Keywords
adolescent health - digital technology - mHealth - screen time - social media
Introduction
In the last decade, there have been advancements in technology and an increase in
popularity and frequency of Internet use on a global scale. The term eHealth describes
a broad range of digital technologies and interventions, and it is the intersection
of medical informatics, public health, and business for healthcare. mHealth is defined
as medical or public health practice supported by mobile devices, such as mobile phones,
personal digital assistants (PDAs), pagers, and tablets.[1]
Preventive mHealth services during adolescence have been used for teleconsultation,
health information delivery, involvement in self-care through tracking and reminders,
and access to health services. These are found convenient, readily accessible, personalized,
with increased family involvement in healthcare and are not limited by geographical
boundaries.[1]
Coronavirus disease 2019 pandemic has brought unforeseen times for the public where
telemedicine emerged as the most expedient solution. Telemedicine has been explored
for providing consultation, managing medications, wellness and fitness, peer-group
support, and maintaining communication.[2] Its use increased exponentially for managing general health issues and developing
indigenous solutions for providing mental health, reproductive health, and substance
abuse services to adolescents and young adults.[3]
Through this review, we evaluate an increasing number of Internet-based interventions
that can be developed and applied to the needs of adolescents.
Methods
This was a narrative review with preferential inclusion of Systematic Reviews and
Meta-Analyses. Studies were selected from the PubMed electronic base. The search terms
included “internet positive adolescents,” “health-related internet use,” “eHealth
adolescents,” “eHealth adolescents positive,” “mHealth adolescents,” and a search
string was created. On filtering for the research in the last 5 years, over 1,776
articles were shortlisted. Two authors independently scrutinized the abstracts for
suitability. The relevant articles included were based on the age group (adolescents
and extending to young people up to 25 years of age) and if relevant to the six key
areas under the national program for adolescents that are nutrition, sexual and reproductive
health, mental health, noncommunicable diseases, substance abuse, and injuries and
violence.[4] The studies using eHealth and mobile health (mHealth) for monitoring or management
of chronic diseases (except mental health problems) were excluded. Similarly, digital
interventions with focus on maternal and child health were also excluded.
The review was intentionally adjusted to include a broad range of interventions to
acquire a deeper understanding of unique aspects of eHealth related Internet use in
adolescents in each intervention.
eHealth Interventions
The key eHealth interventions that may be applicable for adolescents are listed below:
-
Nutrition interventions: The rising incidence of obesity in adolescents globally has implications on incidence
of other chronic diseases and an overall negative impact on health.[5] Digitalization has become rampant as the use of mHealth and wearable technology
is appealing among adolescents and has also demonstrated efficacy in providing approaches
toward weight loss. These apps help to roughly track daily calorie consumption with
micronutrient intake. The results of validation studies for such apps and technology,
however, show variable results with poor accuracy with traditional diet calculation.[6]
Another approach toward providing this is motivational interviewing in which telecounseling
with face-to-face, telephone, group sessions, work books, and activities are used
to resolve ambivalence to change unhealthy behaviors. Internet interventions with
components such as self-monitoring, reminders, web-based lessons, and discussion groups
in addition have also been shown to be very effective. In a systematic review, out
of six studies having solely eHealth interventions (particularly, Internet-related),
four showed significant improvements in body mass index z-score, or obesity-related
behaviors after the intervention.[5]
-
Noncommunicable diseases: Physical exercise and fitness are crucial determinants for wellbeing during growing
years. The last decade reported a huge increase in use of fitness technology through
fitness gadgets and smartphone apps. A meta-analysis on almost 1,740 participants
reported modest increase in physical activity with the use of smartphone apps when
used for a short term (<3 months period). The effect was less pronounced when these
were combined with dietary interventions.[7] Smartphone apps have also shown good performance in weight control and obesity prevention
programs. A meta-analysis of 12 studies on adolescents and adults showed significant
reduction in weight (−1.07 kg, 95% confidence interval [CI]: −1.92 to −0.21) and body
mass index (−0.45 kg/m2, 95% CI: −0.78 to −0.12) with the use of mobile apps; however, with nonsignificant
effect on increase in physical exercise. The duration of intervention in these studies
ranged from 6 weeks to 9 months thereby indicating the need of evaluating the long-term
efficacy of these interventions.[8]
-
Substance abuse: Cigarette use and tobacco consumption are exponentially increasing problems recently
because of their alluring portrayal in the digital world. Digital health interventions
as community outreach apps and personalized teleHealth options have been evaluated
for substance abuse. SIHLEplus is an integrated digital intervention that was found
efficacious among African American female youth for substance use disorder and human
immunodeficiency virus (HIV) prevention.[9] It employs weekly group sessions and personalized teleHealth counseling with parental
involvement conducted as role plays, discussions, interactive games and skill demonstrations.
Mobile phone messaging also showed significantly higher chances of smoking cessation
at 6 and 12 weeks, with nonsignificant effect at 26 weeks.[10] The Internet based intervention delivered by professionals was efficacious in decreasing
drug use (marijuana, cocaine, inhalants and prescription drugs), cigarette and alcohol
use. These can be tailored to mimic the individualism of one-to-one counseling and
were useful in maintaining anonymity and decreasing stigmatization.[11]
-
Sexual and reproductive health (SRH): SRH has long been a coveted topic with limited access to free, correct, and reliable
information for adolescents. Digital technology can play a supportive role with the
presentation of sensitive information in a more casual and amicable manner without
barriers of stigmatization, discrimination, lack of privacy, and confidentiality or
embarrassment.[12] The digital interventions have focused on the ways media influences sexual decision
making and sexual health, identifying gender stereotypes and countering them, representing
healthy romantic relationships and counter portrayal of unhealthy and abusive relationship
behaviors, providing accurate sexual health information and safe sexual health practices,
and countering the wrongly glamorized sexual violence and assault. Media literacy
provides information for menstrual care, contraception, and sexually transmitted infection
protection.[13]
A survey among healthcare providers showed that almost one-third of them had sensitized
their clients to the use of SRH mobile apps, though most reported a need for further
training in better using the app.[14] Creation of supportive peer-groups or support groups on digital social media can
be another positive aspect of technology. A review reported peer support eHealth interventions
for HIV prevention to be acceptable and effective in influencing healthy behaviors
but raised concerns of privacy.[15]
-
Mental health: The excessive use of digital media has been linked with increased vulnerability to
cyberbullying, anxiety, insomnia, and depression. Many recent mHealth applications
have been developed to assist in positive thinking, meditation, relaxation, and maintaining
good sleep hygiene, though they vary in the efficacy, privacy, and availability of
a safe app.[16] A study showed improved engagement of children and young patients with mental health
problems with Internet-based cognitive behavioral interventions (iCBT) as disease
specific interventions and person specific interventions. It consisted of communication
strategies such as limited text messages, ability to personalize, ability to connect
to others, and option to receive text message reminders; virtual experiences like
virtual shows; robotic and computer-based intervention involving quizzes, photographs,
animations, multimedia, psycho education, skill development, etc.[17] iCBT being self-directed has a major issue of adherence, but still moderate-to-high
satisfaction rates have been recorded. Benefits are not just in terms of clinical
improvement but also in terms of cost, availability, accessibility, and time.[18] A systematic review of smartphone apps for mental illnesses showed an increased
usage of these apps for common mental health illness with decreased need for physical
contact with the therapist or psychologist, thereby allowing flexibility and cost-effectiveness
in treatment.[19] Field studies of smartphone apps that provided teleconsult followed by promotional
messages were found useful for the management of depression and anxiety.[20] Another meta-analysis also reported the advantage of mHealth in mental health disorders
and substance abuse with interventions like setting reminders, support messages, psychoeducation,
and setting interactive voice responses.[21]
Computer games have been developed that subject the candidates to relatable situations
similar to the anxiety or low mood provoking situations which they have to solve.
During the game, the candidate can talk/ take guidance from the therapist using a
virtual interface.[22] Furthermore, the Internet-based interventions also allow the family members and
friends to become a part of therapy sessions more frequently, thereby reducing the
sense of isolation or inferiority in the child. Recent studies on high school students
and adolescents have reported positive health outcomes measured for social well-being,
positive mental health, and self-rated health with routine use of social media.[23]
[24] Peer-lead online workshops for students in late adolescence also improved the help-seeking
behavior.[25] The same technology can also be used to promote normal healthy mental well-being
among adolescents right from dealing with emotions, handling stress and anxiety. The
apps can promote relaxation, assist in cognitive behavior therapy, and can suggest
nonstigmatizing interaction with a psychologist during teleconsultation.
-
Violence: The types of violence to which children and adolescents may get exposed include
community and domestic violence, physical and verbal violence at schools, sexual violence,
cyberbullying, and emotional or psychosocial violence by neglect, discrimination and
threat. Adolescents exposed to violence are often in the precontemplation phase and
may be hesitant to share it to seek help. mHealth apps against cyberbullying or bullying
at school and positive parenting digital intervention can play a positive role against
violence during childhood and adolescence.[26] In 2011, “Feel the ViBe” (feel the violence beaten, FtV) was developed to support
adolescents and young adults who faced family violence by providing information, offering
peer support, lowering the threshold to regular healthcare services, and helping find
appropriate need-based healthcare. Like other eHealth interventions, attrition was
a drawback and an increase in the depressive thoughts in those undergoing intervention
as a consequence of seeking help and becoming more aware of the situation. However,
Ftv was found to be effective with most participants feeling helped and 2/3rd starting
other healthcare options.[27] Similarly, Circle of 6 app, which enables alert and support when they face violence,
was used as an integrated approach with other formal measures to reduce dating and
relationship violence among 13 to 15-year-old students in southern England. The study
reported a decrease in dating and relationship violence from 50 to 35% at follow-up
with good acceptability among students.[28]
-
Injuries: During adolescence, mild traumatic brain injuries (mTBIs) or concussions have a high
incidence and pose problems such as associated loss of productivity and longer term
morbidity (somatic, cognitive and/or behavioral symptoms beyond 1 month in up to 30%).
Web-based self-management programs were found to be an innovative way to provide resources
to address consequences of mTBI. A program entitled Self-Management Activity Restriction
and Relaxation Training included daily symptom and activity monitoring along with
personalized feedback and educational modules incorporating principles of anticipatory
guidance, problem-solving, and stress management/relaxation training. The results
of the program demonstrated declining symptoms following mTBI usage and an improvement
in functional disability and executive functioning of the adolescents as reported
by parents. An additional advantage was improved well-being and reduced worries about
recovery.[29] Several assistive technologies, which can be assistive, adaptive, and rehabilitative
to compensate for loss of function and disabilities, leads to a support in cognition
in individuals with acquired brain injury. These are becoming more prevalent with
the advent of mHealth and examples include Neuropage (a paging device that schedules
reminders for individuals with cognitive problems), electronic calendars, PDAs, and
apps (Evernote, Google Calendar, Family tracker, etc.).
Advantages of eHealth Interventions
A review on use of mHealth interventions in low- and middle-income countries showed
that the data on efficacy of mHealth interventions was limited as mHealth was usually
designed as one-way communication as a message or a reminder for follow-up schedule
or health behavior.[30] However, the adoption of the concept of mHealth and digitalization of health informatics
was appreciated even in the rural area. Overall, another systematic review reported
good feasibility and acceptability of text messages and smartphone apps for improving
clinic attendance, contraceptive use, oral health, physical activity, adolescent vaccination
practices, smoking cessation, and sexual health among adolescents.[31] The different health-related Internet interventions have been classified as shown
in [Table 1].[32]
Table 1
Health-related Internet-based interventions[32]
|
Web-based solution
|
Methodology
|
Remarks
|
|
Web-based interventions
|
•Web portals for information on preventive wellness, diagnostic, and therapeutic options
•Websites and blogs for group discussions and peer education
•Automated feedbacks and messaging
|
Information may not be authentic and valid
|
|
Online counseling and therapy
|
•Telemedicine approach that can help users to easily access the healthcare services
and consult their physicians and counselors
|
Lack any emergency care provision and human touch
|
|
Artificial intelligence and virtual reality therapeutic software
|
• Softwares amalgamated with latest smartphone apps to learn and predict responses
and issue reminders
• Auto-check on adherence to medications and therapy
• Virtual assistants like “Alexa” and “Siri” for information
|
Lack of authenticity
|
|
Other online activities
|
•Digital registries
•Tele-ECHO (Extension of Community Healthcare Outcome) to facilitate communication
between different healthcare providers
|
Lack of privacy
|
The Internet and smartphone can also be used in pediatric health promotion by helping
with self monitoring, goal setting, immediate feedback, and contingency management.[33] Few school mandated eHealth programs promoted both harmonious and obsessive Internet
use, while self-initiated programs (goal and education directed) promoted relative
harmonious use without obsessive use.[34] A new mHealth app called “Brain in Hand” is being implemented for autism and mental
health. It synchronizes with a smartphone app and helps users create a structured
daily routine for difficult to remember tasks or problem situations and gives patients
instant solutions, to assess in real time, improving their independence.[35] The Indian Academy of Pediatrics has released the following guidelines on appropriate
use of digital devices among the adolescents as shown in [Table 2].[36]
Table 2
Recommendations on digital wellness in adolescence[36]
|
Adolescents
|
|
A balance of screen time and other activities to be ensured for overall development;
At least 1 hour of outdoor physical activity, 8–9 hours of sleep, time for schoolwork,
meals, hobbies, peer interaction, and family are essential
|
|
Educate about the positive and productive use of devices by ensuring that most of
their screen time is related to education, communication, skill development, and healthy
lifestyle promotion
|
|
Media use to be monitored for violent or undesirable content
|
|
Awareness to be provided of cyber laws and strategies that detect fake messages and
news
|
|
Media use to be monitored for data privacy, cybersecurity, and to detect any signs
of cyberbullying or media addiction
|
|
Regulation of screen time to avoid interference with scholastic performance, mental
health
|
|
Parents
|
|
Keep themselves updated with technology so that they can detect any inappropriate
activity
|
|
Access the online accounts at any time to protect and teach their wards about their
digital footprint
|
|
Familiarize themselves with video games and social media platforms before allowing
the adolescents to use these
|
|
Act as a role model, like limit their own screen time and use social media and other
online platforms appropriately
|
Disadvantages of eHealth Interventions
The ease and availability of Internet and technology have led to an increasing number
of reports highlighting its potential negative consequences to an extent that the
Diagnostic and Statistical Manual of Mental Disorders (DSM–5) has included it as a
distinct disorder.[37] The DSM-5 states Internet addiction disorder as the “inability of individuals to
control their Internet use, resulting in marked distress and/or functional impairment
in daily life” ([Table 3]).[37]
Table 3
DSM criteria for Internet addiction[1]
[37]
|
A preoccupation with the Internet
|
|
Need to use the Internet for increasing amounts of time
|
|
Unsuccessful efforts to stop using the Internet
|
|
Mood change when attempting to stop or cut down Internet usage
|
|
Staying online longer than intended
|
|
Jeopardizing of significant relationships or opportunities due to excessive Internet
usage
|
|
Lying about Internet use
|
|
Using the Internet as an escape from problems or seeking to relieve bad mood states
|
Abbreviation: DSM, Diagnostic and Statistical Manual of Mental Disorders.
The prevalence of Internet addiction has been on a rise, being higher in boys than
girls with similar addiction rates between urban and rural areas.[38]
[39]
[40] The reported prevalence in few countries like India was higher (31–40%),[38]
[39]
[40] than in China (11.3%) and European nations (4.6% to 6%).[41]
[42] The various risk factors for Internet addiction are underlying comorbid psychological
illness, Asian race and few genetic polymorphisms in dopamine receptor, and serotonin
transporter.[43]
Various mechanisms have been proposed for the development of pathological addiction
and high-risk behaviors in adolescents. It has been observed that the development
of the prefrontal cortex takes longer time compared with the limbic system that causes
decreased inhibition of subcortical structures by the cortex and results in more impulsivity
and high-risk behavior during this time. Among neurotransmitters, oxytocin plays an
essential role and regulates mesolimbic dopamine reward system. Other neurotransmitters
like melanocortin, neurotensin, orexin, and substance-P also affect the high-risk
behavior, though the exact mechanism is unclear.[43]
The major problems related to Internet addiction in adolescents include less human
and social interaction, decreased exercise and productivity, decreased sleep related
to night time exposure to light leading to poor sleep quality, depression, anxiety,
and increased exposure to inappropriate and violent online media and cyberbullying.
In a meta-analysis,[44] a significant association between screen time and external behavioral manifestations
like aggression, attention deficit/hyperactivity disorder symptoms as well as internalizing
behaviors such as depression and anxiety was seen in children and adoelscents. Increased
duration of screen time had a small but significant correlation with more externalizing
problems (90 samples; r: 0.11; 95% CI: 0.10–0.12) and internalizing problems (43 samples; r: 0.07; 95% CI: 0.05–0.08) in children.[44]
Furthermore, appearance-related social media consciousness with body image issues
influences teenagers (both boys and girls) and may relate with depressive symptoms
irrespective of time spent online.[45] Children and adolescents who are more prone to mental health problems, based on
their family history, genetics, childhood factors, etc., are likely to be more vulnerable
on online platforms. This influences the quality and quantity of social media and
Internet use, further correlating with depression and related mental health issues.
It also suggests that children and adolescents who are more vulnerable to offline
bullying get trapped in incidents of cyber bullying as well. A supportive parent–child
approach is likely to benefit such teenagers, preventing harmful online interactions.
Way Forward
A review on the implementation of eHealth and mHealth has deepened the understanding
of how the Internet is used by adolescents. As per data from last decade, almost 80%
and more adolescents in Europe and United States had a mobile device of their own.[46] Recent evidence refutes an association between social media use and depression in
adolescents.[46] The documentation from adolescent dairies and population-based capture of daily
life experiences also show insignificant small associations between digital media
use and mental health concerns, negating a causal relationship.[46]
There is a scope for developing online support and platforms that can help in making
social media useful for adolescents. These can mirror offline peer-to-peer support
systems, increased opportunities for self-representation and disclosure, building
resources and channels that ensure online safety and prevent cyber bullying.[46]
The global strategy on digital health, World Health Organization (2020–2024), lays
down the objectives and framework to be adopted for improvement in overall health
with the use of digitalization. The Ministry of Health and Family Welfare, Government
of India, also released the National Digital Health blueprint in April, 2019, to implement
digital health measures in India. The availability of public digital health services
can be the initial impetus to augment eHealth services for adolescents in India.[47]
Conclusion
eHealth strategies are useful for many adolescent health problems, with the need to
monitor overall long-term efficacy, safety, and satisfaction. Although Internet and
technology have many ill effects as highlighted above, with appropriate regulation
of screen time and quality of digital exposure, it can act as a boon for healthcare
during adolescence with right information, supervision, and feedback.
