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The effectiveness of telemedicine on stigmatization and treatment burden in patients with health compromising lifestyles and chronic diseases: A critically appraised topic

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Objectives: To conduct a critical appraisal of peer reviewed articles on the effectiveness of telemedicine on stigmatization and treatment burden in patients with health compromising lifestyles and chronic diseases.Methods: This study critically appraised peer-reviewed article on the effectiveness of telemedicine on stigmatization and treatment burden in patients with health compromising lifestyles and chronic diseases. Treatments included e-health interventions, information and communication technologies used in health care, internet-based interventions for diagnosis and treatments that encouraged collaborative care for patients with chronic diseases. This paper critically appraised the full text of each relevant peer-reviewed article adapting the Occupational Therapy Critically Appraised Topics (CATs) template while using the Oxford Centre for Evidence-based Medicine- Levels of Evidence (2011) model to assess for best evidence or quality. Results: Initial internet search using Psychinformation; PubMed; Medline; ProQuest; CINAHL; OT seeker and the Cochrane Library generated over 1450 titles/abstracts. Following abstract appraisal, 30 articles were selected for full text assessment. Five of the final articles selected for this critical appraisal alluded to the effectiveness of telemedicine in reducing the treatment burden of stigmatization on patients with chronic diseases. Majority of the appraised articles indicated the effectiveness of telemedicine in changing behaviours.Conclusions: All the appraised articles alluded to the effectiveness of telemedicine in curbing some of the treatment burdens of stigmatization for patients with health compromising lifestyles and chronic diseases. However, it is evident that the use of other intervention methods such as government policy, public education and patient empowerment in conjunction with telemedicine would better reduce the effect of stigmatization and facilitate the medical interventions for patients with chronic diseases.
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Open Science Journal March 2018
1
REVIEW
The Effectiveness of Telemedicine on
Stigmatization and Treatment Burden in
Patients with Health Compromising
Lifestyles and Chronic Diseases: A Critically
Appraised Topic
Ebere Ellison Obisike1*
1Burman University, Lacombe Alberta
*Corresponding author: Ebere Ellison Obisike: eobisike@hotmail.com
Abstract:
Citation: Obisike E.E. (2018) The
Effectivemess of Telemedicine on
Stigmatization and Treatment
Burden in Patients with Health
Compromising Lifestyles and
Chronic Diseases: A Critically
Appraised Topic. Open Science
Journal 3(1)
Received: 19th November 2017
Accepted: 31st January 2018
Published: 4th March 2018
Copyright:© 2018 This is an
open access article under the terms
of the Creative Commons
Attribution License, which permits
unrestricted use, distribution, and
reproduction in any medium,
provided the original author and
source are credited.
Funding: The author(s) received
no specific funding for this work
Competing Interests: The
author have declared that no
competing interests exists.
Objectives: To conduct a critical appraisal of peer reviewed articles
on the effectiveness of telemedicine on stigmatization and
treatment burden in patients with health compromising lifestyles
and chronic diseases.
Methods: This study critically appraised peer-reviewed article on
the effectiveness of telemedicine on stigmatization and treatment
burden in patients with health compromising lifestyles and chronic
diseases. Treatments included e-health interventions, information
and communication technologies used in health care, internet-based
interventions for diagnosis and treatments that encouraged
collaborative care for patients with chronic diseases. This paper
critically appraised the full text of each relevant peer-reviewed
article adapting the Occupational Therapy Critically Appraised
Topics (CATs) template while using the Oxford Centre for
Evidence-based Medicine- Levels of Evidence (2011) model to
assess for best evidence or quality.
Results: Initial internet search using Psychinformation; PubMed;
Medline; ProQuest; CINAHL; OT seeker and the Cochrane Library
generated over 1450 titles/abstracts. Following abstract appraisal,
30 articles were selected for full text assessment. Five of the final
articles selected for this critical appraisal alluded to the
effectiveness of telemedicine in reducing the treatment burden of
stigmatization on patients with chronic diseases. Majority of the
appraised articles indicated the effectiveness of telemedicine in
changing behaviours.
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Keywords: Telemedicine, stigma, stigmatization, health compromising
lifestyles, chronic diseases, intervention
Introduction
Stigma can be described as negative attitudes that affect people’s interactions
and activities in a harmful way (Obesity Society, 2018). It can be expressed in
various forms, such as verbal forms of prejudice (for instance, ridicule, teasing,
insults, stereotypes, derogatory names, or through the use of pejorative
language), physical stigma may include touching, grabbing, or other aggressive
behaviours, or other barriers and problems caused by weight (for example,
medical kit that is too small for obese patients, seats in public settings which do
not fit obese persons, or stores which do not sell clothing in large sizes (Obesity
Society, 2018). It is a perceived negative characteristic that causes someone to
degrade or think very little of the person in question (Salters-Pedneault, 2017).
According to Salters-Pedneault (2017), people are likely to exclude individuals in
stereotyped groups, to judge persons in these groups for undesirable actions and
to discriminate against the stigmatized individuals. In an extreme form, stigma
can result in both subtle and overt forms of discrimination, such as employment
discrimination where the stigmatized individual is denied a position or promotion
because of his or her appearance, regardless of being suitably competent for the
position (Obesity Society, 2018).
Unfortunately, Stigmatization remains a debilitating stressor for patients with
chronic diseases (Vanable, Carey, Blair & Littlewood. 2006). Stigma has notable
negative effects on patients in that it contributes to their low self-esteem (Lv,
Wolf & Wang, 2013).In addition, Marta (2008) asserts that stigma is still the
major reason why a lot of people are scared to visit a physician to find out if they
are infected with the HIV virus or to seek for treatment if affected. According to
Omosanya, et al., (2014), stigmatization and discrimination have negative
impacts on treatments and act as barriers to all HIV/AIDS activities. Apart from
this, Druss & Rosenheck (1998) posit that people with serious mental illnesses are
disproportionately uninsured, a situation often associated with discrimination
based on pre-existing health conditions. In addition, The National Mental Health
Reduction Partnership (2013) noted that stigma can be used to discriminate and
downgrade people. The preconception and distress caused by stigma may even
hinder people from coming forward and seeking the medical help they need (The
National Mental Health Reduction Partnership, 2013). In other words, stigma
Conclusions: All the appraised articles alluded to the effectiveness of
telemedicine in curbing some of the treatment burdens of
stigmatization for patients with health compromising lifestyles and
chronic diseases. However, it is evident that the use of other
intervention methods such as government policy, public education
and patient empowerment in conjunction with telemedicine would
better reduce the effect of stigmatization and facilitate the medical
interventions for patients with chronic diseases.
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can also prevent people from providing help or being caring (The National
Mental Health Reduction Partnership, 2013).
Apart from the notable negative effects of stigmatization on people living with
various mental illnesses, Phlelan et al., (2015) affirm that stigma can reduce the
quality of care for patients with obesity notwithstanding the best intentions of
healthcare professionals to offer high-quality care. This is because several
healthcare professionals have strong negative attitudes and stereotypes about
individuals with obesity (Phlelan et al., 2015). There is significant evidence that
supports the assertion that such attitudes impact a person-perceptions, judgment,
interpersonal behaviour and decision-making (Phlelan et al., 2015). Given the
above facts, one can infer that there are correlations between stigmatization and
depression, low-level of medication adherence, poor physician office visits, and
psychological adaptation and lifestyle changes difficulties among patients with
chronic diseases (Link et al., 2001; Phlelan et al., 2013; Markowitz, 1998).
This explains why Howell, Heiser and Harrington (1999) posit that stigma is a
burden for substance abuse women, particularly for pregnant women and nursing
mothers. For instance, Poole and Isaac (2001) state that stigma limits a mother’s
access to health and social services due to shame, projected fear of losing custody
of her child in the process of seeking for medical help, and the possibility of being
treated poorly and judged because of her substance abuse issues. Similarly,
people who are obese are highly stigmatized, and are most likely to face various
forms of prejudice because of their weight (Brownell, Puhl, Schwartz & Rudd,
2005). According to Brownell, Puhl, Schwartz and Rudd (2005), the rate of
weight discrimination in the United States has increased by 66% over the past
decade. The discrimination against individuals who are obese is comparable to
racial discrimination (Andreyeva, Puhl, & Brownell, 2008).
Simply stated, the stigmatization of people with mental illness is often linked
to people who are commonly branded by the public as untrustworthy and
incompetent (Angermeyer& Schulze, 2001). Furthermore, in severe cases, the
stigmatized persons are confined and hidden from their societies (Rabkin, 1974).
This is because people with mental illness are viewed as dangerous, unpredictable
and this in part “justifies” their discrimination by the society (Ku & Ha,
2015).The problem of stigmatization is of notable importance in the prevention
and treatment of chronic diseases such as diabetes, HIV/AIDs, obesity,
infertility, mental illnesses, and in the reduction of health compromising
lifestyles. Stigma can exacerbate depression, promote social seclusion and reduce
one’s quality of life by hindering access to employment, housing and other social
determinants of health (Corrigan & Matthews, 2003). Apart from this, Chang
and Horrocks (2006) state that the social exclusion of families due to
stigmatization is one of the major barriers to informal social network support,
which may be an essential source of respite both from psychological distress and
a means for getting access to formal treatment and other related formal support.
Therefore, this paper conducted a critical appraisal of peer-reviewed articles on
how we may use telemedicine to reduce stigma and the treatment burden among
patients with health compromising lifestyles and chronic diseases. Based on the
reviewed literature, this paper concludes that the use of telemedicine may reduce
the effect of stigma and the treatment burden in patients with health
compromising lifestyles and chronic diseases.
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Methods and Procedures
This study critically appraised peer-reviewed article on the effectiveness of
telemedicine on stigmatization and treatment burden in patients with health
compromising lifestyles and chronic diseases. Treatments included e-health
interventions, information and communication technologies used in health care,
internet-based interventions for diagnosis and treatments that encouraged
collaborative care for patients with chronic diseases. The full text of each
relevant peer-reviewed article was critically appraised using the Occupational
Therapy Critically Appraised Topics (CATs) template. In addition, the Oxford
Centre for Evidence-based Medicine- Levels of Evidence (2011) model was used
to assess for best evidence or quality.
The following terms guided the data collection: telemedicine and obesity;
stigmatization and social determinants of health, telemedicine and chronic
diseases, telemedicine and health compromising lifestyles; the treatment burden
of stigmatization; outcome (s) of the adoption of telemedicine on stigma, and
challenges of telemedicine and chronic diseases.
Data were collected using Psych information; PubMed; Medline; ProQuest;
CINAHL, EMBASE, OT seeker, The Cochrane Library, Nih.gov, Academia.edu,
and Biomedcentral.com databases. To ensure the quality of this study, this paper
selected articles that used randomized control trials, cohort studies, case-control
studies and systematic reviews research methods. The major reason was to limit
bias. Based on the focus of this study, the following journal articles were
included: studies examining patients with chronic diseases and health
compromising lifestyles that can access telemedicine, studies that considered the
effects of telemedicine on treatment burden, studies on the effect of telemedicine
on stigma and stigmatization, studies on the effect of stigma on social
determinants of health, and studies on the challenges facing the utilization of
telemedicine by both health and social care consumers and social providers.
This paper excluded studies examining non-chronic diseases, studies dealing
with face to face health and social care interventions that did not involve virtual
interactions (i.e. videophones, video chats, etc.), and studies on telemedicine,
stigma and chronic diseases that are not peer-reviewed or published in reputable
journals. To ensure that the information in this study is current, Journals
published before 2007 were also excluded.
Results
The Initial internet search using Psych information; PubMed; Medline;
ProQuest; CINAHL; OT seeker and the Cochrane Library generated over 1450
titles/abstracts. Following abstract appraisal, 30 articles were selected for full
text assessment. Five of the final articles selected for this critical appraisal
alluded to the effectiveness of telemedicine in reducing the treatment burden of
stigmatization on patients with chronic diseases. Majority of the appraised
articles indicated the effectiveness of telemedicine in changing behaviours.
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Table 1: Summary of Study Designs of Selected Articles
Study Design/Methodology of
Selected Articles
Number Located
Author/Year
Randomized Control Trials
3
Daviset al. (2013).
Watson et al. (2016).
Wang et al. (2017).
Systematic Reviews
2
Chen et al. (2012).
Kasckowet al.(2014)
Best Evidence
This study identified the above articles as the “best” evidence for this critical
appraisal due to the following reasons:
Since the preconception and distress caused by stigma may hinder
people from coming forward and seeking the medical help they need
(The National Mental Health Reduction Partnership, 2013), and given
the fact that stigma discriminates, and downgrades people base on
their personal features, illnesses, geographical locations, etc.,
therefore, all the articles in this study alluded that the use of
telemedicine may be effective in reducing stigmatization and
treatment burden in patients with health compromising lifestyles and
chronic diseases.
Most of the studies investigated chronic diseases and telemedicine or
e-health
The studies showed the effectiveness of telemedicine in chronic illness
diagnoses and interventions
The authors of the appraised articles controlled for both researchers
and research subject bias using by adopting either randomized control
trials or systematic review research methodologies.
Critical Appraisal of the Final Five Selected
Articles
This study used the template on “how to critically appraise a paper (Sabin,
2013)” to provide additional critical appraisal on the five articles selected for this
study. These five broad questions included:
1. What is the research question?
2. Is the study ethical?
3. Is the study design valid and appropriate?
4. What are the results?
5. What are the implications of the findings for clinicalpractice?
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Davis et al. (2013):
The authors provided scientific rationale for their study. They stated that,
“The number of children living obesity in the United States has increased rapidly
over the past several years to the extent that childhood obesity is now regarded
as one of public health epidemics. In addition, they posited that, existing data
show that weight status by age seven is directly linked to adult weight status and
adult health problems. Apart from providing cogent scientific reasons for their
study, the authors equally provided a pre-defined hypothesis “To extend this line
of research, our team was interested in finding whether such a Stage 3 family-
based behavioral group intervention could be delivered to rural families in their
communities solely relying on interactive technology, including phone and tele-
video, also known as telemedicine.” Furthermore, this research was conducted in
Kansas, United States among elementary students living in rural Kansas. The
interventions involved randomized children, and families who participated in
eight weekly psycho educational groups over telemedicine led by trained PhD-
level psychologists or trained graduate students or postdoctoral fellows, followed
by six monthly meetings. The researchers compared this intervention to a similar
intervention through a standardized visit with a primary care physician (control
group). In addition, the researcher clearly dealt with their research outcome (s).
They considered the effectiveness of a multidisciplinary weekly family-based
behavioral group delivered via telemedicine to rural areas, compared with a
structured physician visit intervention.
The second major question in critically appraising Davis et al. (2013) involves
ethical issues. It seems that there was a real need for this study. The article
stated that the rapid increase in the occurrence of childhood obesity and the
direct link between childhood weight status and adult weight status and health
issues prompted Davis and his colleagues to conduct this trial. The authors
seemed to have been motivated by the principle of equipoise in that they posited
that treating childhood obesity may promote adult weight status and enhance
adult health outcomes. The researchers followed all the stipulated ethical
procedures in recruiting their research participants, and in conducting this study.
For instance, relevant institutional review board approved all the study
procedures while the participants provided written informed consent through
their various schools. Furthermore, representatives from the participating schools
received the mandatory institutional online training in Human Subjects Research,
Conflict of Interest, and HIPAA, including training on study-specific procedures,
which was conducted by the researchers.
However, the research sample was relatively small. In addition, the
participants came from some rural areas in Kansas; therefore, the results of this
research may not be generalized to rural areas in other states. Another problem
with the research sample is the fact that the participants were mainly Caucasian,
which suggests that the research finding may change if other races were
represented. Furthermore, while the researchers stated that National Institutes of
Health (DK068221 to A.M.D.) funded their research, they failed to declare their
financial interest in this study.
The third major question in this appraisal is the research design. It seems that
the research design was appropriate for this study. This is a Non-inferiority trial
(RCT), which demonstrated that the use of a multidisciplinary weekly family-
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based behavioral group delivered via telemedicine to rural areas, is not
substantially worse than a structured physician visit intervention. However, it
seems that this study was not categorically blinded, which seems to leave room
for elements of bias. Another major research question is the research results or
findings. The authors stated that, “Child BMIz outcomes were not statistically
different between the two groups (F¼0.023, p¼.881) and that improvements in
BMIz, nutrition, and physical activity were seen for both group.” This aligns with
the study design. It was also noted that out of the 58 participants, 31 were
randomly assigned to the Telemedicine group while 27 were randomly assigned to
the Physician Visit group; there were no significant between group differences at
baseline.
The fifth question or item in the critical appraisal of Davis et al. (2013) is the
implications of the findings for clinical practice. There several clinical
implications in this study, which may be used to reduce the stigma of childhood
obesity and its associated health issues. For instance, the study has established
that telemedicine or other methods of interactive tele-video appear to be viable
for the delivery of realistically supportive treatments or interventions for rural
families facing the issues of childhood obesity. In addition, this research seems to
suggest that families in remote areas who commit to this type of intervention are
likely to show up for treatment and to encounter few technical problems.
Another implication of this study to public health practice is its positive effects
on health behaviour. This is because, telemedicine or the use of other interactive
tele-video modalities encourages immediate access to care in that this approach
to medical intervention reduce the time it takes families and health providers to
travel from one location to the other (rural area to the medical centre or even
from one’s home to the care facility). In addition, the use of telemedicine may
also facilitate access to highly trained specialists irrespective of the patient-
physician’s location.
Watson et al. (2016)
Like Davis et al. (2013), Watson and colleagues provided scientific
justifications for engaging in this research. For instance, they posit that, research
reports on tele-based lowintensity therapies for cancer patients have largely
provided lowmoderate quality data, primarily due to “lack of patient
preselection at study enrollment based on mental health needs.”In addition, they
asserted that the reason of this study was to evaluate“ a telephonedelivered
highintensity CBT, provided by level 3/4 mental health professionals in a
clinically referred cohort, reflecting a realworld service model.” They also stated
that limited studies, at beginning of the intervention, have used this method.
Apart from providing scientific justifications for this study, Watson and
colleagues had a pre-defined hypothesis for this study. For example, the authors
hypothesized that telephonedelivered CBT (TCBT) will promote“ change in
Hospital Anxiety and Depression Scale (HADS) anxiety and depression after
treatment compared to baseline.” The researchers also provided information on
the location of this study. In addition, the study provided enough data on the
study participants. For instance, the authors posit that study participants were
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drawn from “patients referred to the Royal Marsden Hospital's Psychological
Care Service over an 18month period by clinical staff (predominantly medical
consultants and specialist cancer nurses not necessarily trained in psychological
screening or assessment) was approached.”
What intervention(s) was compared? The study compared
TelephoneDelivered Cognitive Behavioural Therapy (TCBT) to CBT face-to-
face therapy (TAUCBT) in cancer patients with high psychological needs, in
relation to mental health and coping.
In addition to critically appraising Watson et al. (2016) study questions, this
review also appraised the ethical validity of the study. There is enough evidence
from the research report to suggest that the research design was valid and
appropriate. The study was a prospective randomised equivalence trial comparing
TAUCBT with TCBT and it did not use a treatment control group because
previous data indicated efficacy of standard care CBT for cancer patients.
Additionally, this study did not achieve equivalence because of low
participant recruitment. Most of the participants wanted medical interventions
but refused the trial. Given the nature of this study, it is possible that the
researchers failed to adequately control for confounders and bias.
However, the study followed the “CONSORT principles and requirements of
the UK Medical Research Council on assessment of complex psychological
interventions.” Likewise, the Royal Marsden NHS Foundation Trust Ethical
Committee NHS/HSC R&D (Protocol REC 09/H0801/60) approved this study,
and all the study participants provided written informed consent. While the
authors acknowledged the Royal Marsden Foundation Trust Charity CP funded
this study, they failed to declare any conflict of interest. Concerning the research
outcomes, the authors stated that, the “delivery of CBT to patients with clinician
identified high need can be offered according to patient choice without loss of
mental health benefit. Both TAUCBT and TCBT are effective at reducing
mental health problems on the specific outcome measures.”
There several clinical implications in this study, which may be used to reduce
the stigma on the health issues associated with cancer. Simply stated, this study
provides a model for cancer treatment in a realworld service. While telemedicine
may not significantly improve health care equity, this study suggests that
patient's choice and convenience will be major factors in deciding on therapy
delivery method, without hindrances to patients in mental health benefits.
Promoting patient’s choice and convenience through telemedicine or tele-based
cancer intervention will no doubt reduce stigma and cancer treatment burden.
Wang et al. (2017)
This is another randomized controlled trial, which investigated the use of
internet-based integrated approach to the management of diabetes. Like the first
two articles, Wang and colleagues provided scientific motivations for this study.
For instance, they alleged that patients with diabetes are unable to control the
development and progression of diabetics effectively because the existing medical
resources for regular real-time blood glucose management are inadequate and
expensive. In addition, they also provided pre-defined hypothesis by stating that
“an internet-based telemedicine service platform that allows real-time collection
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of the patients’ medical information and timely delivery of the medical team’s
advice on medication, diet and exercise, etc. is urged for helping the patients
with self-management and for improving patient compliance.”
Furthermore, this study seems ethically valid. According to Wang et al.
(2017), “Clinical study protocol for this study was approved by the Ethics
Committee of the First Hospital of Jilin University. And the study was carried
out in accordance with the Declaration of Helsinki.” Thus, one can conclude that
all the 212 patients that participated in this study provided written informed
consents. Based on the nature and outcome of this study, it appears that the
study used valid and appropriate design. According to Portney & Watkins
(2009), randomized controlled trial is the gold standard for true experimental
designs. While one cannot ascertain the level of blinding use in this study, it is
safe to infer that the data collection methods used in this study minimised the
participants’ bias. Likewise, the use of SPSS17.0. in their data analysis equally
contributed to the validity of this study. However, these researchers did not
provide any information on their source of funding, the role their funders played
in this research and any conflict of interest statement.
This study has some positive clinical implications. For instance, it has
ascertained the effectiveness and applicability of integrated remote management
in treating diabetes. This could revolutionize both health care policies the
management of chronic diseases not only in China, but worldwide. Finally, public
health workers and educators now have an evidence-based alternative to the
traditional method of working with individuals with type 2 diabetes, which will
reduce stigma and treatment burdens associated with this illness.
Chen et al. (2012)
While randomized controlled trials are a superior research methodology in the
hierarchy of evidence in therapy due to its ability limit the potential for any
biases (Cantor & Evans, 2013), Chen and colleagues’ systematic review offered a
structured method to analyzing existing information to help clinicians make
therapeutic decisions (Portney, 2009). Apart from the rigorous procedures that
included searching, appraising and summarizing available information on
cigarette smoking cessation, this study focused on the “effectiveness and cost-
effectiveness of computer and other electronic aids for smoking cessation.” From
the onset of this study, Chen et al (2012) clearly stated their reasons for
conducting this research. For instance, they posit that smoking is detrimental to
health. In addition, they stated that normally, chronic“ smokers lose 10 years of
life, and about half of all lifelong smokers have their lives shortened by smoking.”
While these authors acknowledged the existence of smoking cessation services in
the National Health Service (NHS), they alleged that these services achieve in
consistent“ success rates with smokers who want to stop smoking.” This explains
why they hypothesized that “approaches to behaviour change can be
supplemented with electronic aids, and this may significantly increase quit rates
and prevent a proportion of cases that relapse.” Furthermore, using meta-
analysis process allowed this study to use quantitative index to “develop a single
overall estimate of intervention effect,” which lends weight to the outcomes of
this research (Portney& Watkins, 2009). The research methodology adopted in
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this study indicates that adoption of proper ethical principles. However, one may
not generalize the outcomes of this study to the younger population because the
study was limited to “smoking cessation programmes in the adult population
(Chen et al 2012).”
This study has several implications for clinical practice. For example, the
result showed that the “pooled estimate for prolonged abstinence [relative risk
(RR) = 1.32, 95% confidence interval (CI) 1.21 to 1.45] and point prevalence
abstinence (RR = 1.14, 95% CI 1.07 to 1.22).” In this regard, it is plausible to
conclude that computer and other electronic aids may increase the possibility of
“cessation compared with no intervention or generic self-help materials (Chen et
al., 2012).” This provided clinicians with another viable option to working with
individuals with addiction challenges. In addition, EVPI calculations indicated
that the maximum benefit of using this method to smoking cessation is around £
2000-3000 per person (Chen et at., 2102),” which is enough to encourage public
support for the use of this method in conjunction of other services in helping
adult who want to quit smoking.
Kasckow et al. (2014)
These authors used systematic review research method to evaluate the forms
and nature of remote medical treatments for patients with schizophrenia, either
through telephone-based, internet-based or video-based telehealth systems. Like
the rest four articles included in this critical appraisal, Kasckow and colleagues
established plausible justification for engaging in this review. For instant, they
posit that the limited “access to care among patients with schizophrenia can lead
to treatment non-adherence, which usually leads to relapse, which in turn,
increases the risk for inpatient hospitalization (Kasckow et al., 2014).
Accordingly, they hypothesized that “telehealth communication services may offer
one way to improve adherence and to enhance stability of treatment response in
order to bridge the current gap in providing adequate care (Kasckow et al.,
2014).” The researchers enhanced the validity of this study by assigning two of
the researchers to independently code each article from the list to determine if it
was suitable to the study. In addition, two of the authors worked together to
decide which of the articles to select for final review. This approach to systematic
review reduces researchers’ article selection bias. According to Portney and
Watkins (2009), the traditional narrative literature reviews do not provide an in-
depth description of the method and criteria used in the selection and evaluation
of articles that are included in each study. However, the processes of conducting
a systematic review are structured to be “inclusive of the body of research
evidence at the time the review is undertaken (Portney & Watkins, 2009).”
Furthermore, the authors used kappa (value) statistic to test for interrater
reliability.
Conclusively, while the researchers underscored the need for more research on
this subject, the research outcomes provided enough evidence for one to infer
that tele-psychiatric systems may provide better healthcare for patients with
schizophrenia through well-designed quality improvement programs. For
instance, this study posits that telephone intervention improved patient-staff
communication, medication adherence, insight, psychopathologic symptoms,
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reduced patients’ visits to the emergency room and hospitalization rates
(Kasckow et al.,2014).
Interpretation of Results
The objective of this study was to investigate how the use of telemedicine
may reduce the effect of stigma and the treatment burden in patients with health
compromising lifestyles and chronic diseases? Given this study’s definition of
stigma or stigmatization, there is enough evidence from the five critically
appraised articles to support the hypothesis that the use of telemedicine may
reduce the effect of stigma and the treatment burden in patients with health
compromising lifestyles and chronic diseases. While this study included articles
that focused on elementary school children and obesity, others on diabetics,
cancer support, smoking cessation (which is an example of a health-
compromising lifestyle), and schizophrenia, one of the common themes in all the
five articles included in this study is the assertion that any form of medical or
social intervention whether through face to face or by distance is better than
non-access to health and social care. Also, rural location (s) of the research
subjects is another common feature of the five articles included in this study. In
addition, most of the studies emphasised the importance of timely intervention in
reducing the effects of stigmatization on patients. Further to the above evidence,
is the fact that some of the appraised studies suggested that this approach to
stigma reduction tend to be more effective in changing people’s behaviour, which
is one of the major factors for managing health compromising lifestyles and
chronic diseases. This researcher noted that most of the studies in this appraisal
pointed to the feasibility, cost effectiveness and the non-inferiority of telemedicine
to the traditional face-to-face health and social care interventions. For example,
Watson et al (2016) state that the provision of cognitive behavioral therapy to
high need patients may be delivered based on the patient choice without loss of
mental health benefit. This is because “both TAUCBT and TCBT are effective
at reducing mental health problems on the definite outcome measures (Watson et
al., 2016).
The interpretation of the outcome of this systematic review was based on
inductive theory as all the data in this study have evolved through the process of
inductive reasoning starting with empirically demonstrable evidence. According
Portney & Watkins (2009), researchers can determine variables that are related
to a given phenomenon through multiple studies and observations. Therefore,
while most of the articles in this review indicated positive clinical outcomes for
elementary school children and obesity, diabetics, cancer support, smoking
cessation and mental health issues for individuals living in rural areas through
the application of telemedicine, it is evident that this emerging thread or pattern
has developed into a systematic conceptual basis, which has formed the basis for
this study’s assertion that use of telemedicine may reduce the effect of stigma
and the treatment burden in patients with health compromising lifestyles and
chronic diseases. This is because, positive clinical outcomes most times are the
result of successful stigma interventions. For instance, Chen et al., (2012) posit
that computer and other electronic aids may increase the possibility of “cessation
Open Science Journal
Review
Open Science JournalMarch 2018
12
compared with no intervention or generic self-help materials”. Similarly, Davis et
al. (2013) conclude that telemedicine or the use of other interactive tele-video
modalities encourages immediate access to care in that this approach to medical
intervention reduce the time it takes families and health providers to travel from
one location to the other (rural area to the medical centre or even from one’s
home to the care facility). In addition, the use of telemedicine may also facilitate
access to highly trained specialists irrespective of the patient-physician’s location
(Davis et al., 2013).
Conclusion
This critical appraisal of peer-reviewed articles focused on how we may use
telemedicine to reduce stigma and the treatment burden among patients with
health compromising lifestyles and chronic diseases. This was motivated by the
evidence that stigma related to health compromising lifestyles and chronic
diseases is the main deterrent to early and effective intervention of health
compromising habits and the treatment of chronic diseases.
All the appraised articles alluded to the effectiveness of telemedicine in
curbing some of the treatment burdens of stigmatization for patients with health
compromising lifestyles and chronic diseases. Furthermore, most of the appraised
articles underscored the fact that any form of clinical intervention reduces the
treatment burden of health compromising lifestyles and chronic illnesses as lack
of access to medical information and treatment may negatively affect patients’
health outcomes. However, it is evident that the use of other intervention
methods such as government policy, public education and patient empowerment
in conjunction with telemedicine would better reduce the effect of stigmatization
and facilitate the medical interventions for patients with health compromising
lifestyles and chronic diseases. Further studies that focus on the use of
telemedicine in urban settings need to be conducted before the widespread
promotion of this method of intervention as majority of the appraised studies
focused on patients living in rural areas.
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... To reduce traveling and contacts, many activities were moved to a remote format during the COVID-19 pandemic -healthcare was no exception. Physician consultations were carried out remotely when possible, and this virtual approach has previously been shown to help lessen the stigma around various medical issues while making healthcare more accessible (17). This model comes with many benefits, such as reduced travel, clinic wait times, and anxiety related to HBV and HCV testing and treatment. ...
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Smoking is harmful to health. On average, lifelong smokers lose 10 years of life, and about half of all lifelong smokers have their lives shortened by smoking. Stopping smoking reverses or prevents many of these harms. However, cessation services in the NHS achieve variable success rates with smokers who want to quit. Approaches to behaviour change can be supplemented with electronic aids, and this may significantly increase quit rates and prevent a proportion of cases that relapse. The primary research question we sought to answer was: What is the effectiveness and cost-effectiveness of internet, pc and other electronic aids to help people stop smoking? We addressed the following three questions: (1) What is the effectiveness of internet sites, computer programs, mobile telephone text messages and other electronic aids for smoking cessation and/or reducing relapse? (2) What is the cost-effectiveness of incorporating internet sites, computer programs, mobile telephone text messages and other electronic aids into current nhs smoking cessation programmes? and (3) What are the current gaps in research into the effectiveness of internet sites, computer programs, mobile telephone text messages and other electronic aids to help people stop smoking? For the effectiveness review, relevant primary studies were sought from The Cochrane Library [Cochrane Central Register of Controlled Trials (CENTRAL)] 2009, Issue 4, and MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), Health Management Information Consortium (HMIC) (Ovid) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost) from 1980 to December 2009. In addition, NHS Economic Evaluation Database (NHS EED) and Database of Abstracts of Reviews of Effects (DARE) were searched for information on cost-effectiveness and modelling for the same period. Reference lists of included studies and of relevant systematic reviews were examined to identify further potentially relevant studies. Research registries of ongoing studies including National Institute for Health Research (NIHR) Clinical Research Network Portfolio Database, Current Controlled Trials and ClinicalTrials.gov were also searched, and further information was sought from contacts with experts. Randomised controlled trials (RCTs) and quasi-RCTs evaluating smoking cessation programmes that utilise computer, internet, mobile telephone or other electronic aids in adult smokers were included in the effectiveness review. Relevant studies of other design were included in the cost-effectiveness review and supplementary review. Pair-wise meta-analyses using both random- and fixed-effects models were carried out. Bayesian mixed-treatment comparisons (MTCs) were also performed. A de novo decision-analytical model was constructed for estimating the cost-effectiveness of interventions. Expected value of perfect information (EVPI) was calculated. Narrative synthesis of key themes and issues that may influence the acceptability and usability of electronic aids was provided in the supplementary review. This effectiveness review included 60 RCTs/quasi-RCTs reported in 77 publications. Pooled estimate for prolonged abstinence [relative risk (RR) = 1.32, 95% confidence interval (CI) 1.21 to 1.45] and point prevalence abstinence (RR = 1.14, 95% CI 1.07 to 1.22) suggested that computer and other electronic aids increase the likelihood of cessation compared with no intervention or generic self-help materials. There was no significant difference in effect sizes between aid to cessation studies (which provide support to smokers who are ready to quit) and cessation induction studies (which attempt to encourage a cessation attempt in smokers who are not yet ready to quit). Results from MTC also showed small but significant intervention effect (time to relapse, mean hazard ratio 0.87, 95% credible interval 0.83 to 0.92). Cost-threshold analyses indicated some form of electronic intervention is likely to be cost-effective when added to non-electronic behavioural support, but there is substantial uncertainty with regard to what the most effective (thus most cost-effective) type of electronic intervention is, which warrants further research. EVPI calculations suggested the upper limit for the benefit of this research is around £2000-3000 per person. The review focuses on smoking cessation programmes in the adult population, but does not cover smoking cessation in adolescents. Most available evidence relates to interventions with a single tailored component, while evidence for different modes of delivery (e.g. e-mail, text messaging) is limited. 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Our effectiveness review concluded that computer and other electronic aids increase the likelihood of cessation compared with no intervention or generic self-help materials, but the effect is small. The effectiveness does not appear to vary with respect to mode of delivery and concurrent non-electronic co-interventions. Our cost-effectiveness review suggests that making some form of electronic support available to smokers actively seeking to quit is highly likely to be cost-effective. This is true whether the electronic intervention is delivered alongside brief advice or more intensive counselling. The key source of uncertainty is that around the comparative effectiveness of different types of electronic interventions. Our review suggests that further research is needed on the relative benefits of different forms of delivery for electronic aids, the content of delivery, and the acceptability of these technologies for smoking cessation with subpopulations of smokers, particularly disadvantaged groups. More evidence is also required on the relationship between involving users in the design of interventions and the impact this has on effectiveness, and finally on how electronic aids developed and tested in research settings are applied in routine practice and in the community. The National Institute for Health Research Health Technology Assessment programme.
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Background: Telehealth technology has become more available to providers as a means of treating chronic diseases. Consideration of the applicability of telehealth technology in the treatment of schizophrenia calls for a review of the evidence base in light of the special needs and challenges in the treatment of this population. Our aims are to assess the types and nature of distant interventions for patients with schizophrenia, either telephone-based, internet-based or video-based telehealth systems. Methods: The following databases--MEDLINE, PsycINFO, CINAHL, the Cochrane Library, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, and EMBASE--were searched for the following terms alone or in combination with schizophrenia: telepsychiatry or telemedicine or telepsychology or satellite communication or remote communication. Inclusion criteria were: 1) articles dealing with telephone-, internet- or video-based interventions and 2) studies emphasizing development of an intervention, feasibility or clinical trials. Exclusions included were: 1) single case reports and 2) papers not written in English. With our search terms, we retrieved a total of 390 articles, of which 18 unique articles were relevant. Results: Based on the limited data available, the use of modalities involving the telephone, internet and videoconferencing appears to be feasible in patients with schizophrenia. In addition, preliminary evidence suggests these modalities appear to improve patient outcomes. Discussion: More research is needed. Investigators need to improve existing telehealth systems. In addition, researchers need to focus on developing newer interventions and determining whether these approaches can improve patient outcomes.
Article
Objective: To investigate experienced stigma and self-stigma in patients with schizophrenia in mainland China. Methods: Ninety-five patients with schizophrenia, enrolled between January 2011 and March 2011, completed Chinese versions of two self-report questionnaires: the Internalized Stigma of Mental Illness (ISMI) scale and the Modified Consumer Experiences of Stigma Questionnaire (MCESQ). They also completed two other self-report questionnaires: the Social Support Rating Scale (SSRS) and the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire. Patients were also assessed by a senior psychiatrist using the Scale for Assessment of Positive Symptoms (SAPS) and the Scale for Assessment of Negative Symptoms (SANS). All analyses were performed using SPSS 17.0 and included descriptive statistics, correlation analysis and multiple linear regression. Results: On the ISMI, the percentage of participants who rated themselves above the mid-point of 2.5 (meaning high level of self-stigma) on subscales and overall score was 44.2% (n=42) for alienation, 14.7% (n=14) for stereotype endorsement, 25.3% (n=24) for perceived discrimination, 32.6% (n=31) for social withdrawal and 20.0% (n=19) on the overall score. On the MCESQ, the percentage of participants who rated themselves above the mid-point of 3.0 on subscales and overall score was 24.2% (n=23) for stigma, 1.1% (n=1) for discrimination and 1.1% (n=1) on the overall score. Some socioeconomic variables, but not positive or negative symptoms, were related to the severity of psychiatric stigma. Conclusions: Results document the seriousness of experienced stigma and self-stigma in persons with schizophrenia. Strategies are needed to improve how governments and persons with schizophrenia cope with stigma.
Article
Reviews public attitudes toward mental illness during the past 25 yrs. The historical antecedents of such attitudes are traced back even further. By 1960 it had been established that mental patients were dimly regarded in the public view. The medical model was more accepted by professionals than people in general, and when the label of mental illness was authoritatively assigned, the person so labeled was stigmatized and shunned. Studies since 1960 indicate that people have become much better informed and disposed toward mental patients than they had been, but a major portion of the population continues to be frightened and repelled by the notion of mental illness. Factors influencing public acceptance of mental illness among individuals and in society are cited. It is noted that at a time when professionals are increasingly rejecting the medical model, the public at large is just beginning to accept it. (93 ref) (PsycINFO Database Record (c) 2013 APA, all rights reserved)