Perceptions and barriers regarding telemedicine services among Bangladeshi young adults in the COVID-19 pandemic: A qualitative exploration

Use your smartphone to scan this QR code and download this article ABSTRACT The present study aimed to explore perceptions and barriers regarding telemedicine services among Bangladeshi young adults. This qualitative study was performed through telephonic interviews where 20 young adults (cases) were taken for in-depth interviews, using a purposive sampling technique from July 1 to July 20, 2020. The verbatim transcriptions was used, and the thematic analysis was performed through manual coding. The findings of this study revealed that the majority of participants perceived telemedicine as it is a system through which we are able to get healthcare services by using the internet, mobile application, or just a phone call from health care providers. Participants had positive attitudes toward telemedicine. Low trustworthiness, difficulties in getting access to emergency diagnostic services, significant anxieties on the use of telemedicine complexity and observability, shortage of network and power supply, as well as financial complexities were acknowledged as significant barriers in terms of receiving telemedicine services during the COVID-19 outbreak. Concerned authorities, including governmental and private organizations, should take effective measures to make telemedicine services available, reliable, and affordable for all across the country.


INTRODUCTION
Telemedicine refers to the delivery of health care services by healthcare professionals using Information and Communication Technology (ICT) for the exchange of vital 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 interest of advancing the health of individuals and their communities, where distance is a critical factor 1 . A previous study in Bangladesh reported that people perceived telemedicine as a service for prescription of medicines, assessment of disease, and referral of diagnostic tests by using technologies such as the internet, computer, or webcam 2 . ICT systems have been using globally to deliver distant healthcare services via telemedicine 3 . Telemedicine allows healthcare professionals to evaluate, diagnose, and treat patients in remote locations using telecommunications technology 4 . The COVID-19 pandemic poses a considerable obstacle to receive healthcare for non-COVID-19 patients. Telemedicine technology is being used in order to reduce the risk of COVID-19 spread both in the United Kingdom and the United States of America 5 . In the digital health items introduced by the Australian government for the COVID 19 pandemic, over 4.3 million medical and health services have already been provided to more than three million patients 6 . A survey conducted by G&S Business Communications found that 82% of Americans still don't think telehealth is available to them. Two out of five said the COVID-19 pandemic made them more likely to use telehealth 7 . In response to the novel coronavirus, the demand for telemedicine has been growing swiftly. A recent survey has been shown that 23% of adults in the USA have been used telehealth services considering the COVID-19 pandemic 8 . A survey has been conducted through a software provider named MDLIVE regarding telemedicine and found that 82% of young adults aged 18 to 34 found using a mobile phone is the best option to consult with the doctors 9 . Moreover, the provision of telemedicine is far less progressed in lower-middle and low-income countries 1 . Many difficulties and challenges that arise from the implementation of telemedicine occur in both urban and rural areas 10 . Generally, people in rural areas tend to have more restricted access to healthcare resources compared to those living in urban areas 11 . Lack of access to affordable broadband at adequate connection speeds is another roadblock to providing telemedicine in rural areas 12 . Treatment via telemedicine does not occur face-to-face; this does not change the fact that certain interactions establish a physician-patient relationship 13 . There are also linguistic barriers present regarding telemedicine services. In some developing countries such as India and Iran, there is a great diversity of languages, cultural aspects, and dialects. The diversity of languages and dialects makes it difficult to build acceptable verbal communication between physician and patient 14 . Bangladesh is one of the most densely populated lower-middle-income countries where around 85% of the total population lives in rural areas 15 . On March 8, 2020, when the first COVID-19 case has been found in Bangladesh, hospital visit has been restricted, the majority of the doctors stopped practicing in person for self-protection. As a result, public and private organizations introduce telemedicine services. The traditional health care system is more in use than the electronic health care system in Bangladesh. According to the Directorate General of Health Services (DGHS), at present 94 facilities in Bangladesh, including 9 government specialized and medical college hospitals, 11 district hospitals, and more than 50 Upazila level hospitals, have the equipment to provide healthcare by videoconference 16 . In Bangladesh, the spread of the deadly COVID-19 caused people to maintain social distancing, movement restrictions, stay at home. Moreover, telemedicine still poses certain limitations in terms of treating patients during the COVID-19 pandemic 17 . As a developing country, Bangladesh is facing various obstacles to the promotion and implementation of e-Health, including telemedicine. Some major threats and challenges have been identified in our country, which includes: highcost, the lower liability of internet access, lack of appropriate information and technology policy, lack of coordination as well as lack of awareness of government and citizens 18 . Lack of patient satisfaction is one of the major barriers as well as another significant barrier is the lack of patient's trustworthiness towards telemedicine adaptation 19 . Moreover, the insufficient power supply might be the primary challenges and barriers to telemedicine implementation in Bangladesh 20 . Based on the previous studies, limited information has been found on perceptions and barriers regarding telemedicine services among young adults, how they perceived telemedicine services qualitatively. Globally there are about 1.8 billion young out of 7.3 billion populations where majority of them are from developing countries like Bangladesh and nearly 30 percent of total population in Bangladesh is in young stage. Furthermore, developing countries emphasized more on youth investment, especially on their health services for social development. On the contrary, more than eighty percent young adults preferred phones for taking virtual treatment services above mentioned 9,21 . Therefore, the present study aimed to explore perceptions and barriers regarding telemedicine services among Bangladeshi young adults in COVID-19 pandemic through a qualitative approach.

METHODS -MATERIALS
In this qualitative study, the purposive sampling technique was performed for collecting data from 20 young adults (cases) living in the community (urban, semi-urban, and rural) from 1 July to 20 July 2020. In-depth interviews were performed over the phone by considering the convenient state of the participants, and the data collection was continued until it reached its maturation process. The inclusion criteria included: participants who willingly agreed to take part in an online interview. The exclusion criteria included: the participants who were unable to participate in an online interview. The IDI questionnaires were as followed: (1) perception regarding telemedicine services, (2) perception in respect of barriers of telemedicine, and (3) recommendations to overcome the existing barriers from participants.
Each interview took approximately 15 -18 minutes, and the audio recording was also used. All participant's consent was taken during the data collection process and assured that their personal information will be kept strictly confidential and won't be used for any other purposes. The verbatim transcriptions were performed, and the transcripts were cross-checked with the audio taping for finding out which important portions were missed via technical errors. Thematic analysis was performed for summarizing, extracting, and formulating texts through a manual coding system.
In this study, credibility was ensured by the pledge of the researchers in the period of their data collection in which interviewees were able to understand the research objectives. Credibility was also performed in the data analysis phase by the researchers.

RESULTS
In the present study, 20 in-depth interviews (IDI) were conducted. The mean age of study participants was 1.5 (SD: 0.51) years. Half of the study participants were male. The majority of the study participants (25%) were involved in the business, 20% were students, and the rest of them (55%) were involved in different types of occupations. Most of them (40%) were living in rural areas, and 35% and 25% were living in urban and semi-urban areas, respectively ( Table 1).
On the contrary, case-specific information of study participants was also illustrated ( Table 2).

Perceptions regarding telemedicine service
When participants were asked to state perceptions regarding telemedicine, the majority of the study participants said that telemedicine is an online service through which they received health care services particularly primary health care services provided by the doctors through the assistance of phone or internet. A university student (female) explained her perception of telemedicine as:

Theme-02: Participant's perceptions regarding telemedicine's barriers during the COVID-19 pandemic
The majority of participants shared their perceptions toward the barriers of telemedicine service in several sections, which were categorized into different subthemes:

Sub-theme 2.1 : Lack of trustworthiness in telemedicine services
Maximum study participants shared their experience that they couldn't put trust during the period of taking online telemedicine services because they were afraid of becoming a sufferer from another vulnerable health

Sub-theme 2.2: Lack of access to get emergency diagnostic services
The majority of the participants portrayed their perception and real-life experiences that they were faced several problems during the time of taking diagnostic services by using telemedicine. Some statements of the participants are given below:

Sub-theme 2.3: Face to face communication gap for sharing health-related problems
By using telemedicine, it was quite difficult for the patients for creating a suitable platform to share their health-related problems easily to the service providers because participants directly explained that a communication gap exists between physicians and patients such as linguistic barriers, face to face interaction gap, etc. while they receive services by telemedicine. Patient's statements are described below as an example: "An anemic patient expressed her opinion that she was not satisfied when she took telemedicine services for her treatment due to lack of face to face contact with the doctor and also told that through the telemedicine to build a close bridge of mind was quite difficult for her.

Sub-theme 2.4 : The networking problem is a major barrier to receiving the treatment services.
The majority of the participants explained that networking problems such as low frequency of network, load-shedding, and remote areas located at out of network coverage are facing problems for receiving treatment services via telemedicine.

Sub-theme 2.5 : Financial problems to pay doctor's fees during taking telemedicine services.
Two-thirds of the study participants shared their perceptions and experiences that they had to provide the doctor's fees, which crossed the limit of their earning capacity during unemployment situations due to COVID-19; as a consequence, they couldn't able to provide that fees and were unable to get healthcare services. Some of their statements towards the cost of telemedicine are given below:

Theme-03: Urgent recommendations to overcome barriers of telemedicine services in the context of Bangladesh
The majority of the participants explained their recommendations to eliminate barriers by ensuring network coverage from root level to tertiary level with the help of government and non-governmental organizations (NGOs), reducing the cost of telemedicine services, ensuring the authenticity of the doctor's presence, which helps in putting trust on them as well as the SIM operators should consider their cost when we will take telemedicine services over phone or hot line. Some other recommendations of the study participants are exemplified below: "We need to increase the number of doctors in telemedicine service and also need to include a feedback system from the patient so that the whole health care system will be developed gradually and help to decrease barriers of the telemedicine services.

DISCUSSION
In the present study, we found insight perceptions and barriers regarding telemedicine services in Bangladesh during COVID-19 pandemic. The study revealed young adult's perceptions regarding telemedicine services. The majority stated that telemedicine is a system through which we are able to get healthcare services by using the internet, mobile application or just a phone call for receiving primary treatment from an expert doctor panel for any kind of less severe illness without going to the hospital. A previous study in Bangladesh showed that the majority of the participants (70%) defined "Telemedicine Service" as electronic health-related services where patients receive medical treatment using technologies such as the internet, computer, or webcam 2 . Our study found that maximum participants shared their experience that they couldn't put trust in telemedicine service because they were afraid of becoming a sufferer from other vulnerable health conditions if the treatment creates negative or adverse effects on health. This finding is consistent with another study which showed that a lack of patient's trustworthiness was a significant barrier towards telemedicine services adaptation 19 . In our study, we found that the majority of participants explained their perceptions and real-life experiences that they were faced many problems during taking diagnostic services through the telemedicine service system which was unable to provide emergency diagnostic support during emergency situations in Bangladesh. Another study also found that telemedicine is not a viable option in providing diagnostic services; rather it just provides limited primary health care facilities to the patients 22 . In our study, it was seen to that the maximum participants mentioned the communication barriers they faced. As this service has occurred by technological facilities, people from different areas have their own language and absence one to one interactions; it's quite difficult to ensure the quality of treatment for virtual duty doctors. The patients also have not got much time to clarify their problems and also doctors sometimes face difficulties by the local accent of the patients. The previous studies also revealed that treatment via telemedicine does not provide face-to-face interaction and also linguistic barriers present regarding telemedicine services that make it difficult to build acceptable verbal communication between physicians and patients 13,14 . This study also pointed out that online communication has become a major obstacle. In Bangladesh people live in the countryside, where inadequate infrastructure including power supply, weak internet access, inadequate network connectivity interrupts patient-physician bridges in both urban and rural areas. The previous study also showed that shortfall access to affordable broadband at adequate connection speeds is another barrier for providing telemedicine services in rural areas 12 . Devastating pandemic COVID-19 has turned the entire nation stunned. It is also questionable to pay a high service charge for the unemployed to get telemedicine health care services. According to the findings of this study, two-thirds of the participants in the study reported their understanding and their perspective that they had to provide telemedicine service charges that exceeded the limit of the ability as they suffer unemployment issues due to COVID-19, so that they could not afford certain fees and also can't receive healthcare services which created barriers to them. Previous study in Bangladesh revealed that, according to one of the telemedicine users, "Telemedicine is expensive to get treatment services, and he gave a higher cost for a single consultation" 23 . We found such major barriers besides young adult's perceptions that should be coped with interactive healthcare systems in view of young adult's needs and requirements. The study had a couple of limitations. Due to the pandemic-related public health restrictions, we could not able to collect data via face to face interviews, rather we performed telephonic interviews which created a communication gap between the interviewees and interviewers.

CONCLUSION
Findings from this study disclosed that Bangladeshi young adults had several perceptions towards telemedicine services based on their different sociodemographic and cultural views which almost try to cover telemedicine aspect. At the same time they also addressed the telemedicine barriers regarding lack of trustworthiness, emergency diagnostic barriers, absence of intimation between doctor and patient, network and financial barriers in COVID-19 pandemic. The governmental and private organizations have to come forward to work collaboratively and make telemedicine health care services available, reliable, and affordable for all across the country, and only true effort can make it happen.

ETHICAL APPROVAL
The study was carried out in accordance with the Institutional Research Ethics and the Declaration of Helsinki or its comparable ethical standards. In addition, the study's protocol was approved by Sheikh Sayera Khatun Medical College, Gopalganj, Bangladesh. In an informed consent form displayed prior to the questionnaire, participants were well briefed about the procedure, purpose of the study and told that their information would remain confidential. Data were collected anonymously, and all participants provided informed consent.