Research from Australia and New Zealand has suggested that without access to necessary infrastructure, telehealth may exacerbate service exclusion for some regional communities.
Based on an open-ended survey of Dialectical Behaviour Therapy (DBT) team leaders, the study, published 6 October 2022 in PLOS One, emphasised that telehealth will only help address inequities if clients are provided the necessary software, devices, connectivity, and privacy to receive the service.
The research also found that psychologists need additional training and support to navigate the complex challenges associated with virtually assessing and managing the high-risk behaviours and emotions of clients, while trying to build effective therapeutic relationships.
Lead author, Dr Emily Cooney from the Department of Psychological Medicine at the University of Otago, Wellington, explained that the most frequent barrier to participation reported was the lack of necessary resources – highlighting an important source of inequity.
“At first glance, there may be an assumption that telehealth would improve treatment access for patients in remote locations. However, if living in a remote location co-occurs with digital exclusion due to lack of resources or knowledge, then telehealth will increase the health gap rather than reducing it,” Dr Cooney said.
“Equipment access and data insecurity were frequently mentioned by respondents as general barriers to telehealth DBT.
“These findings underscore the need for services to factor in the costs of providing/lending devices and covering data expenses when planning telehealth delivery and to have a strategy for facilitating access to private spaces for service users who do not have one.
“This is particularly relevant to clients experiencing overcrowding, and homelessness, [and] there is a risk that this may particularly impact Indigenous and Pacific People service users, given the social and economic disparities for these ethnic groups in Australia and NZ.”
DBT is a multi-modal intervention for individuals with multiple comorbidities and high-risk behaviours. Due to its intensity, the treatment has typically been provided as a face-to-face only service by most providers, but during pandemic related lockdowns, many DBT services transitioned to delivering treatment via telehealth – yet some did not.
The study sought to explore the experience of DBT teams in Australia and NZ who did and did not transition to telehealth during the early stages of the pandemic, with DBT team leaders asked to complete a survey with open-ended questions about the barriers and solutions they encountered to delivering DBT via telehealth.
“The early days of lockdowns were highly stressful for health professionals and arguably, while many or most services were not telehealth ready, there may have been different levels of readiness which may have impacted transitioning,” the authors explained.
Of the 73 team leaders who took part, 56 reported providing either individual therapy, skills training or both modalities via video-call during lockdown and significantly, most teams who had provided at least one DBT session, had found a way to transition to telehealth without any official guidance.
“This may represent the common commitment by Australian and New Zealand clinicians to ensure their DBT clients received services during a particularly stressful time for both service users and therapists,” the authors suggested.
“Importantly, not all teams moved to telehealth, with the most frequently mentioned reasons for this involving teams being prohibited from doing so by organisation managers. That said, other reasons indicated that teams simply were not ‘telehealth-ready’.
Multiple respondents identified systemic barriers, such as organisations not allowing telehealth, challenges with the provision of hardware and accessible platforms to deliver telehealth, or the lack of adequate training and support, rather than issues specific to clients or staff.
Qualitative analysis revealed two broad and overlapping categories of perceived barriers for both therapists and clients, with concerns about access to necessary resources (software, hardware, and technical knowledge and skill) contrasting with concerns about process (including concerns about therapeutic connection, managing risk and dysregulated behaviour, and lack of confidence in telehealth).
“Respondents’ comments repeatedly highlighted the pivotal role their organisation held in the delivery of remote DBT, from the most basic step of actually allowing DBT via telehealth to occur, through to the provision of software, hardware, connectivity, training and private space integral to its delivery,” the authors concluded.
“Importantly, for many DBT services, the successful transition to telehealth required that these resources be provided for clients, as much as therapists. This is an essential consideration if services are to avoid widening inequities due to digital exclusion.”