Investigating consumer preferences and experiences of telehealth services in Australian allied health practice: a study protocol

Abstract

Introduction

Telehealth service provision and uptake has rapidly increased since the COVID-19 pandemic, allowing healthcare to be delivered safely and reducing non-essential face-to-face (F2F) contact. In Australia, the expansion of subsidisation of telehealth during COVID has led to its permanent installation within Australian primary care in 2022. However, little is known about consumer preferences and experiences with these services, particularly in relation to allied health practice (AHP). Previous studies on telehealth services have focused on general practice rather than allied health (AH) and broader primary care. Given that AH professionals make up a large proportion of the Australian healthcare workforce, the purpose of this study is to explore consumer preferences and experiences with telehealth AHP healthcare.

Methods and analysis

This study uses a mixed methods research design that incorporates three independent but interrelated phases. Phase 2 of the study will use a focus group methodology to discuss consumer attitudes and experiences via a semistructured interview format. Phase 3 involves a discrete choice experiment (DCE) involving a large online survey conducted across the general population. The DCE will be informed by the qualitative findings from phases 1 and 2. The experiment aims to elicit consumer preferences in relation to AH services delivered through telehealth or F2F consultations, based on several hypothetical scenarios and preferences over several different dimensions.

Ethics and dissemination

Ethics approval has been obtained from La Trobe University (approval number HEC23404). Findings will be disseminated as reports, presentations and peer-reviewed journal articles.

Correspondence to Madison Frith; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• Focus group discussions allow for relevant dimensions and levels to be selected for a discrete choice experiment (DCE).

• A DCE allows for a measurable insight into consumer preferences, which may be otherwise difficult to quantify.

• The use of a stated preference survey is subject to hypothetical bias, meaning the responses given may not necessarily wholly reflect the corresponding real-world decision.

• While a strict sampling frame will be imposed to ensure population representativeness, it may be that people willing to complete surveys online have different views about using telehealth than those unwilling to do such surveys.

Introduction

The COVID-19 pandemic has challenged healthcare systems to adapt and expand digitally, accelerating the spread of telehealth and other digital solutions across the globe. Access to telehealth services is becoming increasingly crucial to ensure timely and effective healthcare, particularly to maintain continuity care with the growing threat of health systems reaching capacity.¹ The pandemic indeed allowed telehealth to prove its ability to deliver quality healthcare while also reducing costs to healthcare service providers.¹

Telehealth, or telemedicine, refers to a health consultation conducted via video or phone call and includes services related to diagnosis, treatment and prevention.² The global response to the pandemic saw telehealth bolster with the global telemedicine market shift from a value of US$38 046 million in 2018 to an expected US$103 897 million by 2024. Telehealth services played a critical role not only in high-income countries, but also in low-income and middle-income countries by enhancing healthcare capabilities in these under-resourced areas.¹ Telehealth use within mainstream healthcare systems has been shown to improve access to timeliness and quality of care, ultimately reducing healthcare inequities.^{1 3} Telehealth is particularly useful for regional and rural consumers in Australia. Given the population dispersion in Australia, many individuals living in regional and rural communities have to travel lengthy distances to receive healthcare, telehealth provides an accessible and timely alternative for these consumers. However, there are challenges associated with telehealth use which includes a lack of digital literacy for both practitioners and consumers,⁴ particularly those of an older generation or individuals with a cognitive or hearing/visual impairment.⁵ Furthermore, there are concerns regarding equity of access with socioeconomic factors playing a role in access to telehealth services. With the increasing cost of living, cost of internet access and communication technology required to access telehealth services, it may be unattainable for some.⁴

In the Australian primary care setting, telehealth was introduced in 2012 as a provision for specialist healthcare services and some nursing services. This was only expanded to general practitioners (GPs) in November 2019.⁶ Prior to the pandemic, uptake of telehealth was low; however, the expansion of subsidisation of telehealth by the federal government in 2020 has seen an unprecedented increase in the use of telehealth services in and across primary care. The expansion of telehealth subsidisation ensures primary healthcare delivered through video or phone calls remains affordable to Australians. However, the challenges of telehealth use observed globally are also reflected in Australia with uptake of telehealth video consultations lower in areas with a lower socioeconomic status and areas with a higher proportion of people aged 65 years and above.³

Allied health (AH) professions comprise a large proportion (38.7%) of the Australian health workforce.⁷ While GP telehealth services predominantly focus on primary care and diagnosis, allied healthcare delivered through telehealth extends this reach to encompass a broader range of specialised healthcare disciplines, such as physiotherapy, occupational therapy and mental health counselling. AH practitioners deliver crucial healthcare services to individuals of various age groups, encompassing children, seniors, individuals with chronic conditions or mental health challenges, and those with a disability. AH professionals collaborate with individuals to assess and identify issues, offering treatment and assistance in skill development, recovery and regaining independence. Frequently, their interventions can minimise or eliminate the necessity for medical treatments. The AH field is highly diverse, with notable differences existing both between and within professions.^{8 9} The use of remote technology to deliver healthcare services has enabled healthcare providers to reach more patients, as well as improved access to healthcare services for patients. Despite the potential benefits of telehealth and the increased uptake in primary care, little is known about consumer preferences and experiences with these services, especially in relation to allied health practice (AHP) with previous studies tending to focus on general practice and specialist services rather than AH care. This lack of information is crucial for shaping policies, sustainable funding incentives and robust frameworks aimed at guaranteeing the quality and safety of digitally delivered healthcare. The purpose of this study is to explore consumer preferences and experiences of telehealth usage within AHP in Australia. This study protocol will outline the methods, which includes data collection strategies and analysis techniques that will be used to investigate consumer preferences and experiences with telehealth AHP services.

Research aims

The research aims were to:

• Identify consumer experiences and preferences towards the delivery of AHP healthcare via telehealth.

• Examine the factors influencing the uptake, reach and quality of AHP telehealth services.

Research objectives

The research objectives were to:

• Explore consumer experience and preferences for different types of AHP telehealth delivery modes (ie, video vs telephone) and their views on telehealth versus face-to-face (F2F) consults.

• Explore the appropriateness of different modes of delivery for different health conditions/or services provided.

• Evaluate the barriers and enablers to AHP telehealth.

• Elicit the preference (value) health consumers place on using this as a channel of communication, including their willingness to pay for telehealth.

• Determine the expected outcomes of AH telehealth services from the perspective of consumers.

• Contribute to the broader body of knowledge around the future of healthcare delivery in Australia, centred on the consumer experience.

• Determine differences in consumer experiences and preferences between target population groups including; rural and remote, people with a disability, people with a chronic illness, culturally and linguistically diverse people, lower socioeconomic and lower health literacy to see if there are any differences in population preferences.

Study design

Overview of approach and methods

The process of making decisions related to healthcare as a consumer is multifaceted, with considerations encompassing both health-related benefits and other non-health-related factors, which adds complexity to individual preferences.¹⁰ To understand the factors that impact consumers’ preferences, experiences and attitudes towards telehealth, this study will incorporate a mixed methods research approach across three distinct and interconnected phases which are outlined below and in figure 1.

Figure 1. Study design.

Incorporating the voice of consumers and those with lived experience is important to the research objectives. As such, consumers and those with lived experience are included as members of the research team and as expert advisors to the research. Research team members include representatives from Australia’s Health Issues Centre (HIC) which is Victoria’s peak consumer agency. HIC will convene and facilitate a consumer reference group to provide input and advice throughout the duration of the study. The reference group will consist of four to six consumers, meeting approximately six times at key points of the study. The study will also have an advisory group that consists of AH professionals working alongside academics and policymakers.

Phase 1: literature reviews

This will involve a review of existing evidence around consumer preferences and experiences of care relevant to AH telehealth provision. The study will include two scoping reviews. One will review the evidence on the (dis-)advantages AH professionals and patients perceive in providing and receiving AH services through teleconsultations. The other will involve a review of published discrete choice experiment (DCE) telehealth studies, given the limited number of DCEs undertaken in the field of AH, this study will focus on DCEs conducted on all telehealth services. The results from these reviews will help shape the research approaches used in this study.

Phase 2: focus groups

This qualitative study will involve discussing consumer attitudes and experiences via a semistructured interview format. The aim of this approach is to enable informal and relaxed dialogue, so health consumers, carers and community members can have their say in a safe and supportive environment. HIC will lead the recruitment process and focus group discussions. Data gathered from the focus groups will be analysed using thematic analysis to identify key themes that will define the dimensions explored in the DCE included in phase 3 and will be used to support the interpretation of findings from across all phases.

Phase 3: DCE

The findings from phases 1 and 2 will be used to inform a DCE that provides a set of choice questions to consumers and explores their preferences over several different dimensions. After initially being used commonly in marketing, the use of DCEs as a method has significantly expanded into academic research, particularly in areas of health economics, in recent years.¹¹ A DCE methodology offers advantages over other methods, such as ranking or rating, by requiring respondents to make trade-offs between alternatives and different options within choice sets. This approach allows researchers to delve deeper into understanding the relative importance of each characteristic, also known as attributes. For example, if the focus group found that cost and distance of travel are important when deciding between telehealth and F2F consultations, the DCE provides a way to quantitatively determine the relative importance of each of these two attributes. This information in turn helps to uncover consumer preferences when making decisions related to their healthcare.

In this study, the objective of this DCE is to gather information on consumer preferences in relation to F2F or telehealth consults by presenting a range of hypothetical, but reasonable, scenarios. Participants will then be asked to consider the alternatives in each choice set and to select their preferred response.

Methods

Phase 1: literature review

Qualitative process prior to DCE

Qualitative research is a crucial step in designing a DCE. By systematically searching and synthesising relevant studies, the scoping reviews will identify gaps, trends and areas of interest within the literature. They will provide a foundational understanding of the research landscape and inform subsequent research steps. Conducting a literature review in phase 1 will also assist researchers in finding a broad range of attributes and levels to be considered in designing the DCE.¹² For this study, the literature review will consist of both one scoping review and one systematic review. The first review will look at the (dis-)advantages of AH services through telehealth as experienced by AH professionals and patients. A scoping review methodology will be applied to assess the current status of the literature in the field and to identify themes that influence the successful uptake of AH services through telehealth. The scoping review will be conducted in accordance with the JBI methodology for scoping reviews and will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews statement.¹³ The search will be conducted using the following databases: MEDLINE Complete, EMBASE, CINAHL, PsycINFO and AMED Allied and Complementary Medicine. The search string will be developed in cooperation with a senior librarian and will integrate synonyms for both allied healthcare and teleconsultations along with descriptors of their (dis-)advantages. Relevant Medical Subject Headings (MeSH) terms will be identified and incorporated for all search terms.

The second review will look at existing evidence of DCEs used to evaluate telehealth more broadly with the primary research question being ‘What have DCEs determined about the preferences of telehealth service delivery?’ The following databases will be used to conduct the search: MEDLINE Complete, EMBASE, CINAHL, Psych Info, AMED Allied and Complementary Medicine. The ESTIMATE checklist (Estimates, Stochastic, Tradeoffs, Interpretation, Method, Assumptions, Transparent, Evaluation) will be employed to assess the study’s quality regarding the selection of analysis methods, description of the analysis and interpretation of the results. These reviews will contribute towards the development of topic guides that will be used in focus groups.

Phase 2: focus group discussion

Focus group method

Once themes are identified through the scoping reviews, focus groups will be used to delve deeper into these themes and gather insights from stakeholders or potential users. Focus groups will facilitate open discussion and idea generation, allowing participants to share their perspectives, preferences and suggestions related to the identified themes.

The research team will invite up to 64 community members to take part in approximately eight focus groups that will be organised and facilitated by HIC. Five of the focus groups will take place online, with three focus groups in person. Consumers will be renumerated for their time. Consumers must be 18 years of age or older and living in Australia to participate. Participants do not need to have telehealth experience.

We will aim to recruit eight people per focus group. The size is chosen to give each participant enough time to state their opinions. As thematic saturation is not feasible given the uniqueness of each consumer and the broad field of AH care, thematic sufficiency is expected. The focus group participants will be selected via purposive sampling through a widely disseminated expression of interest process coordinated by the research team. Participants will be recruited through Consumer Networks.

Prior to the focus group, participants will be provided with an information sheet that outlines the details of the study. The information sheet will include a clear explanation about the purpose of the study, the researchers involved, how the research findings will be used and who will have access to their deidentified information gathered from the participants. It will be conveyed that participation in the focus group, and therefore the study, is entirely voluntary and participants may withdraw from the study at any point if they wish to do so.

The HIC project team member facilitating the focus group will ensure informed consent is obtained from participants prior to commencing the session. For all F2F focus groups, participants will be required to sign consent forms before the discussions begin. For online discussions, participants will be sent consent forms via email or post to review before the focus group sessions begin and will provide verbal consent at the start of the session. Additionally, the team member will be instructed to seek separate consent from participants to record the discussion.

Data collection

Researchers will be equipped with a detailed, step-by-step guide that outlines how to run their focus group sessions. They will also receive a semistructured interview template that includes a set of 10 questions, along with additional prompts. In the focus group session, each participant will be given the opportunity to respond to each question, using their own words. Additionally, participants will be encouraged to share any additional comments at the conclusion of each session or via email afterwards. The hosts will record all answers provided by participants onto a feedback report template. Sessions will be recorded and then transcribed.

The set of questions provided to the focus group participants will be informed by the literature reviews, previous research conducted by the researchers, an advisory group (which includes stakeholders and subject–matter experts) and a consumer reference group facilitated by HIC. This will ensure that the focus group questions are drawn from existing research, lived experience, previous work and input from an advisory group to ensure that the questions are well informed and address the research objectives.

The researcher facilitating the focus group will also collect a participant registration sheet and a demographic data sheet. These documents will be completed by the participants and compiled by the researcher.

The demographic data collected will include information such as participant gender, age group, whether they live with a chronic health condition, and whether they have previously used telehealth services. To ensure confidentiality and privacy, all session data will be transferred to the researchers electronically in a deidentified format.

Data analysis

After data collection, the research team will conduct a thematic analysis and apply the phases outlined by Braun and Clarke¹⁴:

• Familiarisation with the data.

• Generation of initial codes.

• Searching for themes.

• Reviewing themes.

• Defining and naming themes.

• Producing the report.

The data gathered from the feedback report template will be analysed sequentially.

An independent researcher will analyse the transcriptions and reports for each of the questions. The analysis will consist of an open-coding method to generate initial codes. This involves thoroughly examining the data without preconceived categories or themes in mind. As the independent researcher goes through the transcripts, they will identify and generate initial codes. These codes will essentially be labels or tags that capture specific concepts, ideas or themes found in the data. These codes will then be applied, reviewed and categorised into subthemes, each then defined and labelled with a collective theme that describes the core concept for each question. This process involves systematically tagging or marking segments of text that correspond to each code. It will help in organising the data for further analysis.

Once the research team has identified the core concepts and themes from the qualitative analysis, these will be used as potential attributes for the DCE. Attributes are the characteristics or features of the alternatives that participants will choose from in a DCE. Based on the attributes and attribute levels, we will design choice scenarios for the DCE. Each scenario will present participants with alternative choices that vary in terms of the identified attributes and levels. Participants will make choices in these scenarios, and their preferences will be used to estimate utility or preference values for each attribute level.

Phase 3: DCE

DCE development process

A DCE is a quantitative research method used to understand individuals’ preferences and decision-making processes. This will be employed to investigate factors influencing consumers’ choices regarding AH telehealth services. By presenting participants with hypothetical scenarios and varying attributes of telehealth services, researchers can analyse how different factors (eg, cost, convenience, quality) influence individuals’ preferences and decision-making.

Designing a DCE requires researchers to determine study objectives. This includes determining the features (or attributes), that are believed to define the topic, that being, AH and telehealth.

Development of attributes and levels for DCE

Phase 3 begins the development of a DCE. Phases 1 and 2 will assist in defining attributes and levels for the DCE that will ultimately answer the research questions. The DCE approach will then combine these attributes and levels to present participants with a series of hypothetical scenarios (called choice tasks or choice sets). In each scenario, or choice set, participants will be instructed to envisage that they are seeking healthcare from an allied healthcare professional for a particular reason.

Experimental design and construction of choice sets

The selection of alternatives to be grouped together in choice sets is a key component of DCEs. Here, we will use Ngene, a widely used software designed specifically for this purpose. In designing the experiment, we will ensure that we balance the statistical efficiency of the questions we ask with the cognitive difficulty for respondents. For example, depending on the difficulty of choice sets, we can impose conditions that make the task easier, such as ensuring that only a subset of attributes differ between options within each choice set. As a minimum, we will ensure that our design will be able to capture the main effects of each level of each attribute and maximise the precision of these main effect point estimates (using a commonly used criterion called D-efficiency).

Questionnaire design and DCE validity

The questionnaire will begin with an introduction, outlining the purpose of the study along with instructions about how to complete the questionnaire. Each attribute and level will be explained in detail to assist participants in understanding what is required of them. Sociodemographic characteristics will also be collected to help understand how these factors may influence participants’ choices.

The questionnaire will be piloted with participants from the focus group to test and enhance validity. Feedback will be collected from the pilot testing and the questionnaire will be amended accordingly.

Participant sampling and recruitment

The implementation of DCE’s in healthcare is a field that is still in development. It has been estimated that a sample size of 100–300 participants may be appropriate in a healthcare context¹⁵; however, this is dependent on the number of choice sets used in a DCE. It has been further estimated that 20–30 respondents per choice set is sufficient,^{16 17} with 1 study stating that it is rare to require more than 20 respondents to estimate a reliable model.¹⁸

To ensure that our sample is representative of the general population, we will impose a sampling frame based on age and gender. Thus, we will use Australian Bureau of Statistics data to estimate the proportion of the adult population in each gender and 10-year age band and then set a limit on the number of people from each group that will match those proportions. Other than fitting within these groups, respondents need to be willing and able to complete the survey online in English.

DCE administration

The survey will be administered through an online platform using Survey Engine, an international organisation with specialised expertise in conducting and hosting DCEs.¹⁹ Survey Engines have long-established links with a range of panels that can provide population-representative samples to complete surveys. Each member of the panel is emailed a link to the survey, which is optional to complete, and we recruit until our quotas (described above) are complete. The questionnaire will be structured in a sequential order consisting of the following; welcome message, details of how the questionnaire is structured, consent, example question item, the DCE questions, demographics (country of birth, education, postcode, primary language, general health question, chronic condition status), question on questionnaire experience and final thank you message to close.

To test data quality, we will build in three checks. First, we will ask a dominant choice task, where one option is logically superior to the other. Second, we will repeat the first choice set each person sees at the end of the DCE section, with the assumption that agreement between the two tasks is a signal of better data quality. Third, we will collect time stamp data; individuals completing the survey in less than 5 min may be considered to have finished too quickly (ie, speeders). While our primary analysis will not exclude anyone, we will conduct robustness checks, identifying the impact of excluding people failing any, or all, of these data quality checks.

DCE data analysis

DCE analysis involves using statistical models to estimate the preferences and trade-offs that participants make when selecting among different alternatives. This includes estimating the utility (satisfaction or preference) associated with each attribute level.

Analysis of DCE data can be done in several ways. As the thing we are trying to predict is the choice itself, that is the dependent variable in our regression analysis. This choice variable is either a 1 (when the option in the choice task is picked) or a 0 (when it is not). Therefore, we focus our analysis on adaptations of logistic regression, which is used to predict these binary outcomes.

In DCE data, the most common analysis approach is the conditional logit (or condition logistic regression).²⁰ This is the standard basic approach for analysing DCE data and is similar to logistic regression. The difference is that all individuals are subjected to different situations before expressing their choice. The fact that the same individuals are used is considered by the model. Conditional logistic regression characterises the mean preferences of the entire sample (ie, it shows what matters to the average person when making a choice in the DCE). The conditional logit, and all subsequent analyses, will be conducted in the statistical software STATA (V.16).

The data collected from the DCE will be analysed in aggregate as well as through various methods aimed at categorising heterogeneity among the participants. These methods will include mixed logistic regression and latent class analysis. In the base case conditional logistic regression, the model estimates a model predicting average behaviour. However, policymakers may want to know about the spread of preferences. In the mixed logistic regression, each coefficient is a distribution rather than simply a single-point estimate.²¹ Thus, we observe both the average response, and an SD showing the degree to which different people felt differently about a particular attribute. The latent class analysis operates differently again, dividing the sample into groups with different response patterns.²²

Integration of results

Our mixed-method study has been designed to integrate results from each stage to gain a more comprehensive understanding of the research question. This approach allows for both breadth and depth in understanding, combining the strengths of qualitative and quantitative methods to generate robust findings and insights.²³ The results obtained from these studies will be tested using a deliberative forum methodology. A deliberative forum involves a structured and facilitated process to bring together a diverse group of participants to discuss complex issues. The purpose of the deliberative forum is to both inform of the research results to participants and clarify and validate the interpretations and conclusions drawn from the research findings. The forums allow the researcher to seek further clarification from stakeholders, drawing on this knowledge and expertise in deliberative processes will increase the prospects of translation.²⁴

30 participants will be recruited for the deliberative forum. The deliberative forum participants will include stakeholders from across policy, practice (AH and consumers) and research. With the research and authorship team having representation across education, research, policy, AH and consumers, participants will be recruited through network links held by the team. Prior to attending the forum, participants will be fully informed with the results of the qualitative and DCE studies. An organised session will be held to enable participants to share both promotive and prohibitive opinions in a safe, respectful and structured way, followed by a deliberation session to synthesise insights and recommendations. The forum will also include guided small group discussions to facilitate more in-depth discussion and resolve discrepancies. The outcomes of the deliberative forum will be used to inform policy development, particularly in the context of health systems and AH service delivery, as well as further research opportunities. The insights gained will make a valuable contribution to understanding the future of healthcare delivery in Australia, with a strong focus on enhancing consumer experience.

Ethics and dissemination

Ethics approval has been obtained from La Trobe University (approval number HEC23404). Findings will be disseminated as reports, presentations and peer-reviewed journal articles.

Patient and public involvement

HIC plays an important role in linking consumers with this project and acts as a gateway to valuable and rich consumer involvement. The consumer reference group will meet six times throughout the duration of the project to review the different phases of the study. Consumers of the reference group and consumers participating in the focus groups will be reimbursed for their time. Depending on the focus group cohorts, we will also explore cofacilitation with a community member. There will be a strong emphasis on trauma-informed facilitation, creating psychologically safe spaces for participation. This project will prioritise ‘close-the-loop communication’ with consumers in the reference group and focus group participants, providing updates and study findings as appropriate.

Ethics statements

Patient consent for publication

Not applicable.

Footnote

X @Madi_Frith

Contributors MF: Substantial contribution to the writing of the study protocol as well as drafting and reviewing. JB: Conceptualisation and design of the study, substantial contribution to the writing of study protocol, involved in drafting and reviewing. FS: Contribution to the writing of the study protocol as well as drafting and reviewing. DS: Contribution to the writing of the study protocol as well as drafting and reviewing. RN: Conceptualisation and design of the study, substantial contribution to the writing of study protocol, involved in drafting and reviewing particularly in regard to discrete choice experiment. JJ: Contribution to the writing of the protocol particularly in relation to focus groups and consumer reference group. SR: Conceptualisation and design of the study, substantial contribution to the writing of study protocol, involved in drafting and reviewing.

Funding This protocol was jointly funded by the Australian Government and Digital Health CRC (DHCRC). DHCRC is funded under the Commonwealth's Cooperative Research Centres (CRC) Program. Program Number DHCRC-0240.

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

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