Digital technology has taken several critical steps to develop e-services for health in all nations.
It has taken considerable advancement to develop different strategies towards target groups.
World Health Organization has set a goal to increase the efficiency of mental health care by expanding globally all services. The use of eHealth services has found to be well suited for different client groups and the applications has noticed to provide better treatment results that in treatment without eHealth services (Hilty et.al 2013) eHealth solutions has seen as a bridge between different sectors and solutions. Because of eHealth, several sectors can improve their collaboration and communication. Increased use of digital technology has been found to increase staff collaboration, patient- orientation and facilitate clinical decision-making (Buckley & Weisser, 2012).
Several studies have shown that technology-based care is effective, efficient and can reduce medical errors and travel time (Buckley & Weisser, 2012). New innovative ways to communicate, e.g. video conferencing is becoming globally more utilized. Using VC, people have more access to support they need regardless of the location they are. Specially in mental health care, doctor-patient interactions become more comfortable and ideal. Therapy sessions become safe and private. However, health care professionals have had contradictory experiences towards VC in mental health care. VC have said to improve health, care management, access and cost when its utilized in care of chronical illnesses. With VC, healthcare professionals have better capacity to support those who are in need. Innovative methods and interventions have become the most essential to enhance the care in mental health.
Nonetheless, healthcare professionals´ negative experiences emerge on their own perceptions and attitudes, not entirely based on the user experiences. However, more research is needed to assess the effectiveness in mental health care and experiences of health care professionals (Mallow et.al 2016).
The introduction of the technology is particularly influenced by the perceived benefits and ease of use. E-health services and applications implementation must be focused because all actors have different technology skills to start with. In its entirety, technology application and solutions towards work in healthcare has been welcomed by several professions. Technical problems, attitudes and perceptions have an influence towards user experiences. Challenges might occur in management and in technical level. Despite the challenges, eHealth does not
only influence health care professionals but other people. It enables virtual care, remote monitoring, health data storage and analytics. Technology plays important role developing new approaches to more personalized care. In the future, more extensive utilization of different technological tools will improve and offer better patient outcomes, improve work efficiency and innovate new approached to healthcare.
Currently, people use technology in their everyday life and studies have shown that if health care professionals used technology in their free time and have a positive attitude towards technology, their attitude towards utilizing technology at work may also be positive. (Van Houwelingenes et al. 2015). E-health solutions have gained more demand because of recent global health threat has occurred, e.g. Corona (2020). Technological application and services will have advanced collaborative response to becoming situations.
Figure 3: Main elements of the literature review and its connections
3 STUDY AIMS
This research study illustrates the experiences, usability, effectiveness, user-friendliness, necessity of the VC meetings in eCAP- project. Aim of this study is to seek health care professional´s perspectives using VC in eCAP- project. Topic will be associated with quality and effectiveness of the service and the future development of VC meetings.
The specific aims of this study are as follows:
1. What need on the local level the VC meetings have been used for?
2. What have the VC meetings been like?
3. How have the respondents perceived the VC meetings?
4. What should the child psychiatric VC meetings be like in the future?
4 METHODOLOGY 4.1 eCAP-PROJECT
eHealth services for Child and Adolescent Psychiatry (eCAP) project was conducted in 2015 to 2018 with Eastern University of Finland and Kuopio University Hospital (KUH) in Finland.
Its goal was to improve the quality and accessibility of the services among young mental health patients, who were living in a remote area in Eastern Finland. The overall aim for the project was to improve diagnosis, consultation, implementation and treatment plan between all actors.
The three-year project partners were including Finland, Norway, Scotland and Sweden.
Furthermore, the projects goals were to integrate new innovative eHealth solution to Norther Savo region and develop collaboration and multi-professional cooperation with primary health care and specialized care towards better health for mental health patient.
The project specific aim in Finland was to develop, test and expand new communication methods which will improve quality and accessibility of mental health services for patients in rural areas. The project utilized ITC which developed consultations upon the existing services and support multi-professional’s co-operation between all those actors who were working with children with mental health professionals. The aim was to improve and implement VC-services in Eastern communities were the services had not yet been introduced. The services included an electronic booking system that allowed health care professionals to easily and flexibly book consultation; and supervision times for child psychiatry expert and location-independent video conferencing solution for professionals use in consultation and follow-up/ support/ monitoring.
The implemented video conferencing booking system was embedded in KUH extranet and the portal with instructions. All materials were intended to be used by all actors and free of charge.
4.2 STUDY DESIGN AND SETTING
This study is a descriptive cross-sectional study based on quantitative and qualitative data from eCAP- project. The study aims to investigate the experiences after using VC services. The data collection was completed in December 2016 in North Savo region. Eighteen municipalities included the study. Those municipalities include: Iisalmi, Kaavi, Keitele, Kiusuvesi, Kuopio, Lapinlahti, Leppävirta, Maaninka, Pielavesi, Rautalampi, Rautavaata, Sonkajärvi, Suonenjoki, Tervo, Tuusniemi, Varkaus and Vesanto. All of the respondents´ worked in those municipalities and were the users of those eCAP- services, including booking system, consultations, electronic
forms for collecting background data, online tutored peer groups and online clinical supervision (Bykachev, 2018).
4.3 SUBJECTS
In this study, subjects were healthcare professionals who were utilizing VC-services in eCAP-project in Northern Savo. The total number of respondents were 94 who voluntary responded the questionnaire after utilizing VC service. More specific, in total number of KUH professionals were 43 and primary healthcare workers were 51. The questionnaire was on a web-based survey. The subjects for this research were considered:
• KUH Child and Adolescent Psychiatry outpatient clinic (CAP) professionals
• Healthcare professionals (other than workers from KUH)
• Social workers
• Family counselling workers (Neuvola)
• School or Day-care professionals
4.4 DATA COLLECTION 4.4.1 TOOL
The tool for data collection was online structured qualitative and quantitative questionnaire. All questions were in Finnish. The questionnaire was conducted in a multi-professional team which consist of professionals from the Department of Nursing Science and KUH Clinic of Child Psychiatry. Executing the questionnaire took time and it was discussed in several meetings.
Official piloted questionnaire was not conducted (Bykachev, 2020). The pre-test for the online questionnaire was conducted among those multi-professional team. And, this was considered at the baseline. The piloted questionnaire´s purpose was to test the comprehensiveness and consistency. The purpose of pre-testing is to reduce errors in the questionnaire and to ensure the veracity of the matter being measured. (Hirsjärvi et.al 2000) After the pilot questionnaire, minor changed were made.
4.4.2 PROCESS
The data were collected in January to September 2018 from health and social care employees working with the mental health services in Northern Savo primary healthcare and CAP professionals. The health care professionals were trained to use the VC and an electronic appointment system in their work. The research included two different questionnaires which were targeted to its target groups. Both questionnaires were sent via electronic survey to their business email address´ after each VC meeting. The feedback form was mentioned in each video conference and participants were asked to provide feedback of the service to improve it.
Responding was voluntary and anonymous. No reminder was sent. The duration of filling the questioner was not mentioned in the questionnaire. However, responding to all questions took approximately 5 to 10 minutes. (Bykachev, 2020) The first question of the online- survey was based on the participants workplace. Through it, the right query could be assigned to the right person.
Both questionnaires addressed the consultation purposes, perceived functionality, experiences and suggestions for improvements for the future. (Appendix 1 & 2) They addressed the same topic, but some of questions were designed differently. E.g. How many clinic / hospital/ school employees avoided traveling due to video conferencing? versus How many employees avoided traveling due to video conferencing? The questionnaires included also similar close and open-ended questions which addressed participants experiences of the VC and further implications for future.
Both questionnaire´s consisted of 10 to 11 questions in the Surveypal feedback process. (See Appendix 1 & 2) They formed of Likert scales, close and open-ended questions as well as graphical presentation options. Due to Likert scale, respondents were required to rate their level of agreement or disagreement. The scale was given to report their responses: completely agree, agreeing to some extent, neither agree nor disagree, somewhat disagree, completely disagree and I cannot say. Also, they were allowed to make specific statement regarding the specific question. Those answers were categorised as qualitative data. Along with the questionnaire included 0 to 5 numerical rating e.g. VC participants quantity. Neither of the questionnaires contained specified sections, but they were organized in logical order.
The structure contained:
1. The purpose and theme of the video consultation 2. The quantity of participants
3. Experiences and technical aspects of the VC 4. Suggestions for future VC development
4.5 DATA ANALYSIS
In this study, quantitative and qualitative data was focused. Combining mixt-methods methodology research components strengthens the conclusions of this study. The data was pre-collected and coded into EXCEL in the eCAP- project and it was offered to the thesis worker.
The data was suitable for this study, as the data address the research questions. All saved data were in Finnish. This study addressed only the issues relevant to this study from the questionnaire. The main focus was to view the data on the healthcare professionals´ experiences of video conference and the technical aspects.
Quantitative data analysis was conducted utilizing indicators, cross-tabulation, percentages and means. Cross-tabulation shows the number of frequencies of the respondent’s feedback. It examines the distribution of the variables and the dependencies between them. In this study, KUH and primary care professionals´ answers were compared. Comparing makes it easier to detect and understand differences and cross-tabulation allows the data to be viewed visually. It supports the possibility to find differences in the effects and interactions of different variables relatively easily. Percentages demonstrate the relative proportions of the cases and in this study, they can be compared. Several figures and charts assist the reader to visually understand all the proportions of the answers. The aim was to review is there differences between two participant groups.
The qualitative data analysis was conducted with content analysis within an inductive approach.
Content analysis is a method of data analysis which is used in qualitative research. It allows authors to highlight the key point, regardless of relationship to previous research. (Neuendorf et.al 2017) The main aim of the content analysis was to find common concepts and regularities describing the data. The challenge was to analyse the data from the its own point of view,
without the theoretical knowledge affecting the issues that arise from the data. Open questioner responses were addressed through different categories. In this study, all the data responses to question about future developments were categorised under several different headings. Creating categories that describes open answers helps the reader see the frequencies of how many times a thing is mentioned in the open responses. The open responses were grouped into separate groups according to similarity, which were then named as a larger entity. In addition to categorization, the responses were also quantified, the frequencies of how many times a thing was mentioned in the open responses were calculated.
With inductive approach, the results are formed on the basis of the data and theory. The data analysis was done without any theorical presuppositions. Recognizing the theory in advance, it is unattainable to describe preconception on the phenomenon of the study. In this study, inductive approach was used because research questions were guiding, and results were developing a theory. Results gave typical pattern and based on that; theory and analysis were developed.
4.6 ETHICAL CONSIDERATION
Acceptable scientific practise must follow scientific practises, including honesty, diligence and accuracy. Data collection, research, reporting and evaluation methods that were scientifically and ethically sustainable were applied. All the results were transparent, and the sources were correctly mentioned. The University of Eastern Finland Committee on Research Ethic granted ethical approval. Also, all eighteen municipalities approved and requested permission for the survey.
All participants safety and rights were declared. Participants were anonymous, non- of the participants could not be identified and participating was voluntary. Filling the questionnaire was based on implied consent. The implied consent was based on participants actions to voluntarily to respond the questioner. Their physical and mental integrity were realized so they knew with sufficient knowledge the aims, purpose, research methods, research funding and recognized the voluntarily of participating.
The data processing, use and storage was based on confidentiality. Research data was granted for thesis worker after signing a written agreement. The access to the data was given on 11th November 2019. The data may not be used or disclosed for any other than the research.
5 RESULTS
5.1 STUDY PARTICIPANTS
The questionnaire was sent to a total of 94 participants working in North Savo region of Finland.
All participants answered to the online survey. Overall, there were 94 different forms returned.
Of the total respondents 45,7% (n=43) were KUH professionals and 54,3% (n=51) primary care professionals. On average of the VC attended primary care respondents, 6.7% (n=2) were social workers, 21.1% (n=1) were day care/school professionals, 6.3% (n=1) were family counselling workers (Neuvola) and 40.9% (n=9) were the family member of the patient. Detailed characteristics of the participants are represented in Table 1 and in Table 2.
Table 1. Characteristics of the all respondents
KUH professionals Other professionals 45 %
55 %
WORKPLACE OF THE PARTICIPANTS
Table 2. Characteristics of the primary care professionals
5.2 WHAT NEED ON THE LOCAL LEVEL THE VC MEETINGS HAVE BEEN USED FOR?
The first question regarding purpose of the VC meetings asked, “What need on the local level the VC meetings have been used for?” Around 67,4% (n=29) of the KUH professionals mentioned that the purpose of the VC meeting was a consultation. Other main proportion, by 14% (n=6), VC meetings were used for tutored peer meetings. With 7% (n=3), the purpose was shared patient meeting were the patient’s family members could have attended. The VC meetings were also mentioned to use as a training purpose with 2,7% (n=1). With 4,7% the purpose for VC meetings were mentioned as a shared professional guidance and something else, what. Open-ended answers included anonymous consultation (n=4), contact with the patient´s parent (n=4), developing overall cooperation between all actors (n=1), group VC with several actors from healthcare sector (n=1), test contact (n=1) and few included contact with occupational therapist (n=1). In addition, the purpose of tutored peer group was also repeat (n=5) in the open-ended answers.
Primary healthcare professionals
44 %
Social workers 6 % School/day care
professionals 17 % Family members
33 %
PROFESSIONALS FROM THE PRIMARY
HEALTHCARE (OTHER THAN KUH)
Table 3. KUH professionals´ responses of the purpose of VC
VC purpose % N
Nobody 67,4% 29
Consultation 4,7% 2
Shared professionals´ guidance 7,0% 3
Shared patient meeting 2,3% 1
Training 14,0% 6
Tutored peer meetings 4,7% 2
Similar question was addressed to the primary care professionals. They were asked about the option for VC: “What would have been the alternative VC option? “A one third of 31.9% (n=15) of the participants responded in the open answer. The responses included contacting the family counselling center (n=7), making a phone or electronical consultation to KUH (n=5), training option (n=4), nothing to replace and maintaining the children´s health and care plan as it is (n=4) and the option for arranging patient´s family to commuting to Kuopio for the appointment (n=1).
One of the primary health care professionals stated:
”.. In addition to the referral, consultations between primary healthcare actors were also being considered..”
Likewise, another health care professional from primary care, related his/hers experience as:
“..They would probably have continued to think about the matter with their own group or called and consulted child psychiatry over the phone..”
The following statements and responses support the open answers from primary care professionals. The main proportion of 23,4% (n=11) answered that the situation would have been continued to follow. With 17,0% (n=8) phone contact to child psychiatry clinic would have been an option. Around 14,9% (n=7) of the respondents comment consultation between all primary care actors would have been good alternative. A small proportion with 12,8% (n=6) of the respondents thought referral for child psychiatric care would have been a correct approach for VC.
Table 4. Primary care perspectives for VC option
Option for VC % N
Referral for special child psychiatric care 12,8% 6 Phone contacting to the child psychiatry clinic 17,0% 8 Consultation between all primary care actors 14,9% 7
The situation would have been followed 23,4% 11
Something else, what? 31,9% 15
According to KUH professionals´ responses about considering about the topic of the VC. All responses were open answers and they are categorized under several headings. Detailed headings and characteristics of the open answers are not attached in this thesis. All responses included child aged 1-year-old to 13-year-old. Topics range from aggression, eating problems, behavioral challenges and emotional regulation, tantrums, sleep difficulties, encountering a multicultural family, self-harm, the challenge of the overall situation, and other challenges.
Most of the respondents mentioned the topic of behavioral challenges and emotional regulation among the child. Tantrums and sensory; and emotional ability were the most common problems that had been mentioned (n=13). A vast majority mentioned was anger attacks and sleeping problems (n=7). The overall challenging situation of the child and family was mentioned (n=6).
Several children had problems with aggression (n=4). Open answers manifested concerns about other healthcare professionals encountering and child´s follow-up-care plan (n=4). Bear minimum were mentioned of eating problems (n=1), multicultural family (n=2) and self-harm (n=1).
KUH professionals related their experiences of the VC topic
“..the challenging regulation and sensory dilemmas of a one-year-old child, which are reflected in the early interaction with the parent as a stress factor and, if they continue, would
jeopardize the development of the child's skills”..
“..The situation of a 1.5-year-old child and family. No developmental concern for the child nor the symptoms, but the overall family situation is challenging..”
“..3-year-old twins, big behavior regulation problems. As a question of how to continue working at the primary care..”
Based on KUH professionals´ responses with 52% (n=22) did not avoid travelling due to the VC. A little over half of the professionals´ had to travel because of the meeting. Around 41%
(n=17) one person was able to avoid travelling due to the VC and with lowest portion of 7,1%
(n=3) two person were able to stay at work due to the VC meeting.
(n=3) two person were able to stay at work due to the VC meeting.