Communication Technology Use by Caregivers of Adolescents With Mental Health Issues: Systematic Review

Background Caregivers of adolescents with mental health issues experience challenges that may result in the caregivers having a variety of unmet needs. There is a growing need to support these caregivers. Effective support to strengthen positive caregiving behavior in caregivers may address their challenges. Communication technologies offer novel opportunities to assist these caregivers and may contribute to strengthening caregiver behavior. However, little is known about the use of communication technologies among caregivers of adolescents with mental health issues. Objective The study aimed to answer the question: “What is the best evidence available to strengthen positive behavior of caregivers of adolescents with mental health issues using communication technology.” Methods A systematic review of articles published between January 2007 and August 2018 was conducted. Searches included articles of multiple study designs from EBSCO Host and Scopus platforms with prespecified eligibility criteria. Methodological quality was evaluated using the applicable Critical Appraisal Skills Programme and Joanna Briggs Institute assessment tools. Results The search yielded 1746 articles. Altogether, 5 articles met the eligibility criteria and were included in the review for data synthesis. Data analysis and synthesis identified three thematic conclusions reflecting the types of communication technologies used, caregivers as the target population, and strengthening of positive behavior through determinants of the Integrated Model of Behavior Prediction. Conclusions The review reported the usefulness of communication technology by caregivers. Caregivers also demonstrated improvement in self-efficacy, knowledge, parent-child communication, and parental skills reflecting positive behavior. Although the use of communication technology is expanding as a supportive intervention to address caregivers’ needs, the evidence for usefulness among caregivers of adolescents with mental health issues is still scarce. More research and information related to preferred methods of communication delivery among caregivers of adolescents is still needed.


Introduction
Background "Nothing about me, without me" [1] The caregiver landscape can be successfully supported through tailored solutions by acknowledging their unique challenges. Caregivers are largely invisible and are mostly underappreciated resources in community health services [2,3]. Caregivers are vital partners who contribute to health care provisioning in communities. They contribute to alleviating resource Evidently, the usefulness of communication technology interventions for caregivers of adolescents with mental health issues differs. DeHoff et al [58] found that parents of children with special needs got support through an online social platform to accept and manage the child's condition. Another study disclosed that parents of youth with mental health problems seem to be positive about the use of computer-based therapies [59]. A web-based health promotion program utilized by adolescent girls and their mothers for drug use, among other conditions, resulted in positive health behavior changes [60]. The study by Russell et al [61] indicated a high satisfaction among parents of children with behavior problems when engaging in a computer-based education program.
The novelty of communication technologies in the management of psychiatric and mental health illnesses may be valuable to investigate [62]. According to Casale et al [63] and Robila [64], there is a need to support parents through interventions that provide resources to improve parenting, particularly in reducing adolescent behavioral and emotional problems. It would appear that communication technologies are beneficial in supporting caregivers in improving their skills, abilities, self-efficacy, and knowledge [65,66]. A review of caregivers caring for adolescents with developmental disabilities similarly highlighted the effect of tailored interventions to augment caregivers' self-efficacy, self-esteem, positive coping skills, and supportive social networks [67].

Theoretical Framework
The Integrative Model of Behavior Prediction (IMBP) endorses determinants such as attitudes, norms, and self-efficacy, by predicting behavior. Consequently, these determinants are based on underlying beliefs that, in turn, influence the intention to perform a specific behavior. Behavior may be challenged due to a lack of skills or environmental constraints [68,69].
The IMBP guided this review in clarifying caregivers' behavioral intention for utilizing communication technologies by determining their belief, attitude, norms, self-efficacy, skills, environment, and intention. Behavioral intention can be predicted if the populations' beliefs, attitudes, norms, self-efficacy, skills, and environment are known [68,70,71]. To our knowledge, however, there have been no systematic efforts to synthesize evidence on the usefulness of communication technologies to strengthen positive behavior in caregivers of adolescents with mental health issues. Any positive response to a determinant was regarded as strengthening [71,72] of caregivers' behavior toward the adolescent.
The authors conducted a systematic review to collect and synthesize all evidence fitting the prespecified eligibility criteria. The authors sought to answer the following question based on the PICO format [73] (see Table 1 for the application of the PICO format): "What is the best evidence available to strengthen positive behavior of caregivers of adolescents with mental health issues using communication technology?" This paper provides a critical review and synthesis of the best available evidence about the use of communication technologies by caregivers of adolescents with mental health issues.

Design
The authors undertook a systematic review that included multiple study designs [73][74][75]. This systematic review has been registered in PROSPERO (CRD42018094680) and was conducted according to PRISMA guidelines. Source, EconLit with Full Text, GreenFILE) and the Scopus database were included. No language or study design restrictions were applied. Search strings determined by the authors in collaboration with the research librarian were used to retrieve articles from the abovementioned databases. It was decided to make use of free text, as the search would be conducted on multiple databases, of which only MEDLINE and CINAHL utilize controlled vocabulary (MeSH and CINAHL subject headings respectively). Before conducting the search, a concept analysis was done to identify synonyms to be used in the free-text search (see Table 2 for a combination of the search string using Boolean operators). The first author (RJ) also searched the reference lists of retrieved articles. Dissertations and book chapters formed part of the retrieved articles. Search strings caregiver* OR "care giver*" OR family* OR families* OR parent* OR mother* OR father* OR sibling* OR carer OR carers OR "lay worker*" OR "next of kin" AND "mental* health*" OR "mental* ill*" OR "mental* disorder*" OR "mental* diseas*" OR depress* OR anxiet* OR substance AND teen* OR adoles* OR juvenile* OR youth* AND belief* OR conviction* OR faith OR trust* OR norm OR norms OR custom* OR attitude* OR outlook* OR approach* OR Self-efficac* OR ability* OR Skill OR skills OR expertis* OR able OR abilit* OR talent* OR proficien* OR knowhow OR capabilit* OR knack OR competen* OR Intent* OR determination* OR planning OR resolve OR decide* OR decision* OR choose OR select* OR choice* AND mobile* OR cell* OR smart OR sms OR "short message service*" OR text* OR device* OR mhealth* OR m-health* OR ehealth* OR e-health* OR "instant messag*" OR app OR apps OR phone* OR smartphone* OR "electronic device*" OR "portable device*" OR "phone intervention*" OR "telephon* intervention*" OR online*) not ("stem cell*" OR "sickle cell*" OR "assist" device*" AND mobile* OR cell* OR smart OR sms OR "short message service*" OR text* OR device* OR mhealth* OR m-health* OR ehealth* OR e-health* OR "instant messag*" OR app OR apps OR phone* OR smartphone* OR "electronic device*" OR "portable device*" OR "phone intervention*" OR "telephon* intervention*" OR online* OR caregiver* OR "care giver*" OR family* OR families* OR parent* OR mother* OR father* OR sibling* OR carer OR carers OR "lay worker*"

Eligibility Criteria
Articles were eligible for inclusion if they (1) focused on caregivers such as families, parents, siblings, or relatives of adolescents with mental health issues (concentrating on depression, anxiety, and substance use disorders) as the target population, (2) reported on communication technology usage, and (3) described caregiver determinants according to the IMBP. Articles were excluded if they did not meet the inclusion criteria or (1) if they focused only on adolescents as the target population, (2) if they reported on non-communication technology interventions, and (3) if the focus was on mental health-related therapies or traditional communication interventions.

Selection Procedure
The first author (RJ) filtered all titles and abstracts obtained from the search against the review question and eligibility criteria. The second author (MR) verified articles for compliance with eligibility criteria. A large number of articles were excluded, and duplicates were removed. Full-texts for the remaining articles were obtained from the librarian. These full-text articles were independently screened for eligibility by both authors, and any discordances were resolved through discussion. Additionally, references of selected articles were screened further for relevant studies.

Quality Appraisal
The first author (RJ), together with two senior researchers, rigorously evaluated the quality of the selected articles according to the Critical Appraisal Skills Programme [76] and Joanna Briggs Institute assessment tools applicable to each study design [77]. All tools evaluated the appropriateness of methods used, clarity of focus, the recruitment process, the accuracy of measures used, data collection, presentation and analysis, clarity in the statement of the findings, and appropriateness of context. If more than two aspects were not addressed in the articles, it was excluded. This was depicted as either Level 1* (full marks obtained) or Level 1 (-1 mark) in Table 3. Table 3 includes a hierarchy classification system in terms of research design, according to the American Dietetic Association [78,79]. This critical appraisal of the full-text articles determined the selection and inclusion of articles in this systematic review.

Data Extraction, Analysis, and Synthesis
The authors extracted specific data from the selected articles in a tabular format to record the study characteristics, types, and delivery method of communication technologies and the strengthening of positive behavior according to IMBP determinants. A meta-analysis was not feasible due to the heterogeneity of the included articles. A thematic data analysis [84][85][86] took place and both authors discussed the themes to refine the data according to the review question. Subsequently, the data were organized into relevant thematic conclusions addressing the research question based on the PICO elements. After that, the results were synthesized across all articles.

Search Results and Selection of Articles
The search identified 1746 electronic records of possible interest. Two additional articles were added, one through contacting an author and another through reference list checking. After electronic and manual removal of duplicates, 1089 records remained. Further screening for eligibility of identified records resulted in the retrieval of 59 full-text articles that were potentially relevant for analysis. The authors then conducted a comprehensive review of these full-text articles and included articles that specifically focused on communication technologies used by caregivers of adolescents with mental health issues. A total of 5 articles met all the eligibility criteria. Figure 1 presents the PRISMA flow diagram of the study, and Table 3 presents a summary of the included articles' study design evaluations.

Characteristics of Included Articles
The final articles included in this systematic review consisted of multiple designs. There were 2 randomized controlled trials [33,80], 1 quasi-experimental study [81], and 2 qualitative studies [82,83]. In all 5 articles, the caregivers had been exposed to communication technologies in caring for adolescents with mental health issues. Of the 5 studies, 3 studies were performed in the United States [80,82,83], 1 was performed in Australia [33], and 1 was performed in Korea [81]. Articles varied in methodology, intervention, outcomes, measurement scales, and findings. Not all of the articles complied with all of the identified IMBP determinants leading to positive behavior. Table 4 presents a summary of the results reported by the 5 articles.
Results from the 5 articles were synthesized and thematically analyzed to formulate conclusions. The thematic conclusions are discussed according to the types of communication technologies used, caregivers as the target population, and strengthening of positive behavior through IMBP determinants. A significant difference was found between experimental and control groups on self-efficacy in handling mental health issues in their children (F=12.73, P=.001).
Significant paired t test analysis of increases in self-efficacy from pretest to posttest among the individuals receiving the intervention was found (t=-3.20, P=.003).
No significant differences between groups on the measures of family communication, adaptability, cohesion, and attitudes toward mental health issues were found.
Deitz et al [80] Chi-square analyses of the postintervention (1-month) assessment revealed a significant difference in attempts to change parenting (n=307, χ 3 2 =19.65, P<.001), with significantly more intervention group parents reporting making some changes to their parenting.
The majority of parents (93.6%) reported they were somewhat or very satisfied with the feedback received, and 95.1% reported the feedback as either somewhat, very, or extremely useful.
Most parents (90.2%) reported they were somewhat or very likely to change their parenting based on the feedback provided.
Conclusion: accessible, low-cost preventive approach Cardamone-Breen et al [33] Participants in the intervention, compared to those in the control group, demonstrated preliminary evidence of improved parental knowledge.
Parents in the intervention group showed increased parental self-efficacy, parent-child communication, and satisfaction with parentchild relationships, and decreased parent-child conflict.
Parents reported accessibility and convenience to complete the intervention.
Parents' positive experience with flexibility, accessibility, and convenience in delivery of eHealth.
Parents also reported the ability to apply the lessons learned from eHealth Familias Unidas to their daily lives.
Molleda et al [82] It was feasible to recruit, engage, and retain Hispanic families into an eHealth intervention and deliver it electronically.
Positive feedback was provided by the parents regarding eHealth.
Parents stated there were multiple lessons learned from engaging in eHealth Familias Unidas: effective parent-adolescent communication and active parental attention and involvement in an adolescent's life.
Culturally appropriate online content allowed parents to access sessions at their convenience and minimized costs for researchers and participants alike Estrada et al [83] a IMBP: Integrated Model of Behavior Prediction.

Types of Communication Technologies Used
All the studies implemented web-based interventions [33,[80][81][82][83]. Content employed via the communication technologies and delivery thereof varied considerably. The web-based program by Deitz et al [80] consisted of 4 multimedia modules that provided information regarding symptoms and treatment options for depression and anxiety, building parental skills, and additional resources with information about mental health issues. Parental skills included communication, relationships, and healthy lifestyles. Estrada et al [83] and Molleda et al [82] adapted an evidence-based intervention, Familias Unidas, into a web-based intervention consisting of 8 e-parent group sessions of video recordings and 4 online family sessions (parent-adolescent) with a facilitator. Choi et al [81] reported on a 4-week web-based intervention (Stepping-stone) containing educational sessions, media files, verbal feedback, weekly assignments, and practice sessions regarding bullying, depression, suicide, and communication skills. Cardamone-Breen et al [33] adapted a single-session web-based component of the Partners in Parenting intervention. This intervention provided personalized feedback and psychoeducation concerning guidelines on adolescent depression and anxiety after the parents completed an online survey to assess parenting practices.

Target Population
The study populations in the included articles predominantly comprised caregivers as parents or family members. Deitz et al [80] used parents or caregivers of youth between the ages 5 and 21, while Molleda et al [82] included clinic personnel, facilitators (ie, physicians, nurse practitioners, administrators, and mental health workers), and parents or primary caregivers of Hispanic adolescents (age range: 12 to 16 years) [82]. Estrada et al [83] also included Hispanic families with parents and adolescents between the ages of 12 and 16 [83]. The study by Choi et al [81] encompassed parents who had at least one child aged 11 to 16 years. Cardamone-Breen et al [33] used a community sample of parents, together with adolescents aged 12 to 15 years old. The most common problems among adolescents were mental health or behavioral issues [80,81], depression and anxiety disorders [33,81], bullying [81], suicide [81], and substance use [82,83]. The majority of participants in the studies were female, recruited from various urban settings, and educated.

IMBP and Other Determinants
Outcomes focusing on the IMBP determinants in the current review were about self-efficacy and skills such as parent-child communication: 2 studies [80,81] measured the effect of the intervention on caregiver self-efficacy that improved after the intervention; 3 studies [81][82][83] also demonstrated the effectiveness of communication skills between caregiver and adolescent, and 1 randomized controlled trial [80] measured no significant differences between study groups in family communication skills. Of the 5 studies, Cardamone-Breen et al's study [33] showed promising changes in parenting skills and behavior, and another study [80], a randomized control trial, reported outcomes regarding parental attitudes demonstrating no significant differences between the two study groups.
Another observation was that effective parental skills resulted in satisfactory parent-child relationships as well as a decline in parent-child conflict [81]. Caregivers similarly appreciated the feedback they received regarding their parental skills after using the intervention [33] and lessons learned to implement in their daily lives [82,83].
We identified 2 studies [80,81] that measured the effect of communication technologies use on caregivers' knowledge showing an improvement. Additionally, Estrada et al [83] found that parents were more involved and attentive in the life of adolescents after engaging with the eHealth intervention. In turn, participants in Estrada et al's study [83] gave positive feedback regarding the use of the eHealth intervention while Molleda et al [82] found that parents experienced the eHealth delivery as positive.

Principal Findings
The review results show the potential value of communication technologies to strengthen caregivers' behavior when caring for an adolescent with mental health issues. Overall, the results yielded evidence of the usefulness of communication technologies by caregivers. Moreover, the results contributed to the limited literature on communication technology interventions for caregivers caring for the adolescent with mental health issues.
As shown by this study, the results were mostly positive, which may raise questions about selection bias. Aligned to the review question, we were interested in determinants showing improved outcomes among caregivers' when using communication technologies. It becomes particularly imperative to recognize users' preferences and acceptance of communication technologies in a health care setting. Identifying appropriate communication technologies to inform and support caregivers may be a challenge, but it is essential to understand their adoption thereof [87,88]. Information dissemination delivered through communication technologies is gradually replacing traditional approaches [89], but the implementation in health care [90] and among caregivers [14,91] is still lacking.
Communication technologies can distribute an unprecedented amount of information through technology such as electronic devices, system software, and information networks such as the internet, which provides access to resources [92,93]. Moreover, Schneider's [94] systematic review reported that utilizing communication technologies to gather and stream information received the highest proportion of use. Multimedia approaches including internet and web-based programs are a means for providing informational support to caregivers; they also found that effective parent education through communication technologies can augment the mental well-being of children [95]. Our results are consistent with earlier reports in this field that suggest that web-based interventions are effective for caregivers managing mental health issues in adolescents [91,96,97].
A prevailing expectation of communication technologies is that it might improve knowledge acquisition regarding illnesses. However, applicable information should be according to the caregivers' specific needs [98]. Statistically significant differences were found related to parental outcomes of knowledge, attitudes, and skills in efficient web-based interventions [99]. Exploiting the internet for knowledge about chronic diseases, as noted by Mahmud et al [53], can assist individuals and communities in health promotion. In contrast, low-income parents were not confident in using the internet and could not distinguish between good-or bad-quality information [100]. Sweeney et al [59] concluded that parents of youth with mental health problems demonstrated poor knowledge regarding computer-based therapies but were positive about using it.
Communication technologies are now mature enough to enable learning and knowledge exchange among caregivers in health care [101]. This functionality is attributable to the fact that communication technologies are associated with boosting the health care landscape through information exchange and transformation among large populations [102]. Our review indicated some evidence that computer-based interventions among large groups of parents are less expensive. The financial implication is particularly relevant in the current global socioeconomic climate, especially in low-resource settings that should keep cost-effectiveness of communication technologies in mind [103] when serving vulnerable populations such as caregivers in deploying health care [104]. According to Sprague et al [105], the world still experiences barriers to internet adoption despite high technology penetration because of disproportionately rural populations, low-income, illiteracy, elderly users, and female users. Therefore, it is vital to explore the best evidence available related to communication technologies barriers such as delivery methods, cost-effectiveness, caregiver characteristics, and outcomes, which will predict adoption thereof.
None of the included studies measured text messaging, phone calls, mobile apps, or social networking as a favored network delivery; however, included studies mentioned the use of communication technologies to recruit participants and send reminders. Domek et al [106] and Anderson-Lewis et al [107] suggest that text message interventions may be useful in rural families and have the potential to disseminate public health information. Mobile apps show some promise in serving families of youth with mental health issues in resource-constraint settings [108]. Breitenstein et al [109] also determined that digital delivery, such as mobile apps, might theoretically be Some studies in this review identified diverse interventions that facilitated the strengthening of caregivers' behavior, such as improved self-efficacy, enhanced knowledge, and better parent-child communication skills and practices. These findings complement those of other studies in that online tools have proved to be successful in improving caregivers' knowledge, skills, coping [122,123], and self-efficacy [120,124]. Nieuwboer et al [99] summarized that the internet supplies information, support and advice to parents with different needs that encourage changes in their parental abilities. Furthermore, technology provides access to others for building support and knowledge through positive engagement [125]. Reportedly, the potential impact of communication technologies on caregivers' well-being is ubiquitous and may guide their behavior toward the care recipient [126].
Caregivers who feel that they can perform behavior effectively will continue to repeat that specific behavior. This performance is based on knowledge, skills, and self-efficacy. A repetition of the behavior will occur if it is associated with a positive feeling and a sense of confidence; the accomplishment of the behavior, reflects self-efficacy and competency in performing the task [127,128]. People hold specific beliefs about behavior and intentionally perform according to that belief. From the IMBP, people who have the necessary skills will perform more satisfactorily, which will lead to favorable outcomes [129]. Hall and Bierman [130] reported improvement in parental knowledge and attitude through technology-based interventions. Of course, targeted interventions strengthening parental knowledge, self-efficacy, and skills may lead to improved child mental health outcomes [100] and positive parental outcomes [9].
Thus, it is legitimate to say that a communication technologies-based intervention has great potential to be used by caregivers to reinforce positive behavior when caring for an adolescent with mental health issues. Communication technologies also represent possibilities to provide support to caregivers by addressing their individual needs which could be highly convoluted. This review shows a need for further research in the area of supporting caregivers of adolescents with mental health issues.

Strengths
The authors conducted a comprehensive review following a stepwise methodological process for a systematic review. We included multiple study designs to understand how communication technologies may strengthen caregivers' behavior and improve caregiver outcomes. We used standardized checklists to appraise selected articles critically. The results provided knowledge related to the use of communication technologies among caregivers of adolescents with mental health issues.

Limitations
We might have missed potentially relevant articles, although explicit inclusion and exclusion criteria were set up. The first author initially screened titles and abstracts independently for applicability while some were verified by the second author for quality control purposes. This review was limited to articles describing caregiver outcomes according to the IMBP determinants, and this restriction may have eliminated meaningful information from other communication technology advantages.

Conclusions
The review results indicate that using communication technology is useful to strengthen caregivers' behavior by providing information and resources. Additionally, a better understanding of caregivers' attitudes and environmental constraints toward communication technologies may inform optimal usefulness thereof. Evidence for caregivers of adolescents with mental health issues using communication technologies is not readily available in the literature. There was limited empirical research outlining the methods of communication delivery, and it is worth exploring this in future research. Besides, future research should focus on the development of more innovative communication technology interventions for caregivers in different contexts and scaling up of efforts to implement them for improved mental health care among adolescents.