, J.M., Geddes, J.R., 2010. The longitudinal course of bipolar disorder as revealed through weekly text messaging: a feasibility study. Bipolar Disord. 12 (3), 327–334, http:// dx.doi.org/10.1111/j.1399-5618.2010.00807.x, PMID: 20565440. Buhi, E.R., Trudnak, T.E., Martinasek, M.P., et al., 2013. Mobile phone-based behavioural interventions for health: a systematic review. Health Educ. J. 72 (5), 564–583, http://dx.doi.org/10.1177/0017896912452071. Canadian Institute for Health Information (CIHI), 2012. The Role of Social Support in Reducing Psychological Distress. Available at: https://secure.cihi.ca/free_products/AiB_ReducingPsychological%20DistressEN-web.pdf. Cole-Lewis, H., Kershaw, T., 2010. Text messaging as a tool for behaviour change in disease prevention and management. Epidemiol. Rev. 32 (1), 56–69, PMID: 20354039. Deglise, C., Suggs, L.S., Odermatt, P., 2012. SMS for disease control in developing countries: a systematic review of mobile health applications. J. Telemed. Telecare 18 (5), 273–281, PMID: 22826375. Elangovan, R., Arulchelvan, S., 2013. A study on the role of mobile phone communication in tuberculosis DOTS treatment. Indian J. Commun. Med. 38 (4), 229– 233, PMID: 24302824. Farooqi, Y.N., 2006. Traditional healing practices sought by Muslim psychiatric patients in Lahore, Pakistan. Int. J. Disabil. Dev. Educ. 53 (4), 401–415, http:// dx.doi.org/10.1080/10349120601008530. Fjeldsoe, B.S., Marshall, A.L., Miller, Y.D., 2009. Behavior change interventions delivered by mobile telephone short-message service. Am. J. Prev. Med. 36, 165–173, PMID: 19135907. Free, C., Whittaker, R., Knight, R., et al., 2009. Txt2stop: a pilot randomised controlled trial of mobile phone-based smoking cessation support. Tob. Control 18 (2), 88–91, PMID: 19318534. Furber, G.V., Crago, A.E., et al., 2011. How adolescents use SMS (short message service) to micro-coordinate contact with youth mental health outreach services. J. Adolesc. Health 48, 113–115, PMID: 21185535. Ganapathy, K., Ravindra, A., 2008. M-Health: a potential tool for health care delivery in India. In: Making: the eHealth connection, Global Partnerships, Local Solutions Conference, Bellagio, Italy, July 13–August 8, In: http://www.ehealthconnection.org/files/conf-materials/mHealth_A%20potential%20tool%20in%20India_0.pdf.
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