Telehealth delivery of paediatric rehabilitation for children with neurodisability: A mixed methods realist evaluation of contexts, mechanisms and outcomes

Abstract

Background

Teledelivery of rehabilitation services has been proposed as a cost‐effective option for supporting children with neurodisability and their families. However, little is understood of the conditions that support uptake of telehealth in paediatric rehabilitation, what is delivered during telehealth or perceptions of its outcomes. The aim of this study was to identify the context, process and outcomes of telehealth for children with neurodisability and their families. A secondary objective was to identify if variations in these aspects of telehealth occurred for Māori, the indigenous people of New Zealand.

Method

A mixed‐methods, three phase, realist evaluation identified context‐mechanism‐outcome configurations (CMOcs) of telehealth. In Phase 1, the Determinants of Implementation Behaviour Questionnaire indicated factors affecting practitioner uptake of telehealth (Context). In Phase 2, a casenote audit identified ‘practitioner input’ during telehealth (Mechanism). Phase 3 interviews with practitioners and parents explored ‘parent response’ to telehealth and practitioner and parent perceptions of its value (Mechanism and Outcomes). Subgroup analyses for Māori were planned.

Results

From Phase 1, practitioners (29/37, 78%) intended to use telehealth; however, few did so regularly (7/37, 22%). Positive experiences of telehealth were described by all practitioners (n = 5) and families (n = 7) in Phase 3. CMOcs explained that practitioners' offering of telehealth occurred when practitioners were confident, valued access to therapy over the familiarity of in‐person delivery, and when practitioners used coaching‐style communication. Parents were receptive to telehealth when they trusted practitioners, felt listened to and were offered telehealth as a choice. When telehealth occurred, access to therapy was timely and more consistent than in‐person delivery. Child outcomes appeared to be positive. Confidence in offering telehealth to Māori was low.

Conclusions

Initiatives to improve uptake of telehealth in paediatric rehabilitation should focus on creating conditions for practitioner implementation. Training in telehealth should include engagement with Māori. Adequate workspace and workplace culture change are required if telehealth is to be offered beyond the current ‘early adopters’.

Key messages.

• Practitioners who were confident in offering telehealth, and who framed it as a choice, triggered family's decision to try telehealth, thus achieving wider access and greater dose of therapy to families. Conversely, parents described that if telehealth was the only option offered, they would feel ‘fobbed off’, perceiving telehealth as less valuable than in‐person delivery.

• Initial in‐person delivery was perceived to trigger high trust relationships with families that were sustained over telehealth delivery. Trust in practitioners and flexibility to return to in‐person delivery appeared to be instrumental in telehealth delivery being perceived as successful; thus, a hybrid approach is indicated.

• Highly collaborative communication by practitioners and targeting improvement in children's participation in life situations appeared to transition easily to teledelivery, affording advantages over in‐person therapy at times.

• A perception of inadequate training, resource and organizational support, by many practitioners, may have failed to trigger practitioners to offer telehealth often or at all. Multi‐factorial approaches will be needed to embed telehealth as part of usual care.

1. INTRODUCTION

Telehealth is the use of technology to augment healthcare provision in the absence of in‐person contact between health professional and recipient of care (Allied Health Professions Australia, 2020). Emergent empirical evidence of the effect of telehealth in paediatric rehabilitation is positive (Camden et al., 2020; Krasovsky et al., 2021; Önal et al., 2021); yet, anecdotally, its uptake in paediatric rehabilitation appears low, even after COVID‐19‐related periods of higher use. Improving access to services is a critical advantage of telehealth. An understanding of the specific contexts that facilitate clinician uptake of telehealth and positive responses from families are needed to advance its use (Camden & Silva, 2021). Māori, the indigenous people of New Zealand may have particular needs if use of telehealth is to be expanded and to ensure that existing inequities in access to resources are not exacerbated (Gurney et al., 2021; Murray & Loveless, 2020). For example, it is currently unclear if culturally distinct ways of relating to others are disrupted through telehealth or if they require alternative processes.

An initial programme theory was developed to guide this realist evaluation (Pawson & Tilley, 1997) represented in its logic model (Table 1). Mechanisms (processes) being examined within this evaluation were informed by the normative theories and empirical evidence related to health professional behaviour change, drawing on the Theoretical Domains Framework (TDF) (Atkins et al., 2017) and family‐centred practices (FCPs) (Rosenbaum et al., 1998).

TABLE 1.

Teledelivered Paediatric rehabilitation logic model

	Mechanisms
Context (measure)	Practitioner resource /FACE T Rx key components (Mp)	Intended client response (Mc)	Outcomes (measure)
Telehealth services should reflect best practice principles of family‐centred care and target participation‐level outcomes. Practitioner and parent/child demographics and beliefs about telehealth may influence their use of telehealth. Parent geographic location may also influence uptake of telehealth. (DIBQ; casenote audit; interviews) Dosage of intervention, including amount, frequency and intensity, may affect child and parent outcomes. (casenote audit; interviews)	1. Establishes supportive trusting relationship, tailored for Māori using the hui process.	1. Strong therapeutic alliance	High engagement in intervention (SRS total score)
	2. Facilitates child and or family led goal setting of improvement in participation in life situations (e.g., home, school community roles and activities)	2. Child/family feel that rehab episode of care focuses on what is important to them à high engagement	High engagement in intervention Personally meaningful change. (GBO within casenote audit)
	3. Active involvement of child and family during treatment decision‐making.	3. Spontaneous innovation/self‐management of issues.	High sense of parental competence Ongoing self‐management (casenote description parent/child action or problem‐solving)
	4. Explicit statement of planned action of family outside of practitioner presence.	4. Spontaneous innovation/self‐management of issues	High sense of parental competence Ongoing self‐management (casenote description of parent/child planned action)
	5. Delivered by telehealth	5. Engages as per in‐person delivery	Greater access to intervention

Notes: The multifactorial context statements indicate salient, overarching features of the context in which telehealth occurs in paediatric rehabilitation; thus, the context information does not correspond to any single item in the remainder of the table but rather informs the context in which the items collectively are situated. FACE T‐Rx (Family‐centred Teledelivered Rehabilitation). Session Rating Scale (SRS) (Duncan et al., 2003). Goals Based Outcome Tool (GBO) (Law & Jacob, 2013); Determinants of Implementation Behaviour Questionnaire (DIBQ) (Huijg et al., 2014).

The TDF guided the collection and interpretation of data related to therapists' uptake of telehealth services. Shifting clinical practice behaviours is challenging and requires multiple and sustained strategies (Grol & Grimshaw, 2003; McCluskey & O'Connor, 2017). The TDF is a validated, integrative framework of theories of behaviour change (Atkins et al., 2017) that explains the perceived conditions that influence behaviour choices, such as implementation of interventions by health professionals. Domains within the TDF include knowledge; skills; social/professional role and identity; beliefs about capabilities; optimism; beliefs about consequences; reinforcement; intentions; goals; memory, attention and decision processes; environmental context and resources; social influences; emotions; and behavioural regulation. Identification of specific psychological domains influencing behaviour can be helpful in determining targeted knowledge translation strategies to support greater uptake of desired professional behaviours (Hovden & Skudutyte‐Rysstad, 2021) including use of telehealth (Wenke et al., 2021).

FCP has been the cornerstone of child health and development service delivery across professions, settings and child health conditions for decades (Rosenbaum et al., 1998). Irrespective of specific interventions employed, FCP behaviours should be evident in practitioners' delivery of rehabilitation. This study therefore drew on FCP in establishing the expected ‘practitioner input’ in telehealth service provision (see Table 1). Core principles of FCP include that the family is the unit of care, with the child at its centre; and that each family is unique, and parents are the constant in a child's life, and is the expert on a child's needs and abilities (McCarthy & Guerin, 2022; Rosenbaum et al., 1998). Practitioners' enactment of these principles relies on (1) working in partnership with families to address their concerns and realize their ambitions; (2) encouragement of active engagement of the family (including the child) in decision‐making; (3) a focus on child and family strengths and resources (rather than deficits); (4) conveyance of respect, non‐judgement and trust in families. Thus, the quality of the therapeutic alliance (including partnership, respect and trust) and active engagement of families in decision‐making were itemized in the logic model. Culturally competent rehabilitation is an additional expectation in New Zealand when working with Māori (‘Health Practitioners Compentence Assurance Act’, 2003). One structured approach to enhancing health professionals' cultural competence is the Hui Process (Pitama et al., 2017). While congruent with FCP in intention, the Hui Process emphasizes ways of engaging particular to Māori culture, such as building rapport through shared connection to people or places. Outcomes intended by FCP include child/family goal attainment in the life situations they value, well‐being, for example, quality of life, parental self‐esteem and child skill development (McCarthy & Guerin, 2022). Among these FCP outcomes, this evaluation focused on child/parent identified goal attainment as these represented multiple aspects of FCP and represented the recommended focus of rehabilitation on improved participation in life situations (Imms et al., 2017). Specifically, the aim of this study was to identify the conditions that facilitate teledelivered rehabilitation for children with neurodisability (ND) and their families, to improve participation of children in life situations. A subgroup analysis for Māori families was planned a priori.

2. METHODS

A realist evaluation (Pawson & Tilley, 1997) using mixed methods of data collection (Creswell & Plano Clark, 2007) was employed in order to examine the context, processes and outcomes of telehealth for children with ND and their families. Realist evaluation can provide generative explanation for phenomena and help identify patterns linking contexts and mechanisms with particular outcomes (Marchal et al., 2012) and has proven helpful in understanding implementation of complex paediatric rehabilitation interventions (Martin et al., 2020; Willis et al., 2018). In this study, we sought clarification on the contexts that triggered practitioners in community child development services to offer telehealth to children with ND and their families (context), what practitioners offered during telehealth sessions (mechanisms) and if these practices led to the intended child and parent outcomes (goal progress). RAMESES‐II reporting standards were adhered to Wong et al. (2016) as were COREQ guidelines for qualitative data. Ethical approval for this study was provided by the relevant University of Otago ethics committee (REF# HD20/106) alongside locality approval and Māori consultation for each site.

This evaluation took place among all publicly funded child development services (N = 11) in the South Island of New Zealand, spread over 150 000‐km area from March to June 2020. Children seen by these services are aged 0 to 21 years (upper age limit varies between services) with ~95% of children having ND diagnoses including premature infants, chromosomal abnormalities, cerebral palsy, autism and developmental delay (excluding accidental injury ¹ ). Each service operates independently and comprises between 2.5 and 30.5 Full Time Equivalent (FTE) staff (combined total workforce N = ~110) with a range of professional backgrounds including occupational therapy, physiotherapy, speech and language therapy, psychology, early intervention teaching and social work. Additional specialists employed include kaitautoko (Māori advisor), Conductive Education Conductors and a music therapist. Some services receive additional funding through philanthropy (N = 2). One service provides Conductive Education only. Processes of care vary between services including in relation to location of service delivery (home, school, clinic), intensity of intervention, group versus individual service delivery and multidisciplinary versus transdisciplinary teamwork. For this evaluation, a project working party (N = 12) was established to guide evaluation design and execution, with an external academic lead. Working party members were practitioners (n = 8), managers (n = 3) from the services described above, family members of service users (n = 3) and academics (n = 4). Three working party members also identified as Māori (n = 3).

To clarify the therapy delivered to families during this evaluation (mechanism‐practitioner [Mp]), we identified five key ingredients of best practice paediatric rehabilitation, informed by FCP plus a ‘delivered via telehealth’ ingredient to represent the focus of this evaluation. Collectively, practitioner input was articulated as FACE T‐Rx (Family‐centred Teledelivered Rehabilitation). FACE T‐Rx is not a novel intervention but represents the basic components of evidence‐based best practice interprofessional rehabilitation with children with neurodisability (McCarthy & Guerin, 2022; Novak et al., 2020). To fully describe FACE T‐Rx the Template for Intervention Description and Replication (TIDieR) (Hoffmann et al., 2014), checklist is provided in the Supporting Information. The FACE T‐Rx description enables specific description of what was delivered against current best practice guidance in telehealth delivery with the community paediatric rehabilitation.

This three‐phase study involved provision of training in telehealth to frontline staff and a questionnaire that examined the determinants of implementing telehealth (Phase 1), a retrospective casenote audit of delivery of telehealth (Phase 2) followed by interviews with practitioners and parents about their experiences of telehealth (Phase 3). Table 2 outlines study phases and timing in relation to realist evaluation components. All practitioners at participating services were invited to take part in this evaluation by email invitation.

TABLE 2.

Study phases and realist evaluation focus

Study phase	Phase 1 Weeks 1–4	Phase 2 Weeks 5–14	Phase 3 Weeks 15–18
Realist focus	Context	Mechanisms & outcomes
Study activity (n)	FACE T‐Rx Training (34) DIBQ (37)	Casenote audit Practitioners (5) Child casenotes (15)	Interviews Practitioners (5) Caregivers (8)

Abbreviations: DIBQ, Determinants of Intervention Behaviour Questionnaire; FACE T‐Rx, Family‐Centred Telehealth Rehabilitation.

2.1. Phase 1

Following consent, an electronic questionnaire was sent to practitioners seeking demographic information, current use of telehealth and the Determinants of Implementation Behaviour Questionnaire (DIBQ; Huijg et al., 2014). The DIBQ provided quantitative information about practitioner readiness to implement telehealth. Second, a 2‐h training in FACE T‐Rx was provided live online via Zoom videoconferencing by specialists in each component of the intervention. The purpose of the training was to provide the opportunity for baseline information on telehealth applied to community child development services to all eligible practitioners. Training included theory, practices and evidence related to family‐centred rehabilitation including the use of patient reported outcome measures (PROMs), participation in life situations as the primary target of interventions (Imms et al., 2016; Imms et al., 2017), culturally responsive engagement with Māori (Pitama et al., 2017) and the use of technology in delivery of rehabilitation (Camden & Silva, 2020). Training was available to all practitioners working within child development services in the South Island (recording of training available at https://www.youtube.com/playlist?list=PLoYgkS35H0IwwC3yn-0fPZP6l_FwdUeiG). Training methods included didactic teaching, small and large group discussion and individual reflective tasks. Practitioners who completed the DIBQ and had attended the telehealth training were invited to take part in phase two.

2.2. Phase 2

Phase 2 was a retrospective casenote audit of how telehealth was used. Brief 30‐min training on the casenote audit tool was provided prior to 6 weeks of telehealth delivery that was later audited.

2.3. Phase 3

Practitioners who participated in Phase 2 and the families who engaged in telehealth were invited to take part in interviews about their experience.

3. RECRUITMENT AND SAMPLING

Eligible participants included rehabilitation practitioners and parents of children with neurodisability who had received intervention via telehealth. Practitioners were recruited through emailed invitation sent to all child development services via representatives of their organization. Emails contained a hyperlink to electronic consent forms and Phase 1 questionnaires.

Child case selection criteria for Phase 2 were that the child had a diagnosis resulting in neurodisability, was aged between 0 and 16 years and teledelivery of rehabilitation had occurred at least once during the 6‐week data collection period. Exclusion criteria for case selection were any current forensic circumstance with the family. Written consent for parents to participate in interviews was obtained by treating practitioners. A sample size of six practitioners, with casenotes examined for up to four child cases was sought (total n = 24), with 25% Māori child cases (n = 6). This size of sample was expected to provide indicative context‐mechanism‐outcome configurations (CMOcs) of the conditions that facilitate teledelivered rehabilitation.

4. MEASURES

4.1. Phase 1 measure

The DIBQ (Huijg et al., 2014) measures 18 domains of behavioural determinants outlined in the TDF (Michie et al., 2011), thus indicating the context of knowledge, beliefs, skills, resources and social context of the delivery of FACE T‐Rx of practitioners. The DIBQ uses item‐stem methods, to enable the target, action, context and time of behaviours, to be modified to be relevant to specific research enquiries. In this current study, the target (Ta) was children with neurodisability and their family; the action (A) was telehealth; the context (C) was paediatric rehabilitation; and time (T) was the point or episode of clinical care. An example root DIBQ questionnaire item is as follows: ‘I have the skills to [A] in [C, T] with [Ta]’. In this study, the wording was completed as follows: ‘I have the skills to use telehealth [A] in my work [C, T] with children with neurodisability and their family [Ta]’. Each item was rated on a 7‐point scale from Strongly Disagree (=1) to Strongly Agree (=7). The original 79‐item DIBQ was considered by the working party to be too long to achieve an adequate response rate; thus, two rounds of blind voting by the working party were undertaken to select what each member perceived as the most informative items for each domain (to keep) and most duplicitous items (to delete). Subsequently, a 24‐item DIBQ, with one to two items for each domain resulted. Given the DIBQ items cannot be summated in the absence of psychometric evidence, reduction of items did not influence analysis or reporting. All DIBQ items used in this project are provided in the Supporting Information.

4.2. Phase 2 measures

The casenote audit tool (see Supporting Information) comprised items that indicate each of the five FACE T‐Rx core components, the dose, tailoring and location of intervention provided that thus afforded a proxy fidelity indicator of the extent that best practice family‐centred telehealth was being delivered. The casenote audit also included any PROM's gathered, child and family demographics, and travel time from service centre. Two PROMS specifically included in the FACE T‐Rx training and audit, the Session Rating Scale (SRS; Duncan et al., 2003) and the Goal Based Outcome Measure (GBO; Wolpert et al., 2012), and are thus described below. Both PROMS have been recommended for clinical practice to enact and monitor key aspects of family‐centred care (Duncan et al., 2003; Wolpert et al., 2012).

The SRS is a clinical tool to describe and enhance the therapeutic alliance (Duncan et al., 2003), thus was presented during FACE T‐Rx training as helpful in attending to the relational elements of FCP. The SRS is a four‐item visual analogue measure with good internal consistency (.88), test–retest reliability (r = .64) and high utilization rates in clinical practice (96%) (Campbell & Hemsley, 2009). The GBO measures progress in child and/or parent identified priorities, as perceived by the recipient of care (Wolpert et al., 2012). Goal statements are developed through collaborative interview and rated by the client on a 10‐point scale in which 10 indicates full ability and 0 indicates inability (Wolpert et al., 2012). The casenote audit was completed independently by one co‐located peer of the treating practitioner and one geographically remote peer using Qualtrics, as an electronic data entry system. Two auditors also delivered telehealth; however, they did not audit their own casenotes (CDHB CDS).

4.3. Phase 3 measures

Interview data were collected via videoconferencing or telephone. Parents were interviewed by four colleagues of participating practitioners, who had no prior relationship with the family being interviewed. Practitioner interviews were completed by LS, a paediatric practitioner who did not work directly with any of the practitioners. Interviewers underwent 2‐h training in qualitative interviewing. A semi‐structured interview schedule was developed a priori (see Supporting Information). Interviews were transcribed manually by a professional transcription service.

5. ANALYSIS

5.1. Phase 1 analysis

Participant demographic data are reported as count and percent. Data from the DIBQ are presented for each of the 18 domains using a stacked horizontal bar chart.

5.2. Phase 2 analysis

Casenote data are reported descriptively (count, percent, mean, range). To determine if goals documented in casenotes reflected children's participation, examples were coded against the International Classification of Functioning, Disability and Health (ICF) (World Health Organization, 2001) using established methods for coding from casenote data (Graham et al., 2020) that drew on the principle that actions executed in the social (i.e. lived) environment reflect the concept of ‘participation’ (World Health Organization, 2013). Participation in life situations was therefore operationalized as a child or family activity executed in life contexts (i.e. home, school and community) stated either explicitly or if it was implicit in the activity description (e.g., sleeping). Activity descriptions without a life context indicated were coded as ‘activity’. Other ICF categories were coded using standard definitions (World Health Organization, 2013). Coding was undertaken independently by three of the authors, with differences resolved through clarification of coding rules.

5.3. Phase 3 analysis

Interview data were analysed using thematic analysis (Braun & Clark, 2013). Parent and practitioner data were analysed separately, then combined given overlap in themes. Thematic analysis was undertaken to understand participant perceptions of telehealth in relation to context, mechanisms and perceived outcomes. Both interview analysts (FG, MW) were experienced child development practitioners and experienced in qualitative analysis. Major themes are briefly described with extensive quotes provided in table format for themes and sub‐themes. Pseudonyms are used in all reporting.

5.4. Realist synthesis analysis

Following all other analysis, CMOcs were developed as narrative summaries (FG), refined through multiple discussions of findings with all authors and the project working group.

6. RESULTS

6.1. Participants

The online training was attended by 34 practitioners from 11 service sites. The DIBQ was then completed by an anonymous sample of CDS staff (n = 37) (see Table 3).

TABLE 3.

Practitioner demographics for DIBQ respondents (n = 37) and practitioners who were audited and interviewed (n = 5)

Demographic	Phase 1 DIBQ	Phases 2 & 3 Practitioners' casenotes audited & interviewed
Gender	n (%)	n (%)
Male	2 (5.4)	0
Female	35 (94.6)	5 (100)
Age range
20–29 years	7 (18.9)	2 (40)
30–39 years	9 (24.3)	1 (20)
40–49 years	13 (35.1)	0
50–59 years	7 (18.9)	2 (40)
60+ years	1 (2.7)	0
Ethnicity
European	34 (91.9)	5 (100)
Māori	1 (2.7)	0
Other (not specified)	2 (5.4)	0
Discipline
Speech‐language therapist	11 (29.7)	1 (20)
Occupational therapist	14 (37.8)	2 (40)
Physiotherapist	9 (24.3)	2 (40)
Conductor	1 (2.7)	0
Psychologist	1 (2.7)	0
Social worker	1 (2.7)	0

Note: Phase 2 and 3 participants are a subset of phase one participants.

Abbreviation: DIBQ, Determinants of Intervention Behaviour Questionnaire.

Casenote audits (n = 15) were completed for five practitioners, with 2–6 child cases audited per practitioner (see Table 4). Two casenotes for Māori children were audited. Interviews were completed with all practitioners whose casenotes were audited and all parents who consented to be interviewed (8/15, 53%), including one parent of Māori ethnicity.

TABLE 4.

Characteristics of children (n = 15) whose casenotes (n = 33) were audited and parents interviewed (n = 8)

Characteristics	Children	Parents
Gender	N (%)	N (%)
Female	4 (27)	7 (100)
Male	9 (60)	1 (14) a
Ethnicity
Māori	2 (13)	1 (14)
Pacifica	2 (13)	1 (14)
Asian	3 (20)	2 (29)
NZ European	8 (53)	3 (43)
Diagnosis
ASD	1 (7)
Cerebral palsy	1 (7)
Chromosomal abnormality	3 (20)
Global developmental delay	6 (40)
Prematurity	1 (7)
Other neuro‐developmental disorder	3 (20)
Child age (years)
<1	1 (7)
1–2	4 (27)
3–5	3 (20)
6–10	6 (40)
15 years	1 (7)
Travel time from service base (min)
0–15	9 (60)
16–30	4 (27)
31–45	1 (7)
106–120	1 (7)

Abbreviation: ASD, autism spectrum disorder.

^a One interview occurred with both mother and father.

6.2. Phase 1 results

Use of telehealth among practitioners varied with 32/37 (87%) reporting currently using and most (29/37, 78%) intending to use it. Yet, only half of practitioners reported daily or weekly use (16/33, 53%). Despite modest use of telehealth, most practitioners intended to use it. Perceived knowledge about telehealth (17/35, 49%) was high, whereas perceived skills in applying it (5/35, 14%) were low. Organizational support to implement telehealth was considered inadequate by most (22/36, 61%). In contrast, professional culture was perceived as supportive of telehealth by most (22/37, 60%). Few practitioners had strategies in place to regulate their implementation of telehealth (i.e. a plan for using it; 7/35, 20%). See Figure 1 for responses per DIBQ item.

FIGURE 1.

Illustrates responses from the Determinants of Implementation Behaviour Questionnaire (DIBQ) by front line practitioners in child development services

6.3. Phase 2 results

An absence of detail in most casenotes resulted in substantial missing data from the casenote audit to indicate delivery of FACE T‐Rx. Strength of therapeutic alliance, indicated in SRS scores, was reported in 9/33, 27% of casenotes, with strong therapeutic relationships reported (M > 9 for all four items: range 9.4–9.7). Goals were documented for 11/15 (73%) of cases. Goals reflected ICF domains of activity (11/29, 38%) participation (10/29, 35%), impairments (2/29, 7%), environmental change (3/29, 10%) or were uncodable (3/29, 10%) (see Table 5). Goal progress was not documented for any goal. Extent of parent or child active engagement during telehealth or between sessions was not able to be reliably extracted from casenotes.

TABLE 5.

Goal statements documented in casenotes

Site	Practitioner (profession)	Case	Goal statement	ICF code
1	1 (PT)	1	Create a daily routine so that [child] sits less and is more independent with ADLs.	Participation
			Return to playing basketball this term.	Participation
			Achieve bed transfers without bed lever.	Activity
1	1	2	No goals documented	‐
1	1	3	Improve dorsa‐flexion range	Impairment
			Work on lunge technique	Environment
			Glute strengthening	Impairment
1	1	4	No goals documented	‐
1	1	5	To see how gross motor skills and overall development going.	Uncodable
1	1	6	Achieve pre‐op function and ROM a in 4 months	Impairment
			Use standing frame	Activity
			Use walking frame.	Activity
2	2 (OT)	1	Do wees on the toilet by himself.	Participation
			Dressing himself in shorts	Participation
2	2	2	Delayed language	Uncodable
			Numeracy/literacy	Uncodable
			Going to new places	Participation
			Learning to share in play	Participation
			Going out in public	Participation
			Leaving something fun	Participation
2	3 (PT)	3	No goals documented	‐
2	3	4	Independently stepping/walking and to progress these skills further	Activity
2	3	5	To reduce the amount of times child rolls her ankles and trips each day	Activity
			To do an independent handstand on the ground	Activity
			To walk 45 min in hilly park area.	Participation
2	3	6	Crawling forwards.	Activity
			Sitting up independently from the floor.	Activity
			Cruising along couch side.	Activity
			Long‐term goal of independent walking.	Activity
2	4 (OT)	7	No goals documented	‐
3	5 (SLT)	1	Use single words to request activity of choice	Participation
			Following one‐step instructions	Activity
3	5	2	Child will be modelled total communication, and use same strategies for expressive language	Environment

Abbreviations: ADLs, activities of daily living; ICF, International Classification of Functioning, Disability and Health.

^a Range of Motion (ROM).

6.4. Phase 3 results

Five major themes in practitioners' and parents' experiences of telehealth emerged: (1) I'd recommend you try it, (2) I felt listened to, (3) Motivated to enable access, (4) It's a tool not a go‐to and, (5) When not to telehealth. Each theme relates to context, mechanism or outcomes and includes sub‐themes (see Table 6 for subthemes and quotes).

TABLE 6.

Interview themes and quotes from practitioners and parents

Major theme	Subtheme	Illustrative quote
I'd recommend you try it		‘She [practitioner] asked me if I felt comfortable doing a zoom one, instead of trying to link up a time that would work for both of us, to see each other in person. It did work better’ (Kristy, parent).
	Easy once you know how	‘So we just say, “would you like to come into the clinic, would you like a home visit, or would you like telehealth?” It's just become very standard’ (Kate, physiotherapist).
	Easier scheduling	‘Because [practitioner] works limited hours herself, and then I work fulltime and I'm only home one day a week with the kids. Lining up, online, seemed to work better for both of us. She asked me if I felt comfortable doing a zoom one, instead of trying to link up a time that would work for both of us, to see each other in person. It did work better’ (Kristy, parent).
	Time and timing	‘It [telehealth] really helps with keeping the momentum with the intervention, the goal strand that you are working on, because you can actually keep that connection going with the family … from the therapist's point of view, you can see more people, you can get more work’ (Maddy, occupational therapist).
		‘It saves time and effort travelling to the Centre, especially when it's cold and wet’ (Sophie, parent).
	Clearer view of real life	‘Then we were able to move the computer to watch him; so that she could still monitor him and pick up on all the cues and steps that he's been taught. I think it still worked really well. She was like still in the room, if that makes sense’ (Kristy, parent).
	Promotes active involvement	‘She's very hands on so she'll do an example of what she would like [child] to do and then we do it which is really good. I find her really great’ (Sam, parent).
		‘In some ways it's quite good if you aren't there on the spot because the parents have to be a bit more active and engaged with the children too’ (deb, physiotherapist).
I felt listened to		‘I've trusted it [telehealth] and I've enjoyed it because I still feel like she has a good idea of what I'm trying to say and explain and a good idea about my wee boy, and so I feel listened to. If I was getting advice, I'm like, “you do not even know him, you have never met him,” that would get really frustrating to me and I would want to say, “I'm going to bring him in so you can spend time [with my child]”’ (Rosie, parent).
		‘To a family with lots of appointments, lots of things going on, just the ability for me to be able to check in regularly and for mum to just actually unload what was happening’ (deb, physiotherapist).
	Collaborative approach	‘It [telehealth] was exactly the same [as in‐person]; talking about his goals and reviewing what he had been doing, and identifying areas that he still needs some help with. So, still like the same kind of agenda as it would be in person’ (Kristy, parent).
	Connection is critical	‘…if you do not have a good relationship from that initial hit [in‐person contact], I feel you could feel like you are being let down or just brushed off because all we are getting is the quick interactive zoom meeting. And if you feel like, they cannot be bothered coming round to help us, you are not actually going to be proactive to go, “let us have a crack at this.” if you do not understand it or see the benefits from it you'll just be like, “they cannot be bothered coming round. We really need some help. All we get is a phone call and a meeting. They do not do anything”’ (Steve, dad).
		‘So, having that follow up stuff, she's very contactable as well and always gives the option of, “do you want to meet face‐to‐face or make another phone call?” so, she constantly gives me the option, “you know that we can meet up if you need to, but if you are happy to just keep talking on the phone”’ (Rosie, parent).
Motivated to enable access		‘We just need to keep thinking about different ways to make it work better for the families, and I think there's plenty of scope for that’ (Maddy, occupational therapist).
	Future‐proofing	‘I think it's useful in the sense that lockdowns can happen again at any time, so offering kind of a range of services that can continue still during periods like that is really useful’ (Kristy, parent).
		‘That was probably the biggest outcome and that's what a lot of the clients noted, was considering the impact of the lockdown last year, if we were to go into a lockdown again they'd be happy to still receive treatment via telehealth as opposed to having nothing’ (Kate, physiotherapist).
	Reducing burden	‘To actually just be able to slot it in at a time of day that worked for them meant that they could actually engage in our service and engage in that therapeutic goal setting and whole intervention’ (Sarah, physiotherapist).
It's not a go‐to tool; hybrid works best		‘Everyone learns and takes an interest from different aspects, audial, visual and the hands on. I can see how people get disheartened if you have a really good first consult and then the go‐to is, “Here's half a dozen videos. This will lead you into something,” and it's like, “no. That's why we have called you or we have asked for help. I want someone to come and visit me. Help me”’ (Sam, parent).
		‘I would say there's pros and cons for both, like all different modalities. It's just another tool in the toolbox’ (deb, physiotherapist).
	Rapport better in person	‘If the person is already known to the client it is useful, but I would really like them to have an initial appointment with the clinician to help, because it is important to see the client and the family and a talking person. You have better engagement that lasts, or that you need to develop, to go ahead with the staff’ (Georgia, parent).
		‘So they [children] did not feel I was quite as present because I was either looking at exercise programmes or typing notes up as I went, which is nothing different to what I would do if they were here, I'd just be scribbling on a piece of paper, but I found that they were more aware that it was a session they have to focus in, whereas when I'm interacting one‐on‐one with them in the gym to keep them engaged I can just play games with them and they do not notice that it's a therapy session’ (Kate, physiotherapist).
When not to telehealth		‘When there was (sic) issues or things going wrong with the technique it was quite hard to adjust over the phone or over telehealth’ (Kate, physiotherapist).
	Physical assessments/equipment	‘I think that when she goes to change her programme because she'll need to have more exercises a bit later on, then it would be of an advantage to see [practitioner] so she can run through them with her and show her how to do them correctly… You have got to be shown the correct way to do it, and I do not know necessarily that you could do that over a conversation over telehealth’ (Olivia, parent).
		‘Where I have not offered it as well it's often if I'm setting up equipment like wheelchairs or standing frames. That stuff, I mean, you are delivering a product, so you have to be there on the spot. …. But there are certainly some moments where you just want to put your hands on the kids to help with the technique and you cannot’ (deb, hysiotherapist).
	Behaviour management	‘It's harder to manage like the behaviour of the children when you are still trying to be the parent in front of the screen and talk’ (Maddy, occupational therapist).
	Family violence	‘Actually, when there were family violence concerns that's when a parent actually stopped engaging with us and did not click on to her zoom links and did not reply even though we'd been talking on the phone, she just would not turn up for her appointment online because … whereas if we'd been there in person, we would have probably picked up on more of those external cues’ (deb, physiotherapist).
	Limited technology/ space	‘One of the downsides in our specific child development service I think it's finding breakout space. Like I work in a big office so I would have to organise a free treatment room or work from home to be able to do these telehealth interventions’ (deb, physiotherapist).
	Māori and Pacifica more reluctant	‘It feels like it's a lot harder for [Māori and Pacifica] families, like they want the in‐person they want the support, they want to build a relationship with you, and the way they traditionally do that is in person’ (Maddy, occupational therapist). ‘Some of the families, I think, I was just trying to blanketly ask all my families where it could be appropriate. There were some families who just wanted a face‐to‐face. They preferred a face‐to‐face in the home visit. Some of those did identify as being from a Māori ethnicity or background. Some of them, they just preferred being able to talk to someone on the spot and that was a preference, and we were still offering all options’ (deb, physiotherapist).

Theme 1, I'd recommend you try it, (outcome) reflected unanimity that telehealth was highly valued by parents and practitioners because it enabled greater access to therapy, particularly more timely and intensive access. The ease of scheduling for both practitioner and parent was a key facilitator of improved access. Parents and practitioners described the child/parent outcomes as ‘no different’ to in‐person delivery with the exceptions described in Theme 5. Quality of care improved through telehealth at times as practitioners gained insight into daily life and parents assumed more active roles during sessions. Two quotes illustrate this theme:

So we just say, ‘Would you like to come into the clinic, would you like a home visit, or would you like telehealth?’ It's just become a very standard (Kate, physiotherapist).

Then we were able to move the computer to watch him; so that she could still monitor him and pick up on all the cues and steps that he's been taught. I think it still worked really well. She was like still in the room, if that makes sense (Kristy, Parent).

Theme 2, I felt listened to (mechanism), captures multiple references to parents feeling respected and understood by practitioners and that this was intentionally facilitated by practitioners. Collaborative problem‐solving between parent and practitioner was also illustrated. Both practitioners and parents felt this style of communication was instrumental in the success of telehealth delivery. One quote illustrates this theme:

I've trusted it [telehealth] and I've enjoyed it because I still feel like she has a good idea of what I'm trying to say and explain and a good idea about my wee boy, and so I feel listened to. If I was getting advice, I'm like, ‘You do not even know him, you have never met him’, that would get really frustrating to me and I would want to say, ‘I'm going to bring him in so you can spend time [with my child]’ (Rosie, Parent).

Theme 3, Motivated to enabling access (context), reflects a valuing of telehealth by parents and practitioners. Telehealth was valued for the increased access it could afford those awaiting services, living rurally or during future pandemics. Motivation to improve access to telehealth was a salient condition in parent and practitioners' persistence through learning to use telehealth effectively. Two quotes illustrate this theme:

We just need to keep thinking about different ways to make it work better for the families, and I think there's plenty of scope for that (Maddy, occupational therapist).

I think it's useful in the sense that lockdowns can happen again at any time, so offering kind of a range of services that can continue still during periods like that is really useful (Kristy, Parent).

Theme 4, It's a tool not a go to: hybrid works best (mechanism), reflects a dominant perspective of parents and practitioners that telehealth was accepted by parents and could work only if it was offered as a choice for each family and for each therapy session. Telehealth was recognized as an important tool, and a critical professional skill, but that its usefulness would be rejected by families or undermined without trust in practitioners' skill and understanding of their child and parents' priorities (see Theme 2). Trust was raised by some (non‐Māori) practitioners as contributing to their reluctance to offer telehealth to Māori, given a perception that trust was more easily fostered with Māori through in‐person contact. One quote illustrates this theme:

I can see how people get disheartened if you have a really good first consult and then the go‐to is, ‘Here's half a dozen videos. This will lead you into something’, and it's like, ‘No. That's why we have called you or we have asked for help. I want someone to come and visit me. Help me’ (Sam, Parent).

Theme 5, ‘When not to telehealth’ (context), represents the pragmatic examples of when telehealth was perceived as not appropriate or as unsuccessful. This included when the resources for telehealth were not available, privacy could not be maintained or at times of change or crises for families. One quote illustrates this theme:

It's harder to manage like the behaviour of the children when you are still trying to be the parent in front of the screen and talk (Maddy, occupational therapist).

7. CMO CONFIGURATIONS

An explanatory theory is now presented as four CMOcs drawing from all three data sources outlining the context in which telehealth is offered to families by practitioners, how it was offered and patterns of responses associated with goal achievement.

CMO#1: Practitioners who were confident in offering telehealth (C), and who framed it as a choice (Mp) appeared to trigger family's decision to try telehealth (Mc), perceived as linked to wider access and greater dose of therapy to families (O). Conversely, parents described that if telehealth was the only option offered (Mp) they would feel ‘fobbed off’, perceiving telehealth as less valuable than in‐person delivery (Mc).

CMO#2: Initial in‐person delivery (C) was perceived to trigger high trust relationships with families (Mc) that were sustained over telehealth delivery. Trust in practitioners (Mc) and flexibility to return to in‐person delivery (Mp) appeared to be instrumental in telehealth delivery being perceived as successful (O).

CMO#3: Highly collaborative communication by practitioners and targeting improvement in children's participation in life situations (Mp) appeared to transition easily to teledelivery, affording advantages over in‐person therapy at times (O).

CMO#4: A perception of inadequate training, resource and organizational support, by many practitioners (C), may have failed to trigger practitioners to offer telehealth often or at all (Mp). Conversely, experimentation, failure and learning in the initial use of telehealth were experienced and considered normal by practitioners and parents who used it (C).

An infographic communicating CMO configuration is provided available at http://hdl.handle.net/10523/12775.

8. DISCUSSION

The aim of this study was to identify the conditions that facilitate telehealth for children with ND to improve children's participation in life situations. This study identified emergent CMOs that inform an explanatory theory of what triggers use of telehealth, how parents responded to this offer and how well telehealth improved access to therapy and enabled family goal achievement. Critical in triggering practitioners to offer telehealth to families (context) was their confidence to try telehealth despite uncertainty and inexperience and practitioners' motivation to make therapy accessible to more families. Practitioner confidence and flexibility to move between in‐person and telehealth, in turn, appeared to trigger parent willingness to try telehealth as an alternative to in‐person care. Parent and practitioner accounts within interviews of what was delivered by practitioners during telehealth indicate that FACE T‐Rx was partially implemented; intervention was relational and addressed participation‐focused goals about a third of the time. There was some indication that active engagement of families improved through teledelivery. Insufficient data pertaining to Māori were gathered to inform theory development of their needs or perspectives in relation to telehealth.

Greater offering of telehealth across community paediatric services is needed to move telehealth from its current realm of innovators and early adopters (Dearing & Cox, 2018) to standard care. Current organizational support for telehealth makes it possible but challenging to offer telehealth, with implementation relying on considerable intrinsic motivation of practitioners (to improve access to therapy) and compromise on personal comfort (i.e. inadequate training and workspaces). While service and professional cultures appear supportive if practitioners choose to use telehealth, targeted strategies that support implementation behaviours are needed to close the current intention‐to‐practice gap (Campbell et al., 2020). Findings informed by the TDF indicate that intensive, experiential and ongoing training including guided practice of telehealth is needed to overcome the hurdle of the uncomfortable and unfamiliar start to using telehealth. Clinician‐telehealth trainers, embedded within services, may be more effective and more sustainable than single training courses (Cox et al., 2021). Service policy and procedures that outline when, with whom and how to offer telehealth, including script examples for introducing telehealth to families, may enable practitioners to plan telehealth behaviour and self‐monitor, thereby refining skills and behaviour (National Institute for Health and Care Excellence, 2014). Tailored resources may be helpful in enhancing culturally competent offering of telehealth to Māori.

Collaborative practices, characterized by listening, respect, active parent involvement in intervention discussion, activity and decision‐making, are hallmarks of FCP (An et al., 2019) (King, 2009) and were evident in examples of parent–child–practitioner interaction reported in this study. These relational aspects of FCP appeared to be pivotal to parents' trust in practitioners that telehealth could work and once experienced, felt familiar. The atypical (Anaby et al., 2017; Graham et al., 2020) but universally applied collaborative/coaching style used by practitioners in this study may also therefore contribute to the context of practitioners' uptake of telehealth, given a collaborative approach is more amenable to telehealth delivery (Camden et al., 2020; Rosenbaum, Silva, & Camden, 2021). Practitioners' collaborative approach included presenting telehealth as a choice, which families in this evaluation acted on by moving between in‐person and telehealth delivery. A hybrid approach such as this has been suggested elsewhere as optimal (Camden & Silva, 2020) and is supported by our findings.

Targeting of improved participation in life situations may also be more amenable to telehealth than a focus on children's impairments or activities. Interview data suggested that therapy was mostly directed at addressing life situations, for example, play, meal times and moving to valued activities; however, goal‐related content in casenote data indicated a greater focus on impairments and activity performance. Future quantitative research examining the specific content of what is delivered by practitioners would provide value insight into the process and outcome of telehealth in paediatric rehabilitation.

Access to therapy occurred more quickly and frequently for those who took up the offer of telehealth, largely because scheduling was easier. It is unclear if telehealth altered the total amount of therapy delivered, but it appeared to affect two other key parameters of dose: duration of sessions (decreased) and intensity (increased) as observed in other studies of telehealth (Galloway et al., 2019; Rosenbaum et al., 2021). Findings prompt a reconsideration of dose‐parameters of interventions when delivered by telehealth versus in‐person. The impact of telehealth on access for Māori remains an important unanswered question.

9. STRENGTHS AND LIMITATIONS AND FUTURE DIRECTIONS

The value of casenotes to retrospectively indicate practitioner input fidelity to FACE T‐Rx was limited. Prospective casenote entry may have resulted in more complete information and be a valuable strategy for audit‐feedback cycles. Ideally, future research would establish key components of the intervention delivered through video/audio recordings of sessions.

Classification of goal statements in the analysis of the mechanisms of telehealth adhered to ICF definitions of impairment, activity and participation; however, more nuanced definitions have since been proposed that data could have been analysed against. Contemporary conceptualization of participation outcomes increasingly emphasizes a distinction between improved activity competence (e.g., toileting more independently) and expanded participation in life situations in which greater attendance and meaningful involvement are targeted (e.g., playing basketball) (Imms et al., 2016). It is noteworthy that interview data suggested more focus on attendance and involvement than practitioners documented in casenotes. It may be that professional contexts orientate practitioners to impairments despite a relatively strong orientation to participation when engaging with families.

This evaluation focused on how telehealth was being applied rather than how it could be applied; thus, alternative models to in‐person forms of engagement with families (such as one‐to‐many models) were not discussed.

Although three Māori participated in this evaluation, data collection processes were insufficiently sensitive to determine if culturally specific needs influenced the response to telehealth. A future study solely exploring telehealth in relation to the experiences and needs of Māori and needs of health professionals in working effectively with Māori is warranted. Assessment of health professionals' cultural competence by families receiving services would be a valuable component to this investigation.

10. CONCLUSION

This realist evaluation explored the use of telehealth with families of children with neurodisability in community‐based child development services to identify the context and mechanisms of telehealth delivery to improve access to services and outcomes for children. Access to therapy improved, and child outcomes of interventions were perceived to be equivalent to in‐person delivery. A minority of practitioners felt equipped to offer telehealth to families. Practitioners that do offer telehealth were motivated to enable access, were highly collaborative in their therapeutic approach and were willing to move between in‐person and telehealth delivery.

CONFLICT OF INTEREST

No conflicts to declare.

Supporting information

Data S1: Supporting Information.

Graham, F. , Williman, J. , Sutherland, L. , & Wijninckx, M. (2023). Telehealth delivery of paediatric rehabilitation for children with neurodisability: A mixed methods realist evaluation of contexts, mechanisms and outcomes. Child: Care, Health and Development, 49(1), 156–169. 10.1111/cch.13028

DATA AVAILABILITY STATEMENT

Data are not available due to restrictions imposed by ethical review boards.