A mixed methods realist analysis of telehealth delivery of complex wheelchair assessment in Aotearoa New Zealand: contexts, mechanisms, and outcomes

This study examined telehealth delivery of complex wheelchair assessment in Aotearoa New Zealand, specifically: what works, for whom, and in which contexts, with exploration of culturally specific factors for indigenous Māori. A mixed methods realist evaluation was conducted with remote specialist assessors (physiotherapists and occupational therapists), on-site assistants, and wheelchair users. Interviews/focus groups, mobility goal achievement, satisfaction, and fidelity of tele-delivered assessment of wheelchair and seating (tAWS) contributed to Context-Mechanism-Outcome configurations (CMOc). Four remote specialist assessors delivered tAWS, but it was declined by on-site assistants in 78% of cases in which specialist assessors perceived it could work. When tAWS was delivered to wheelchair users (<i>N</i> = 5), the majority of goals were achieved, with high service satisfaction. CMOc’s highlight the influence of system design in the uptake of telehealth by health professionals. While therapists can navigate complexity for successful tAWS, therapist and system barriers limit its uptake, particularly confidence in conducting assessment and use of technology among the non-adopters. Telehealth specific training in culturally-responsive rehabilitation is recommended. This evaluation contributes to telehealth program theory and the mechanisms to be addressed for telehealth to meet its potential to enhance equity in health outcomes. Appropriately fitted wheelchairs are an essential tool for participation in society for those who need them.Access to specialist assessors to undertake complex wheelchair and seating assessments is extremely limited in many health systems, particularly for indigenous people, such as Māori.Tele-delivered wheelchair assessments by trained and experienced assessors can improve access and equity in receiving services for wheelchair users.Barriers to uptake of tele-delivered wheelchair assessment related to system design disincentivising use of telehealth, and low confidence of on-site (allied health) assistants. Facilitators included high trust between specialist and onsite assessors and their orientation to learning and meeting wheelchair users’ needs.Tele-delivered wheelchair assessment warrants further research to determine its effectiveness when implementation barriers are addressed. Appropriately fitted wheelchairs are an essential tool for participation in society for those who need them. Access to specialist assessors to undertake complex wheelchair and seating assessments is extremely limited in many health systems, particularly for indigenous people, such as Māori. Tele-delivered wheelchair assessments by trained and experienced assessors can improve access and equity in receiving services for wheelchair users. Barriers to uptake of tele-delivered wheelchair assessment related to system design disincentivising use of telehealth, and low confidence of on-site (allied health) assistants. Facilitators included high trust between specialist and onsite assessors and their orientation to learning and meeting wheelchair users’ needs. Tele-delivered wheelchair assessment warrants further research to determine its effectiveness when implementation barriers are addressed.

本研究针对新西兰（奥特亚罗瓦）境内的复杂轮椅评估远程医疗服务开展考察，具体聚焦于“何种方案有效、适用人群及应用场景”，并探索针对原住民毛利人的文化特异性影响因素。本研究联合远程专科评估师（物理治疗师与作业治疗师）、现场助理及轮椅使用者开展混合方法实在论评估。通过访谈/焦点小组、移动目标达成情况、服务满意度及轮椅与座椅远程评估（tAWS）的实施保真度数据，构建了“情境-机制-结果”配置（CMOc）框架。共有4名远程专科评估师开展了tAWS服务，但在评估师认为可行的场景中，有78%的案例被现场助理拒绝。当tAWS服务面向轮椅使用者实施时（样本量N=5），绝大多数移动目标得以达成，且服务满意度较高。CMOc框架凸显了系统设计对医疗从业者采用远程医疗服务的影响。尽管治疗师能够应对复杂流程以成功开展tAWS服务，但治疗师自身及系统层面的障碍限制了该服务的推广，其中未采用者尤为突出的问题包括评估实施信心不足以及技术使用能力欠缺。建议开展针对文化适配性康复的远程医疗专项培训。本评估丰富了远程医疗项目理论，并明确了远程医疗需通过优化相关机制以充分发挥其提升健康结局公平性的潜力。适配恰当的轮椅是有需求人群参与社会生活的必要工具。在诸多医疗系统中，获取专科评估师开展复杂轮椅与座椅评估的渠道极为有限，对于毛利人这类原住民群体而言尤为如此。由训练有素且经验丰富的评估师开展的轮椅远程评估，能够改善轮椅使用者获取服务的公平性与可及性。轮椅远程评估服务的采用障碍主要与系统设计不利于远程医疗使用、现场（辅助医疗）助理信心不足相关。促进因素则包括专科评估师与现场助理之间的高度信任，以及双方秉持的学习意愿与满足轮椅使用者需求的导向。轮椅远程评估服务值得开展进一步研究，以明确在解决实施障碍后的实际效果。适配恰当的轮椅是有需求人群参与社会生活的必要工具。在诸多医疗系统中，获取专科评估师开展复杂轮椅与座椅评估的渠道极为有限，对于毛利人这类原住民群体而言尤为如此。由训练有素且经验丰富的评估师开展的轮椅远程评估，能够改善轮椅使用者获取服务的公平性与可及性。轮椅远程评估服务的采用障碍主要与系统设计不利于远程医疗使用、现场（辅助医疗）助理信心不足相关。促进因素则包括专科评估师与现场助理之间的高度信任，以及双方秉持的学习意愿与满足轮椅使用者需求的导向。轮椅远程评估服务值得开展进一步研究，以明确在解决实施障碍后的实际效果。