mHealth for mental health in the Middle East: Need, technology use, and readiness among Palestinians in the West Bank
Introduction
Mental health conditions are a major cause of disability in the Arab World (Mokdad et al., 2014). Palestinians in the West Bank are at especially high risk for mental health problems due to their extensive and chronic exposure to political violence, protracted displacement, insecurity, and limited professional, educational, and financial opportunities that are linked to the prolonged conflicts and instability in the region (Hobfoll et al., 2011, Espié et al., 2009). These vulnerabilities are compounded by limited availability of high quality mental health providers, inconsistent mental health services, and stigma associated with seeking mental health care (Marie et al., 2016). Further, the geopolitical (i.e., different governing entities, travel restrictions, discontinuity due to settlements and military outposts), topographical (i.e., rugged mountainous terrain), and infrastructural characteristics (e.g., dirt roads, inconsistent public transportation) of the West Bank do not lend themselves to centralized clinic-based treatment models that can serve close to 3 million Palestinian residents effectively. Innovative mental health treatment approaches are needed to overcome these significant barriers.
Mobile Health (mHealth) approaches that use mobile devices to support healthcare offer innovative methods to bypass some of the obstacles associated with in-person care (Ben-Zeev, 2014, Marzano et al., 2015, Kay et al., 2011). All mobile phones can facilitate interactions between patients and clinicians or mental health workers via call or text (SMS) functions. Mobile phones with computational capacities and internet access (i.e., smartphones) can enable additional bidirectional communication approaches via video, email, instant messaging, or social media platforms. Individuals in need of services can also access relevant information and resources independently online, or via illness self-monitoring, self-management, and decision support software (apps) hosted by “smart” devices (Ben-Zeev, 2014, Luxton et al., 2011, Proudfoot, 2013). A range of mHealth interventions targeting mental health conditions are already proving to be feasible and clinically promising in developed countries (Agyapong et al., 2012, Ben-Zeev et al., 2014, Berrouighet et al., 2016, Depp et al., 2015). These approaches may have even greater impact in under-resourced developing countries; while the majority of the population in these regions often do not have access to high-quality mental health clinics, they may have access to mobile devices and mobile-cellular or mobile-broadband infrastructure that would allow them to connect with others remotely or access online resources (ITU, 2015).
Whether mHealth for mental health approaches are viable for Palestinians in the West Bank is unclear. First, the proportion and demographic characteristics of people who use mobile phones in the region are unknown. It is possible that only a select minority has access to the technologies that could potentially serve as instruments for mHealth interventions. Second, it is unclear what type of infrastructure (e.g., electricity, Wi-Fi) is available to the population in the West Bank. Finally, whether Palestinians in the West Bank are open to mobile phone-supported mental health services is unknown. Answering these questions is an essential step in determining whether mHealth approaches may be feasible, and if so, which mobile intervention strategies would be of greatest interest to Palestinians contending with mental health problems. To answer these questions, our investigative team surveyed 272 individuals in multiple locations in the West Bank.
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Materials and methods
The project was approved by the Committee for Protection of Human Subjects at Dartmouth College. Data were collected in the summer of 2016 at multiple sites in the West Bank. The study was supported by the United Nations Relief and Works Agency (UNRWA) who assisted in transporting the team across sites and provided access to the agency’s clinics in the region. Two study surveyors fluent in Arabic (one male, one female) administered a survey with questions focusing on demographics, access and
Sample characteristics
The study sample consisted of 272 individuals with a mean age of 31.6 (SD = 12.6), 160 (58.8%) were male. The majority (156, 57.4%) lived in refugee camps, 82 (30.1%) lived in urban settings, and 34 (12.5%) lived in rural settings. Respondents reported living in households of an average of 6.3 (SD = 2.8) people. On average, survey respondents had 12.3 (SD = 3.9) years of education. The majority were married (149, 54.8%), 119 (43.8%) were unmarried, and 4 (1.5%) were divorced/widowed. Anecdotally, the
Discussion
To our knowledge, this paper summarizes the findings of the first systematic evaluation of mobile phone use among Palestinians in the West Bank and the first examination of the potential viability of mHealth for mental health interventions in this population. The area known as the West Bank is comprised of sub-regions, each with their own political, infrastructural, and socio-economic characteristics. A major strength of this study is that data were collected in multiple locations in the West
Funding
This work was supported by The John Sloan Dickey Center for International Understanding at Dartmouth College and the Houston chapter of the National Arab American Medical Association. Travel expenses were in part supported by private donations to Dunia Health.
Acknowledgments
The authors would like to thank the United Nations Relief and Works Agency (UNRWA) for their logistical support of the project and for allowing our team to visit their treatment centers; Ibdaa’ Center and Lajee Center for hosting our team and allowing us to visit their facilities; Shoruq Center at Shoruq at Dheisheh camp. The authors also appreciate the support and guidance of Dr. Akihiro Seita and Dr. Ummayieh Khammash. Tony Bero, Nadia Shokeh, Naji Shehadeh, Sudqi Abdel Rahman, Abdullah
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