Perspectives on telemedicine across urban, rural and remote areas in the Philippines during the COVID-19 pandemic

Background

Telemedicine has shown potential in reducing poor health outcomes and healthcare-related expenditures.1 2 Remote consultations in the USA allowed healthcare providers to give necessary prescriptions and provide immediate clarification for health-related queries, decreasing the needed frequency of in-person consultations.3 A 2015 study in Canada reported that 85% of patients expressed intent of continuing telemedicine use due to an average cost reduction of US$200 for them and their caretakers.4

The impact of telemedicine varies by setting and availability of resources. A study in Southeast Asia reported limited access to gadgets and internet sources to sustain telemedicine use in certain countries such as Indonesia and the Philippines.5 To expand internet access in the latter, Executive Order (EO) 127 was passed. This EO aimed to address the gap in telemedicine care through inclusive access to satellite services.6 However, the distance of signal sites from communities remained a barrier to obtaining healthcare, with 57.4% of Filipinos remaining offline.7 Technology-related anxiety also deters patients and caretakers from investing in telemedicine care.8 9 Furthermore, training healthcare workers to navigate the platform has yet to be integrated into healthcare training curricula.5

The COVID-19 pandemic hastened the development of alternative means for utilisation of primary care services.10–12 The Philippine Primary Care Studies (PPCS) introduced telemedicine services to sustain primary care service utilisation during the pandemic and beyond. The PPCS team expanded internet access in its three partner sites to provide telemedicine services. The initial implementation of telemedicine services was launched on platforms that participants had easy access to. In the context of this study, telemedicine refers to remote patient–clinician consultations. The telemedicine platforms made available in the study sites were Facebook Messenger (with consultations done through video call, phone call and chat), and phone call using a landline phone for patients who had difficult access to the internet despite the provision of Wi-Fi access in the sites.

Telemedicine’s potential cannot be fully maximised by patients without uncovering the factors that either increase hesitancy or fully hinder utilisation. Thus, this study aimed to explore attitudes, subjective norms and perceived behavioural control of telemedicine users and non-users in urban, rural and remote settings and to examine intention-to-use telemedicine during the COVID-19 pandemic.

Study design

This is a cross-sectional study on factors that affect telemedicine usage. Data gathering was conducted from February to March 2022 through focus group discussions (FGDs) to assess experiences and attitudes towards telemedicine as a mode of healthcare delivery among end-users at the height of the COVID-19 pandemic. FGDs were used for data collection. This allowed the team to understand shared and diverging perspectives from groups who have common backgrounds. FGDs were done online due to the to prevent COVID-19 transmission during the pandemic.

A semistructured interview guide (online supplemental appendix A) was adapted from George et al.13 We conducted a pilot test of this interview guide with patients from the urban, rural and remote sites. Based on the results of the pilot test, we added questions on prior knowledge about telemedicine, preferred platforms of use, and desired features. We also added questions about the necessity to consult during a pandemic to assess how COVID-19 may have influenced telemedicine utilisation behaviour.

Participants and study site

We included patients who consulted from April 2020 to March 2022 in the study. Recruitment was done in a reverse sequence order. The team first contacted the patients who consulted most recently to secure consent for participation.

UPHS14 was the urban site of the study. It was a 25-bed facility serving a population of approximately 31 000 students, faculties, employees and campus residents. 12 family physicians were employed during the study period.

Samal, Bataan14 was a fourth-class rural municipality with approximately 36 000 residents during the study period. Residents were able to avail of primary care services through the rural health unit (RHU) or barangay health stations (BHSs). The RHU hosted doctors, nurses and midwives. BHSs were primarily supervised by nurses and midwives.

Bulusan, Sorsogon14 was a fourth-class municipality with approximately 23 000 residents. It was declared as a geographically isolated and disadvantaged area by the Philippine Department of Health. This classification can be attributed to its mountainous terrain, unstable connectivity, and limited transportation options. Residents may also receive care from either RHU or BHS. Both rural and remote areas only had one physician at the start of the study. Purposive sampling was done. Demographic distribution can be seen in Table 1.

Four FGDs per site were conducted. Two FGDs included participants who resided near the health facilities (on-campus residents for the urban site and people living in the lowland barangays for the rural and remote sites): one FGD included participants who were users of telemedicine while the other FGD included participants who were non-users. Telemedicine usage may vary over time. In this study, we defined ‘users’ of telemedicine as individuals who have used telemedicine through any platform at the time of the study, and ‘non-users’ as individuals who have not used telemedicine using any platforms at the time of the study.

Thematic analysis

As a framework, the theory of planned behaviour examines how attitudes, subjective norms and perceived behavioural control impact the intention of a person to adopt a particular behaviour (Figure 1).15 We analysed the data and classified responses according to domains, including internal perceptions (referring to attitudes), external influences (referring to subjective norms) and availability of resources (referring to perceived behavioural control). Categorising data into these domains allowed us to compare which domains strongly informed telemedicine utilisation behaviour among participants. Data were processed using NVivo V.12. The research lead performed the initial coding. Elicited themes reveal participant perceptions and/or experiences under each domain. Codes were then presented to a multidisciplinary team of public health practitioners to determine if codes aligned with sentiments elicited from the study. Dissenting opinions on the themes were resolved by reviewing the transcript to verify the context of a participant’s response.

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Key demographics

A total of 60 participants were included in this study. There were more females (83%, n=50) in our study population.

Response of telemedicine users

A comprehensive overview of sentiments from participating telemedicine users is found on Table 2. Under the attitude domain, telemedicine was largely perceived to increase the respondents’ feeling of safety against COVID-19. Motivators for telemedicine use included its applicability for minor and chronic illnesses. Respondents also espoused that it helped them save time, money and effort travelling to health facilities. However, deterring attributes made participants more hesitant towards continued use. A few participants shared that the specialisation of certain physician may not match the health concerns of a patients.

Exploration of the subjective norms domain revealed high awareness across all participants of our telemedicine platform’s features. Information sources and prevailing sentiments from key persons highly influenced their perception. These included individuals whose opinions participants were most open to consider. Consultations via Facebook Messenger or call were considered straightforward. Participants were aware of how bookings are conducted, which was either through Facebook Messenger or call reservations in rural and remote sites and reservations through the online portal in the urban site. Awareness did not necessarily translate to maximisation of the online portal. Participants in the urban site would often maximise internal networks within the PPCS partner facility to book consults. CHWs were integral sources of information in the rural and remote sites. Through CHWs, they felt especially guided by a trusted source while exploring telemedicine.

Factors related to the perceived behavioural control domain had the greatest influence on the likelihood of continued telemedicine use. Urban site respondents generally perceived that they have good behavioural control as resource capacity and familiarity with the platform were high. High exposure to technological devices at their jobs gave them the confidence to use devices outside work. Respondents from the urban site relayed that technical glitches hinder the full utilisation of telemedicine services. One participant mentioned that ‘it took long for my consultation request to get accommodated. I was passed on from one attendant to another before someone entertained my teleconsultation concern. I had to confirm with my doctor if the consultation request was approved’. Participants from the rural and remote sites were eager to continue using the service; however, the lack of material resources decreased the likelihood of consistent use. Participants in all sites agreed that integrating telemedicine in Facebook increased their level of confidence. A familiar platform allowed them to invest more effort on their health instead of learning the application.

Response of telemedicine non-users

A comprehensive overview of insights from participating non-users is found on Table 3. In the attitude domain, deterring factors more strongly influenced their decision to decline use. Non-users from the urban site emphasised that ‘convenience was a case-to-case basis’. They relayed that the effectiveness of telemedicine was limited to people who were technologically competent and comfortable with discussing their concerns online. One participant also shared, ‘I think the physician can assess me better when we see each other in-person. They are also more able to make me feel at peace in-person. Physical contact makes me more certain that an actual person is taking care of my health’.

In the subjective norms domain, non-users relayed that government officials or workplace personnel for the urban setting, and efforts of CHWs for the remote setting were integral sources of information. Hesitancy of the participants in the remote and rural sites to use telemedicine were related to their lack of familiarity with telemedicine and inadequate resources.

In the perceived behavioural control domain, low-resource capacity was the primary deterrent in both rural and remote sites. One participant mentioned that ‘I was very eager to use telemedicine, but the cellular data signal is too weak in our area. I’m hesitant to invest a lot of money for load and an advanced smartphone since I must prioritize spending on my medications’. Participants also shared that investing in telemedicine-related resources is risky since natural calamities can cause power outages and decreased internet connectivity. All non-users in the urban site preferred face-to-face consultation. They felt that this avenue allowed them to consider alternative providers more carefully. They could use face-to-face interactions with facility staff to ask which providers fits their schedule and had experience with other cases like theirs. They did not have to spend extra time evaluating whether the chosen online platform was suitable to address their health concern.

Attitude

The theory of planned behaviour defines attitude as the tendency to make a decision that is likely to produce positive feelings.15 Users from the urban site shared that the lack of specialist care demotivates use. These respondents desired to consult with specialists because there was an increased likelihood of being given an immediate diagnosis. Direct consultation with specialists lessened their anxiety of expending time and resources before their concern is addressed. Positive feelings about telemedicine services were associated with a provider’s capacity to answer a patient’s queries about their health concerns.

Non-users in the urban site believed that the convenience of telemedicine services varied on a ‘case-to-case basis’. Telemedicine was considered inconvenient since they cannot fully express themselves in an online setting. Non-users relayed feelings of anxiety when contemplating telemedicine usage. Being physically separated from their providers made them feel that they were outsiders each others’ worlds. This perceived mutual exclusion decreased the feeling of trust necessary in building a therapeutic relationship. Participants in the rural and remote site similarly felt anxious about their inability to see their providers’ movements and expressions. This sentiment is akin a 2010 article which reported that immersion of a patient’s senses into a healthcare setting may make them feel more cared for and attended.16

In sum, participants from all sites generally felt that telemedicine is a temporary alternative while in-person consultations were unavailable during the pandemic. Telemedicine was a convenient tool that can accommodate people with busy schedules and those living in localities far from the healthcare centre. However, these perceived benefits were outweighed by hesitancy. Many felt that the therapeutic touch was diminished in an online setup.

Subjective norms

Subjective norms refer to perceived social beliefs or expectations that may influence a participant’s decision to use telemedicine services.15 Access to information is as important as the actual content in influencing decision-making. Participants in all sites agreed that receiving information on telemedicine from representatives showed that healthcare workers were confident in the platform’s capacity to support remote consultations.

Effective dissemination of telemedicine announcements depends on the locality’s setup.17 For users and non-users in the urban site, coursing telemedicine-related announcements through offices was considered effective. Participants from the rural and remote sites acknowledged that they were more likely to engage in content promoted through the personal Facebook accounts of CHWs. This can be attributed to the pre-existing level of trust that patients have for CHWs.18 Aside from healthcare workers, relatives, friends and work colleagues also influenced a patient’s decision to access telemedicine care. Positive feedback is more likely to incentivise use.19 Participants were more optimistic that they can experience good outcomes with telemedicine when someone they know has experienced it. The introduction of new healthcare services is optimised when local populations are encouraged to try a service for themselves.20

There was no stark difference in subjective norms when we responses were analyzed per age group. Willingness to learn was a greater determinant to telemedicine usage rather than age. Some non-users in the less than 30-year-old group relayed that they would be more likely to explore applications or social media sites that interest them, rather than learning tools that do not satisfy immediate personal goals. Some non-users in the older age groups shared that they would be willing to learn more about telemedicine applications if someone will help them navigate it in the future.

Some non-users in the rural and remote sites expressed that it was their first time knowing that it was possible to consult via text, call or messenger. This shows that an information gap exists in these sites.

Perceived behavioural control

Perceived behaviour control corresponds to the availability of human and material resources that help someone achieve a desired outcome.15 This also includes the ability of a patient to use available resources at hand.15 The presence of a user-friendly platform was significant in increasing usage among participants. User-friendliness was predominantly associated with the integration of telemedicine in Facebook—a mainstream platform in the Philippines.21 Since Facebook was a platform participants used for other socialisation activities; the interface was not challenging to deal with. They can independently consult with providers without having to rely on caretakers.

Participants in the urban site expressed the highest level of behavioural control. Despite this, most users and non-users shared the sentiment that telemedicine provided by UPHS is largely incompatible with their needs. Participants explained that telemedicine services provided did not have sufficient infrastructure to genuinely help patients. It is important to have a system that anticipates a population’s needs, complemented by a workforce with compatible skillset. If these are not provided, patients would decline to use the provided service despite necessity.22

Users and non-users from rural and remote areas expressed that decreased access to a compatible smartphone, electricity and/or internet load hampered use. Telemedicine access requires adequate economic capital.23 Participants shared that they repeatedly declined to purchase the resources needed for telemedicine to prioritise basic health needs.

In the remote site, participants expressed that insufficient staffing in the local health unit to support telemedicine services and the frequency of natural calamities decreased their perceived level of control. The absence of healthcare workers was most prominent in the remote site. Healthcare workers are more likely to be present in urban areas due to increased pay and better opportunities for family members.24 Users in the remote site constantly thought about reverting to face-to-face consultations. They were more certain that a healthcare provider would be available to assist them. These participants also felt that investing in telemedicine-related resources can be potentially counterproductive since signal is usually down during calamities.

Policy recommendations