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Gullslett MK, Ronchi E, Lundberg L, Larbi D, Lind KF, Tayefi M, Ngo PD, Sy TR, Adib K, Hamilton C. Telehealth development in the WHO European region: Results from a quantitative survey and insights from Norway. Int J Med Inform 2024; 191:105558. [PMID: 39084085 DOI: 10.1016/j.ijmedinf.2024.105558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 06/21/2024] [Accepted: 07/16/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND The COVID-19 pandemic sent shock waves through societies, economies, and health systems of Member States in the WHO European Region and beyond. During the pandemic, most countries transitioned from a slow to a rapid adoption of telehealth solutions, to accommodate the public health and social measures introduced to mitigate the spread of the disease. As countries shift to a post-pandemic world, the question remains whether telehealth's importance as a mode of care provision in Europe continues to be significant. OBJECTIVE This paper aims to present, synthesize, and interpret results from the Telehealth Programmes section of the 2022 WHO Survey on Digital Health (2022 WHO/Europe DH Survey). We specifically analyze the implementation and use of teleradiology, telemedicine, and telepsychiatry. Norwegian telehealth experiences will be used to illustrate survey findings, and we discuss some of the relevant barriers and facilitators that impact the use of telehealth services. METHODS The survey tool was revised from the 2015 WHO Global Survey on eHealth, updated to reflect recent progress and policy priorities.The 2022 WHO/Europe DH Survey was conducted by WHO and circulated to Member States in its European Region from April to October 2022. RESULTS The data analysis revealed that teleradiology, telemedicine, and telepsychiatry are the telehealth services most commonly used in the WHO European Region in 2022. Funding remains the most significant barrier to the implementation of telehealth in the Region, followed by infrastructure and capacity/human resources. The survey results highlighted in this study are presented in the following sections: (1) telehealth strategies and financing, (2) telehealth programmes and services offered by Member States of the WHO European Region, (3) barriers to implementing telehealth services, and (4) monitoring and evaluation of telehealth. CONCLUSION Based on WHO's 2022 survey, the use of telehealth in the WHO European Region is on the rise. However, merely having telehealth in place is not sufficient for its successful and sustained use for care provision. Responses also uncovered regional differences and barriers that need to be overcome. Successful implementation and scaling of telehealth requires rethinking the design of health and social care systems to create robust, trustworthy, and person-centred digital health and care services.
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Affiliation(s)
| | - Elettra Ronchi
- Division of Country Health Policies and Systems, WHO, Europe
| | - Lene Lundberg
- Norwegian Centre for E-health Research, Tromsø, Norway
| | - Dillys Larbi
- Norwegian Centre for E-health Research, Tromsø, Norway
| | | | - Maryam Tayefi
- Norwegian Centre for E-health Research, Tromsø, Norway
| | | | - Tyrone Reden Sy
- Division of Country Health Policies and Systems, WHO, Europe
| | - Keyrellous Adib
- Division of Country Health Policies and Systems, WHO, Europe
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Ådnanes M, Kaasbøll J, Kaspersen SL, Krane V. Videoconferencing in mental health services for children and adolescents receiving child welfare services: a scoping review. BMC Health Serv Res 2024; 24:729. [PMID: 38877459 PMCID: PMC11177372 DOI: 10.1186/s12913-024-11157-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/31/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND Videoconferencing is considered an alternative to face-to-face consultations and a possibility to help overcome access-to-care barriers in mental health care services. Barriers to child and adolescent mental health services are particularly apparent in the case of children and adolescents receiving child welfare services. This scoping review aims to provide an overview of research on videoconferencing in the mental health treatment of children and adolescents receiving support from child welfare services. METHODS This scoping review follows the review framework outlined by the Joanna Briggs Institute. The following databases were searched from January 2012 to April 2024: Scopus, Web of Science, PubMed, PsycINFO (Ovid), CINAHL Plus, Social Services Abstracts (ProQuest), Sociological Abstracts (ProQuest), and Google Scholar. RESULTS The search yielded 4322 unique records and resulted in the inclusion of 22 articles that met the inclusion criteria. The studies originated from Denmark, England, Australia, Norway, Canada, Chile, and the USA, and were grouped into four areas: (1) videoconferencing to increase access to mental health treatment for vulnerable groups (2) young people's perspectives (3) videoconferencing in interdisciplinary collaborative meetings, and (4) use, awareness, and acceptance of videoconferencing among health and social care providers. CONCLUSIONS This scoping review shows that if videoconferencing in mental health care is to become an established and trusted method aimed at children and adolescents receiving child welfare services, several unresolved and potentially negative issues need attention and more research. This particularly applies to whether videoconferencing decreases or exacerbates inequalities in access to mental health services. A further question is whether new barriers are raised by screen-based treatment to threaten good therapeutic relationships, and by extension treatment quality and clinical outcomes.
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Affiliation(s)
- Marian Ådnanes
- Department of Health Research, SINTEF Digital, Trondheim, Norway.
| | - Jannike Kaasbøll
- Department of Mental Health, Norwegian University of Science and Technology (NTNU), Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU Central Norway), Trondheim, Norway
| | | | - Vibeke Krane
- Department of Health, Social and Welfare Studies, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
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Møller OM, Vange SS, Borsch AS, Dam TN, Jensen AM, Jervelund SS. Medical specialists' use and opinion of video consultation in Denmark: a survey study. BMC Health Serv Res 2024; 24:516. [PMID: 38658946 PMCID: PMC11044495 DOI: 10.1186/s12913-024-10868-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/14/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic accelerated the use of telemedicine which is seen as a possibility to reduce the pressure on healthcare systems globally. However, little research has been carried out on video as a consultation medium in medical specialists' practice. This study investigated the use of and opinion on video consultation among specialists in Denmark. METHODS An online survey on use of video consultation, as well as relevance of and opinion on video consultation, was distributed to all 963 medical specialists in private practice in Denmark throughout May and June 2022, resulting in 499 complete answers (response rate: 51.8%). Data were analysed using descriptive and logistic regression analyses, and data from open text fields were analysed using thematic network analysis. RESULTS Among the respondents, 62.2% had never used video consultation, while 23.4% were currently using video consultation, most particularly among psychiatrists. A total of 47.3% found video consultation medically irrelevant to their specialty, especially radiologists, plastic surgeons, ophthalmologists and otorhinolaryngologists. According to the specialists, video consultation was most suitable for follow-up consultations and simple medical issues, where the patient had an established diagnosis. In these cases, mutual trust remained present in video consultations. Better access for the patients and fewer cancellations, especially for psychiatrists, were highlighted as benefits. IT problems were reported as obstacles hindering optimal use of video consultation. CONCLUSION The political aspiration to digitization in healthcare systems should be rooted in professionals' and patients' perceptions and experiences with video consultation which emphasize that it is not a standard tool for all consultations.
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Affiliation(s)
- Olivia Mandal Møller
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353, Copenhagen, Denmark.
| | - Sif Sofie Vange
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353, Copenhagen, Denmark
| | - Anne Sofie Borsch
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353, Copenhagen, Denmark
| | | | - Anja Mb Jensen
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353, Copenhagen, Denmark
| | - Signe Smith Jervelund
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353, Copenhagen, Denmark
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Krane V, Kaasbøll J, Kaspersen SL, Ådnanes M. 'It's not like real therapy': young people receiving child welfare services' experiences of video consultations in mental healthcare in Norway: a mixed methods approach. BMC Health Serv Res 2023; 23:949. [PMID: 37670314 PMCID: PMC10481608 DOI: 10.1186/s12913-023-09939-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/18/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Video consultations has been suggested to lower the threshold for child and adolescent mental healthcare treatment. This study explores how young people receiving child welfare services experience video consultations in child and adolescent mental healthcare. The study is part of a larger Norwegian study of access to health services for this target group. METHODS The study has a mixed methods design including qualitative interviews and a quantitative survey, with young people receiving child welfare services. The qualitative interviews included 10 participants aged 15-19. The survey included 232 participants aged 16-24 of which 36 reported having received video consultations in mental healthcare. The interviews were analysed using thematic analysis. The survey data was presented as frequencies to clarify the distribution of positive and negative perceptions of video consultation. RESULTS The results show that the participants experienced video consultations as more superficial and less binding, compared to in-person sessions. They raised concerns of the therapeutic relationship, however some found it easier to regulate closeness and distance. In the survey several reported that their relationship with the therapist got worse, and that it was much more difficult to talk on screen. Moreover, a large proportion (42%) claimed that video consultations did not fit their treatment needs overall. However, a minority of the participants found it easier to talk to the therapist on screen. CONCLUSIONS The study reveals important weaknesses and disadvantages of online therapy as experienced by young people receiving child welfare services. It is particularly worrying that their criticism involves the relational aspects of treatment, as children receiving child welfare services often have relational experiences which make them particularly sensitive to challenges in relationships. This study shows that youth involvement in decision making of video consultations in therapy has been rare. Clinicians should be aware of these young people's doubts regarding the quality of video consultations in child and adolescent mental health care. Further studies should examine how user involvement can be incorporated in video consultations in therapy and how this could improve experiences and the quality of video consultations.
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Affiliation(s)
- Vibeke Krane
- Faculty of Health and Social Sciences, Department of Health, Social and Welfare Studies, University of South-Eastern Norway, Drammen, 3007, Norway.
| | - Jannike Kaasbøll
- Department of Mental Health, Faculty of Medicine and Health Sciences, Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU Central Norway), Norwegian University of Science and Technology, Trondheim, Norway
- Department of Health Research, SINTEF Digital, Trondheim, Norway
| | | | - Marian Ådnanes
- Department of Health Research, SINTEF Digital, Trondheim, Norway
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Galvin E, Desselle S, Gavin B, Quigley E, Flear M, Kilbride K, McNicholas F, Cullinan S, Hayden J. Stakeholder perspectives and experiences of the implementation of remote mental health consultations during the COVID-19 pandemic: a qualitative study. BMC Health Serv Res 2023; 23:623. [PMID: 37312119 DOI: 10.1186/s12913-023-09529-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 05/10/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Remote mental health consultations were swiftly implemented across mental health services during the COVID-19 pandemic. Research has begun to inform future design and delivery of telemental health services. Exploring the in-depth experiences of those involved is important to understand the complex, multi-level factors that influence the implementation of remote mental health consultations. The aim of this study was to explore stakeholder perspectives and experiences of the implementation of remote mental health consultations during the COVID-19 pandemic in Ireland. METHODS A qualitative study was conducted whereby semi-structured, individual interviews were undertaken with mental health providers, service users, and managers (n = 19) to acquire rich information. Interviews were conducted between November 2021 and July 2022. The interview guide was informed by the Consolidated Framework for Implementation Research (CFIR). Data were analysed thematically using a deductive and inductive approach. RESULTS Six themes were identified. The advantages of remote mental health consultations were described, including convenience and increased accessibility to care. Providers and managers described varying levels of success with implementation, citing complexity and incompatibility with existing workflows as barriers to adoption. Providers' access to resources, guidance, and training were notable facilitators. Participants perceived remote mental health consultations to be satisfactory but not equivalent to in-person care in terms of quality. Views about the inferior quality of remote consultations stemmed from beliefs about the inhibited therapeutic relationship and a possible reduction in effectiveness compared to in-person care. Whilst a return to in-person services was mostly preferred, participants acknowledged a potential adjunct role for remote consultations in certain circumstances. CONCLUSIONS Remote mental health consultations were welcomed as a means to continue care during the COVID-19 pandemic. Their swift and necessary adoption placed pressure on providers and organisations to adapt quickly, navigating challenges and adjusting to a new way of working. This implementation created changes to workflows and dynamics that disrupted the traditional method of mental health care delivery. Further consideration of the importance of the therapeutic relationship and fostering positive provider beliefs and feelings of competence are needed to ensure satisfactory and effective implementation of remote mental health consultations going forward.
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Affiliation(s)
- Emer Galvin
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | | | - Blánaid Gavin
- School of Medicine, University College Dublin, Dublin, Ireland
| | | | | | | | - Fiona McNicholas
- School of Medicine, University College Dublin, Dublin, Ireland
- Children's Health Ireland, Crumlin, Dublin, Ireland
- Lucena Child and Adolescent Mental Health Service (CAMHS), Rathgar, Dublin, Ireland
| | - Shane Cullinan
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John Hayden
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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Bavngaard MV, Lüchau EC, Hvidt EA, Grønning A. Exploring patient participation during video consultations: A qualitative study. Digit Health 2023; 9:20552076231180682. [PMID: 37325071 PMCID: PMC10265318 DOI: 10.1177/20552076231180682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 05/19/2023] [Indexed: 06/17/2023] Open
Abstract
Objective Video consultations enable a digital point of contact between the general practitioner and patient. With their medium-specific characteristics, video consultations may create novel conditions for the enactment of patient participation during consultations. Although numerous studies have explored patients' experiences of video consultations, research explicitly investigating patient participation within this new consultation setting remains sparse. This qualitative study explores how patients participate during interactions with their general practitioner by drawing on the affordances of video consultations. Methods The data corpus comprises eight recorded video consultations (59 minutes and 19 seconds in total) between patients and their general practitioner, all subjected to reflexive thematic analysis yielding three themes illustrating concrete participatory use cases. Results We find that video consultations provide an accessible format for patients otherwise unable to attend a physical consultation due to physical and mental barriers. Moreover, patients participate by drawing on resources situated in their spatial setting to settle health-related questions of doubt arising during the consultation. Lastly, we posit that patients enact participation by visually communicating their impromptu engagement in decision-making and reporting to their general practitioner by making use of the qualities of their smartphone during their consultation. Conclusions Our findings illustrate how video consultations provide a communicative context in which patients may enact distinct forms of participation by drawing on its technologically contingent affordances during interactions with their general practitioner. More research is needed to explore the participatory opportunities of video consultations in telemedical healthcare services for different patient groups.
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Affiliation(s)
- Martin Vinther Bavngaard
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Elle Christine Lüchau
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Elisabeth Assing Hvidt
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Anette Grønning
- Department of Language, Culture, History and Communication, University of Southern Denmark, Odense, Denmark
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Mavragani A, Torous J, Jacobs R. IT and the Quality and Efficiency of Mental Health Care in a Time of COVID-19: Case Study of Mental Health Providers in England. JMIR Form Res 2022; 6:e37533. [PMID: 36423321 PMCID: PMC9822565 DOI: 10.2196/37533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 10/26/2022] [Accepted: 11/24/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In England, COVID-19 has significantly affected mental health care and tested the resilience of health care providers. In many areas, the increased use of IT has enabled traditional modes of service delivery to be supported or even replaced by remote forms of provision. OBJECTIVE This study aimed to assess the use and impact of IT, in remote service provision, on the quality and efficiency of mental health care during the pandemic. We drew on sociotechnical systems theory as a conceptual framework to help structure the gathering, analysis, and interpretation of data. METHODS We conducted a national scoping survey that involved documentary analysis and semistructured interviews with 6 national stakeholders and case studies of 4 purposefully selected mental health providers in England involving interviews with 53 staff members. RESULTS Following the outbreak of COVID-19, mental health providers rapidly adjusted their traditional forms of service delivery, switching to digital and telephone consultations for most services. The informants provided nuanced perspectives on the impact on the quality and efficiency of remote service delivery during the pandemic. Notably, it has allowed providers to attend to as many patients as possible in the face of COVID-19 restrictions, to the convenience of both patients and staff. Among its negative effects are concerns about the unsuitability of remote consultation for some people with mental health conditions and the potential to widen the digital divide and exacerbate existing inequalities. Sociotechnical systems theory was found to be a suitable framework for understanding the range of systemic and sociotechnical factors that influence the use of technology in mental health care delivery in times of crisis and normalcy. CONCLUSIONS Although the use of IT has boosted mental health care delivery during the pandemic, it has had mixed effects on quality and efficiency. In general, patients have benefited from the convenience of remote consultation when face-to-face contact was impossible. In contrast, patient choice was often compromised, and patient experience and outcomes might have been affected for some people with mental health conditions for which remote consultation is less suitable. However, the full impact of IT on the quality and efficiency of mental health care provision along with the systemic and sociotechnical determinants requires more sustained and longitudinal research.
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Affiliation(s)
| | | | - Rowena Jacobs
- Centre for Health Economics, University of York, York, United Kingdom
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Galvin E, Desselle S, Gavin B, Quigley E, Flear M, Kilbride K, McNicholas F, Cullinan S, Hayden J. Patient and provider perspectives of the implementation of remote consultations for community-dwelling people with mental health conditions: A systematic mixed studies review. J Psychiatr Res 2022; 156:668-678. [PMID: 36399859 PMCID: PMC9637462 DOI: 10.1016/j.jpsychires.2022.10.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Remote, or tele-, consultations became a necessary form of mental healthcare provision during the COVID-19 pandemic. As the prevalence of mental health problems rises, they may have a role in future mental health services. We aimed to review the literature on patient and provider perspectives on factors influencing the implementation of remote consultations for community-dwelling people with mental health conditions. We searched five electronic databases (PubMed, EMBASE, Web of Science, CINAHL, and PsycINFO) for empirical research up to July 13th, 2022. Only studies of synchronous, interactive remote consultations conducted via video, phone, or live-messaging between patients and providers were included. Two reviewers independently assessed the quality of included studies using the Mixed Methods Appraisal Tool. We integrated qualitative and quantitative data from 39 studies into a single mixed-methods synthesis. We mapped reported factors to the domains of the Consolidated Framework for Implementation Research (CFIR). Acceptability was generally high among participants, despite concerns about the quality of care and the perceived impeded therapeutic relationship. A prominent facilitator was the increased accessibility and convenience of remote consultations, while lack of appropriate infrastructure and low patient comfort and competence were among the most prevalent barriers. This review highlights the importance of patient preferences and provider buy-in to the future of remote consultations.
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Affiliation(s)
- Emer Galvin
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | | | - Blánaid Gavin
- School of Medicine, University College Dublin, Dublin, Ireland.
| | - Etain Quigley
- National University of Ireland, Maynooth, Maynooth, Ireland.
| | - Mark Flear
- Queen's University Belfast, Belfast, United Kingdom.
| | | | | | - Shane Cullinan
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - John Hayden
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
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Moeller AM, Christensen LF, Hansen JP, Andersen PT. Patients' acceptance of video consultations in the mental health services: A systematic review and synthesis of qualitative research. Digit Health 2022; 8:20552076221075148. [PMID: 35154803 PMCID: PMC8832590 DOI: 10.1177/20552076221075148] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 01/03/2022] [Indexed: 11/18/2022] Open
Abstract
Background Clinical effectiveness of video consultations in the mental health services is comparable with in-person consultations. Acceptance has typically been rated in surveys that do not give a deeper understanding behind the phenomenon. The aim of this synthesis is to explore mental health patients’ perceptions of factors that influence their acceptance of video consultations viewed from the perspective of the patient. Methods A literature search in scientific databases was conducted. Peer-reviewed reports of qualitative research exploring patients’ experiences with video consultations from the patients’ perspectives were included. Then a meta-summary and a taxonomic analysis were conducted. Results A total of 11 reports met the inclusion criteria. Through the analysis, a model was generated with five factors that precede each other and interact with each other. Patients thought video consultations were acceptable when (1) they experienced barriers and inconvenience to accessing the location of services, (2) they had already established a trustful relationship with their therapist, (3) technical interferences were minor and problems were resolved quickly, (4) patients expected a less personal meeting, and (5) the degree of the patients’ issues were less complex. Discussion This model is intended to help clinicians identify circumstances where offering video consultations make best sense to patients and help sustain meaningful use prospectively. When patients encounter barriers to in-person services, clinicians should consider offering video consultations when the technology is adequately integrated in practice, and it is perceived not to intervene with treatment or the therapeutic process.
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Affiliation(s)
- Anne Marie Moeller
- Department of Public Health, University of Southern Denmark, Denmark.,Research Unit for Telepsychiatry and E-mental Health, The Mental Health Services in the Region of Southern Denmark, Denmark
| | - Lone F Christensen
- Department for Clinical Development, Odense University Hospital, Region of Southern Denmark, Denmark.,Psychiatric Research Unit Esbjerg, The Mental Health Services in the Region of Southern Denmark, Denmark
| | - Jens Peter Hansen
- Psychiatric Research Unit Esbjerg, The Mental Health Services in the Region of Southern Denmark, Denmark.,Center for Clinical Nursing Research, Department of Clinical Research, University of Southern Denmark, Denmark
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