ABSTRACT
Stroke is a chronic health condition that requires monitoring. In this sense, telehealth emerges as a tool to enable better access. However, since it is related to use of technology, this modality might face new barriers. Our goal was to identify, with a systematic literature review, the perceived barriers to telehealth access by stroke patients and conceptualize them within the Unified Theory of Acceptance and Use of Technology (UTAUT) model. The systematic review was carried out in the following electronic databases: PubMed, MEDLINE, SciELO, LILACS, and PEDro; and the combination of descriptors were: “Barriers to Access to Health Care,” “Telerehabilitation,” “Telehealth,” “Stroke,” and “Physical Therapy Modalities.” The included studies focused on telehealth barriers perceived by stroke patients. Initially, 298 articles were found, 295 via databases search, and three via active search; of these, only six articles were included in this review. Overall, the articles revealed the perception of more than 220 stroke patients, with barriers categorized into eight types, most of them related to the dimensions of Effort Expectancy and Facilitating Conditions of the UTAUT model. The barriers of the Effort Expectation dimension that are related to the knowledge in the use of technologies are likely to be overcome since training can be carried out before the telehealth service. However, the barriers related to the Facilitating Conditions dimension regarding financial aspects, the internet, and home context are difficult to overcome, possibly interfering with user’s acceptance of telehealth.
Keywords:
Barriers to Access of Health Services; Telerehabilitation; Telehealth; Stroke; Physical Therapy Modalities
RESUMEN
El accidente cerebrovascular (ACV) como una condición de salud requiere de monitoreo. En este contexto, la telesalud emerge como una posibilidad que permite un mejor acceso a los servicios de salud. Sin embargo, dado que esta modalidad está relacionada con el uso de la tecnología, se pueden surgir nuevas barreras. El objetivo de esta investigación fue identificar, mediante una revisión sistemática de la literatura, las barreras percibidas por los pacientes con ACV con respecto al acceso a la telesalud y conceptualizarlas dentro del modelo de la Teoría Unificada de Aceptación y Uso de la Tecnología (UTAUT). La revisión sistemática se realizó en las siguientes bases de datos electrónicas: PubMed, MEDLINE, SciELO, LILACS y PEDro; a partir de la combinación de los descriptores “barreras de acceso a la atención médica”, “telerrehabilitación”, “telesalud”, “accidente cerebrovascular” y “modalidades de fisioterapia”. Inicialmente, se encontraron 298 artículos, de los cuales se obtuvieron 295 mediante la búsqueda en la base de datos y tres por la búsqueda activa; de estos, solo seis artículos se incluyeron en la revisión. Los artículos revelaron la percepción de más de 220 sujetos que sufrieron ACV y ocho tipos de barreras; la mayoría de ellas relacionadas con las dimensiones Expectativa de Esfuerzo y Condiciones Facilitadoras del modelo UTAUT. Las barreras de la dimensión Expectativa de Esfuerzo, relacionadas con el conocimiento en el uso de tecnologías, se pueden superar mediante una capacitación previa antes de utilizar la telesalud. Sin embargo, las barreras asociadas con la dimensión de las Condiciones Facilitadoras respecto a los aspectos financieros, de Internet y el contexto del hogar son difíciles de superar y, por lo tanto, pueden interferir en la aceptación del uso de la telesalud por parte del usuario.
Palabras clave:
Barreras de Acceso a los Servicios de Salud; Telerrehabilitación; Accidente Cerebrovascular; Modalidades de Fisioterapia
RESUMO
O acidente vascular cerebral (AVC), como condição crônica de saúde, requer monitoramento. Nesse sentido, a telessaúde surge com o objetivo de possibilitar um melhor acesso aos serviços de saúde. Porém, por estar relacionada ao uso de tecnologia, essa modalidade pode enfrentar novas barreiras. O objetivo desta pesquisa foi identificar, por meio de uma revisão sistemática da literatura, as barreiras percebidas por pacientes com AVC quanto ao acesso à telessaúde e conceituá-las dentro do modelo da Teoria Unificada de Aceitação e Uso de Tecnologia (UTAUT). A revisão sistemática foi realizada nas seguintes bases de dados eletrônicas: PubMed, MEDLINE, SciELO, LILACS e PEDro; por meio da combinação dos descritores “barreiras de acesso aos cuidados de saúde”, “telerreabilitação”, “telessaúde”, “acidente vascular cerebral” e “modalidades de fisioterapia”. Inicialmente, foram encontrados 298 artigos, sendo 295 por meio da busca em bases de dados e três por meio de busca ativa, e, destes, apenas seis artigos foram incluídos na revisão. Somados, os artigos revelaram a percepção de mais de 220 indivíduos que sofreram AVC e oito tipos de barreiras, a maioria delas relacionadas às dimensões de Expectativa de Esforço e Condições Facilitadoras do modelo UTAUT. As barreiras da dimensão Expectativa de Esforço relacionadas ao conhecimento no uso de tecnologias são passíveis de serem superadas, pois treinamentos podem ser realizados previamente ao serviço de telessaúde. No entanto, as barreiras relacionadas à dimensão das Condições Facilitadoras no que se refere a aspectos financeiros, internet e contexto domiciliar são difíceis de superar, podendo, portanto, interferir na aceitação do usuário quanto ao uso da telessaúde.
Descritores:
Barreiras ao Acesso aos Cuidados de Saúde; Telerreabilitação; Telessaúde; Acidente Vascular Cerebral; Modalidades de Fisioterapia
INTRODUCTION
Stroke continues to be the second leading cause of death and the leading cause of adult disability worldwide11. Krishnamurthi RV, Ikeda T, Feigin VL. Global, regional and country-specific burden of ischaemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage: a systematic analysis of the Global Burden of Disease Study 2017. Neuroepidemiology. 2020;54(2):171-9. doi: 10.1159/000506396.
https://doi.org/10.1159/000506396...
. Stroke patients are at a greater risk of suffering temporary or permanent disability, around 70% and 80% of stroke survivors become dependent22. Copstein L, Fernandes JG, Bastos GAN. Prevalence and risk factors for stroke in a population of Southern Brazil. Arq Neuropsiquiatr. 2013;71(5):294-300. doi: 10.1590/0004-282X20130024.
https://doi.org/10.1590/0004-282X2013002...
),(33. Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, et al. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke. 2005;36(9):e100-43 doi: 10.1161/01.STR.0000180861.54180.FF.
https://doi.org/10.1161/01.STR.000018086...
.
Although rehabilitation and healthcare follow-up are essential for the functional recovery of stroke patients, most of the population in low- and middle-income countries faces challenges in accessing this type of care44. Furlan L. Potential barriers and promising opportunities for stroke rehabilitation in Brazil. Int J Stroke. 2014;9(Suppl A100):144. doi: 10.1111/ijs.12338.
https://doi.org/10.1111/ijs.12338...
. Access barriers include a lack of rehabilitation centers available in a country, socioeconomic status, lack of adequate transport, and low level of education are factors that restrict access to rehabilitation services44. Furlan L. Potential barriers and promising opportunities for stroke rehabilitation in Brazil. Int J Stroke. 2014;9(Suppl A100):144. doi: 10.1111/ijs.12338.
https://doi.org/10.1111/ijs.12338...
.
Sarfo et al.55. Sarfo FS, Adamu S, Awuah D, Sarfo-Kantanka O, Ovbiagele B. Potential role of tele-rehabilitation to address barriers to implementation of physical therapy among West African stroke survivors: a cross-sectional survey. J Neurol Sci. 2017;381:203-8. doi: 10.1016/j.jns.2017.08.3265.
https://doi.org/10.1016/j.jns.2017.08.32...
stated that in a lower-middle income country, less than 30% of stroke patients have accessed rehabilitation program. The time spent in and the cost of transportation to rehabilitation services were the most cited reasons for abandoning rehabilitation by family members and patients55. Sarfo FS, Adamu S, Awuah D, Sarfo-Kantanka O, Ovbiagele B. Potential role of tele-rehabilitation to address barriers to implementation of physical therapy among West African stroke survivors: a cross-sectional survey. J Neurol Sci. 2017;381:203-8. doi: 10.1016/j.jns.2017.08.3265.
https://doi.org/10.1016/j.jns.2017.08.32...
. Other factors mentioned as barriers to accessing rehabilitation services, especially in public health services, are the bureaucratic processes of referral and scheduling and the degree of disability. People with a moderate and severe motor disability, such as those who are unable to walk, are most likely to remain restricted to their homes without access to rehabilitation services, which results in further impairment and worsening of clinical conditions66. Silva MA, Santos MLM, Bonilha LAS. Users' perceptions of outpatient physiotherapy in the public healthcare system in Campo Grande (MS, Brazil): problem-solving capacity and difficulties. Interface Comun Saude Educ. 2014;18(48):75-86..
During the COVID-19 pandemic, more barriers to healthcare services are perceived77. Lieneck C, Herzog B, Krips R. Analysis of facilitators and barriers to the delivery of routine care during the COVID-19 global pandemic: a systematic review. Healthcare (Basel). 2021;9(5):528. doi: 10.3390/healthcare9050528.
https://doi.org/10.3390/healthcare905052...
. Technological services such as telehealth and telemedicine were considered as support services within the health system until COVID-19. Although the use of these technologies has increased in recent decades, especially with the COVID-19 pandemic, it was only after the pandemic that their implementation became a necessity88. Caetano R, Silva AB, Guedes ACCM, Paiva CCN, Ribeiro GR, et al. Challenges and opportunities for telehealth during the COVID-19 pandemic: ideas on spaces and initiatives in the Brazilian context. Cad Saude Publica. 2020;36(5):e00088920. doi: 10.1590/0102-311X00088920.
https://doi.org/10.1590/0102-311X0008892...
.
Previous studies on the stroke population, such as the one by Laver et al.99. Laver KE, Adey-Wakeling Z, Crotty M, Lannin NA, George S, et al. Telerehabilitation services for stroke. Cochrane Database Syst Rev. 2020;(1):CD010255. doi: 10.1002/14651858.CD010255.pub3.
https://doi.org/10.1002/14651858.CD01025...
, have attempted to address efficacy, safety (including the presence of adverse effects), and the type of telehealth system. However, the perception of users on the difficulty to undertake and maintain adherence to this type of therapy has not been addressed.
With the growing number of smartphones worldwide, which greatly improves the potential for the use of “mobile health,” telehealth may shorten the distance between health professionals and individuals in need of health monitoring1010. Pandian JD, Gall SL, Kate MP, Silva GS, Akinyemi RO, et al. Prevention of stroke: a global perspective. Lancet. 2018;392(10154):1269-78. doi: 10.1016/S0140-6736(18)31269-8.
https://doi.org/10.1016/S0140-6736(18)31...
. Thus, in this scenario of new emerging health technologies, such as telehealth, we must recognize the access barriers, users’ perceptions about applications, and acceptance of the current technology.
When addressing acceptance of health technology, the most applied method is the Unified Theory of Acceptance and Use of Technology (UTAUT) model, since it incorporates approaches of the human behavior theory1111. Khatun F, Palas JU, Ray P. Using the unified theory of acceptance and use of technology model to analyze cloud-based mHealth service for primary care. Digit Med. 2017;3(2):69-75. doi: 10.4103/digm.digm_21_17.
https://doi.org/10.4103/digm.digm_21_17...
. Consequently, it covers questions about the amount of use, resistance to adherence, and abandonment of technology use in health, thus contemplating the user reactions to health technologies, such as telehealth1212. Venkatesh V, Morris MG, Davis GB, Davis FD. User acceptance of information technology: toward a unified view. MIS Q. 2003;27(3):425-78. doi: 10.2307/30036540.
https://doi.org/10.2307/30036540...
.
Our review is based on the need to explore the barriers that users identify as the main obstacles to access telehealth regarding the inclusion of health technologies for stroke healthcare. This study aimed to identify, by a systematic literature review, the perceived barriers to telehealth access by stroke patients and conceptualize the UTAUT model.
METHODOLOGY
This is a systematic literature review carried out following the recommendations proposed by the Preferred reporting items for Systematic Reviews and Meta-Analyses statement (PRISMA)1313. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1016/j.ijsu.2021.105906.
https://doi.org/10.1016/j.ijsu.2021.1059...
.
Search strategy
The search for pre-selected and selected studies was performed in the following electronic databases: National Center for Biotechnology Information, US National Library of Medicine (PubMed), Medical Literature Analysis and Retrieval System Online (MEDLINE), Scientific Electronic Library Online (SciELO), Latin American and Caribbean Literature on Health Sciences (LILACS), and Physiotherapy Evidence Database (PEDro). The search strategy was developed with descriptors indexed in DeCS/MeSH and their equivalents in the English and Portuguese languages were: “Barriers to Access to Health Care,” “Telerehabilitation,” “Telehealth,” “Cerebral Vascular Accident,” “Physical Therapy Modalities,” and “Internet Access” (Table 1). For the database search, the Boolean operator “AND” was used between the descriptors in each of the databases. The search was carried out by two researchers on April 14th, 2021.
Inclusion and exclusion criteria
Original studies published in English and Portuguese were included, without year restriction. The inclusion criteria were studies involving adults (≥18 years old) of both sexes, at any time after the stroke; studies that use information and communication technologies with valid information for the diagnosis, treatment, and prevention of diseases and injuries, as well as those with valid research, evaluation, and for the continuing education of health care providers (telehealth); outcomes included were related to barriers and perceptions reported by the studies participants. Regarding the exclusion criteria, the following were established: review studies; studies that did not include the stroke population; studies that did not address telehealth or barriers to telehealth access; and barriers to the user and/or caregivers’ perceptions.
Studies selection
After searching all databases, duplicates were removed. Then, the selection was carried out by titles and abstracts of the studies. If the study did not meet the inclusion criteria, they were excluded. After the first selection, the full papers were read and those meeting the inclusion criteria were selected. An active search was also carried out to identify other potentially relevant studies. Two reviewers independently assessed the titles and abstracts of all identified records from the electronic searches. Full-text articles were screened for eligibility by both reviewers. Disagreements were settled by discussion and consensus. When required, a third reviewer was consulted. Those that met the inclusion criteria were added to the included studies. Figure 1 illustrate the selection process according to the PRISMA statement.
Illustrative flowchart of the article selection process, according to PRISMA Statement 2020
Theoretical framework: The Unified Theory of Acceptance and Use of Technology model
The UTAUT model consists of four main dimensions called essential determinants of behavioral intention. They are: 1. Performance Expectancy (PE); 2. Effort Expectancy (EE); 3. Social Influence (SI); 4. Facilitating Conditions (FC). Additionally, the UTAUT model contains four intention-behavior moderators that affect technology use, which are: gender, age, experience, and willingness to use (Figure 2) (1212. Venkatesh V, Morris MG, Davis GB, Davis FD. User acceptance of information technology: toward a unified view. MIS Q. 2003;27(3):425-78. doi: 10.2307/30036540.
https://doi.org/10.2307/30036540...
.
By definition, Performance Expectancy (PE) refers to the degree to which an individual believes that the use of technology will help them to improve their performance; Effort Expectancy (EE) is the degree to which an individual believes that a feeling of ease is associated with using the system or device; Social Influence (SI) is the degree to which an individual realizes that other important people believe the system or device should be used; Facilitating Condition (FC) is the degree to which an individual believes that the organizational and technical infrastructure exists to support the use of the technology; finally, Behavioral Intention (BI) refers to the degree to which an individual intends to use the system or device1212. Venkatesh V, Morris MG, Davis GB, Davis FD. User acceptance of information technology: toward a unified view. MIS Q. 2003;27(3):425-78. doi: 10.2307/30036540.
https://doi.org/10.2307/30036540...
.
RESULTS
The systematic search found 295 articles in all databases, and three articles were identified by other sources, totaling 298 articles. After screening and full-text reading, six were included. Table 1 summarizes the descriptors and search terms used for the search, as well as the number of studies found in each database. Table 2 summarizes the articles information, with the following data: author and year, type of study, sample, gender, average age, type of telehealth, and perceived barriers within the correspondent dimensions UTAUT model.
Qualitative and quantitative studies that inquire about user perception were included, most of them were published in the last five years (from 2016 to 2020). In summary, the results of included studies investigated the perception of more than 220 stroke patients and caregivers regarding barriers to access telehealth services. Studies that reported gender, presented an equivalent response between men and women; the participants’ age ranged from 45 to 90 years old; videoconferencing was the most common system to deliver telehealth. Among the users who reported barriers, they perceived difficulties regarding equipment, internet, proper space at home, and low literacy (Figure 3). Table 2 shows the main barriers to telehealth access identified by the users and the correspondent UTAUT dimension. The dimensions of Effort Expectancy and Facilitating Conditions had the most reported barriers with four and six barriers, respectively. These dimensions (EE and FC) were reported in all included studies except one55. Sarfo FS, Adamu S, Awuah D, Sarfo-Kantanka O, Ovbiagele B. Potential role of tele-rehabilitation to address barriers to implementation of physical therapy among West African stroke survivors: a cross-sectional survey. J Neurol Sci. 2017;381:203-8. doi: 10.1016/j.jns.2017.08.3265.
https://doi.org/10.1016/j.jns.2017.08.32...
. The described barriers identified in these dimensions were the most influential in the intention to use telehealth technologies by stroke patients. The dimensions were:
Effort expectation barriers
These barriers related to EE were: 1. Low health literacy; 2. Participant’s difficulty using the computer, software program, and/or technical equipment; 3. Difficulties related to the setup of the equipment; 4. Technical skills1414. Øra HP, Kirmess M, Brady MC, Sørli H, Becker F. Technical features, feasibility, and acceptability of augmented telerehabilitation in post-stroke aphasia-experiences from a randomized controlled trial. Front Neurol. 2020;11:671. doi: 10.3389/fneur.2020.00671.
https://doi.org/10.3389/fneur.2020.00671...
)-(1717. Tyagi S, Lim DSY, Ho WHH, Koh YQ, Cai V, et al. Acceptance of tele-rehabilitation by stroke patients: perceived barriers and facilitators. Arch Phys Med Rehabil. 2018;99(12):2472-2477.e2. doi: 10.1016/j.apmr.2018.04.033.
https://doi.org/10.1016/j.apmr.2018.04.0...
.
Barriers to facilitating conditions
Barriers related to this dimension are: 1. Internet connection; 2. Sound and image quality of videoconferencing; 3. Limited space at home; 4. Internet connections barriers; 5. Rapid changes in technologies (obsolete equipment; wireless technology); 6. Problems with equipment functionality (video limitations; technical support required) (1414. Øra HP, Kirmess M, Brady MC, Sørli H, Becker F. Technical features, feasibility, and acceptability of augmented telerehabilitation in post-stroke aphasia-experiences from a randomized controlled trial. Front Neurol. 2020;11:671. doi: 10.3389/fneur.2020.00671.
https://doi.org/10.3389/fneur.2020.00671...
),(1616. Chen Y, Chen Y, Zheng K, Dodakian L, See J, et al. A qualitative study on user acceptance of a home-based stroke telerehabilitation system. Top Stroke Rehabil. 2020;27(2):81-92. doi: 10.1080/10749357.2019.1683792.
https://doi.org/10.1080/10749357.2019.16...
)-(1818. Chumbler NR, Quigley P, Li X, Morey M, Rose D, et al. Effects of telerehabilitation on physical function and disability for stroke patients: a randomized, controlled trial. Stroke. 2012;43(8):2168-74. doi: 10.1161/STROKEAHA.111.646943.
https://doi.org/10.1161/STROKEAHA.111.64...
.
DISCUSSION
This review is the first to systematically summarize the barriers to access real-time remote health services for individuals with stroke, according to dimensions in UTAUT. In the six studies included, all UTAUT dimensions were reported as barriers to accessing telehealth. Effort Expectancy (EE) and Facilitating Conditions (FC) had a larger number of reported barriers. In summary, stroke patients reported several challenges to access telehealth.
As previously reported, older individuals, as well as the overall profile of stroke patients, have greater difficulty in using technologies1919. Wallace SE, Graham C, Saraceno A. Older adults' use of technology. Perspect Gerontol. 2013;18(2):50-9. doi: 10.1044/gero18.2.50.
https://doi.org/10.1044/gero18.2.50...
, in this sense, the need to understand what these barriers mean for telehealth use is stated with the need for an explanatory theoretical model on the use of technology. The perceived barriers to telehealth identified are related to the dimensions of the UTAUT model; the practical implications of this review and its limitations are discussed.
Perceived barriers to Telehealth access and Unified Theory of Acceptance and Use of Technology dimensions
The main barriers related to effort expectation can be inferred as a dimension of barriers that can be solved since it involves a level of knowledge, use, and operation that can be taught to the patient. It involves the individual’s preference for the use of technology, since the delivery method and application of telehealth can be individualized. However, for this same dimension, the cognitive level of individuals should be considered. According to Chakraborty et al.2020. Chakraborty I, Hu PJH, Cui D. Examining the effects of cognitive style in individuals' technology use decision making. Decis Support Syst. 2008;45(2):228-41. doi: 10.1016/j.dss.2007.02.003.
https://doi.org/10.1016/j.dss.2007.02.00...
, cognition has an important effect on the perception of utility, and, consequently, on the expectations of individuals regarding their performance and effort in the use of technologies. Since stroke patients may present cognitive sequelae, in addition to motor and speech sequelae2020. Chakraborty I, Hu PJH, Cui D. Examining the effects of cognitive style in individuals' technology use decision making. Decis Support Syst. 2008;45(2):228-41. doi: 10.1016/j.dss.2007.02.003.
https://doi.org/10.1016/j.dss.2007.02.00...
, they may face more barriers related to effort and performance expectations. This implies the need for cognitive screening and assessment of individuals before insertion into a rehabilitation program via telehealth.
Within the facilitating conditions dimension, the perceived barriers are related to financial aspects, access to the internet, and home context that are difficult to overcome and may interfere with the user’s acceptance of telehealth. Due to body function impairments and activity limitations, stroke patients face environmental barriers within their own homes2121. Martins EF, Sousa PHC, Barbosa PHFA, Menezes LT, Costa AS. A Brazilian experience to describe functioning and disability profiles provided by combined use of ICD and ICF in chronic stroke patients at home-care. Disabil Rehabil. 2011;33(21-22):2064-74. doi: 10.3109/09638288.2011.560332.
https://doi.org/10.3109/09638288.2011.56...
. Thus, it is appropriate to consider an assessment of the individual’s home space and their safety support before the implementation of telehealth service. The individual’s context, and consequently individualization of the delivery method of telehealth must be carried out before the introduction of telehealth care to avoid the rise of new barriers, which are difficult to overcome.
Other dimensions of the UTAUT model were also reported as minor barriers, namely: the perception of the system’s usefulness; extrinsic motivators, such as how the system improves the individual’s results and/or performance; relative advantage, or the use of innovation were conceptualized in the Performance Expectancy dimension. In the Social Influence dimension, only aspects regarding the financial condition and communication failure between providers and users were identified. These two dimensions were the ones with the fewest barriers addressed in the included studies, covering only three in each dimension.
Notably, these barriers, for the most part, had issues related to the telehealth method of delivery, and no barrier was identified regarding the conditions related to the individual, which highlights the lack of information about barriers that are specific to stroke, including its sequelae. Examples of this include cognitive and communicative ability impairments, which encompass the ability to understand commands; difficulty in learning tasks; post-stroke depression; and motor deficit. These impairments make individuals dependent or semi-dependent on a caregiver to perform tasks2222. Kauhanen M, Korpelainen J, Hiltunen P, Määttä R, Mononen H, et al. Aphasia, depression, and non-verbal cognitive impairment in ischaemic stroke. Cerebrovasc Dis. 2000;10(6):455-61. doi: 10.1159/000016107.
https://doi.org/10.1159/000016107...
),(2323. Aprile I, Guardati G, Cipollini V, Papadopoulou D, Monteleone S, et al. Influence of cognitive impairment on the recovery of subjects with subacute stroke undergoing upper limb robotic rehabilitation. Brain Sci. 2021;11(5):587. doi: 10.3390/brainsci11050587.
https://doi.org/10.3390/brainsci11050587...
. In this sense, the absence of a caregiver could negatively interfere and should be considered as a barrier to telehealth access2424. Cumming TB, Marshall RS, Lazar RM. Stroke, cognitive deficits, and rehabilitation: still an incomplete picture. Int J Stroke. 2013;8(1):38-45. doi: 10.1111/j.1747-4949.2012.00972.x
https://doi.org/10.1111/j.1747-4949.2012...
. However, our analysis showed that the addressed barriers that stroke patients face in accessing telehealth did not consider the specific characteristics of this population.
Practical implications
The identified barriers in this study should be used for future analyses or during the development of software programs to provide remote health services in real time. Health care providers can use the UTAUT framework as a guideline to anticipate and attempt to minimize or eliminate potential barriers, thus ensuring an effective online service delivery to their patients at home.
Limitations
The use of a qualitative method of content analysis to address the barriers perceived in the studies is one of our limitations. This is mainly inferred by the small number of studies that quantitatively assess limitations proven as barriers to telehealth access. Thus, this review addressed the results of cause-and-effect studies alongside the results arising from descriptions in qualitative studies.
CONCLUSION
The main barriers to telehealth access by stroke patients refer to the use of technology and the required infrastructure to deliver this method of healthcare, according to the dimensions Effort Expectancy and Facilitating Conditions of the UTAUT model, respectively. It can be observed that the barriers related to the Effort Expectancy dimension are barriers that can be overcome by providing knowledge about the use of technologies with training that can be carried out before the telehealth service is offered. However, the barriers in the dimension of Facilitating Conditions, which are related to financial aspects, internet conditions, and home contexts are difficult to overcome and, therefore, can also interfere with the user’s acceptance of telehealth. This review consisted mainly of subjective approach research, therefore, it is necessary to carry out studies with a quantitative approach, thus identifying the main barriers and predicting possible failures to access telehealth.
REFERENCES
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1Krishnamurthi RV, Ikeda T, Feigin VL. Global, regional and country-specific burden of ischaemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage: a systematic analysis of the Global Burden of Disease Study 2017. Neuroepidemiology. 2020;54(2):171-9. doi: 10.1159/000506396.
» https://doi.org/10.1159/000506396 -
2Copstein L, Fernandes JG, Bastos GAN. Prevalence and risk factors for stroke in a population of Southern Brazil. Arq Neuropsiquiatr. 2013;71(5):294-300. doi: 10.1590/0004-282X20130024.
» https://doi.org/10.1590/0004-282X20130024 -
3Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, et al. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke. 2005;36(9):e100-43 doi: 10.1161/01.STR.0000180861.54180.FF.
» https://doi.org/10.1161/01.STR.0000180861.54180.FF -
4Furlan L. Potential barriers and promising opportunities for stroke rehabilitation in Brazil. Int J Stroke. 2014;9(Suppl A100):144. doi: 10.1111/ijs.12338.
» https://doi.org/10.1111/ijs.12338 -
5Sarfo FS, Adamu S, Awuah D, Sarfo-Kantanka O, Ovbiagele B. Potential role of tele-rehabilitation to address barriers to implementation of physical therapy among West African stroke survivors: a cross-sectional survey. J Neurol Sci. 2017;381:203-8. doi: 10.1016/j.jns.2017.08.3265.
» https://doi.org/10.1016/j.jns.2017.08.3265 -
6Silva MA, Santos MLM, Bonilha LAS. Users' perceptions of outpatient physiotherapy in the public healthcare system in Campo Grande (MS, Brazil): problem-solving capacity and difficulties. Interface Comun Saude Educ. 2014;18(48):75-86.
-
7Lieneck C, Herzog B, Krips R. Analysis of facilitators and barriers to the delivery of routine care during the COVID-19 global pandemic: a systematic review. Healthcare (Basel). 2021;9(5):528. doi: 10.3390/healthcare9050528.
» https://doi.org/10.3390/healthcare9050528 -
8Caetano R, Silva AB, Guedes ACCM, Paiva CCN, Ribeiro GR, et al. Challenges and opportunities for telehealth during the COVID-19 pandemic: ideas on spaces and initiatives in the Brazilian context. Cad Saude Publica. 2020;36(5):e00088920. doi: 10.1590/0102-311X00088920.
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1
This study is the product of Luana’s conclusion work in the specialization course in the multidisciplinary residency modality in neurology and neurosurgery in the multiprofessional and uniprofessional residency program in health at the Ceará School of Public Health in partnership with Fortaleza General Hospital, presented in 2021: “Barriers to telehealth access in cerebral vascular accident: a systematic review”.
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The abstract of this study was presented at the XIV Research and Postgraduate Meeting of the Federal University of Ceará, online in 2021.
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Financing source: CAPES
Publication Dates
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Publication in this collection
20 Oct 2023 -
Date of issue
2023
History
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Received
20 Dec 2022 -
Accepted
19 Apr 2023