Perceptions on Telemedicine in Portugal During Sars-Cov-2

Pandemic: A Mixed-Methods Study

Ana Dias

1,3 a

, Sandra Duarte

, Joaquim Alvarelhão

and Conceição Cunha

1,3 c

Department of Economics, Management, Industrial Engineering and Tourism, University of Aveiro, Aveiro, Portugal

Health Sciences School, University of Aveiro, Aveiro, Portugal

GOVCOPP, Aveiro, Portugal

Keywords: Telemedicine, Sars-Cov-2, User’s Perception.

Abstract: This study aimed to investigate how patients and professionals faced telemedicine or telehealth in Centre

Region in Portugal during the Sars-Cov-2 pandemic. Mixed-methods exploratory and parallel study including

data from a survey of 190 healthcare patients and seven qualitative interviews with healthcare professionals

from the Centre Region of Portugal were carried out. Descriptive and multiple correspondence analysis was

used for survey results evaluation while healthcare professionals' perceptions were studied using a thematic

analysis approach. Although few participants (15%) experienced telemedicine before the pandemic, most

(73.2%) consider the health sector prepared to provide it. The most mentioned benefits of telemedicine were

the avoidance of travel, convenience, and comfort for the patient. The limitations that may exist in this

modality relate to patients who do not have the necessary technological devices, the lack of adequate

diagnostic tools, and limitations to the patient-doctor relationship. Younger participants (<30y) were

associated with characteristics of the telemedicine operating system, like the adequacy of diagnostic tools

while persons more than 50 years old were associated with the lack of preparation or predisposition of

professionals to provide telemedicine.

1 INTRODUCTION

Telemedicine is defined by the World Health

Organization as “The delivery of health care services,

where distance is a critical factor, by all health care

professionals using information and communication

technologies for the exchange of valid information for

the diagnosis, treatment, and prevention of disease

and injuries, research and evaluation, and for the

continuing education of health care providers, all in

the interests of advancing the health of individuals

and their communities” (WHO, 2010). Despite being

a theme present both in the literature and in

examples/cases of remote healthcare provision, the

practice of telemedicine or telehealth has fallen to

spread through health systems that some optimistic

perspectives anticipated (Waller & Stotler, 2018;

Wootton et al., 2017). Kruse and colleagues (2018)

identified some of the barriers to the implementation

https://orcid.org/0000-0003-3259-1602

https://orcid.org/0000-0002-4564-4323

https://orcid.org/0000-0001-8797-549X

of telemedicine mainly related to issues with

technically challenging staff, followed by resistance

to change and cost. Before the pandemic, the practice

of telemedicine was driven by technological

developments (Chan et al., 2020; Weinstein et al.,

2018) and gains in terms of the cost-benefit ratio,

although the literature is not clear on this effect

(Shigekawa et al., 2018; De La Torre-Díez et al.,

2015), seeking to reach populations far from urban

centers. However, the current pandemic caused by the

SARS-COV-2 virus caused an urgent need for the

adaption of healthcare provision, where distance

service provision appears to be the best available

solution across different healthcare levels.

This rapid change has transformed the experience of

patients and professionals, so understanding their

perspective can help establish patterns of use and

reveal clues that deserve further investigation. Based

on the principle that patients favor the provision of

Dias, A., Duarte, S., Alvarelhão, J. and Cunha, C.

Perceptions on Telemedicine in Portugal During Sars-Cov-2 Pandemic: A Mixed-Methods Study.

DOI: 10.5220/0011745100003414

In Proceedings of the 16th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2023) - Volume 5: HEALTHINF, pages 471-476

ISBN: 978-989-758-631-6; ISSN: 2184-4305

 2023 by SCITEPRESS – Science and Technology Publications, Lda. Under CC license (CC BY-NC-ND 4.0)

471

face-to-face health services, the eventual willingness

to opt for other modalities deserves to be explored

beyond the current moment. In the same sense, with

a professional practice focused on the reception of

patients in person, health professionals’ perception

regarding the implementation of telemedicine

delivery channels could contribute to developments

in the area. This study aimed to investigate how

patients and professionals faced telemedicine or

telehealth in Centre Region in Portugal during the

Sars-Cov-2 pandemic.

2 METHODS

2.1 Ethics & Informed Consent

The study addressed personal perceptions and didn’t

include any kind of personal health data. The study

was conducted in compliance with data protection

regulations and Helsinki Declaration. All participants

were informed about the study’s aims, and informed

consent was obtained before data collection

procedures took place.

2.2 Study Type & Context

A mixed-methods exploratory and parallel study

including data from a survey of healthcare patients

from the Centre Region of Portugal and a qualitative

approach using interviews with healthcare

professionals from the same geographic area (Östlund

et al., 2011) was carried out.

2.3 Patient Survey

A short questionnaire was developed containing

seven questions about the perception of telemedicine

use, readiness of the health system, its advantages,

and limitations. In addition to those seven questions,

other four others were included to characterize the

participants (district of residence, age group, type of

geographic area, and access to health services).

Participants were recruited digitally in different

health-related forums, expressing the request for

dissemination by other users with whom they interact.

As inclusion criteria, participants should be over 18

years old and live in the Centre region of Portugal.

Data collection was carried out between July and

August of 2021.

2.4 Healthcare Professionals’

Interviews

Participants were selected using a maximum variation

purposive sampling criterion (Palinkas et al., 2015) to

document diverse modifications that have emerged in

adapting to different conditions. Inclusion criteria

comprised being familiarized with telemedicine

practice during 2021. Invitations were made through

direct contact. The interview guide was designed to

explore the perception, experience, and challenges of

telemedicine practice. The interviews were conducted

using videoconference in August of 2021.

2.5 Data Analysis

Descriptive and multiple correspondence analysis

(MCA) was used for survey results, using SPSS

Window version 25.0. Qualitative data obtained from

healthcare professionals' perceptions were studied

using a thematic analysis approach (Braun & Clarke,

2006).

3 RESULTS

3.1 Patient Survey

The online questionnaire was answered by 190

participants, with the district of Viseu being the most

represented (n=90, 47.4%). Most participants were

between 18 and 30 years old (n=72, 37.9%), and live

in cities (n=93, 49.0%). The vast majority consider

having easy access to health services (n=168, 88.4%).

There was an association between ‘geographic area’

and ‘access to health services’ (Chi-square (1, n=190)

= 9.72, p<0.01), where the urban areas (Small towns

or cities) show a higher proportion of ‘easy access'.

The use of remote health services is mentioned by

100 (52.6%) of the participants, with only 15 having

this experience before the Covid-19 pandemic started.

Of the participants who had no experience with

telemedicine, more than half (n=46) were willing to

use it if proposed.

Most participants (n=139, 73.2%) consider that

the health sector is prepared to provide telemedicine

services, with the private sector being prepared to

receive the greatest number of favorable opinions.

The most mentioned benefits or advantages of

telemedicine concern the avoidance of travel,

convenience, comfort for the patient, and the

possibility of saving resources.

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The limitations or constraints that may exist in this

modality concern the fact that many patients do not

have the necessary technological devices, the lack of

adequate diagnostic tools, and the limitations of the

patient-doctor relationship - Table 1.

Table 1: Answers to the questionnaire.

Have you already used distance

health services?

Yes:, n (%) 100 (52,6)

Before Covid-19 pandemic 15 (15,0)

After Covid-19 pandemic 85 (85,0)

No:, n (%) 90 (47.4)

Yes, if proposed 46 (51.1)

No, or not sure, if proposed 44 (48.9)

Do you think the health sector is

prepared to provide telemedicine

services?

Yes:, n (%) 139 (73.2)

Public Sector 24 (17.2)

Private Sector 66 (47.5)

Both private and public 49 (35.3)

No, n (%) 51(26.8)

Benefits or advantages of

telemedicine, n

Avoid traveling 165

Convenience and comfort 117

Economy of resources 101

Infection prevention/avoidance 91

Faster response from professionals 71

Limitations or constraints of

telemedicine

Users without technological

165

Inadequate diagnostic tools 137

Limited patient-doctor

113

Resistance to change 86

Service additional complexity 25

Health professionals not prepared 24

Privacy flaws 20

Being available to receive health services at a

distance was not associated with age group,

geographic area, or access to health services. Age was

associated with the opinion of the health sector's

readiness to provide telemedicine services with a

statistically significant proportion of younger people

considering the health sector to be ready to do so

(Chi-Square (4, n=190)= 10.94, p<0.05).

The first MCA considered all the variables

presented in Tables 1 and 2, except the first. In this

model ‘Geographic area’ and ‘Access to Health

Services’ showed poor discrimination, so they were

not considered for the second model.

For the second model, after obtaining the total

inertia for the 16 dimensions, the MCA considered a

two-dimension solution. The first and second

dimensions presented, respectively: eigenvalue,

1.992 and 1.695; inertia, 0.142 and 0.121; and

Cronbach’s alpha, 0.536 and 0.441.

The analysis also considered plots for

discrimination measures and joint category points -

Figure 1.

Figure 1: Plots for discrimination measures and joint

category points.

All the discrimination measures were below 0.5,

with a maximum of 0.388 for ‘resistance to change’

in the first dimension and 0.410 for ‘inadequate

diagnostic tools’ in dimension 2. From the results and

the graphic visualization, it is possible to distinguish

three groups according to age.

The first includes younger people and has

associated concerns with characteristics of the health

system's functioning - the adequacy of diagnostic

tools, infection prevention, or the patient-doctor

relationship.

The second one includes persons aged between

31-50 years old who are associated, on the one hand,

with a positive view of the health system’s readiness

for telemedicine.

On the other hand, the advantages of avoiding

travel and concerns about the existence of persons

who do not have the appropriate technical means to

access this type of health service provision. The third

group corresponds to people over 50 years old,

highlighting the consideration of the lack of

preparation or predisposition of professionals to

provide telemedicine.

3.2 Healthcare Professionals’

Interviews

Seven health professionals from the following areas

participated in the interviews: Child Psychiatry,

Gynecology, Neurosurgery, Ophthalmology,

Otolaryngologist, Psychiatry, and Psychology.

Perceptions on Telemedicine in Portugal During Sars-Cov-2 Pandemic: A Mixed-Methods Study

473

Table 2 summarizes the key findings from

interviews, where the difficulties of using

telemedicine with children, in physical examinations,

or in health conditions that imply serious disability,

clearly emerged. Several activities were identified

where telemedicine would be positive, such as in the

renewal (without change) of medication, in follow-up

consultations, or for analysis of diagnostic tests.

Health professionals consider that the technological

infrastructure is prepared for the practice of

telemedicine, as well as the planning and organization

of services. However, there are clear concerns about

the loss of quality in the patient-physician

relationship, as well as the need for specific software

for clinical management using this type of service

delivery.

Considering the current skills of professionals, it

is recognized as existing in terms of digital literacy

and online time management, but lacking in ensuring

privacy and data protection, as well as in the

challenges that interpersonal communication entails.

4 DISCUSSION

This mixed-methods study reports findings on

perceptions about the telemedicine approach in the

Centre Region of Portugal during the Sars Cov-2

pandemic. Telemedicine seems to be accepted by

patients, many of them already involved in distance

delivery of health services, although adherence could

be mainly motivated by the pandemic context.

However, even those who have not yet had contact

with this modality state that are willing to try it if

proposed, suggesting this issue deserves further and

broader studies about this channel for contact with

health service users.

Despite the huge increase in health activities

carried out remotely in the public sector in Portugal

(SNS, 2022), there seems to be a perception of better

preparation of the private sector for the provision of

health services through this modality. This result may

be due to the enormous pressure that the context of

the pandemic has put on the National Health Service,

with the media focused on its daily indicators, leaving

little room for the adaptations made by the public

sector.

The advantages and limitations of telemedicine

are in line with other works that have addressed the

topic (Breton et al., 2021; Kichloo et al., 2020;

Scherer et al., 2021). There is an agreement between

patients and professionals in some of the limitations

like clinical/diagnostic assessment tools or

hindrances on the patient-doctor relationship, for

example, and in some of the advantages - fewer

travels through follow-up appointments, for example.

However, the concern with patients who do not have

technological means is a major concern as a potential

barrier to the adoption of this modality. Older patients

group need special attention from health managers

regarding the telemedicine model because this study

suggests that some under-preparation of professionals

or even the complexity of such a system may arise

additional challenges to the successful development

of health services based on information and

communication technologies.

These results seem to point to the importance of

reviewing the ways of interacting with clients in the

health sector, far beyond the constraining experience

of the pandemic, and this is probably the time to

evaluate which practices can be preserved and

developed, because they may allow relevant gains in

efficiency and effectiveness in the provision of care.

Table 2: Key findings from interviews.

adequate

no or to

rove

to be used?

medication renewal

follow-up consultations

to analyze diagnostic tests

when physical

assessment is

needed

with children

severe

pathology

readiness of

the system?

communication

infrastructure

doctor-patient

relationship

loss

work

planning/organization

specific

clinical

management

software

competencies

of health

professionals?

digital literacy

privacy and

data protection

online time management

interpersonal

online

communication

This may also be the time to assess whether

organizations have the skills and material resources to

change and improve the logic of care provision and

whether there is a need to review the processes

themselves. This may help to identify critical

processes that would suffer the deepest impact from

this type of change, and therefore, contribute more to

increasing proficiency and service quality. It will also

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be relevant to understand in which situations and in

which target groups it would be wise to invest more

since telemedicine will not be a solution for all

situations or all target groups (Timpel et al., 2020;

Chunara et al, 2021). This is eventually the moment

to learn from experiences, to assess and identify what

aspects do or do not deserve to be treated as

conjectural. Realizing which of the changes that

occurred can be assumed as worth incorporating into

organizational systems as a part of a new way of

creating value in healthcare provision (Losorelli et al.,

2021). This value, both for external customers

(patients) and for internal customers (health

professionals), would enable gains at various levels,

from greater convenience and comfort, lower

infection rates, and gains in access, to new

opportunities for skills development for

professionals. All these aspects can have a relevant

impact on satisfaction levels, both of patients and

professionals, a dimension that increasingly is desired

to consider in the evaluation of healthcare institutions

Dorsey et al., 2020).

This work has methodological limitations. On the

one hand, the method of recruiting participants may

imply a selection bias, both in terms of health

professionals and users of health services. On the

other hand, the lack of control mechanisms over

survey responses may introduce an information bias.

5 CONCLUSIONS

The recent Sars-Cov-2 pandemic seems to have

increased awareness of the potential of using the

modality of health services at a distance, with the

need of refining the best aspects of offering this

modality to maintain quality levels.

Future studies could approach the skills and

competencies of professionals to be improved to

guarantee more proficiency and adaptation to

patients' different requirements. Technology

investments needed to implement and develop

telemedicine would also benefit from further

research, to help mitigate some mentioned

difficulties.

ACKNOWLEDGMENTS

This work was financially supported by the Research

Unit on Governance, Competitiveness and Public

Policies (UIDB/04058/2020) + (UIDP/04058/2020),

funded by national funds through FCT - Fundação

para a Ciência e a Tecnologia.

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