Journal of Telemedicine and Telecare

LOST IN THE DIGITAL SPACE: PERSPECTIVES ABOUT

STRENGTHENING TELEMEDICINE ACCESS IN THREE
GEOGRAPHICALLY DIVERSE TERRAINS IN PHILIPPINES
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Journal: Journal of Telemedicine and Telecare

Manuscript ID JTT-23-06-004
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Manuscript Type: Research

Date Submitted by the

02-Jun-2023
Author:
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Complete List of Authors: Fabian, Noleen; University of the East Ramon Magsaysay Memorial
Medical Center Inc,
De Mesa, Regine; University of the Philippines Diliman
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Tan-Lim, Carol; University of the Philippines Diliman

Sandigan, Gillian; University of the Philippines Diliman
Lopez, Johanna ; University of the Philippines Diliman
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Loreche, Arianna; University of the Philippines Diliman

Dans, Leonila; University of the Philippines Diliman
Benzon, Zharie; University of the Philippines Diliman
Zabala, Herbert; University of the Philippines Diliman
Sanchez, Josephine ; University of the Philippines Diliman
Bernal-Sundiang, Nanette; University of the Philippines Diliman
Rey, Mia; University of the Philippines Diliman
Dans, Antonio; University of the Philippines Diliman

Keyword: Teleconsulting, Online health, Telehealth, Telemedicine

ScholarOne, 375 Greenbrier Drive, Charlottesville, VA, 22901

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3 LOST IN THE DIGITAL SPACE: PERSPECTIVES ABOUT STRENGTHENING TELEMEDICINE
4
ACCESS IN THREE GEOGRAPHICALLY DIVERSE TERRAINS IN PHILIPPINES
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7 AUTHORS: Noleen Fabian1,2, Regine De Mesa1, Carol Tan-Lim1, Gillian Sandigan1, Johanna Lopez1,
8 Arianna Loreche1, Leonila Dans1, Zharie Benzon1, Herbert Zabala1, Josephine Sanchez1, Nanette Bernal-
9 Sundiang1, Mia Rey1, Antonio Dans1
10
11
1 Philippine Primary Care Studies
12 2 University of the East Ramon Magsaysay Medical Center Inc.
13
14
15 ABSTRACT
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17 Introduction. The Philippine Primary Care Studies implemented telemedicine services in 3 partner sites to
18 improve healthcare accessibility. This study aimed to explore attitudes, subjective norms, and perceived
19 behavioral control of telemedicine users and non-users across urban, rural, and remote settings; and to
20
21 examine intent-to-use telemedicine during the COVID-19 pandemic.
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23 Methods. Twelve FGDs and KIIs were conducted to gather insights from 30 diverse telemedicine users
24 and 30 non-user patients in urban, rural, and remote settings. Data were analyzed in NVivo 12 using the
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Theory of Planned Behavior as the framework of this study.

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28 Results. Participants identified telemedicine as a suitable alternative during the COVID-19 pandemic.
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29 Perceived benefits of telemedicine include protection from COVID-19 exposure, decreased expenditures,
30 and more balanced work schedules. Despite this, participants expressed some hesitation for telemedicine.
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Users from the urban site relayed that the lack of desired providers disincentivized use. Users from the rural
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33 and remote sites were largely concerned about the long-term resources needed for telemedicine. Non-users
34 from all 3 sites reported feeling anxious regarding telemedicine usage due to unfamiliarity with
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35 technological platforms. Participants from all 3 sites mentioned that they will not continue telemedicine use
36 if they feel lost while navigating the platform.
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38
39 Discussion. Telemedicine is integral to increasing healthcare access among Filipinos. Sustainable access
40 beyond the pandemic requires an understanding of factors that prevent usage. Sufficient investment in
41 infrastructure and other related resources are needed if telemedicine is to be used to address inequities in
42 healthcare access especially in rural and remote areas.
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45 Keywords. Telemedicine, COVID-19 pandemic, community health, digital health
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50
Corresponding Author: Noleen Marie C. Fabian
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E-mail: nmcfabian@gmail.com
52
Address: Philippine Primary Care Studies
53 University Health Service,
54 Laurel Avenue, University of the Philippines,
55 Diliman, Quezon City 1101 Philippines
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4 1.0 INTRODUCTION
5 1.1 Background
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7 Telemedicine serves as an avenue for people to access health services remotely.1 Healthcare
8 providers conduct telemedicine services by using electronic audio-visual devices to provide clinical
9 services for a patient through voice calls, video conferencing, and/or text2. Through telemedicine, Filipino
10 patients residing in geographically challenging terrains can correspond with healthcare providers.2
11
Telemedicine has shown potential in reducing poor health outcomes and healthcare-related expenditures.
12
13 Results of a 2014 study done in the United States showed that patients with chronic illnesses had a 56.2%
14 decrease in unpredictable hospitalizations with usage of telemedicine services.3 Remote consultations
15 allowed healthcare providers to give prescriptions of necessary medicine and provide immediate
16 clarification for health-related queries, decreasing the needed frequency of in-person consultations.3 A 2015
17
study done in Canada reported that 85% of patients expressed intent of continuing telemedicine use due to
18
19 an average cost reduction of $200 for them and their caretakers. 4
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21 Sustainability of telemedicine access is affected by availability of resources. The passage of
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22 Executive Order 127 in the year 2021 expands provision of internet services in the Philippines through
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inclusive access to satellite services—an initiative projected to upscale access to digital care.5 However, the
25 distance of signal sites from communities may serve as a barrier to obtaining healthcare, with 57.4% of
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26 Filipinos remaining offline.6

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Other reported barriers to telemedicine services include limited spending power, and hesitancy to
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30 explore and use technology. Literature posits that technology-related anxiety deters patients and caretakers
31 from investing in telemedicine care.7,8 Some patients believe that they cannot fully focus on their recovery
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32 if they are having a hard time navigating remote care platforms.8

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The World Health Organization emphasizes the necessity for a well-supported primary care system
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36 to address the needs of vulnerable populations. 9 Primary care allows patients to coordinate with healthcare
37 professionals who support their rehabilitation, treatment, and recovery from illnesses. 10,11 The COVID-19
38 pandemic hastened the development of alternative means for utilization primary care services. The
39 Philippine Primary Care Studies (PPCS) is a network of pilot studies that aim to bolster multiple strategies
40
to strengthen the country’s primary care system. One strategy is the introduction telemedicine services to
41
42 sustain primary care service utilization during the pandemic and beyond. The PPCS team provided
43 expanded internet access for residents and consulting physicians in its 3 partner sites. Expanded access also
44 allowed participants to consult via messenger. Evaluation of the impact of telemedicine services is needed
45 to ensure sustainable implementation.
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47
48 1.2 Objectives
49
50 The present study aimed to determine facilitators and barriers to telemedicine usage by exploring
51 the insights of its primary beneficiaries. The specific objectives of this study are: 1) to explore attitudes,
52 subjective norms, and perceived behavioral control of telemedicine users and non-users in urban, rural, and
53
54 remote settings; and 2) to examine intent-to-use telemedicine during the COVID-19 pandemic.
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3 2.0 METHODOLOGY
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5 2.1 Study Design
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The is a qualitative study on factors that affect telemedicine usage. Data gathering was conducted
8 through focus group discussions (FGDs) to assess perceptions and attitudes towards telemedicine as a mode
9 of healthcare delivery among end-users. FGDs were conducted from February to March 2022. Patients from
10 healthcare facilities in the 3 PPCS pilot sites served as respondents of this study. A semi-structured
11 interview guide (Appendix A) was adapted from George et al. (2009)12 in assessing telemedicine
12
13 accessibility and usage across different settings. The FGDs were conducted in the language spoken by
14 participants (i.e., English, Filipino-Tagalog, or Bikolano). Qualitative data from the FGDs were then
15 transcribed and thematically analyzed. Written and verbal informed consent were obtained from all
16 respondents of the study.
17
18
19 2.2 Participants
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21 The study participants consisted of patients in the University of the Philippines Health Service
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22 (UPHS), Samal, and Bulusan who consulted from April 2020 until March 2022. These sites were the urban,
23 rural, and remote sites respectively. Respondents of diverse ages and place of residence were invited to
24 participate in the study. Purposive sampling was done.
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27 Four FGDs per site were conducted to determine telemedicine perceptions and attitudes among
28 users and non-users. Two FGDs included participants that resided near the health facilities (on-campus
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29 residents for the urban site, and people living in the lowland barangays for the rural and remote sites): one
30 FGD included participants who were users of telemedicine, while the other FGD included participants who
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32 were non-users.
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34 The other 2 FGDs in each site included participants living far from the health facilities (off-campus
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35 residents in the urban site, and residents living in highland barangays for the rural and remote sites). Similar
36
to the “near facility” groups, one FGD included participants who were users of telemedicine, while the
37
38 other FGD were for non-users.
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40 In all, 12 FGDs were conducted. Every FGD consisted of 5 participants – one each from the
41 following age groups: a) 18-30 years old, b) 31-40 years old, c) 41-50 years old, d) 51-60 years old, and e)
42
61-70 years old.
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45 2.3 Thematic Analysis
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47 Responses were transcribed on a Microsoft document and then analyzed in the original language
48 spoken using NVivo 12. Thematic analysis was done by 1 author. Initial reading of the transcripts was done
49 to identify themes of relevance to the study. The themes were classified under one of 3 domains, namely
50
51
attitudes, subjective norms, and perceived behavioral control. Key themes and findings were translated
52 from Filipino to English by a fully bilingual research team. We conducted initial analysis through coding
53 of similar responses into themes. Post-thematic analysis centered on assessing the consistency of results
54 with previous research findings.
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3 Data analysis was done using the Theory of Planned Behavior as the study framework. The Theory
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of Planned Behavior suggests that attitudes, subjective norms, and perceived behavioral control impact the
5
6 intention of a person to utilize health services (Figure 1).13 Attitude refers to a respondent’s tendency to
7 make decisions that will produce a positive impact. Subjective norms pertain to feedback from
8 organizations or peers that may influence a respondent’s view about telemedicine services. Perceived
9 behavioral control refers to the availability of human and material resources that facilitate ease of use. These
10
11
perceptions affect the decision to initially use and continue to use telemedicine services.
12
13 <figure 1 here>
14 Figure 1. Diagram of Theory of Planned Behavior Framework
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18 2.4 Ethical Considerations
19 Ethical approval was granted under the performance indicators of the Philippine Primary Care
20
21 Studies with study protocol code UPMREB 20-15-489-01. The participants’ privacy and confidentiality
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22 were maintained by deidentifying all data. All data were stored in a password-protected laptop and were
23 accessible only to the authors.
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27 3.0 RESULTS
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29 3.1 Key Demographics

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A total of 60 participants were included in this study, with 20 participants each from the urban,
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32 rural and remote sites. There were more females (83%, n=50) in our study population.
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34 <Table 1 here>
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3.2 Response of Telemedicine Users
37 The responses of telemedicine users are summarized in Table 2. Responses for the attitude domain
38
were positive among users in all 3 sites. Telemedicine was largely perceived to increase the respondents’
39
40 feeling of safety against COVID-19. Telemedicine was also regarded as an economical alternative to face-
41 to-face consultation. Participants explained that teleconsultations could be done for minor and chronic
42 illnesses, so they could save time, money and effort traveling to health facilities. Most of the participants
43 were working professionals. Thus, telemedicine was generally favored because it allowed them to consult
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from the comfort of their homes and/or offices. A respondent from the remote site shared that telemedicine
46 consultations allowed them to dedicate more time to the rice fields during harvest season. Participants
47 believed that the use of telemedicine services was most recommended for children, senior citizens, and
48 persons with disabilities. A few participants shared concerns that people could feign illnesses to obtain a
49 medical certificate in telemedicine, and that the specialization of the physician may not match the health
50
51 concern of the patients.
52 Exploration of the subjective norms domain among users revealed high awareness of the features
53 of the telemedicine services implemented by the Rural Health Unit (RHU) or UPHS. Promotional materials,
54 particularly online posters shared through the personal Facebook accounts of Community Health Workers
55
(CHWs), significantly improved their familiarity. House-to-house campaigns of CHWs, or even casual
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3 conversations with CHWs, provided participants a sense of support. They felt that they were guided by a
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trusted source while exploring telemedicine, especially since they had opportunities to ask questions and
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6 clarify what they may encounter during the teleconsultation. A participant from the rural site mentioned
7 that “telemedicine reminders from our family physician encouraged me to consult since it allowed me to
8 be accountable for my health”. Participants from the rural and remote sites shared that their neighbors’
9 feedback, which were generally positive, affected their willingness to use telemedicine services.
10
11
For those in the urban site, coursing telemedicine-related announcements through offices was an
12 effective strategy. Participants shared that promotion by the office made them feel that it was important to
13 access this service to make sure that they are fit to work. They were more likely to check announcements
14 since these were integrated into their occupational email address. Widely promoted telemedicine initiatives
15 by public and private entities also made participants curious if similar services were offered by UPHS.
16
17 Factors related to the perceived behavioral control domain were considered to have the greatest
18 influence in the likelihood of continued telemedicine use. Respondents from the urban site generally
19 perceived that they have good behavioral control. They had available devices and were familiar with
20 telemedicine services. They shared that technical glitches hinder full utilization of telemedicine services,
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and that they would appreciate more efficient and intuitive telemedicine platforms. They shared that the
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23 portal was not enough to accommodate the number of patients who wished to consult. One participant
24 mentioned that “it took long for my consultation request to get accommodated. I tried booking through the
25 portal, but the system kept on loading. I was passed on from one attendant to another before someone
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26 entertained my teleconsultation concern. I had to confirm with my doctor if the consultation request was
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approved”.
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29 Participants from the rural and remote sites were eager to continue using the service; however,
30 the lack of material resources decreases the likelihood of consistent use. They similarly would appreciate
31 more efficient and intuitive telemedicine platforms. Participants in all sites agreed that integrating
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32 telemedicine in Facebook increased their level of confidence in using telemedicine.

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34
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<Table 2 here>
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36
37 3.3 Response of Telemedicine Non-users
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39 The responses of non-users of telemedicine are summarized in Table 3. In the attitude domain,
40 non-users believed that telemedicine has positive effects, including protection from possible COVID-19
41 exposure, enabling more time for work, and improvement of healthcare access for senior citizens and
42
43 persons with disabilities. Telemedicine was generally perceived as an effective tool for regulating the
44 number of patients in urban and remote areas. However, their reservations about telemedicine were very
45 apparent. Non-users from the urban site emphasized that “convenience was a case-to-case basis”. They
46 relayed that the effectiveness of telemedicine was limited to people who were technologically competent
47
and comfortable with discussing their concerns online. Non-users felt that the online platform led to
48
49 difficulties in communicating with healthcare providers, since they cannot effectively express themselves
50 in this setting. Some participants in the urban site relayed that they did not need telemedicine since they
51 can consult doctors in their social media. A few participants in the remote site regarded telemedicine as
52 inappropriate for their specific health condition. One participant shared, “the doctor did everything in their
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capacity to make me feel attended to during the consultation. However, I didn’t feel like my consultation
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55 experience was complete. I think the physician can assess me better when we see each other in-person.
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3 They are also more able to make me feel at peace in-person. I can ask all the questions I have. Physical
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contact also makes me more certain that an actual person is taking care of my health”.
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6 In the subjective norms domain, non-users in the urban and remote site relayed that they were
7 aware about telemedicine through the efforts of government officials or workplace personnel for the urban
8 setting, and efforts of CHWs for the remote setting. Non-users in the rural site reported limited exposure to
9 information on telemedicine services. Hesitancy of the participants in the remote and rural sites to use
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telemedicine were related to their lack of familiarity with telemedicine and inadequate resources. Despite
12 this, they shared eagerness to continue learning about telemedicine services from their neighbors and
13 healthcare workers so that they may access it in the future. Non-users in the urban site showed less
14 enthusiasm. Negative feedback from peers who tried telemedicine made them hesitant to try the platform.
15 In the perceived behavioral control domain, non-users in the rural site felt that internet was too
16
17 costly. They preferred going to nearby health centers which they feel will require less out-of-pocket
18 expenses. One participant mentioned that “I was very eager to use telemedicine, but the cellular data signal
19 is too weak in our area. I’m hesitant to invest a lot of money for load and an advanced smartphone since I
20 must prioritize spending on my medications.” Non-users in the remote site were anxious about the
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decreased availability of healthcare providers and natural calamities. They relayed concerns that healthcare
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23 providers might be unable to attend to their needs if too many patients consult through telemedicine at a
24 given point in time. Participants also shared that investing in telemedicine-related resources is risky since
25 natural calamities can cause power outage and decreased internet connectivity. Non-users in the urban site
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26 preferred face-to-face consultation since they feel that this avenue has more health provider options. They
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also shared concerns that the physician may not be able to fully examine patients in online consultations.
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30 <Table 3 here>
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4.0 DISCUSSION
33
34 4.1 Attitude
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36 Our findings show that participants had varying attitudes towards telemedicine services. The
37 Theory of Planned Behavior defines attitude as the tendency to make a decision that is likely to produce a
38 positive feeling. 13 Users of telemedicine in the 3 sites relayed several benefits to telemedicine services,
39
40
including protection from COVID-19 exposure, decreased expenditures, and more balanced work
41 schedules. While feedback was mostly positive, users from the urban site shared that the lack of specialist
42 care demotivates use. Positive feelings about telemedicine services were associated with a provider’s
43 capacity to answer a patient’s queries about their health concerns. Since urban users desired specialists to
44
address these concerns, the lack of certain practitioners was concerning for them.
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46
47 Non-users relayed feelings of anxiety when contemplating or attempting to use telemedicine
48 services. Non-users in the urban site believed that convenience of telemedicine varied on a case-to-case
49 basis. They recognized that internet and gadgets were not difficult to obtain; however, telemedicine was
50
considered inconvenient since they cannot fully express themselves in that setting. Participants felt that
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52 their ability to see a provider’s movements and expressions strongly encouraged them to be open. Similar
53 sentiments were expressed by non-users in the rural and remote sites. This sentiment is similar to a 2010
54 article which reported that seeing physicians in-person and in established healthcare settings provide
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3 patients comfort and ease.14 The full immersion of a patient’s senses into a healthcare setting may make
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them feel more cared for and attended.
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6
7 In sum, participants from all sites generally felt that telemedicine is a temporary alternative while
8 in-person consultations is too risky due to COVID-19. They saw the potential of telemedicine services as a
9 convenient alternative that can accommodate people with busy schedules and those living in localities far
10
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from the healthcare center. However, these perceived benefits were outweighed by hesitancy. Many felt
12 that the therapeutic touch was diminished in an online set-up.
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15 4.2 Subjective Norms
16 Subjective norms refer to perceived social beliefs or expectations that may influence a
17
18 participant’s decision to use telemedicine services.13 Access to information is as important as the actual
19 content in influencing decision-making. Participants in all 3 sites agreed that receiving information on
20 telemedicine from representatives of their health facility was encouraging, since this showed that healthcare
21 workers were confident in the platform’s capacity to support remote consultations.
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Effective dissemination of telemedicine announcements depends on the locality’s set-up.15 For both
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24 users and non-users in the urban site, coursing telemedicine-related announcements through offices was
25 considered effective. Accessibility of internet also played a role in increased awareness. Despite its
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26 availability from outside entities, participants believed that availing of services from familiar providers
27 lessened their discomfort during telemedicine consultations. Facebook was an avenue used to promote
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telemedicine services in rural and remote areas. Participants from the rural and remote sites acknowledged
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30 that they were more likely to engage in the content if it was promoted through the personal Facebook
31 accounts of CHWs. This can be attributed to the pre-existing level of trust that patients have for CHWs.16
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32 In offline spaces, these CHWs were crucial in encouraging people to try telemedicine services. Aside from
33 healthcare workers, relatives, friends, and work colleagues also influence a patient’s decision to access
34
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35 telemedicine care. Positive feedback is more likely to incentivize use.17 Participants are more optimistic
36 that they can experience good outcomes with telemedicine when someone they know has experienced it.
37 The introduction of new healthcare services is optimized when local populations are encouraged to try a
38 service for themselves.18
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41 Some non-users in the rural and remote sites expressed that the FGD was the first time they heard
42 about the telemedicine service. Despite their regular contact with CHWs, it was their first time knowing
43 that it was possible to consult via text, call, or messenger. This shows that an information gap exists in these
44 sites.
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46 4.3 Perceived Behavioral Control
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48 Perceived behavior control corresponds to the availability of human and material resources that
49 help them achieve a desired outcome.13 This also includes the ability of the participant to use available
50 resources at hand.13 The presence of a user-friendly platform for telemedicine was significant in increasing
51 usage among participants. User-friendliness was predominantly associated with the integration of
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telemedicine in Facebook - a mainstream social media platform in the Philippines.19 Since Facebook was a
54 platform participants use for other socialization activities, the interface was not challenging to deal with.
55 They can also independently consult with providers without having to rely on caretakers.
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3 Participants in the urban site expressed the highest level of behavioral control. Both users and non-
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users believed that they had enough resources to access the platform. Despite this, most users and non-users
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6 shared the sentiment that telemedicine provided by UPHS is largely incompatible with their needs.
7 Participants explained that the telemedicine service provided does not have sufficient infrastructure to
8 genuinely help patients. It is important to have a system that anticipates a population’s needs, complemented
9 by a workforce with compatible skillset. If these are not provided, patients would decline to use the provided
10
11
service despite their need for it. 20 Available telemedicine primary care services remain underutilized in the
12 Philippines, most likely due to these deficiencies.
13
14 Users and non-users from rural and remote areas expressed that decreased access to material
15 resources significantly hampered telemedicine use. Telemedicine access requires adequate economic
16
17 capital.21 A patient is more likely to access the service when they have the income to purchase a compatible
18 smartphone, electricity, and/or internet load. Participants shared that they repeatedly declined to purchase
19 the resources needed for telemedicine to prioritize purchase of prescription medicines. Thus, limited income
20 among participants served as a significant barrier to telemedicine.
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23 In the remote site, participants expressed that insufficient staffing in the local health unit to support
24 telemedicine and services and the frequency of natural calamities decreased their perceived level of control.
25 The absence of healthcare workers was most prominent in the remote site, as healthcare workers are more
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26 likely to be present in urban areas due to increased pay and better opportunities for family members.22 Users
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in the remote site constantly thought about reverting to face-to-face consultations since they were more
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29 certain that a healthcare provider would be available to assist them. Participants also felt that investing in
30 telemedicine-related resources can be potentially counterproductive since the remote site is badly hit during
31 natural calamities. Given these circumstances, telemedicine-related resources are more likely to remain
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32 underutilized the remote site.

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35 5.0 POLICY RECOMMENDATIONS

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37 5.1 Augmenting Community Engagement
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39 Participants expressed that their lack of familiarity with technological devices and telemedicine
40 platforms hinders them from using telemedicine services. They feel that their lack of knowledge would
41 significantly decrease their quality of participation during an online consultation. To bridge this gap, we
42 recommend stronger engagement down to the community level, especially in rural and remote areas. This
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44 may come in the form of house-to-house or town hall orientations, where residents can learn the skills
45 necessary to navigate the available telemedicine platforms. Being able to directly communicate with a
46 professional who is knowledgeable about these platforms can allow residents to clarify situational questions
47 related to the application’s usage.23 Alongside training, conducting a trial run of services is strongly
48
encouraged. This allows residents to get accustomed to using the telemedicine platform as part of their
49
50 healthcare routine before its wide-scale implementation.
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5.2 Building Healthcare Worker Capacities
54 CHWs are integral facets of the healthcare system. They serve as the conduit between the formal
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healthcare sector and the community.16 They increase the morale toward telemedicine services in the
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3 community and connect residents with telemedicine providers. Impressions formed by CHWs for or against
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telemedicine providers may spread throughout the community. Helping healthcare providers understand
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6 how to manage online platforms produces a more welcoming environment and increases the likelihood that
7 providers will strongly recommend the platform to their peers.
8
9
10 5.3 Providing Infrastructure Support
11
12
There needs to be greater coordination between the healthcare sector and local government units to
13 ensure the provision of adequate infrastructure for communication technology. This can be done in
14 cooperation with local telecommunication companies. This is especially necessary for rural and remote
15 settings where there is generally less established infrastructure.6 Infrastructure support can be facilitated by
16 identification of areas with strong reception. These will serve as potential areas for setting up satellite
17
18 telemedicine sites that residents within a certain locale can access if they wish to avail of telemedicine
19 services. Proper dissemination of information regarding the creation of these sites is necessary to increase
20 awareness of such satellite sites and maximize usage.
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23 6.0 CONCLUSION
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25 In the advent of the COVID-19 pandemic, telemedicine re-surfaces as a potential avenue through
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26 which healthcare can remain accessible. Participants generally expressed that telemedicine services
27 increased their options for health and wellness consultations during the pandemic. However, participants
28 also perceived telemedicine as only a temporary alternative to face-to-face consultations. It was not seen as
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a long-term staple for healthcare services, primarily due to technological hesitancy and inadequacy of
30
31 resources. This suggests that there is work to be done to upscale the usage and acceptance of telemedicine
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32 services beyond the pandemic.

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34 Analysis of sentiments revealed that the decision to use telemedicine services is largely contextual
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36 and socially informed. People make decisions depending on their most recent beliefs about telemedicine,
37 the feedback they receive from people around them, and the perceived availability of resources. Positive
38 feedback from trusted individuals and availability of public infrastructure are likely to positively impact a
39 person’s belief about the service. This suggests that policymakers must carefully assess all domains when
40
crafting interventions. The need to create a telemedicine platform that is easy for caretakers and patients to
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42 navigate was a distinctive idea expressed by most participants. Nevertheless, the long-term improvement
43 for each site is dependent upon addressing systemic concerns specific to each locality. Telemedicine
44 services serve as an alternative consultation platform during the pandemic, but with sufficient investment,
45 it reveals promise for addressing inequitable health access for hard-to-reach populations.
46
47
48 7.0 CONFLICT OF INTEREST
49 The Authors declare that there is no conflict of interest.
50
51 8.0 FUNDING
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3 9.0 REFERENCES
4
5 1. Ryu S. History of telemedicine: Evolution, context, and transformation. Health Inform Res 2010;16:65.
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7 2. Noceda AVG, Acierto LMM, Bertiz MCC, et al. Patient satisfaction with telemedicine in the Philippines
8 during the COVID-19 pandemic. Public and Global Health 2022.
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10 3. Bashshur RL, Shannon GW, Smith BR, et al. The empirical foundations of telemedicine interventions
11 for chronic disease management. Telemed E-Health 2014;20:769-800.
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13 4. Qiang JK, Marras C. Telemedicine in Parkinson’s disease: A patient perspective at a tertiary care centre.
14 Parkinsonism Relat Disord 2015;21:525-528.
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16 5. President of the Philippines. Executive order no. 127,
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https://www.officialgazette.gov.ph/downloads/2021/03mar/20210310-EO-127-RRD.pdf (2021,
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accessed 28 December 2022).
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6. Albert JRG, Quimba FMA, Tabuga AD, et al. Expanded data analysis and policy research for national
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22 ict household survey. Report, Philippine Institute of Development Studies, Philippines, August 2019.
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24 7. Lau LL, Hung N, Go DJ, et al. Knowledge, attitudes and practices of COVID-19 among income-poor
25 households in the Philippines: A cross-sectional study. J Glob Health 2020;10:011007.
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27 8. Kohnke A, Cole ML and Bush R. Incorporating UTAUT predictors for understanding home care
28 patients’ and clinician’s acceptance of healthcare telemedicine equipment. J Technol Manag Innov
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29 2014;9:29-41.
30
31 9. Sabatello M, Burke TB, McDonald KE, et al. Disability, ethics, and health care in the COVID-19
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32 pandemic. Am J Public Health 2020;110:1523-1527.

33
34 10.Gray R and Sanders C. A reflection on the impact of COVID-19 on primary care in the United Kingdom.
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35 J Interprof Care 2020;34:672-678.

36
37 11.Kearon J and Risdon C. The role of primary care in a pandemic: Reflections during the COVID-19
38 pandemic in Canada. J Prim Care Community Health 2020;11:215013272096287.
39
40 12.George SM, Hamilton A and Baker R. Pre-experience perceptions about telemedicine among African
41 Americans and Latinos in South Central Los Angeles. Telemed E-Health 2009;15:525-530.
42
43 13.Godin G and Kok G. The theory of planned behavior: A review of its applications to health-related
44 behaviors. Am J Health Promot 1996;11:87-98.
45
46
14.Sun R, Blayney DW and Hernandez-Boussard T. Health management via telemedicine: Learning from
47
the COVID-19 experience. J Am Med Inform Assoc 2021;28:2536-2540.
48
49
50
15.Rice T. ‘The hallmark of a doctor’: The stethoscope and the making of medical identity. J Mater Cult
51 2010;15:287-301.
52
53 16.Campbell C and Gillies P. Conceptualizing social capital for health promotion in small local
54 communities: A micro-qualitative study. J Community Appl Soc Psychol 2001;11:329-346.
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3 17.Mallari E, Lasco G, Sayman DJ, et al. Connecting communities to primary care: a qualitative study on
4 the roles, motivations and lived experiences of community health workers in the Philippines. BMC
5 Health Serv Res 2020;20:860.
6
7
18.Jagosh J, Bush PL, Salsberg J, et al. A realist evaluation of community-based participatory research:
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Partnership synergy, trust building and related ripple effects. BMC Public Health 2015;15:725.
9
10
11
19.Wlodarczyk JR, Wolfswinkel EM, Poh MM, et al. Defining best practices for videoconferencing in the
12 era of telemedicine and COVID-19. J Craniofac Surg 2020;31:e658-e660.
13
14 20.John RBA and Lucila OB. Personality traits as predictors of Facebook use. Int J Psychol Couns
15 2016;8:45-52.
16
17 21.Subramanian DU, Hopp F, Lowery J, et al. Research in home-care telemedicine: challenges in patient
18 recruitment. Telemed J E Health 2004;10:155-61.
19
20 22.Nikolian VC, Williams AM, Jacobs BN, et al. Pilot study to evaluate the safety, feasibility, and financial
21 implications of a postoperative telemedicine program. Ann Surg 2018;268:700-707.
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22
23 23.Wilson N, Couper I, De Vries E, et al. A critical review of interventions to redress the inequitable
24 distribution of healthcare professionals to rural and remote areas. Rural Remote Health 2009; 9:1060.
25
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26 24.Heckemann B, Wolf A, Ali L, et al. Discovering untapped relationship potential with patients in
27 telehealth: A qualitative interview study. BMJ Open 2016;6(3):e009750.
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3 10.0 TABLES
4
5 Table 1. Demographic characteristics of 60 study participants
6 Urban site Rural Remote Total
n (%) n (%) n (%) n (%)
7 Sex
8 Female 14 (70) 19 (95) 17 (85) 50 (83)
9 Male 6 (30) 1 (5) 3 (15) 10 (17)
Residence
10 Near health facility 10 (50) 10 (50) 10 (50) 30 (50)
11 Far from health facility 10 (50) 10 (50) 10 (50) 30 (50)
12 Telemedicine use
User 10 (50) 10 (50) 10 (50) 30 (50)
13 Non-user 10 (50) 10 (50) 10 (50) 30 (50)
14
15
Table 2. Attitudes, subjective norms, and perceived behavioral control among telemedicine users
16
17 Attitude Subjective Norm Perceived Behavioral Control
18
19 Urban ● Telemedicine prevents possible ● Information is mostly ● Prefer intuitive platforms
20 exposure to COVID-19 provided by which may include the
21 ● Telemedicine allows for a announcements by the integration of
Un
balanced work schedule health facility and word of telemedicine services in
22 ● Telemedicine is particularly mouth commonly used social
23 useful for minor injuries, fit to ● Majority tried telemedicine media networks
24 work permit, chronic conditions because it was required by ● Doctors had very limited
25 ● Telemedicine allows consultation their office availability as listed on the
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26 with a doctor who is already ● Likely to consult online appointment setting

familiar with the patient’s sources and peers for more platform, invoking a
27 medical history information on doctor’s perception of
28 ● Concern about others feigning credibility inaccessibility despite
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29 illness just to get a medical infrastructure being

30 certificate since it makes the present
queue longer ● When technical
31
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● The perceived mismatch between difficulties arise, they feel

32 providers’ specialization and like they are not fully able
33 patient’s health concerns may to maximize the
34 disincentivize the use appointment because time
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35 becomes even more

limited
36
● Feel that they can access
37 telemedicine services
38 when they want to.
39 However, additional
40 support will be greatly
appreciated. This includes
41 a more efficient system of
42 streamlining
43 appointments.
44
45 Rural ● Telemedicine prevents possible ● Information is mostly ● Inadequate material
46 exposure to COVID-19 provided by the Rural resources (i.e., stable
47 ● Telemedicine allows for a Health Unit Facebook page electricity supply,
48 balanced work schedule and Barangay Health sufficient internet, or
49 ● Increased certainty that Workers mobile data connectivity)
consultations will push through ● Hear positive feedback to access telemedicine
50 ● Economical alternative from neighbors services
51 ● Regard telemedicine as most ● Telemedicine services
52 fitting for minor and chronic may be more accessible if
53 ailments it is installed in messenger
54 ● Recommend use for senior or landline services
citizens and children ● Prefer platforms that are
55 intuitive
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and affordable
4
5
6 Remote ● Telemedicine prevents possible ● Information is mostly ● Lack of material resources
exposure to COVID-19 provided by the Rural (i.e., phone)
7
● Allows for more time for Health Unit Facebook page ● Increased susceptibility to
8 agricultural work and Barangay Health calamities decreases
9 ● Appreciate that they do not have Workers control
10 to travel long distances ● Feel that feedback from ● Platforms must be
11 ● Economical alternative neighbors influenced their intuitive, inclusive, and
● Regard telemedicine as most decision to try the platform affordable
12
fitting for minor and chronic out ● There must be sufficient
13 ailments providers to address their
14 ● Recommend use for senior concerns
15 citizens and persons with
16 disabilities
17
18
19 Table 3. Attitudes, subjective norms, and perceived behavioral control among telemedicine non-users
20 Attitude Subjective Norm Perceived behavioral control
21
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22
Urban ● Telemedicine is perceived as an ● Information is mostly ● Feel that they can adapt to
23
effective tool for managing the provided through any platform. However,
24 number of patients seeking workplace announcements they prefer platforms that
25
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consult and announcements of are straightforward.

26 ● Telemedicine prevents possible projects by government ● Concern that doctors
27 exposure to COVID-19 officials cannot fully perform
● Telemedicine is helpful in ● Hesitant to use telemedicine physical examination of
28
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interpreting lab results services because their peers patients in telemedicine

29 ● No need for telemedicine because feel that care is better
30 they can easily consult doctors experienced in-person
31 who are on their social network settings
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32 ● Online consultations feel lacking

33 ● Difficult to express themselves in
34 online consultations
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36 Rural ● Telemedicine is perceived as an ● Low exposure to ● The cost of internet
37 effective tool for managing the information about services is prohibitive
38 number of patients seeking telemedicine services; news ● Hesitant to use
39 consult comes from Community telemedicine services due
40 ● Telemedicine prevents possible Health Workers to unfamiliarity of patients
exposure to COVID-19 ● Non-user peers are and caretakers with
41 ● Largely hesitant to use generally eager to try gadgets
42 telemedicine services because telemedicine services but ● Feels under-supported by
43 there is less opportunity to talk there is some hesitancy due the local health unit if they
44 with providers to lack of resources or choose to access
unfamiliarity. telemedicine services.
45
46
47 Remote ● Allows provincial workers to ● Information and assistance ● Perceive that they lack
48 perform their jobs with accessing telemedicine resources such as
● Allows persons with disabilities/ services is provided by stable electricity, internet
49
senior citizens to access care Community Health or mobile data
50 ● Open to telemedicine services, Workers connectivity, compatible
51 but they believe that their ● Non-user peers are devices
52 ailments are not fitting for generally eager to try ● Hesitant to use
telemedicine. telemedicine services but telemedicine services due
53 ● Difficult to express themselves in there is some hesitancy due to unfamiliarity of patients
54 online consultations to lack of resources or and caretakers with
55 unfamiliarity. gadgets
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● Participants perceive that
4 the rural health unit is
5 understaffed and less
6 capable of supporting
7 telemedicine use.
8
9
10 11.0 FIGURES
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3 12.0 SUPPLEMENTARY FILES - APPENDIX
4
5 Appendix A
6 FGD Interview Guide
7
Partly Adapted from George et al. (2013)
8
9
10 1. Telemedicine services in your community
11
12 1.1 What do you know about the telemedicine services offered by UPHS/RHU/BHS?
13
14 1.2 How do you feel about the telemedicine service?
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16 1.3 How did you form this impression?
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18 1.4 From what experiences did this impression come from?
19
20 2. Accessing services during the pandemic
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22 2.1 Did you feel the need to consult with your provider during the pandemic?
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24 2.2 How did you plan on consulting with your provider during the pandemic?
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26 2.3 What factors influenced you to choose the platform you mentioned?
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28 3. Perceived advantages and disadvantages of telemedicine services
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30 3.1 What do you think are the specific benefits of telemedicine services?
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32 3.2 What are potential factors that may prevent you from accessing telemedicine services?
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34 3.3 What are potential challenges that can be encountered during telemedicine services?
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36 3.4 Do you think telemedicine services can address any specific/gaps issues you have with your present form of healthcare?
37
38 4. Platform of use
39
40 4.1 What telemedicine platform do you use to consult with your providers?
41
42 4.2 Why do you use this platform when engaging in a telemedicine service with your primary care provider?
43
44 4.3 Are you open to using other platforms for telemedicine services?
45
46 4.4 Why / why not are you open to trying alternative platforms for telemedicine services?
47
5. Ideal recipients of telemedicine services
48
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50 5.1 Would you use telemedicine services yourself?
51
52 5.2 Would you recommend it to a friend/relative?
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54 5.3 Would it be particularly suitable for older people/children?
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4 6. Conditions and context of the use
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6 6.1 For what types of health conditions would you be most comfortable using telemedicine services?
7
8 6.2 How often and under what conditions (i.e., weekends only) would you make use of the telemedicine services?
9
10 6.3 What features would you like to be improved and/or included in the telemedicine services?
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