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

Quazi Maksudur Rahman; Md Estiar Rahman; Rashenda Aziz; Mamun Ur Rashid Pranta; Abdullah Al Zubayer; Md. Bulbul Islam; Md. Rifat Al Mazid Bhuiyan; Kamrul Ahsan Khan; Ashraf Uddin Chowdhury; Liakat Hosain

doi:10.15419/ajhs.v6i2.477

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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, signiï¬cant 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.

Keywords: Telemedicine Perception Barriers Young-adults COVID-19 pandemic Bangladesh

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: high-cost, 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 ).

**Table 1** **Socio-demographic information of the study participants**














Urban	7	35.0

**Table 2** **Case specific information of the study participants**

Theme-01 : 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:

"Telemedicine is an online primary treatment service provided by the doctors that services are adopted by us while not attending to the hospital as well as staying at home over the assistance of a phone." [Case: 03; Age: 24 years]

Other participants expressed their perceptions in the following way:

"By using the telephone as well as purchasing megabytes (MB) for using telemedicine apps for receiving the doctor's advice when we suffer from any kind of illness or disease is called telemedicine." [Case: 01; Age: 38 years]

"When we make a bridge between doctors and patients over the phone for taking healthcare services is regarded as telemedicine." [Case: 02; Age: 22 years]

"Telemedicine is a system through which we are able to get healthcare services but not emergency services by using hotline number or apps through using Wi-Fi from several doctors from several disciplines by paying the doctor's treatment fees." [Case; 20; Age: 22 years]