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Cited by 451Telemedicine and Telehealth ImplementationTechnology Use by Older AdultsMobile Health and mHealth Applications

Exploring barriers to participation and adoption of telehealth and telecare within the Whole System Demonstrator trial: a qualitative study

Open access
Sanders, Caroline, Rogers, Anne, Bowen, Robert, Bower, Peter, Hirani, Shashivadan, Cartwright, Martin, Fitzpatrick, Ray, Knapp, Martin +5 more·2012·BMC Health Services Research
DOI 10.1186/1472-6963-12-220PMC PMC3413558
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Abstract

BACKGROUND: Telehealth (TH) and telecare (TC) interventions are increasingly valued for supporting self-care in ageing populations; however, evaluation studies often report high rates of non-participation that are not well understood. This paper reports from a qualitative study nested within a large randomised controlled trial in the UK: the Whole System Demonstrator (WSD) project. It explores barriers to participation and adoption of TH and TC from the perspective of people who declined to participate or withdrew from the trial. METHODS: Qualitative semi-structured interviews were conducted with 22 people who declined to participate in the trial following explanations of the intervention (n = 19), or who withdrew from the intervention arm (n = 3). Participants were recruited from the four trial groups (with diabetes, chronic obstructive pulmonary disease, heart failure, or social care needs); and all came from the three trial areas (Cornwall, Kent, east London). Observations of home visits where the trial and interventions were first explained were also conducted by shadowing 8 members of health and social care staff visiting 23 people at home. Field notes were made of observational visits and explored alongside interview transcripts to elicit key themes. RESULTS: Barriers to adoption of TH and TC associated with non-participation and withdrawal from the trial were identified within the following themes: requirements for technical competence and operation of equipment; threats to identity, independence and self-care; expectations and experiences of disruption to services. Respondents held concerns that special skills were needed to operate equipment but these were often based on misunderstandings. Respondents' views were often explained in terms of potential threats to identity associated with positive ageing and self-reliance, and views that interventions could undermine self-care and coping. Finally, participants were reluctant to risk potentially disruptive changes to existing services that were often highly valued. CONCLUSIONS: These findings regarding perceptions of potential disruption of interventions to identity and services go beyond more common expectations that concerns about privacy and dislike of technology deter uptake. These insights have implications for health and social care staff indicating that more detailed information and time for discussion could be valuable especially on introduction. It seems especially important for potential recipients to have the opportunity to discuss their expectations and such views might usefully feed back into design and implementation.

AI snapshot

Written from the paper’s full text.

TL;DR

This nested qualitative study explored why people declined or withdrew from the Whole System Demonstrator telehealth/telecare trial, finding barriers related to technical competence, threats to identity and independence, and feared disruption to existing services. Concerns often reflected misunderstandings about the equipment and were not always resolved during home visits.

Key findings

  • Barriers to participation and adoption clustered into three themes: requirements for technical competence and operation of equipment; threats to identity, independence and self-care; and expectations/experiences of disruption to health and social care services.
  • Many concerns about needing special skills were based on misunderstandings: for example, one respondent thought he would need to “type” on a keyboard, though no typing, computer, or internet familiarity was required.
  • Respondents often viewed telehealth/telecare as appropriate for someone “a lot more ill” or more dependent, and worried the interventions could undermine self-care, control, and independence; some carers considered the person they cared for too ill or too dependent for the equipment.
  • Participants were reluctant to risk disruptive changes to existing services they valued; those who withdrew described technical difficulties, false alarms, slow/frustrating responses, and service changes such as discharge from specialist professionals.

Methods

  • Qualitative semi-structured interviews with 22 people: 19 who declined to participate after explanations of the intervention and 3 who withdrew from the intervention arm. Participants came from four trial groups (diabetes, COPD, heart failure, or social care needs) across Cornwall, Kent, and east London/Newham.
  • Observational field notes were also collected by shadowing 8 health and social care staff during home visits to 23 people. Interviews were audio-recorded and transcribed except for one respondent; data were analysed thematically using grounded theory techniques, including constant comparison and independent coding by three team members in Atlas.ti.
  • Sampling was initially planned as purposeful/theoretical for maximum variation but became opportunistic because recruitment depended on staff obtaining consent to be contacted; interviews continued until saturation.

Limitations

  • The paper states the study is based on a small, primarily convenience sample due to difficulties recruiting people who declined the trial; it could not fully examine contextual and organizational factors across all three sites, and there were only a small number of withdrawals. It also notes the trial context may have influenced decisions and that ethical constraints restricted encouragement to participate.
  • The paper states findings offer “transferability” rather than “generalizability,” consistent with qualitative research goals.
  • Evident from the text: the sample was skewed toward Newham (13 participants) and men (n = 14), with a mean age of 71; only 19 of 61 non-entrants telephoned agreed to be interviewed, and observational data came from 8 staff visiting 23 people, which may limit the range of perspectives captured.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/1472-6963-12-220

Cites

48 of 48 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 34 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Perceived uncertainties and questions that remained unaddressed from the initial visit sometimes led respondents to ask the interviewer more questions about the intervention.

    “Perceived uncertainties and questions that had remained unaddressed from the initial visit sometimes led to the respondents asking the interviewer more questions about the intervention:”
    Quote in the paperNot a substantial claim
  • Findingown data

    In the Whole System Demonstrator trial, of 9214 people who agreed to a home visit and eligibility assessment, 36.7% (3384) did not enter the trial.

    “Of those who agreed to receive a visit at home to discuss the potential installation of TH or TC equipment (n = 9214), and to be assessed for eligibility to join the trial, 36.7% (n = 3384) did not enter the trial.”
    Quote in the paperSubstantial claim
  • Findingown data

    Participants were reluctant to risk potentially disruptive changes to existing services that were often highly valued.

    “Finally, participants were reluctant to risk potentially disruptive changes to existing services that were often highly valued.”
    Quote in the paperSubstantial claim
  • Findingown data

    For some participants, especially those with English as a second language, a combined lack of confidence with language and technology contributed to their decision to decline the trial.

    “The following respondent in the east London site, who spoke some English as a second language, explained his decision to decline the trial as being due to a combined lack of confidence with language and a lack of confidence with technology.”
    • Also stated in: § Requirements for technical competence and operation of equipment · plain
      “This was an important issue because of the ethnic diversity within the Newham population where the equipment was only being provided to operate in English:”
    Quote in the paperNot a substantial claim
  • Findingown data

    Some participants who felt they would have difficulty engaging with the technological requirements of the equipment had found other forms of technology to be problematic.

    “It seemed unsurprising that some people who felt they would have difficulty engaging with the technological requirements of the equipment, had found other forms of technology to be problematic.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 37
  • Classified as probably not a substantial claim. 29

  • May combine two claims.

    Findingown data

    Explanations at the home assessment visit did not mitigate uncertainties about the technology; some participants misunderstood the equipment, for example believing they would need to type on a keyboard or use a computer or the internet when they would not.

    “Uncertainties regarding the technological aspects of the equipment did not seem to be mitigated by explanations presented at the home assessment visit. For example, the above respondent was not alone in thinking (following the home visit) that he would need to ‘type’ on a keyboard, when in reality no typing was involved, nor was there any need for familiarity with using a computer or the internet.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Some participants perceived telehealth and telecare as appropriate for someone who was 'a lot more ill' or if there was 'no-one in the house'.

    “Further examples illustrate the perception of TH and TC as appropriate for someone who was ‘a lot more ill’ (ID31) or if there was ‘no-one in the house’ (ID35).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Interviews following the home visit indicated a high level of uncertainty regarding the technology being offered and that staff varied in their own knowledge of the intervention.

    “Comments made in interviews following the home visit indicated a high level of uncertainty regarding the technology being offered and that staff varied in their own knowledge of the intervention:”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Responses commonly indicated a strong sense of personal responsibility for health, illness and self-care, and the interventions threatened to undermine such a sense of control and current approaches to managing health problems.

    “Responses commonly indicated a strong sense of personal responsibility for health, illness and self care; and the interventions threatened to undermine such a sense of ‘control’ and current approaches to managing health problems:”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The three participants who withdrew after receiving equipment described technical difficulties getting equipment to work, false alarms due to faulty readings, slow and frustrating responses, and additional disruption from proposed solutions such as an additional phone line.

    “The three participants who withdrew from the trial after they had received the equipment, described some technical difficulties they had in getting the equipment to work (ID156, ID89), and false alarms due to faulty readings (ID92). They described the response to some of these problems as being ‘slow’ and ‘frustrating’, and one described how the proposed solution (an additional phone line) brought”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Respondents' views were often explained in terms of potential threats to identity associated with positive ageing and self-reliance, and views that interventions could undermine self-care and coping.

    “Respondents’ views were often explained in terms of potential threats to identity associated with positive ageing and self-reliance, and views that interventions could undermine self-care and coping.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Respondents held concerns that special skills were needed to operate equipment, but these concerns were often based on misunderstandings.

    “Respondents held concerns that special skills were needed to operate equipment but these were often based on misunderstandings.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At one observed home visit, a potential telehealth recipient assumed she might be able to use the internet connection for general purposes, and was uncertain about taking part because she did not think she would know how to use it and did not think it would help.

    “The patient then asked if she would be able to get lots of information from the internet and seemed to assume she might be able to use it for general purposes. However, she also went on to state that she was not at all certain she wanted to take part because she did not think she would know how to use it and because she did not think it would help.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Most respondents associated use of telehealth and telecare with a high degree of dependency and ill health; in the majority of cases they wanted to distance themselves from negative connotations of old age, sickness and dependence, and depicted themselves as having strong personal responsibility for maintaining health, self-care and independence that could be threatened by the interventions.

    “Most respondents indicated that they associated the use of telehealth and telecare with a high degree of dependency and ill health. In the majority of cases, respondents seemed to want to distance themselves from negative connotations of old age, sickness and dependence, and instead depicted themselves as having a strong sense of personal responsibility for maintaining health, self-care and”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Staff reported having restricted time to explain interventions because they were often required to conduct 8 or 9 home visits each day, and often met with blank faces.

    “Observation visits in the three sites also recorded views from staff that they had restricted time in which to explain the interventions because they were often required to conduct 8 or 9 home visits each day. As one member of staff stated, she always tried to explain the equipment but often met with very ‘blank faces’. On the day she was shadowed to conduct home visits, this particular member of”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Many accounts indicated that part of respondents' existing approaches to self-care included a desire for their long-term health problems to fade into the background within day-to-day life, and responses reflected their busy and active lives.

    “Many accounts indicated that part of their existing approaches to self-care included a desire for their long-term health problems to fade into the background within day-to-day life, and responses reflected their busy and active lives.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Concerns about competency to manage technology, or concerns about costs, were sometimes compounded or left unaddressed at the home visit.

    “However, discussions about decisions to decline the trial indicated that concerns about competency to manage technology, or concerns about costs were sometimes compounded or left unaddressed at the home visit.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The majority of respondents depicted themselves as too healthy and too independent for the interventions to be of value, while a small number depicted the people they cared for as 'too sick' or 'too dependent', demonstrating that these interventions can end up falling between two stools.

    “However, whilst the majority of respondents in this study depicted themselves as too healthy and too independent for the interventions to be of value, the small number of respondents who depicted the people they cared for as ‘too sick’ or ‘too dependent’ demonstrate that these interventions can end up falling between two stools.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In 3 cases potential recipients of the intervention were considered too ill or too dependent by their carers, and their views highlighted the importance of the identity and role of carers.

    “In 3 cases potential recipients of the intervention were considered too ill or too dependent by their carers, and their views highlighted the importance of the identity and role of carers.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Among 61 people who did not enter the trial and were invited to the qualitative study, 42 declined; reasons offered included being too ill or incapacitated (8), not understanding the intervention (8), not thinking they needed or wanted telehealth or telecare (11), finding the trial too disruptive (3), and personal reasons (6).

    “Forty-two out of the 61 declined to take part in the qualitative study when telephoned.”
    • Also stated in: § Participants and methods · plain
      “8 stated that they (or the person they cared for) were too ill or incapacitated; 8 did not understand the intervention and why they were being offered to join the trial; 11 did not think they needed TH or TC and/or did not want it; 3 thought the trial was too disruptive; 6 cited personal reasons (e.g. going away, death of a family member, work commitments) for not taking part.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Respondents were reluctant to disrupt services that were currently working well and that they often valued highly.

    “Comments regarding current services indicated that respondents were reluctant to disrupt services that were currently working well and that they often valued highly.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Some respondents referred to the lack of integration of the trial with routine care and expressed surprise that doctors they consulted were not always aware of the trial.

    “Some respondents referred to the lack of integration of the trial with routine care and expressed surprise that doctors they consulted were not always aware of the trial (ID92).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Some respondents viewed the intervention as having the potential to make them 'hypochondriac'.

    “some viewed the intervention as having the potential to make them ‘hypochondriac’ (ID33P, ID145[wife]).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Much of this satisfaction seemed to be associated with stable relationships developed with specific service providers, and there were concerns about what changes the equipment might bring to those relationships.

    “Much of this satisfaction seemed to be associated with stable relationships that had been developed with specific service providers and there were concerns about what changes the equipment might bring to those relationships.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Respondents did not feel comfortable with the time pressures and disruption that equipment might bring, and some felt uneasy about the effects of intensive monitoring.

    “Thus, they did not feel comfortable with the time pressures and disruption that equipment might bring, and some felt uneasy about the effects of intensive monitoring.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Other respondents were keen not to dwell too much on their illness, preferring not to be reminded if their recordings were abnormal because it would make them worry, or remind them that they were not 'behaving'.

    “Other respondents were also keen not to dwell too much on their illness, preferring not to be reminded if their recordings were abnormal because it would make them worry (ID35), or remind them that they were not ‘behaving’ (ID89).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Common barriers to participation in randomized controlled trials include general concerns with the trial setting and research process, and concerns about randomization.

    “Such studies have found that common barriers to participation include general concerns with the trial setting and the research process; and more specifically, concerns about randomization [25-27].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [25] Mills EJ, Seely D, Rachlis B, Griffith L, Kumanan PW, Ellis P, Wright JR: Barriers to participation in clinical trials of cancer: a meta-analysis and systematic review of patient-reported factors. The Lancet Oncology. 2006, 7: 141-148. 10.1016/S1470-2045(06)70576-9. source

      Not checked in the free run.

    • cites [26] Featherstone K: Random allocation or allocation at random? Patients' perspectives of participation in a randomised controlled trial. Quality and Safety in Health Care. 1998, 317: 1177.

      Not checked in the free run.

    • cites [27] Ross S, Grant A, Counsell C, Gillespie W, Russell I, Prescott R: Barriers to participation in Randomised Controlled Trials: A systematic Review. Journal of Clinical Epidemiology. 1999, 52: 1143-1156. 10.1016/S0895-4356(99)00141-9. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Evaluation studies and trials have reported recruitment difficulties with up to 80% refusal rate.

    “Additionally, evaluation studies and trials have reported recruitment difficulties with up to 80% refusal rate [6].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [6] Subramanian U, Hopp F, Lowery J, Woodbridge P, Smith D: Research in homecare telemedicine: challenges in patient recruitment. Telemedicine Journal and e-Health. 2004, 10: 155-161. 10.1089/tmj.2004.10.155. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Domiciliary oxygen therapy can be perceived as fostering greater independence but also as inducing dependence.

    “For example, ambivalent ideas about domiciliary oxygen therapy in one study indicated perceptions that it fostered greater independence, but on the other hand there were concerns that the technology could induce dependence on its use [16].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [16] Cornford CS: Lay beliefs of patients using domiciliary oxygen: a qualitative study from general practice. Br J Gen Pract. 2000, 50: 791-793.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Survey studies have identified frequent reasons for refusal to join telehealth or telecare trials: being too busy, discomfort with the technology, belief that the technology could not help, and preference for existing services.

    “Survey studies have been able to summarise and quantify some reasons why potential participants refuse to join such trials, with frequent reasons described as participants being too busy, discomfort with the technology, belief that the technology could not help them, and preference for existing services [6-8].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [6] Subramanian U, Hopp F, Lowery J, Woodbridge P, Smith D: Research in homecare telemedicine: challenges in patient recruitment. Telemedicine Journal and e-Health. 2004, 10: 155-161. 10.1089/tmj.2004.10.155. source

      Not checked in the free run.

    • cites [7] Mair FS, Goldstein P, Shiels C, Roberts C, Angus R, O'Connor J, Haycox A, Capewell S: Recruitment difficulties in a home telecare trial. Journal of Telemedicine and Telecare. 2006, 12: 26-28. source

      Not checked in the free run.

    • cites [8] Palmas W, Teresi J, Morin P, Wolff LT, Field L, Eimicke JP, Capps L, Prigollini A, Orbe I, Weinstock RS, et al: Recruitment and Enrollment of Rural and Urban Medically Underserved Elderly into a Randomized Trial of Telemedicine Case Management for Diabetes Care. Telemedicine and e-Health. 2006, 12: 601-607. 10.1089/tmj.2006.12.601. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Patients can be ambivalent about the benefits and drawbacks of home health technologies because technology can make patients autonomous but also imposes heavy restrictions interwoven with the disease and the patient's life trajectory.

    “They found that patients were ambivalent about the benefits and drawbacks of technology because whilst technology can be pivotal in making patients autonomous, it also imposes heavy restrictions that are intimately interwoven with the nature of the particular disease and with the patients’ personal life trajectory [17].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Lehoux P, Saint-Arnaud J, Richard L: The use of technology at home: what patient manuals say and sell vs. what patients face and fear. Sociol Health & Ill. 2004, 26: 617-644. 10.1111/j.0141-9889.2004.00408.x. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    McCreadie and Tinker stress the importance of researching 'felt need' because their respondents were often managing bravely in difficult circumstances but did not see themselves as needing help.

    “McCreadie and Tinker also stress the importance of researching ‘felt need’ because their respondents were often managing bravely in difficult circumstances but did not see themselves as needing help [20].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] McCreadie C, Tinker A: The Acceptability of Assistance Technology to Older People. Ageing & Society. 2005, 25: 91-110. 10.1017/S0144686X0400248X. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Acceptability of assistive technologies for older people depends on whether the device is perceived to support or undermine their sense of identity.

    “Gitlin et al., highlight that acceptability of assistive technologies for older people is dependent on whether the device is perceived to support or undermine their sense of identity [18]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18] Gitlin LN, Luborsky MR, Schemm RL: Emerging concerns of older stroke patients about assistive devices. Gerontologist. 1998, 38: 169-180. 10.1093/geront/38.2.169. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Perceived priorities regarding discussions on the potential benefits of remote monitoring are often based on assumptions rather than empirical understanding.

    “Additionally, perceived priorities regarding discussions on the potential benefits of remote monitoring are often based on assumptions rather than empirical understanding [24].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [24] Finch T, Mort M, May C, Mair F: Telecare: perspectives on the changing role of patients and citizens. J Telemed Telecare. 2005, 11: 51-53. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    There is concern among key stakeholders regarding the impact of telecare interventions on autonomy associated with close surveillance.

    “and there has been some concern amongst key stakeholders regarding the impact of telecare interventions on autonomy associated with close surveillance [19].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [19] Percival J, Hanson J: Big brother or brave new world? Telecare and its implications for older people's independence and social inclusion. Critical Social Policy. 2006, 26: 888-909. 10.1177/0261018306068480. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Problems of non-participation and barriers to adoption of telehealth and telecare have been acknowledged but not yet addressed in published evidence.

    “A focus on the reasons for non-participation in the trial is important because the problems of non-participation and barriers to adoption of TH and TC have been acknowledged but not yet addressed in published evidence [23].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [23] McCartney M: Show us the evidence for telehealth. Br Med J. 2012, 344: e469-10.1136/bmj.e469. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    Interventions should be tailored to ensure they fit with life circumstances and individual approaches to self-management because one intervention is unlikely to suit all people with the same long-term condition.

    “It also implies that interventions should be tailored to ensure they will fit in with life circumstances and individual approaches to self-management because one intervention is unlikely to suit all people with the same long-term condition.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Given assumptions about appropriate candidacy and concerns about technology and service changes, it is important for potential recipients to have the opportunity to discuss their expectations and additional common concerns about technological aspects of equipment and service changes prior to installation.

    “Given the assumptions about appropriate candidacy for telehealth and telecare evident amongst respondents here, and concerns about technology and service changes, it seems important for potential recipients to have the opportunity to discuss their expectations and additional common concerns about technological aspects of equipment and service changes prior to installation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    Analysis of initial interviews informed subsequent interviews and prompted additional observational data collection from home visits, and field notes were explored thematically alongside interview data.

    “In keeping with an iterative approach common in qualitative research, analysis of the initial interviews informed subsequent interviews and prompted additional observational data collection from home visits where the intervention and the trial were explained as part of the consent process.”
    • Also stated in: § Participants and methods · plain
      “Field notes were made of observational visits and explored thematically alongside interview data.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The study continued to follow up willing participants until saturation in data analysis, and conducted interviews iteratively so that analysis of initial interviews informed further data collection.

    “Whilst the sample was opportunistic, we ensured that we continued to follow-up willing participants until we reached saturation in the data analysis, and we conducted interviews iteratively, whereby the analysis of initial interviews was used to inform further collection.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    More detailed information and time for discussion could be valuable when introducing these interventions for the first time.

    “This indicates that more detailed information and time for discussion could be valuable when introducing these interventions for the first time.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    These findings suggest the need for closer proximity between innovation design and evaluation, so that critical insights might usefully feed back into design and implementation, ensuring interventions are 'minimally disruptive' for recipients.

    “Additionally, these findings suggest the need for closer proximity between innovation design and evaluation, so that critical insights might usefully feed back into design and implementation [11,13] ensuring interventions are ‘minimally disruptive’ for recipients [42].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [11] Murray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C, Finch T, Kennedy A, Mair F, O'Donnell C, et al: Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Medicine. 2010, 8 (63): -10.1186/1741-7015-8-63. source

      Not checked in the free run.

    • cites [13] Greenhalgh T, Hinder S, Stramer K, Bratan T, Russell J: Adoption, non-adoption, and abandonmentof a personal electronic health record: case study of HealthSpace. Br Med J. 2010, 341: c5814-10.1136/bmj.c5814. source

      Not checked in the free run.

    • cites [42] May C, Montori V, Mair F: We need minimally disruptive medicine. Br Med J. 2009, 339: 485-487. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The trial itself may have had some influence on decisions to use telehealth and telecare.

    “It also needs to be recognized that this is a study within a randomized controlled trial and the trial itself may have had some influence on decisions to use telehealth and telecare.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Transcript data and field notes were analysed thematically using grounded theory techniques including constant comparison across cases to elicit common key themes and unusual cases.

    “Transcript data and field notes were organised with aid of Atlas.ti and the data were analysed thematically using some of the techniques of a grounded theory approach including constant comparison whereby we compared the data across cases to elicit common key themes and unusual cases [30].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Green J, Thorogood N: Qualitative Methods for Health Research. 2004, Sage, London

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Previous studies have described the challenges brought by the new 'work' and scrutiny associated with such interventions, and the disruption of normalised everyday practices and interactions regarding management has been recognised as a major barrier to the integration of e-health interventions into routine care and management.

    “Previous studies have described the challenges brought by the new ‘work’ and scrutiny associated with such interventions [12,38,39] and where the disruption of normalised everyday practices and interactions regarding management have been recognised a major barrier to the integration of e-health interventions into routine care and management [13,40,41].”
    Quote in the paperNot a substantial claim0 of 6 sources checked
    • cites [12] Donovan J, Mills N, Smith M, Brindle L, Jacoby A, Peters T, Frankel S, Neal D, Hamdy F: Quality improvement report: improving design and conduct of randomised trials by embedding them in qualitative research: ProtecT (prostate testing for cancer and treatment) study. BMJ British medical journal (Clinical research ed). 2002, 325: 766-770. 10.1136/bmj.325.7367.766. source

      Not checked in the free run.

    • cites [38] Nicolini D: The work to make telemedicine work: a social and articulative view. Soc Sci Med. 2006, 62: 2754-2767. 10.1016/j.socscimed.2005.11.001. source

      Not checked in the free run.

    • cites [39] Oudshoorn N: Diagnosis at a distance: the invisible work of patients and healthcare professionals in cardiac telemonitoring technology. Sociol Health & Ill. 2008, 30: 272-288. 10.1111/j.1467-9566.2007.01032.x. source

      Not checked in the free run.

    • cites [13] Greenhalgh T, Hinder S, Stramer K, Bratan T, Russell J: Adoption, non-adoption, and abandonmentof a personal electronic health record: case study of HealthSpace. Br Med J. 2010, 341: c5814-10.1136/bmj.c5814. source

      Not checked in the free run.

    • cites [40] May C, Gask L, Atkinson T, Ellis N, Mair F, Esmail A: Resisting and promoting new technologies in clinical practice: the case of telepsychiatry. Social Science & Medicine. 2001, 52: 1889-1901. 10.1016/S0277-9536(00)00305-1. source

      Not checked in the free run.

    • cites [41] May C, Finch T: Implementing, Embedding, and Integrating Practices: An Outline of Normalization Process Theory. Sociology. 2009, 43: 535-554. source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    The study is based on a small group that is primarily a convenience sample due to difficulties in recruiting people who declined the trial.

    “One of the limitations of the study is that it is based on a small group that is primarily a convenience sample due to the difficulties in recruiting people who declined the trial.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Poor uptake of and adherence to interventions for complex chronic conditions are often due to the heavy burden on patients and the lack of congruence with patients' perspectives on care.

    “This finding resonates with the analysis of May et al. who suggest that poor uptake of and adherence to interventions for complex chronic conditions are often due to the heavy burden on patients and the lack of congruence with patients’ perspectives on care [42].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [42] May C, Montori V, Mair F: We need minimally disruptive medicine. Br Med J. 2009, 339: 485-487. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Within the context of a trial, the ability to encourage participation is restricted through the ethical constraints of a technology that as yet lacks firm evidence.

    “Within the context of a trial, the ability to encourage participation is restricted through the ethical constraints of a technology that as yet lacks firm evidence.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The analysis approach reflected elements of both deduction and induction because the team had preliminary ideas about factors influencing decisions to decline participation based on previous research, but remained open to new and unexpected findings.

    “The whole approach to analysis reflected elements of both deduction and induction because we had some preliminary ideas about factors that might influence decisions to decline participation (based on previous research in the field), but we were also open to being surprised by the data in order to allow new and unexpected findings to emerge.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    There were only a small number of those who withdrew from the trial within this sample.

    “There were also only a small number of those who withdrew from the trial within this sample.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The qualitative study used an opportunistic sampling approach rather than the initially planned purposeful and theoretical sampling because recruitment depended on health and social care staff gaining verbal consent at home assessment visits, which did not systematically happen.

    “However, circumstances of recruitment necessitated an opportunistic approach. This is because sampling was contingent upon health and social care staff within the trial sites gaining verbal consent from potential participants at the home assessment visit to be contacted by the evaluation team, and this did not systematically happen.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    People are often keen to distance themselves from negative stereotypes of ill health and ageing, and health-related interventions, including telehealth and telecare, can be perceived to undermine identity and autonomy, especially amongst older people.

    “Previous research demonstrates that people are often keen to distance themselves from negative stereotypes of ill health and ageing [34], and that health-related interventions, including telehealth and telecare, can be perceived to undermine identity and autonomy, especially amongst older people [19,20,35].”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [34] Sanders C, Donovan J, Dieppe P: The significance and consequences of having painful and disabled joints in older age: co-existing accounts of normal and disrupted biographies. Sociol Health Illn. 2002, 24: 227-253. 10.1111/1467-9566.00292. source

      Not checked in the free run.

    • cites [19] Percival J, Hanson J: Big brother or brave new world? Telecare and its implications for older people's independence and social inclusion. Critical Social Policy. 2006, 26: 888-909. 10.1177/0261018306068480. source

      Not checked in the free run.

    • cites [20] McCreadie C, Tinker A: The Acceptability of Assistance Technology to Older People. Ageing & Society. 2005, 25: 91-110. 10.1017/S0144686X0400248X. source

      Not checked in the free run.

    • cites [35] Yardley L, Donovan-Hall M, Francis K, Todd C: Older people's views of advice about falls prevention: a qualitative study. Health Education Research Theory and Practice. 2006, 21: 508-517. source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductreasoning

    The sample includes a mix of men and women with both telehealth and telecare needs, and the strength of the study lies in the focus on a group of people who are not usually considered within a trial evaluation and who represent an often hidden group with important viewpoints on the intervention.

    “Despite these factors, the sample does include a mix of men and women with both telehealth and telecare needs, and the strength of the study lies in the focus on a group of people who are not usually considered within a trial evaluation and who therefore represent an often hidden group with important viewpoints on the intervention focused upon.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Previous qualitative research within trials highlights that the importance of how information is imparted and discussed can have a major impact on recruitment.

    “This finding resonates with previous qualitative research within trials highlighting the importance of how information is imparted and discussed can have a major impact on recruitment [12].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] Donovan J, Mills N, Smith M, Brindle L, Jacoby A, Peters T, Frankel S, Neal D, Hamdy F: Quality improvement report: improving design and conduct of randomised trials by embedding them in qualitative research: ProtecT (prostate testing for cancer and treatment) study. BMJ British medical journal (Clinical research ed). 2002, 325: 766-770. 10.1136/bmj.325.7367.766. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Three members of the team independently coded interview data using open coding in Atlas.ti, entering codes into separate Atlas.ti hermeneutic units, and discussed initial codes at regular team meetings to develop and refine themes.

    “Three members of the team (CS, RB, AR) independently coded interview data using an open coding technique in Atlas.ti and each member of the team entered codes into separate versions of an Atlas.ti hermeneutic unit.”
    • Also stated in: § Participants and methods · plain
      “These initial codes were discussed at regular team meetings in order to develop and refine the initial codes into key themes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationcitation

    It is important to include carers' perspectives when evaluating such interventions, and there is a need for a wider range of programmes to address carers' diverse needs.

    “This highlights the importance of carers’ perspectives when evaluating such interventions, and the need for a wider range of programmes to address carers’ diverse needs [37].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [37] Magnusson L, Hanson E, Nolan M: The impact of informationand communication technology on family carers of older people and professionals in Sweden. Ageing & Society. 2005, 25: 693-713. 10.1017/S0144686X05003673. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The study offers 'transferability' of findings rather than 'generalizability' and is in keeping with the common goals of qualitative research, whereas the emphasis is placed on the latter in quantitative research.

    “In this sense, the study offers ‘transferability’ of findings rather than ‘generalizability’ and is in keeping with the common goals of qualitative research, whereas the emphasis is placed on the latter in quantitative research [43].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [43] Sandelowski M: Using Qualitative research. Qual Health Res. 2004, 14: 1366-1386. 10.1177/1049732304269672. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    With additional recruits from Cornwall and Kent, the study achieved a wide variation of participants with various health conditions and social care needs.

    “With additional recruits from Cornwall and Kent, we were able to achieve a wide variation of participants with the various health conditions as well as social care needs (see table 1).”
    Quote in the paperNot a substantial claim
53 of 53

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • In our review, no studies reported participants concern about others seeing into their homes.

    “In our review, no studies reported participants concern about others seeing into their homes [64,65].”

    From Telehealth Interventions Delivering Home-based Support Group Videoconferencing: Systematic Review (2018) · cites this paper as [65]

  • Problems of context extend across policy-led interventions too.

    “These are not just problems in trials. They extend across policy-led interventions too.”

    From Implementation, context and complexity (2016) · cites this paper as [17]

  • Changes in the organisation of clinical work in surgery, delivery of telemedicine systems at scale, and scaling out and spread of new health technologies provide evidence of the role of environmental mechanisms in shaping interventions.

    “Changes in the organisation of clinical work in surgery [15, 16], the delivery of telemedicine systems at scale [17, 18] and the scaling out and spread of new health technologies [19, 20], all provide evidence of the role of environmental mechanisms in shaping interventions.”

    From Implementation, context and complexity (2016) · cites this paper as [17]

  • Due to absent or insufficient motivation strategies such as interactivity, proper incentives and rewards, and experiential value, the effects of digital interventions in asthma are prone to be negatively affected by the temporal decline in patients' engagement and motivation.

    “Additionally, due to absent or insufficient motivation strategies such as interactivity, proper incentives and rewards [48], and experiential value [49-51], the effects of the previously reported digital interventions in asthma, such as the health condition of the young patients, are prone to be negatively affected by the temporal decline in the patients’ engagement and motivation [10,52-54].”

    From Conversational Agents as Mediating Social Actors in Chronic Disease Management Involving Health Care Professionals, Patients, and Family Members: Multisite Single-Arm Feasibility Study (2021) · cites this paper as [52]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Jane's father is assigned two participant IDs

    Minor

    A quotation about caring for Jane is attributed to ID31_Father, but another quotation about Jane is attributed to ID32_father. Table 1 also identifies ID32, rather than ID31, as the telecare participant interviewed through both parents.

1 of 1

Cites

Flagged first, then by citations

1 of the 49 references couldn’t be matched to a known paper.

Research works printed but not linked: 2

  1. Everett C: Testing Telehealth and Telecare. 2009, Guardian Professional Weds, , 3-6. http://www.smarthealthcare.com/telehealth-telecare-whole-systems-demonstrator-03jun09 .
  2. Department of Health: 3millionlives. , http://www.3millionlives.co.uk/pdf/3millionlives-News-Release.pdf Press Release 19-1-2012

Cited by

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Related

Authors
Sanders, C., Rogers, A., Bowen, R., Bower, P., Hirani, S., Cartwright, M., Fitzpatrick, R., Knapp, M., Barlow, J., Hendy, J., Chrysanthaki, T., Bardsley, M., & Newman, S. P.
Affiliations
  • University of Manchester (GB)
  • City, University of London (GB)
  • University of Oxford (GB)
  • London School of Economics and Political Science (GB)
  • Imperial College London (GB)
  • University of Surrey (GB)
  • Nuffield Trust (GB)
Corresponding author
Sanders, Caroline
ORCID
Venue
BMC Health Services Research
Publisher
Springer Science and Business Media LLC
Published
2012-07-26
Volume
12
Issue
1
Pages
220-220
ISSN
1472-6963 (ISSN-L)
DOI
10.1186/1472-6963-12-220
PMC
PMC3413558
OpenAlex
W2110228606
Semantic Scholar
4fc6cc58ffa308faf516318e61d74382f82c1ae4
Cited by
450
References
49
Citations by year
2026: 10 · 2025: 9 · 2024: 16 · 2023: 20 · 2022: 33 · 2021: 37 · 2020: 31 · 2019: 34 · 2018: 37 · 2017: 43 · 2016: 52 · 2015: 56 · 2014: 47 · 2013: 24 · 2012: 1
FWCI
39.56
Type
journal article
Language
en
Open access
Licence
Locations
  • BMC Health Services Research (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • City Research Online (City University London) (acceptedVersion)
  • LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
  • Open Research (University of Surrey) (submittedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • ePrints Soton (University of Southampton) (submittedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • Surrey Research Insight Open Access (The University of Surrey) (submittedVersion)
  • Research Explorer (The University of Manchester) (submittedVersion, cc-by)
  • Spiral (Imperial College London) (submittedVersion, cc-by)
Funders
  • National Institute for Health and Care Research
  • Engineering and Physical Sciences Research Council (EP/I029788/1)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
  • Social Sciences › Demography › Technology Use by Older Adults
  • Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
Keywords
telemedicine, telecare, barriers to adoption, trial withdrawal, older adults, self-care, aging, health and social care staff, technology acceptance, home visits
MeSH terms
Adult, Aged, Aged, 80 and over, Diffusion of Innovation, Female, Health Services Needs and Demand, House Calls, Humans, Health Knowledge, Attitudes, Practice, London, Male, Middle Aged, Patient Dropouts, Self Care, Telemedicine, Qualitative Research

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

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