e-Health Technological Ecosystems: Advanced Solutions to Support Informal Caregivers and Vulnerable Populations During the COVID-19 Outbreak

Abstract

Introduction:

This study highlights the importance of technological ecosystems in supporting informal caregivers and vulnerable populations in coping with the ongoing coronavirus disease 2019 (COVID-19) pandemic.

Methods:

This study integrates the available literature on internet of things (IoT) e-health ecosystem and informal care.

Results:

In the first part of this article, we describe the health consequences of quarantine and isolation and outline the potential role of informal care in containing the risk of spreading the infection and reducing the burden on the health care system. Then, we present an overview of the characteristics of emerging technological ecosystems in health care and how they can be adopted as a strategic option to achieve different goals: (1) support informal carers to help vulnerable populations during quarantine and isolation and facilitate the recovery process; (2) promote the adoption of e-health and telemedicine resources to reduce the well-documented burden experienced by caregivers; and (3) lessen the various forms of digital disadvantage among vulnerable individuals, who are at more risk to be digitally excluded. In the last part of this work, we introduce solutions to overcome potential challenges related to the development and adoption of advanced technological ecosystems and propose a reflection on the legacy of COVID-19 on telemedicine.

Conclusions:

Thanks to the disruptive potential of IoT for health and wellness promotion, technological ecosystems emerge as a valuable resource to support both informal carers and vulnerable populations. The main factors that represent a strategic advantage of a technological ecosystem are affordability, regulatory, and availability. A high degree of interconnection between all the stakeholders emerges as a key element for the provision of intergenerational care. The most important technical challenges of IoT e-health require to optimize privacy, security, and user-friendliness of IoT e-health.

Introduction

There is an increasing consensus emerging about the key role of telehealth for delivering mental health services during the coronavirus disease 2019 (COVID-19) crisis that is afflicting our time. Telehealth can be delivered through various modalities, such as videoconference, telephone, apps, online self-help platforms, e-mail, and chats. A growing evidence supports the effectiveness of telemental health for issues, such as anxiety,¹ depression,² or post-traumatic stress disorder.³

The psychological impact of COVID-19 pandemic is complex and largely unknown, with manifestations on both the individual and psychosocial level. Previous research has highlighted the significant psychological impact that outbreaks can have on individuals, affecting both those with and without mental illness. It can aggravate the condition of those with a pre-existing condition, affecting not only the individual but also their caregivers, and it can accelerate the manifestation of new psychiatric symptoms in those without any mental illness.⁴

Mental Health and Physical Consequences of Quarantine and Isolation

Quarantine and isolation are two critical measures adopted to limit the transmission of an infectious disease among individuals and communities.⁵ These two terms are often used interchangeably⁶; however, despite sharing the same purpose (preventing the spread of an infection), they refer to different practices. While isolation has the purpose to separate infected individuals from those without the infection, quarantine aims to separate and restrict the movement of people who could have been exposed to an infectious disease, monitoring them to determine if they develop the disease over time as well as reducing the risk that they could infect others.⁷

The consequences of the epidemic on people with mental health conditions are particularly alarming, as failing to recognize its “differential impact” on this patient population might not only hinder the efforts in place to contain the outbreak but also aggravate existing health inequalities.⁸ Evidence has shown that severe mental illness represents a risk factor for infectious diseases.⁹

The link between social relationships and a range of comorbid conditions is well known. Research has clearly demonstrated the contribution of social network ties and active social participation toward better mental health in older adults.¹⁰ Frequent conditions associated with loneliness include depression, cognitive decline, cardiovascular disease, and high blood pressure.¹¹ The elderly population is particularly vulnerable to psychiatric issues associated with social isolation. Previous research on severe acute respiratory syndrome (SARS) epidemic revealed that some older adults were more likely to develop a range of feelings and attitudes (such as pessimistic attitudes, hopelessness, less confidence in life, and reduced social integration), which contributed to increasing the likelihood of suicidal attempts.^12,13

Physical Health Consequences of Social Isolation

In studying the association between loneliness and social isolation with ill-health, researchers have focused primarily on mortality, mental health, and cardiovascular health.¹⁴ Cacioppo and Hawkley¹⁵ found that in socially isolated young adults the perceived intensity of daily stressful events resulted in a tendency to deploy passive coping with stressors and greater vascular resistance, a mechanism of blood pressure control that is considered a risk factor for hypertension. Additionally, the authors found a reduced potency of restorative processes, such as reduced sleep efficiency and diminished efficacy of an explicit repair process, and wound healing.¹⁵

Loneliness has shown to influence sleep efficacy resulting in poorer sleep efficiency and more time awake after onset, a result that confirms the capacity of loneliness to modulate the quality of restorative behaviors, in addition to influencing the selection of health behaviors.¹⁶ A reduced sleep quality, or lack of sleep, may lead to a downregulation of the immune system and neuroendocrine dysregulation.¹⁴

A recent systematic review conducted by Leigh-Hunt et al.¹⁴ showed solid evidence about the association of both social isolation and loneliness with increased all-cause mortality, and social isolation with cardiovascular disease (CVD) and depression. Moreover, the authors indicated that there is a similarity in the pattern of health risk for both the subjective state of loneliness and the objective state of social isolation.

Informal Care

Simply put, informal care is nonfinanced care that is outside the realm of formal health care, such as personal care or household tasks. For several chronic and fatal diseases, informal care plays an essential role, whose contribution is growing due to the consequences of the aging population.¹⁷ Its provision, across a life course and in later life, is becoming more and more common.¹⁸ As pointed out by Pickard et al.,¹⁹ formal care, and in particular that provided by family, is considered the most important source of care for most elderly people, who rely on it significantly more than on formal care.

In Canada, >23% of population provided informal care to a family member or a friend.²⁰ Furthermore, informal care for the elderly accounts for 80% in communities and 30% in institutions.²¹ The economic impact of informal care is also significant. In Canada, it is estimated to save from $24 to $31 billion annually, in 2011 dollars.²²

Adoption of Informal Care

In most countries, informal care provides a significant proportion of the total care in support of individuals affected by a condition, in particular with a chronic condition.²³ The contribution of informal care in the care process can assume different shapes: it can play the role of “an informant,” while interacting with formal care workers, as well as the role of the “therapy assistant,” “co-client,” “collaborator,” or “director.”^24(p.94) Whatever role we want to consider, it implies the existence of a certain relationship between the informal caregivers and health and social care professionals: the two domains influence each other, in a given context of policy setting.²⁵ The nature of caregiving is fluid, as individuals move into and out of the caregiving role during the different life course stages: the caregiving process, through the various stages, influences necessities and experience of the informal caregiver.²⁵

RELATIONSHIP BETWEEN FORMAL AND INFORMAL CARE

The relationship between formal and informal care is complex: deciding whether they are substitutes or complements is strictly related to the purpose of formal care. Most of the health care involves services delivered by trained professionals with the main purpose of restoring or maintaining health; however, the bulk of long-term care services is mostly provided by individuals with limited or no training and aims to facilitate the activities of daily living to improve the general welfare.²⁶ Studies on the relationship between informal and formal care have found that the two types of care can be substitutes or complements.

We summarized in Table 1 the relationship between formal and informal care, according to the studies conducted so far.

Table 1.

Relationship Between Informal and Formal Care Services

ROLES OF INORMAL CARE IN ITS RELATIONSHIP WITH FORMAL CARE
INFORMAL CARE AS A SUBSTITUTE OF FORMAL CARE	INFORMAL CARE AS A COMPLEMENT OF FORMAL CARE	INFORMAL CARE COMPLEMENTED BY FORMAL CARE
The probability that informal care can substitute formal care (and vice versa) is higher when there is an increase of ADL dependency. The severity of the disability, also indicated by a decrease of ADL dependency, is associated with a higher chance of choosing either formal or informal care, not both combined⁸⁶	Home health care services for the elderly with high levels of disability: stroke, diabetes, heart disease, lung disease. Elderly with more social support, whose informal caregiving network is stronger. Informal care might complement the access to paid home care, whose likelihood is higher for those with greater social support and for those living with their children⁸⁷	Informal care is complemented by formal care for the elderly whose informal caregivers have more competing needs (such as daughters join the labor force). The increase of women in the economic workforce may contribute for part of the increase in reliance on combined use of both informal and formal care^86,88
Availability of immediate family increase reliance on informal care (rather than formal care)⁸⁹	Informal care acted as a complement of formal care in the following cases: Elderly, chronically disabled living in the community, with highest levels of ADL dependencies (i.e., five ADLs) Elderly with more social support, whose informal caregiving network is stronger Elderly with less financial resources Elderly with less access to community services Informal caregivers with more competing needs Severity of disability might determine a higher probability to complement formal with informal care⁸⁶	Informal care is complemented in case of changes in family structure, due to divorced parents and children living far away providing less care⁸⁸
In the United States, formal care emerged a substitute for nursing home care⁸⁸	In the United States, informal care is a complement of formal care in case of outpatient surgery⁸⁸	State-provided home help was found to be a stronger substitute for informal care than home help provided by a non-state organization⁹⁰
Informal care has demonstrated to be a substitute of formal care for services provided in the household⁹¹	Complement for services provided in hospitals and doctors' offices⁹¹
North-south gradient due to (and institutional) differences between northern and southern European countries. In regions with “strong” family ties (i.e., southern Europe), informal care tends to substitute formal care⁹²	Informal care complements nursing care (high skilled), independent of the level of disability⁹³
Informal care substitutes low-skilled formal home care (paid domestic help); however, the substitution effect tends to disappear as the level of disability increases⁹³	Among patients with dementia in Spain and Sweden, informal care complements the use of day care facilities^94,95
In Korea, for the elderly aged 65 years and older, informal care substitutes formal care only in certain cases, such as individuals with diabetes⁹⁶	Among individuals with dementia, informal care and outpatient visits complement each other, in contrast with the study of Bolin et al.⁹⁷
Among patients with dementia in Spain and Sweden, informal care substitutes for paid domestic help^94,95	Informal care act as a complement to health visitor use, general practitioner visits, and hospital inpatient use⁹⁰
Among individuals with dementia, informal care act as a substitute for home care and nurse visits in four European countries: Finland, France, Germany, and Sweden⁹⁷
Informal care acts as a substitute for state and non-state provider⁹⁰

ADL, activities of daily living.

The complex plethora of studies addressing the relationship between informal and formal network care services has resulted in the development of two models. The first model, also known as the dual specialization model, indicates that when each type of service addresses the responsibilities to which they are most suited the nature of their interaction is coordinated and synchronized.²⁷ However, in case of a supplementary relationship between the two services, we can refer to a supplemental model.²⁷

ECONOMIC EVALUATION

Although important, the role of informal carers in economic evaluation remains ambiguous.²⁸ Ignoring the contribution of informal care on economic evaluations will lead to different types of underinvestment in health care, depending on the purpose of the evaluation. Ignoring informal care in economic evaluations designed to inform decisions on the amount health care funding will lead to an underinvestment in health care, while ignoring informal care in economic evaluations designed to inform resource allocations will lead to underinvestment in interventions that benefit carers.²⁸ Economists, indeed, agree about the fact that informal care is a non-negligible component of a specific health care program, which should be incorporated into economic evaluation.

As confirmed by Oliva-Moreno et al.²⁹ in their systematic review on the valuation of informal care in cost-of-illness studies, informal caregiving has a highly significant economic impact at an aggregated level. The systematic review conducted by the authors focused on a group of selected diseases, from 2005 to 2015: arthritis or osteoarthritis, cancer, dementia, mental diseases, multiple sclerosis, and stroke. They found that hourly unit costs used under the opportunity cost method were lower compared with those used under the proxy good method (on average €10.14 vs. €14.86). The approaches to evaluate the monetary value of informal caregiving can be different, such as the proxy good or the opportunity cost method (Table 2): the monetary value of informal care remains high even taking into consideration countries displaying more conservative figures (by Oliva-Moreno et al.²⁹).

Table 2.

Technical Challenges for the Deployment of Internet of Things e-Health Ecosystems

TECHNICAL CHALLENGES FOR THE DEPLOYMENT OF IoT e-HEALTH ECOSYSTEMS
PRIVACY AND SECURITY
MAIN THREATS	ACTIONS NEEDED
Unauthorized authenticationsHarm to end users, endangerment to user's privacy⁵⁶ Threats and attacks to each IoT layer⁵⁶ Cloud polling attacks: attempts to redirect the network traffic so that the attacker can inoculate their commands to the device⁷⁷	Enhance securing interactions between objects in IoT; protect information and service delivery⁷⁷ Building IoT e-health life cycle around privacy and security, beginning from specification generation, until implementation and deployment^56,98

BLOCKCHAIN TECHNOLOGY IN IoT
Blockchain technology demonstrated to bring security in the health care ecosystem.^69,78 –81 Its main characteristics can be summarized as follows: Decentralized peer-to-peer technology, combining peer-to-peer protocols, hashing algorithm, cryptographic primitives (such as public key), and distributed consensus algorithms⁹⁹ Transparency, instant access to data (thanks to its replication on all nodes), and the elimination of trusted third-party interceder (thanks to the decentralization) Decentralized approach supporting “three functions: peer-to-peer messaging; distributed file sharing; autonomous device coordination”⁸²	Regulation, standardization, and cross-border health data retrieving policies: sharing data among different and conflicting jurisdictions might hinder the benefits of blockchain's data sharing⁸⁰ Blockchain's capacity to store and process massive data access transactions with efficient timing⁸⁰ Blockchain capacity to adopt innovative algorithms and mechanism to minimize the delay in mining blocks when processing higher volumes of transactions⁸⁰

BLOCKCHAIN TECHNOLOGY IN IoT

ADVANTAGES

CHALLENGES

Blockchain technology demonstrated to bring security in the health care ecosystem.^69,78

–81 Its main characteristics can be summarized as follows: Decentralized peer-to-peer technology, combining peer-to-peer protocols, hashing algorithm, cryptographic primitives (such as public key), and distributed consensus algorithms⁹⁹ Transparency, instant access to data (thanks to its replication on all nodes), and the elimination of trusted third-party interceder (thanks to the decentralization) Decentralized approach supporting “three functions: peer-to-peer messaging; distributed file sharing; autonomous device coordination”⁸²

Regulation, standardization, and cross-border health data retrieving policies: sharing data among different and conflicting jurisdictions might hinder the benefits of blockchain's data sharing⁸⁰ Blockchain's capacity to store and process massive data access transactions with efficient timing⁸⁰ Blockchain capacity to adopt innovative algorithms and mechanism to minimize the delay in mining blocks when processing higher volumes of transactions⁸⁰

USER-FRIENDLINESS IoT e-HEALTH FOR ELDERLY USERS
Increasing usability and acceptance among elderly users by studying how to make design more interactive, how to evoke emotions and perceptions that influence user's behavior, as demonstrated by research on emotions and cognition¹⁰⁰ Combination and integration of emotional and attractive elements during the design phase to obtain more attractive devices, capable of having a positive impact on people's mood and motivation, and ultimately improving the perception of the devices as easier to use¹⁰¹	The design of technology tools has neglected the special needs of elderly people⁸³ The effects of information and communication technologies on social isolation are largely unknown as majority of the studies focused on loneliness, social connectedness, and social support⁸⁴ Appearance of technologies developed for older people has not made significant progresses¹⁰²

USER-FRIENDLINESS IoT e-HEALTH FOR ELDERLY USERS

ACTIONS NEEDED

CURRENT WEAKNESSES

Increasing usability and acceptance among elderly users by studying how to make design more interactive, how to evoke emotions and perceptions that influence user's behavior, as demonstrated by research on emotions and cognition¹⁰⁰ Combination and integration of emotional and attractive elements during the design phase to obtain more attractive devices, capable of having a positive impact on people's mood and motivation, and ultimately improving the perception of the devices as easier to use¹⁰¹

The design of technology tools has neglected the special needs of elderly people⁸³ The effects of information and communication technologies on social isolation are largely unknown as majority of the studies focused on loneliness, social connectedness, and social support⁸⁴ Appearance of technologies developed for older people has not made significant progresses¹⁰²

IoT, internet of things.

The Canadian government offers a nonrefundable tax credit, named the Canada caregiver credit, which can be claimed by those who support a spouse or common-law partner or a dependent with a physical or mental impairment. The government specifies that an eligible dependent can be (1) the caregiver or the caregiver's spouse's or common-law partner's child or grandchild or (2) the caregiver or the caregiver's spouse's or common-law partner's parent, grandparent, brother, sister, uncle, aunt, niece, or nephew (if resident in Canada at any time in the year).

The amounts that can be claimed for the spouse or common-law partner, and dependents aged 18 years or older, are $2,230 and, in some cases, up to $7,140, in case the dependent net income is between $7,159 and $23,906. The Canada caregiver credit was introduced since 2012, replacing at a federal level the provincial tax credits: the family caregiver credit, the caregiver credit, and the infirm dependent credit (Duncan et al.³⁰).

The introduction of a single credit probability aims to streamline the claim process, increasing the probability of the acceptance of this benefit. As noted by Duncan et al.,³⁰ although the Canada caregiver credit provides about the same level of financial support as the previous credits replaced, except from the provinces of Manitoba and Québec, none of these credits are (or were) refundable. For carers with lower income, nonrefundable credits are less valuable; in addition, nonrefundable credits are not available to carers with no income.³⁰

Informal Care and Informal Caregivers: Key Players for the Sustainability of the Health Care System During the Pandemic

During quarantine and social isolation, vulnerable populations are particularly at risk of developing neuropsychiatric complications. Evidence has shown that mortality is substantially elevated in individuals who are severely mentally ill.^31
–33 A recent meta-analysis conducted by Walker et al.³⁴ has shown a mortality rate in mentally ill patients more than twice as high as in the general population.

One of the key messages of this work is to stress the importance of informal care as a strategic element to contain the risk of spreading the infection and lower the risk of developing neuropsychiatric complications for the more vulnerable ones. By supporting dependent persons to stay home, informal caregivers can also contribute to reducing the burden on the care system.

However, the efforts required by long-term continuous care might expose caregivers to a significant physical and mental burden: a recent study showed that excessive workload, depression, or anxiety result in a decrease of their quality of life associated with an increase of social isolation.³⁵ For caregivers, it is important to have easy and reliable access to a variety of information and answers that can guide them during their daily care duties, in addition to provide a reliable psychological support. Therefore, another key point refers to ensure that informal caregivers can receive adequate psychological support.

e-Health technological ecosystems might represent a promising avenue to address the problems exposed. Designed and developed to support caregivers and promote informal care, they can deploy a variety of strategies to (1) contain the risk of spreading the infection and (2) provide critical support to all those delivering services to relatives whose condition, already vulnerable (e.g., presence of mental illness or disabling pathology), can be further deteriorated by the psychological effects of the current pandemic.

Internet of Things and Technological Ecosystems in Support of Caregivers and Vulnerable Populations

CAREGIVER BURDEN

Growing evidence indicates the burden of informal care provision on carers' quality of life. Caregiver burden is a complex and multidimensional concept: for example, in caring for loved ones with dementia, Dang et al.³⁶ have proposed that it encompasses the overall physical, psychological, emotional, and financial toll of providing care. The features of caregiving characterize a chronic stress experience, with prolonged exposure to physical and psychological strain associated with high levels of unpredictability and uncontrollability.³⁷ Caregiving is associated with a risk of mortality that was 63% higher for subjects providing care and experiencing caregiver strain.³⁷

A meta-analysis conducted by Pinquart and Sörensen³⁸ investigated the differences in psychological and physical health between caregivers and non-caregivers, finding the largest differences in depression (g = 0.58), stress (g = 0.55), self-efficacy (g = 0.54), and general subjective well-being (g = −0.40). Caregivers can be considered a critical national health care resource. Thanks to the evidence on health effects of caregiving that emerged over the last decades, policymakers are now considering caregiving as a major public health issue.³⁹ The professional health care force is facing a burden due to the continuous pressure caused by the high number of inpatients critically ill with COVID-19. This dynamic has reinforced the importance of the role of family caregivers, as we depend on them now more than in the past.⁴⁰

The stressors affecting caregivers during the current pandemic can be summarized in three main factors: (1) the health consequences of social isolation, (2) the economic stressors caused by COVID-19, and (3) the need to manage the complex decision-making to support their care recipients on a daily basis.⁴⁰ The impact of social distancing measures can increase the risks of social isolation and loneliness, with negative repercussions for the global well-being of the individual: substantial evidence indicates that risks associated with these conditions are comparable with well-known risk factors for mortality and that social isolation and loneliness might trigger psychological, behavioral, and biological pathways leading to poorer and decreased longevity.⁴¹

TECHNOLOGICAL ECOSYSTEMS FOR CAREGIVERS

Several effects of the caregiving role can be adverse to the caregivers themselves, impacting negatively their physical and psychological health, with potential financial and social challenges.⁴² Technology can contribute to substantially support caregivers, offering the opportunity to access hotlines for decision support, access individual or group sessions of cognitive behavioral therapy or other psychosocial treatments, training sessions to enhance problem-solving skills as well as parenting skills, access psychoeducational material to increase knowledge about the condition of loved ones, and, if necessary, self-diagnose and refer them.⁴³

Accessing the necessary information is important for caregivers not only to address the questions arising on a daily basis during their duties but also to receive psychological support and professional guidance. At the same time, they will benefit from being connected with a community composed of both equals and experts, providing the opportunity to enhance their competencies and share knowledge.⁴⁴ Thanks to virtual teaching–learning environments, technological ecosystems can overcome geographical barriers (e.g., for those living in rural areas) and face-to-face limitations in granting access to psychoeducational material. Moreover, technological ecosystems can facilitate social inclusion through easy access to social networks, guaranteeing ongoing support from experts.⁴⁴

Technological ecosystems represent a change of paradigm in developing health research initiatives, from user-centered solution to collaborative environments connecting stakeholders from different platforms. They provide a general framework through which it is possible to define and develop any type of solution.⁴⁵

Technological ecosystems are developed to support knowledge management in a variety of contexts. They differ from similar concepts that can be found in the literature, such as software ecosystems⁴⁶ or digital ecosystems.^47,48 In fact, the development of a technological ecosystem is based on a decentralized solution constituted of different software tools, resources, and information flows continuously supporting the process to adapt to the needs of the organization.⁴⁴ These structural characteristics differ from those of other types of ecosystems, in which the main approach consists of developing a central platform to connect or develop other tools and where the actors connected to the system are involved in the development of the platform either directly as developers or, alternatively, more indirectly as stakeholders.⁴⁹

Technological ecosystems can be seen as a framework to develop any type of solution where the flow in information is the core of the system.⁵⁰ The basic structure of a technological ecosystem encompasses three elements: software tools for the delivery of various services; human resources, to guarantee a continuous evolution of the ecosystem and to contribute to the knowledge management process; information flow, as a key element for the interactions among tools and between humans and resources.⁴⁹

A model prototype of a technological ecosystem in support of informal caregivers has been recently proposed by García-Holgado et al.⁴⁹ The technological infrastructure conceived by the authors is intended to serve two main purposes: (1) improve the quality of life of the caregivers and (2) provide a set of services for relatives and patients, with particular attention to those living in rural areas.

In line with what envisioned by the authors, the macro functions served by this type of ecosystem can be categorized in three main domains: (1) education/educational, thanks to the implementation of a dedicated environment where to deliver training programs (such as psychoeducational training programs); (2) social, providing an environment that can generate a community of individuals who can share their experiences and contrast the social isolation (in particular for those located in rural areas); (3) health promotion and healthy aging, intended as a form of support for both caregivers and those who are in need of care and isolated, especially the elderly affected by chronic conditions (including those with mental illness).

PSYCHOEDUCATION

Psychoeducation has an essential role as caregivers are daily committed to providing care for at-risk populations without direct supervision, support staff, or formal training about safety precautions in COVID-19.⁴⁰ Psychoeducational interventions generally consist of sessions providing specific information about a condition and its management. These interventions are typically provided by a clinician, in charge of leading the session, whereas patients and caregivers are the participants; they are delivered by means of either individual groups or group programs.⁵¹ The type of communication addressing informal carers is important as well: caregivers will benefit from receiving appropriate balanced communications from clinicians about how to use personal protective equipment, including procedures regarding proper removal and disposal.⁴⁰

In studying the effectiveness of psychoeducational interventions for informal carers of individuals with psychosis, it has been hypothesized that psychoeducation enhances knowledge in caregivers about the illness and associated caregiving issues, based on the application in family caregiving of the stress appraisal coping theory. Enhancing knowledge might be one of the keys for a more positive appraisal of caregiving experiences, a better self-efficacy of carers, and a reduction of in perceived burden and global morbidities.⁵¹

e-Health technological ecosystems might represent an effective alternative to access psychoeducation, which is mostly accessed face-to-face. In fact, for caregivers, the obstacles in accessing face-to-face programs relate not only to potential logistic barriers (e.g., living in remote areas) but also the impossibility of leaving the alone the individual in need of care. Customized technological solutions can allow—overcoming barriers imposed by the situation and context.

MULTIMODULAR PROGRAMS

During the last decade, a variety of multimodular programs have been developed, including resources about coping strategies as well as problem-solving techniques addressing common illness management or care-related issues and peer support groups.

Yesufu-Udechuku et al.⁵² have recently conducted a recent systematic review and meta-analysis of randomized control trials of interventions provided by health and social care services to informal carers supporting individuals with severe mental illness (including schizophrenia spectrum disorders, psychosis, schizophrenia, and bipolar disorder). Their results showed that psychosocial interventions focused on carers enhanced both experience and quality of life, at the same time reducing the burden and psychological distress. As pointed out by the authors, the largest contribution of studies in their review relates to studies of psychoeducation and support groups: their work provides evidence in support of carer-focused interventions to complement patient-focused family interventions for patients with severe mental illness.

Technology-based interventions have demonstrated to be a valuable strategy to promote caregivers' interaction, for example, adopting peer support groups and chat rooms, support caregivers with time constraints, and overcome logistic barriers and financial limitations.⁵³ e-Health solutions are a valuable ally to support informal caregivers, offering the advantage to enable individually adjusted support: their adoption has shown the be particularly advantageous and helpful for caregivers located in rural areas if compared with conventional forms of support, such as support groups, financial support, feel-good activities, counseling, and education.⁵⁴

Hu et al.⁵⁵ conducted a systematic review of open-label trials and randomized controlled trials of internet-based interventions to reduce the burden in informal caregivers. Their results showed that in around 2/3 of studies internet-based services contributed to reduce stressors in caregivers and enhance their quality of life and well-being. The internet-based resources already available for caregivers include chat rooms, discussion boards, online classes and workshops, individualized problem behavior diaries and exercise logs, stress and medical regimen management, and online multifamily group programs.⁵⁵

As reiterated by García-Holgado et al.,⁴⁴ the capacity to effectively support both the learning and knowledge management processes represents the main aim of an e-health technological ecosystem designed for caregivers.

INTERNET OF THINGS E-HEALTH FOR MENTAL HEALTH

There is a growing consensus about the disruptive potential of internet of things (IoT) not only for the health care and medical sectors but also more in general for health and wellness promotion. The premise to ensure that all the stakeholders, from organizations (such as hospitals or communities) to single individuals (such as physicians or caregivers), can be interconnected is to have an intelligent ecosystem capable of enabling such highly complex and efficient interconnectivity.⁵⁶

The innovations in mobile (m-health) and e-health are creating not only opportunities for individuals to become more independent in monitoring their health and ultimately improve their health but also to create opportunities caregivers to monitor and support remotely patients' health.⁵⁷ This implies that, among those who benefit from technological advancements, we find the plethora of agents responsible for informal care.

The provision of intergenerational care has become one of the points of the political agenda. Information and communication technologies (ICT) represent a driver of innovation, capable of contributing to a change in living standards and new social behaviors.⁵⁸ Personalized and IT solutions can provide both informal caregivers and dependent individuals various forms of support for their needs, for example, adopting environments for remote teaching–learning environments and social networks for social inclusion and contact with experts.⁴⁴ In the last decade, the interest in the development of new solutions to facilitate the interaction between various actors in the health and care sector has grown considerably.^59

–64

Technological ecosystems, therefore, are considered as a strategic element to support health care services due to three main factors: (1) affordability, to reduce costs and expenses; (2) regulatory, to address the problem of safety in services provided, in accordance to multilevel standards compliance; and (3) availability, to serve remote regions.⁶⁵

Therefore, the goal of a technological ecosystem is to improve the living conditions, thanks to the deployment of smart environments. Smart environments are characterized by their capacity to “acquire and apply knowledge about the environment and its inhabitants in order to improve their experience in that environment.”⁶⁶

IoT can be considered a wide ecosystem in continuous growth, interconnecting and integrating a multitude of hardware, objects, and people over a network, enabling them to communicate together to share information, collect, and exchange data, and coordinate decisions.^56,67

Nowadays, a general consensus on architecture for IoT has not been reached yet. Among the different models proposed, the most basic one, introduced during the early stages of research in this area, is a three-layered architecture, where the layers have been defined, respectively, as perception, network, and application layers.⁶⁸ The perception layer is composed of objects responsible for capturing the information about the environment and transform it into a digital signal. Some components of this layer are wireless sensors, smartphones, or wearables. The network layer supports the transmission of digital information and data exchange processes in wired and wireless networks: it connects to other smart objects, devices, and servers. The application layer enables the delivery of application-specific services to the user, defining various applications for the deployment of the IoT, including smart health.⁶⁸

In the literature, we find many more layered architectures, such as the four-layered model conceptualized by Farahani et al.,⁵⁶ or the five-layer architecture, which includes processing and business layers.^69,70

Farahani et al.⁵⁶ described a four-layered conceptual model of IoT. Assuming a bottom-up view, the first level is a sensing layer, which, integrated with all the types of hardware, connects to the physical world and collects data. The second level is represented by a networking layer, which supports the data exchange processes in wired and wireless networks. The service layer, the third level, aims to satisfy the user requirements by creating and managing all the services. Finally, the interface layer enables data analysis and efficient delivery of outputs by offering interaction methods to users and other applications.⁵⁶

As pointed out by the authors, the four-layered model finds a vast range of applicability among health care technologies and services with different advantages, such as enabling different technologies to work together, allowing to process and analyze large quantities of data, allowing to personalize the content or service, and enabling lifetime monitoring.⁵⁶

In the five-layered model introduced by Khan et al.,⁶⁹ we find the following layers: perception, transport, processing, application, and business layers. While perception and application layers have the same functions of the basic model described above, the three new layers have the following roles: (1) the transport layer utilizes different networks to transport the information gathered by sensors from the perception to the processing layers and vice versa; (2) the processing layer (also named middleware layer) processes, analyzes, and stores large quantities of data gathered by the transport layer. Through the adoption of various technologies (such as databases or could computing), it supports the lower layers providing a range of services⁶⁸; the business layer is responsible for managing the entire IoT system (Fig. 1).

Fig. 1.

Architecture of IoT: (A) three layers; (B) five layers. Reprinted from Sethi and Sarangi.⁶⁸ IoT, internet of things.

Some authors reflect about future scenarios where the future IoT are internet of everything, the internet of services, and internet of networks, where everything is highly interconnected with networks, services, and reality world.⁷¹ An interesting consideration stemming from this analysis, as Ning and Wang⁷¹ pointed out, refers to the fact that the architecture of for future IoT shall be ubiquitous: the architecture envisioned by the authors is inspired by the levels of processing of the mankind nervous system. According to this model, the first layer is represented by the human brain, acting as a management and centralized data center; the second layer is represented by the spinal cord, acting as a distributed network of control nodes; finally, a network of nerves, corresponding to the networking components and sensors.^68,71

Some of the applications of e-Health ecosystems are:

m-Health smartphone apps or web-based cloud dashboards.

Ambient Assisted Living ecosystems, consisting of an ecosystem of medical sensors, computer, wireless networks, and software application to monitor and support the health status of the individual.⁷²

Wearable sensor systems designed to monitor and predict the medication adherence.⁷³ Particularly relevant, in the context of this pandemic, is the presence of pulmonary disease sensors, technological solutions to detect and classify coughing, typically based on the utilization of audio microphones.^74,75 Among the interesting solutions, we find, for example, a wearable health monitoring sensor, which, integrated with a body area network, aims to diagnose pulmonary edema. Dieffenderfer et al.⁷⁶ presented a wearable sensor system that supports a better understanding of the impact of increased ozone levels and other pollutants on chronic asthma conditions.

Miniaturized implantable medical devices capable of restoring or improve human functions, such as pacemakers, cochlear implants, or deep brain stimulations.⁵⁶

Technical Challenges for the deployment of IoT e-Health Ecosystems

Among the technical challenges for the deployment of IoT e-health ecosystems, we focus on three main points: privacy, security (including possible scenarios connected to the adoption of blockchain technology), and user-friendliness.

Real-world security is one of the major challenges in IoT, whose architectures are expected to deal with billions of objects, which, in turn, interact with each other as well as with other entities, including human beings. Securing these interactions is a priority not only to contain the number of incidents that can impact the IoT but also to protect information and service delivery.⁷⁷ Protecting an IoT e-health ecosystem is a complex task. In fact, each layer is exposed to different types of threats and attacks.

Blockchain technology demonstrated to bring security in the health care ecosystem.^69,78

–81 It can be deployed in IoT as one of the remedies to tackle the security and privacy issues, thanks to the elimination of the central server concept that characterizes IoT, allowing data to move with apposite authentication through the blockchain distributer ledger for each transaction.⁸²

It is relevant to notice how, despite the rapid expansion of ICT tools designed to improve daily life, the design of technology tools has neglected the special needs of elderly people.⁸³ Many of the studies conducted to analyze the impact of ICT in preventing or reducing social isolation have produced ambiguous outcomes. As noted by Chen and Schulz,⁸⁴ ICT effects on social isolation are largely unknown as the majority of the studies focused on loneliness, social connectedness, and social support. Identifying the potential elderly user is therefore a prerequisite to maximizing the benefits of ICT interventions to enhance social interactions in older adults.⁸³

In Table 2, we present the main aspects related to the topics presented above: privacy and security, blockchain technology, and user-friendliness.

Telemedicine After COVID-19

There are no doubts about the exponential increase in the adoption of telemedicine since the beginning of the COVID-19 pandemic. During the previous SARS-CoV epidemic of 2003, we simply did not assist to the enormous boost supporting massive adoption on a large scale of telemedical applications. Although one partial explanation might refer to the different entity of the epidemics, it would be fair to assume that the main reason lies in the exceptional availability of much more advanced mobile phone technology.

As noted by Shachar et al.,⁸⁵ privacy concerns should not obstacle the actual need of patients to receive care. Although the risk of breaches of privacy under the more lenient standards of this pandemic deserves attention and consideration, privacy may not be the most important concern during this crisis.⁸⁵ After this pandemic, it is reasonable to expect that the issues related to privacy and security will be addressed, ensuring a more user-friendly approach.⁸⁵

Finally, the current pandemic has perhaps provided an opportunity to reflect about not only possibly setting new boundaries for telemedicine but also to consider its role as a preventive strategy or tool.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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