Developing a typology of mobile phone usage in social care: A critical review of the literature

1 INTRODUCTION: THE RISE OF MOBILE TECHNOLOGIES

The mobile phone is “arguably the most rapidly diffused technological artefact in history” (Wajcman, 2008, p. 68). The most recent data suggested that over 90% of adults in the UK had a mobile although only 66% had a “smartphone”—a phone powerful enough to act as an internet-enabled pocket computer (Ofcom, 2015). In some countries, including the UK, it has been suggested that there are rates of mobile phone ownership higher than 100% (Bittman, Brown, & Wajcman, 2009). Mobile phones have collapsed boundaries between work and leisure, and between our public and our private lives. Because mobile phones operate anywhere (provided there is a signal), they create spaces for communication that are not tied to physical locations and so many activities have been displaced from their traditional locations in time and space: they are “without borders” (Wajcman, Bittman, & Brown, 2008) particularly those between work/public time and private/leisure time. How people manage these increasingly blurred boundaries and use their mobile phones to negotiate social relationships, social roles and personal identity is the subject of a burgeoning literature almost all of which has been written since 2000 (Green & Haddon, 2009). The dizzyingly rapid and transformative developments in mobile technology and the sophisticated and creative ways users adapt the technology to their social needs make this an emergent and rapidly evolving field. These transformations permeate the “empirically specific social practices through which time and space are framed and apprehended on an everyday basis” (Green, 2002, p. 281).

Despite the figures cited above, there is evidence of a digital divide in the UK: the most recent data suggest that mobile phone usage ranges from 90% of 16- to 24-year olds to just 18% of those aged 65 and over (Ofcom, 2015). Similarly, while 11% of all UK adults had never used the Internet, 24% of those aged 65–74 and 61% of those aged 75 and over had never used it. About 27% of disabled people (based on self-assessment against the Equality Act definition) also reported never using the Internet. These data suggest that a significant minority of the population may be excluded from Internet-based interventions which can be accessed with a smartphone (e.g. messaging services such as Whatsapp and social media sites like Twitter and Facebook which are increasingly used for communication and group “chat”). The blurring of space-time boundaries and expectations of constant availability are not socially neutral: they affect people differently depending on their degree of control over their time and their social and professional status (Green, 2002).

The area of everyday social practice forming the focus of this paper is the use of mobile phones in social care. There have been overlapping developments in Internet-based interventions but the focus here is mobile phone activities involving calls, short message service (SMS) texts and messaging services. It should be noted, however, that insights from Internet-based interventions may have relevance for mobile phone interventions and some studies group Internet and mobile technologies under a broad “Information and Communications Technology” (ICT) label, meaning some joint consideration is necessary and useful.

There is now a body of research on the potential for mobile phone technology to improve preventative care and illness management in health-related fields, but much less on the use of mobiles in social work and social care and very little on the perspectives of service users, how the service provider/service user relationship might be altered, or the practice implications for professional social workers and third sector volunteers.

2 METHODS

This study was informed by Arksey and O'Malley's (2005) scoping review framework, as well as Levac, Colquhoun, and O'Brien's (2010) additional recommendations. An initial research question was developed based on the findings from the Masters study described in the introduction. Using this research question, search terms were developed from reading already-cited literature and following reference trails to relevant papers. Because of a diversity of terms used in different studies based on different fields (e.g. studies from healthcare versus those from psychology), as well as different terms in US and UK English, search terms were deliberately broad (see Table 1). Initial database searches were run and search terms refined in consultation with team members. Initial inclusion criteria were selected:

The full database searches were run 21–22 September 2015. The following databases were searched: Proquest (including ASSIA, IBSS, Proquest Dissertations and Theses, Social Services Abstracts and Sociological Abstracts); Ovid (including AMED, Global Health, HMIC, Medline and PsycINFO); Scopus; Web of Science; SCIE; and Science Direct. Additionally, three journals—British Journal of Social Work, Australian Social Work and Journal of Evidence Informed Social Work (previously Evidence Based Social Work)—were searched directly.

Where the search engine allowed (in every case except Science Direct, SCIE and the individual journals), three sets of “AND” criteria were applied: one for technology; one for relationship type; and one for service user type (see Table 1). Searches were made in Title, Abstract and Key Word fields where possible (as opposed to full text).

All results—citations and abstracts—were imported into Endnote: a total of 1,311. These were checked and five dated pre-2005 and one non-English language paper were removed (1,305). A further 587 duplicates were identified (the majority using the automatic duplicate identifier and the rest via a visual check of authors, year, title and journal title). About 718 abstracts were eventually selected for review.

After initial abstract reading, key word searching using Endnote, and discussion with the research team, a further set of inclusion criteria was agreed:

This second criteria was further refined during the abstract reading to emphasise a focus on—rather than merely a mention of—social support. This meant a large number of healthcare studies where mobile interventions which focused predominantly on adherence to treatment or management regimes, and also noted some relevance of social support, could be excluded. Three researchers read through the abstracts and selected papers according to these further inclusion criteria. Once three provisional lists (one per team member) had been assembled, these were checked for agreement. Papers with two out of three and three out of three agreements were automatically selected for full text reading; papers with one out of three agreements were further checked (including in some cases referring to the full text) by two of the team.

Twenty-one papers (1 Cochrane review, 4 doctoral theses and 16 peer-reviewed journal articles) remained after this stage. Full texts were then sought and the 15 peer-reviewed journal articles and Cochrane review were successfully obtained. In the case of the doctoral theses, one was unobtainable. Another was found to be related to a more recent peer-reviewed journal article (Barlott, Adams, Díaz, & Molina, 2015) that addressed the same study, and so this thesis was excluded from the full text read. Similarly, another thesis requested from the original author resulted in the receipt of a more recently published peer-reviewed academic journal article (Brown, Hudson, Campbell-Grossman, & Yates, 2014), and this was also used in place of the full thesis. The fourth thesis was received from the author and included in the full text read (Moon, 2013). One further paper (Walker, Koh, Wollersheim, & Liamputtong, 2015) was added when journal articles reporting pilot studies were followed up to check if full trials had since been undertaken. Twenty papers (1 Cochrane review, 1 doctoral thesis and 18 peer-reviewed journal articles) were eventually taken forward for the full text read.

The first and second author then read and charted the full texts in Microsoft Excel. The following information was recorded:

A number of complementary themes were identified across the different papers and a potential typology of different kinds of mobile phone intervention has then been suggested.

3 FINDINGS

The findings have been grouped into three complementary themes concerning:

4 DISCUSSION: A POTENTIAL TYPOLOGY OF MOBILE PHONE INTERVENTIONS

The reviewed papers explored different relationships between service providers and service users. These reflect, in part, the facilitation of particular relationships by mobile phone technologies—between service provider and service user, between service users themselves or a mix of the two—as well as challenging the professional/client binary in the context of trained peer support. Here we suggest a typology of mobile phone interventions, based on the relationship types they facilitate. These different intervention styles facilitate have various implications for changing relationships between service providers and service users, as well as potentially different risks and benefits for those involved.

4.3 Type 3: Multidirectional interventions

Four papers focused specifically on interventions developing multidirectional relationships (between service users themselves and/or trained peer supporters) within services facilitating those relationships (Hackett et al., 2005; McColl et al., 2014; Walker et al., 2015; Wollersheim et al., 2013). McColl et al. (2014) reviewed the literature relating to peer support mobile phone applications for people experiencing mental distress, while Hackett et al. (2005) in the context of an intervention for young people with chronic rheumatic diseases noted that one benefit was the development of peer relationships maintained by text messaging. Wollersheim et al.'s (2013) pilot and Walker et al.'s (2015) subsequent study reported an intervention providing peer support training and mobile phones with free calls to refugee women who had migrated to Australia.

The different intervention types have implications for power relations between service providers and users. While some unidirectional (Type 1) interventions were experienced as empowering by service users, this model also most closely resembles a traditional professional–client hierarchy, raising questions about its emancipatory potential (Rivest & Moreau, 2015). While bidirectional (Type 1) interventions also carry this risk (particularly those set in more medicalised contexts), they also have the potential to realign (at least partially) power relations between service provider and user.

Although interventions of types 2 and 3—involving multidirectional relationships—were in the minority among the papers included, they may offer the most potential for communications and interventions that resist current hierarchical and linear conventionalities of service provision. In these interventions, communication may be enriched and empowerment increased in comparison to type 1 interventions and they therefore represent a potentially transformative approach to using mobile phone technologies with service users by facilitating a collective development of networks and social capital. A dilemma for service providers is that these forms of intervention make it much harder for them to control the communications that occur.

Types 2 and 3 interventions have potential for developing service users’ social capital. While only one paper (Wollersheim et al., 2013) specifically used the concept of social capital, a similar approach could be identified in all seven papers covering these intervention types: one fitting the Organisation for Economic Co-operation and Development (2001) definition of social capital: “networks together with shared norms, values and understandings that facilitate co-operation within or among groups.” This is also the definition underlying the UK's official measurement of social capital (Office for National Statistics, 2014) and draws on the work of a number of prominent social capital theorists including Putnam (1995, 2001). These approaches tend to be used to highlight the positive aspects of social capital—for example the sense of community derived from robust social networks and shared values. However, other understandings of social capital focus on its role in reproducing, and being produced by, social inequalities (e.g. Bourdieu, 1986). While studies such as Wollersheim et al. (2013) and Walker et al. (2015) look at increasing social capital in the sense of developing broad social networks and increasing community cohesion, the more critical perspective of scholars such as Bourdieu should not be overlooked (Figure 1).

Several papers note the potential for mobile phones to enhance social networks for people isolated by geography, disability or other circumstances. Walker et al. (2015) described their intervention as providing a welfare service tailored to the needs of the refugee population, based around the provision of mobile phones and free calls, highlighting the unique contribution mobile phone technologies can make to communication networks offering support. These studies highlight the potential of interventions which unlock potential and increase social capital among service users directly—reducing the service provider's direct influence on communication. This highlights the potentially transformative potential of mobile phone technology in service delivery and its significance for resource-limited contexts.

A number of important implications concerning risks and benefits of mobile communication emerged from the papers. Several note the concerns of service providers—risks of crossing work/private boundaries, out of hours communications reporting self-harm or suicidal thoughts—which have made some reluctant to engage with mobile phone communication and highlighted the need for staff training and new policies. Ben-Zeev et al. (2014) noted the importance of service users receiving training in using mobile phones in these contexts and the need for accountability and confidentiality. Issues such as saving peoples’ contacts and texts will need careful exploration.

An issue raised in several of the cited papers, and by Lawton (2014) in her original study, is that professionals and volunteer peer mentors/befrienders may be viewed differently and may have different training needs. Befrienders may be seen as more approachable, flexible and non-judgemental by service users, raising implications about how boundaries are negotiated and the potential for tension and conflict between professionals and peer mentors. The way mobile phones blur or collapse boundaries between work and private spaces has already been noted.

A question raised in several of the cited papers and by Lawton (2014) was whether calls and texts serve different purposes with asynchronous communications allowing people to say things they may not feel able to otherwise communicate.

5 CONCLUDING REMARKS

This scoping review has covered a number of topics and raised significant questions and areas for future research. A lack of any really definitive literature beyond that closely associated with health outcomes means much of the evidence is not yet robust. The difficulty in distinguishing the specific effect of the mobile phone intervention (as opposed to other online interventions) is another issue but several papers pointed to the rich possibilities offered by easily portable phones.

The need for appropriate training of service providers regarding the delivery of mobile phone interventions appears significant, both in terms of new technology and in relation to expectations of confidentiality and data protection. The reluctance of some service providers to engage with new technologies was noted in some of the studies and has also been discussed in the wider literature relating to technology and social work practice. The lack of concrete guidance, even where professional standards do exist, is a key concern (Mattison, 2012). Reamer's (2015) consideration of social workers’ use of ICT addressed similar issues, including blurring of boundaries, dual relationships and conflicts of interest, and the need for practitioners to develop specific protocols for these issues. However, the risks of this leading to potentially harmful practices are noted by Mattison (2012). Chan (2015) draws attention to work that indicates practitioners relying largely on their own discretion. This means there may be a risk of at best inconsistent, and at worst unsafe and potentially harmful, practice where appropriate guidance is not in place.

This is particularly relevant given the changes that mobile phone technologies inevitably bring to a service provider–service user relationship. Wajcman et al. (2008) drew attention at the start of this review to mobile phones reducing or removing boundaries between the personal and professional. While none of the studies in this review explicitly investigated changing relationships, concern around service user/provider boundaries was a key issue for practitioners in a number of the studies (e.g. Ben-Zeev et al., 2014; Moon, 2013). Professionals and peer mentors may differ in their roles but may have similar training needs in many respects. Commonalities would include issues of staff exploitation and burnout, of boundaries and confidentiality, of the implications of surveillance of service users and the unequal power relationships between professionals and peer mentors.

There is growing evidence that many service users wish to use these technologies in the context of service provision (see for example Dodsworth et al., 2013; Mattison, 2012) and may themselves also need training. Greater accessibility for remotely located service users or those with limited mobility are both potential benefits of mobile phone interventions, but accessibility of services for those who struggle to access mobile phone technology (due to cost, literacy or impairment) also needs to be taken into account.

The role of mobile phones in developing social networks and increasing social capital seems particularly significant. There are similarities between some of the findings of these studies and other research examining mobile phones as “network capital” in everyday life (Rettie, 2008). Rettie follows Larsen et al.'s definition of network capital as ‘access to communication technologies, affordable and well-connected transport, appropriate meeting places and caring significant others that offer their company and hospitality’ (Larsen et al., 2006, in Rettie, 2008, p. 292). Some have drawn on Castell's network society thesis to describe the role of social workers in modern society (Baker, Warburton, Hodgkin, & Pascal, 2014; Smith, 2012) as “network-makers,” for example assisting service users to change and develop their networks and multidirectional mobile phone use may play an increasingly important role here.

In the UK, current government-led austerity measures mean finding efficiencies and reducing costs is a necessity for many service providers, demanding a need to explore the cost-effectiveness of interventions. Several papers emphasise the importance of face-to-face contact before or alongside interventions involving bidirectional interventions, suggesting that mobile phone interventions enhance more traditional service user relationships rather than replacing them in a bid to reduce costs (Ben-Zeev et al., 2014; Moon, 2013; Nolan et al., 2011; Yoo et al., 2015).

In contrast, some interventions were potentially designed to replace face-to-face services (e.g. Brown et al., 2014; McColl et al., 2014), while others aimed to offer a new service where none had previously existed (e.g. Barlott et al., 2015; Chen et al., 2010; Rana et al., 2015). The relatively low cost and wide reach of mobile phone interventions may thus be a positive first step for developing services in some contexts. Further potential for cost-efficiency and continued service quality is suggested by being able to offer alternative service provision in interventions involving bidirectionality, such as the “hovering” described by Ben-Zeev et al. (2014). Such potential is also suggested where participants experienced social support from unidirectional interventions (Agyapong et al., 2013; Brown et al., 2014; De Jongh et al., 2012; Rana et al., 2015). The work undertaken by Walker et al. (2015) and Wollersheim et al. (2013) suggests potential for cost-effective service provision by developing the self-efficacy and social capital of service users and training them to support each other may reduce reliance on other services. However, none of these studies were undertaken in the UK context. The lack of UK studies—and the way that phone use is socially constructed—means further UK-specific research is particularly needed to test the applicability of these types of interventions to British communities.

We suggest that the typology of mobile phone interventions outlined here may be a very useful model for future research to draw on in exploring the advantages, limitations and dilemmas of using mobile phone technology in social care settings to support and empower isolated and vulnerable service users. This remains an under-researched area and the development of a robust knowledge base is essential as mobile phone technologies come increasingly to shape and transform the ways we live our personal and professional lives.