Introduction

Based on both moral incidence ratios and life years wasted, people with mental health problems are at higher risk of premature mortality, according to the findings of a systematic study.  Men and women with a psychiatric illness had a lower overall life expectancy than those without a diagnosis, based on the years of life lost. Data were obtained from patients diagnosed in a hospital, outpatient, or emergent environment who received treatment and did not capture individuals seen by a general practitioner or who did not receive care for a mental health condition. In addition, the researchers noted that due to overestimating the age of mental illness onset, they may have marginally underestimated life years lost. Mental health problems are major public health issues worldwide and account for 8.5% of premature death and also disability [1–4]. The handling of mental health problems is still a challenge for developing countries, especially Indonesia. Around 6.1%-9.8% of Indonesians suffer from mental disorders such as depression, schizophrenia, and other psychological problems [5]. The main reason for lack of treatment for patients with mental health problems was lack of awareness regarding the importance of mental health, the stigma related to mental illness that affected the health-seeking behaviour, lack of appropriate mental health services, and limited of trained mental health professionals [6,7].  Persistent care is the solution for various health problems being currently faced. Hariyati and Sahar [8], in their qualitative research, found that patients expected to receive sustainable health services after undergoing treatment at a hospital through easy and fast communication. In Indonesia, mental nursing services are still conventional without paying attention to the unique geographic characteristics, often hindering services delivery to patients in need. Health services tended to be centred on urban areas that therefore have not been able to meet people's needs in rural areas. These conditions are more severe in rural populations [9], especially in regions with particularly poor infrastructure and resources for health care delivery in general, with almost no capacity for providing mental health care. A geographical factor was a problem faced in delivering the services in Indonesia. Officers faced complex cases with limited resources and had to work with unique communities. Being unique in this case was in the context of environment, distance, geography, policy, structure, and social contexts.

With ever-advancing technologies, the number of electronic health applications is also increasing, including many of those that can be used for mental health [10]. Telehealth is a communication technology-based program aiming at providing health services to isolated communities [11–15]. Telehealth has been widely used as a health care program that can reach all society levels in various developed and developing countries such as the Netherlands, Australia, Britain, America, and others. In Sweden, telenursing services have been applied since 2003 and have been receiving good responses from the public. There are currently 1.300 telenursing services in the country, and it is estimated that more than five million calls go to these services each year [16]. Telehealth provides quick and easy access, transfer, and tracking of health of information and interactive displays and interventions that can allow users to be highly engaged in promoting health outcomes and changing health-related behaviours [17]. The research identified three potential benefits of the app: Providing remote consultation, organizing, and analysing based on providing tutorial support for non-specialized care-givers [18]. In Indonesia, the implementation of Telehealth or Telenursing is considered not optimal yet since the number of health practitioners providing consultation and information to patients is still low.

Utilization of digital technology, for example mobile applications that anyone can access from a smartphone, would reduce the healthcare cost, and also improve the relationship between patients and their families with a healthcare professional. This could also resolve the geographical barrier and possibly reduce stigma in mental health services [19]. Although many technology-based tools are widely available, most of them are not adapted to local settings, and users have not been consulted to develop tools [20]. Efficacy, satisfaction, and effectiveness are key elements of the usability of technology-based equipment. These factors have to be fulfilled for tools to be tailor-made to meet the needs of users, mainly in mental health fields [21]. Me-CO Care is a special application of community mental health service developed based on the needs and expectation of the patients and also healthcare provider [22] to answer the global challenge of the importance of improving access and quality of cares for patients, families and community. This research aims at reviewing the feasibility of the Me-Co Care application to be applied to health service management in the community.

Material and methods

The research was carried out at four local health centres (puskesmas) in DKI Jakarta, the capital city of Indonesia. The research was conducted from August to December 2020.

Study design

This was a pre-post-test without a control group study. Participants received training and use the mobile application for a week which allowed us to determine the feasibility of Me-Co Care in supporting mental health services in a community setting.

Participants

The research focused on three groups, namely patient caregivers, health volunteers, and mental health nurses from each local health centres. In fulfilling their rights, the participants had to meet the inclusion and exclusion criteria. Caregivers of the patients (a) had to be the part or member of the biological family of the patients with a mental disorder, (b) had contact with the patients every day; health volunteers (a) had to live in the neighbourhood, (b) had been trained as health volunteers; and the mental health nurses (a) were medical nurses, (b) had been registered as a mental nurse in the neighbourhood. All respondents were able to speak (c) Indonesian, (d) read and use cell phones, and (d) they were willing to be participants, and did not have any physical or mental illness.

The samples consisted of 43 caregivers, 46 Health volunteers’, and 4 mental nurses selected based on the records from the local health centres. Mental health nurses and researchers were responsible for the selection and deployment processes. All participants who took part in the research were given approval information. Three caregivers of patients left the research without reason, so, there were 43 patient caregivers, 46 Health volunteers and four mental nurses joining this research (Local Health Centre of Koja, North Jakarta, Local Health Centre of Makassar, East Jakarta, Local Health Centre of Bukit Duri, South Jakarta, and Local Health Centre of Tanjung Duren Selatan, West Jakarta).

Outcome and assessment tools

Participants were assessed at two times point, baseline, and one-week post-treatment. Assessment consisted of one demographic characteristic, mobile application feasibility as a primary outcome, and mental health knowledge as a secondary outcome.

Demography

Demographic data consisted of age, gender, relationship with the patient, and address. Mental disorder data were obtained from local health centres.

Primary outcome

The feasibility of the mobile application was measured using the Me-Co Care calculation scale. The research team designed this instrument by referring to the feasibility of the previous mobile application. Some modifications were carried out to find the purpose of this research. This scale consisted of 22 questions-accuracy, format, easiness of use, timelessness, and satisfaction in using the Me-Co Care application.

Secondary outcome

The research team developed mental health variable questionnaire through an extensive literature search and expert review. After the calculation, the mean item content validity index (I-CVI) was .79 and in the current study, alpha coefficient showed acceptable internal reliability (α = .701) the I-CVI should not be lower than .78 [23]. Consisting of 10 questions, the tool was made to measure the basic knowledge based on mental health knowledge available at the first health setting, signs and symptoms of mental disorders, and how to deal with emergencies. The scores ranged from 0 to 10 of which the highest score was expressed as good knowledge.

Intervention

The research was divided into three sections, training for patient caregivers, application use practice, and evaluation process. All participants who agreed to participate in this research had filled out the consent information. In the first phase, health volunteers were invited to attend 8-hour training organized within two days by the research team. Subsequently, the research team gave them the knowledge questionnaires before and after the training. In the next two days, all participants, namely, patient caregivers, health volunteers, and mental health nurses, attended the 8-hour training about the Me-Co care application, which was informed in two days. The participants were trained to download, enter data and how to use their cell phones. The application feasibility evaluation process was carried out one week after the use.

Ethical Considerations

The approval to conduct the research was received from the Independent Review Committee of Universitas Muhammadiyah Jakarta (079/KEPK/UMJ/III/2019). Informed written consent was obtained from all participants and data were collected according to the Declaration of Helsinki on ethical research. Approval for conducting the project was obtained from all the local health administrations.

Data Analysis

The descriptive statistics [24,25] were calculated based on the characteristics of the participants and the results of the application feasibility study, of which the measuring of knowledge was analysed using the Dependent T-Test where the data was normally distributed. The data was calculated by approaching and imputing the missing data using the average scores. The results of knowledge were presented as average difference scores and standard deviations with a significance of 0.05. The result of the feasibility study was presented proportionally for each part. Data were analysed using SPSS v.21 for windows (IBM Corp., Armonk, NY).

Result and Dissection

The average age of the 93 participants analysed was 46.7 years old, with a range of 16 to 80 years old. 93.4% of participants were female health volunteers, and 76% of patients’ caregivers were old people.

The application feasibility study consisted of six sections. Referring to the results of the health volunteers, 100 percent showed that they were satisfied with the use of the Me-Co Care application in all respects. 100% of Me-Co Care users got the latest information about mental disorders and how to treat patients. 100% of participants stated the accuracy of the application and the fact that it was relevant to clinical information, 91 percent of them found out that the application was easy to use, 93 percent stated that it had an attractive format, and 93 percent found out that the application was able to save their time in providing mental health services. Referring to the results of the caregivers, 100 percent said that they were satisfied with the Me-Co Care application in all respects. 93% of Me-Co Care users got information relevant to mental health disorders and how to treat patients, 95 percent said that the application was able to provide accurate information with respect to the clinical situation they perceived; 95 percent found out that the application was easy to use, only 79 percent of them who said that the application had an attractive format, and 97 percent experienced that the application could save their time in providing mental health services. The mental nurses were very satisfied with this application in all respects.

The data analysis indicated a significant difference in the calculation of knowledge before and after the intervention (the average difference was 1.67, with a confidence level of 95% 0.00-6.00) by showing a correlation between the knowledge before and after giving the intervention 0.000.

Table 1: Demographic information for all participants (N=93)

Table 2: Feasibility of Me-Co Care Application (N=93)

Table 3: Calculation of the difference in knowledge before and after intervention