Digital Psychosocial Follow-up for Childhood Critical Illness Survivors: A Qualitative Interview Study on Health Professionals’ Perspectives

Expert interviews with health professionals with insight into psychosocial follow-up for childhood critical illness survivors were utilized to gather specific knowledge of the digital potential (20). This study design has also been used in a similar study to identify health professionals’ perspectives on the potential for digitalizing a healthcare process (21).

The Division of Paediatric and Adolescent Medicine at a Norwegian public hospital, treating children and adolescents below the age of 18, served as the primary site of recruitment for health professionals who work with childhood critical illness survivors. The first author recruited health professionals through hospital-provided phone numbers and mail addresses, using a combination of snowball and purposive sampling methods to ensure diverse perspectives. The demographic information of the interviewees can be found in Table 1. To enhance the study’s trustworthiness, the interviews were triangulated (22) with stakeholders covering the five most prominent roles concerning the psychosocial follow-up of childhood critical illness survivors. Out of the hospital’s eight departments that interact with children with critical illness, the interviewees worked across three departments; the most relevant departments for the subsequent phase of this research project focuses on a target group from the surgery department. The interviewees provided informed consent to be able to participate in the audio-recorded interviews.

From February to March 2022, the first author collected the data utilizing semi-structured interviews to maintain a general structure while allowing the interviewees to discuss aspects not initially considered (23). The main topics covered in the interview guide included: 1) the current psychosocial follow-up for the childhood critical illness survivors at the hospital, 2) the psychosocial needs of the survivors, and 3) the hospital’s experiences with digital solutions. Different perspectives were gathered through both group and individual interviews. I2 was included in a group interview with I1 at I1’s request, while the remaining interviews were conducted individually. Using an iterative data collection and analysis strategy, interviews were conducted until no new codes were identified. Interviews were conducted in Norwegian and lasted between 24 and 45 minutes. Due to the COVID-19 pandemic, the interviews were performed digitally and audio-recorded on the video communication platform Zoom because it is the preferred and licensed platform for the hospital. The first author verbatim transcribed a total of 2 hours, 50 minutes, and 55 seconds of audio recordings of the interviews in the word processing software Microsoft Word. Moreover, these transcriptions were anonymized for analysis.

The first author analyzed the Norwegian transcriptions using the software NVivo Release 1.7 and Braun and Clarke’s six-phase framework for thematic analysis (24), applicable in qualitative health research (25). These phases included: 1) familiarizing with the data, 2) generating initial codes, 3) searching for themes, 4) reviewing the themes, 5) defining the themes into a model, and 6) writing the research by including quotes that were the most representative of the findings (24). An inductive approach was utilized to ensure that the generated codes and themes were strongly linked to the data (24). Concurrent data collection and analysis were employed for Phases 1 through 4 to identify emergent themes and construct a model. Following each interview, emergent themes were discussed with the other authors. After interviewing I6, it was observed that this final interview yielded no new codes, leading to the decision to terminate the data collection process. Phases 5 and 6 of the analysis were then completed, and the extracted data and model were translated into English. All authors agreed on the model and the presentation of the research.

The first main theme, Affecting Factors, was divided into the sub-themes Demographic (Table 2) and Environmental (Table 3). These factors affect the psychosocial follow-up for childhood critical illness survivors at the hospital and, consequently, the potential for the adoption of digital psychosocial follow-up.

The second main theme, Digital Usage, was divided into the sub-themes of Limitations (Table 4) and Opportunities (Table 5) for digitalizing childhood critical illness survivors’ psychosocial follow-up at the hospital.

The interview findings indicated that different demographic factors affect the current psychosocial follow-up. The interviewees expressed that the psychosocial follow-up could vary with both age and medical condition in terms of content and frequency. These findings expand on previous research, which emphasized medical condition (28) and age (17, 29) as affecting factors for psychosocial follow-up, by underscoring the significance of both factors in the same study. Furthermore, this aspect points to the importance of the personalized dimension of P5 medicine (1) in a digital solution for psychosocial follow-up. Similar qualitative research also reflects this need for tailored solutions (17, 26, 30), and a review of personalized intervention for youth mental health further supports this idea by calling for tailored treatments to optimize patient outcomes (31).

Regarding the gender of the child, the interviewees indicated boys are more likely to withdraw from the psychosocial follow-up. This tendency is in line with a systematic literature review of factors associated with males’ low medical and psychological help-seeking rates that identified that adherence to traditional masculinity norms like emotional control reduces males’ willingness to seek help (32). One interviewee also outlined that the child’s residence is another factor involving a tendency for increased risk of less psychosocial follow-up for a specific group: people living far from the hospital. This observation of residence as an affecting factor for psychosocial follow-up is directly in line with other related studies (17, 28), and a recent literature review finding people’s probability of using psychiatry services decreased as the distance to the offer increased (33). Thus, adapting of digital solutions should prioritize solutions including boys and children living far from the hospital.

Moreover, the interview findings revealed that a child’s current psychosocial follow-up is affected by environmental factors— family and health professionals. This points to the significance of considering the participatory dimension of P5 medicine (1) in a digital solution for psychosocial follow-up, as seen in a German expert interview study targeting a similar population about psychosocial follow-ups for survivors of rare diseases (29). To ensure the adoption of such a digital solution, family and health professionals, important stakeholders in the child’s psychosocial follow-up, should be involved in the design process along with the child. Health professionals’ support is especially essential for implementing such digital solutions into their practice (13).

Research on patients’ willingness to adopt telehealth during COVID-19 found that their health professionals’ attitudes could impact this willingness (34). Similarly, a meta-analytic literature review on dropout in child and adolescent psychiatry found higher effect size on factors related to the child’s health professionals as a dropout predictor compared to factors related to the family (35). The interview findings highlighted that medical doctors primarily determine whether a child should receive a psychosocial follow-up offer, and the timing of when the health professional gives this offer could also affect the decision. This finding is broadly in line with a qualitative Australian study on health professionals’ perspectives on digital psychosocial follow-up for childhood critical illness survivors, highlighting a need to offer such solutions early (17).

Regarding the child’s family, the interviewees explained that it is not the child but its guardians or parents who get or have the authority to request the offer until the child is 16 years old. Moreover, the whole family plays a crucial role in the health professionals’ evaluation of how the child’s offer should be. The cultural background of the family also influences the utilization of psychosocial follow-up, with immigrant families tending to use it less than non-immigrant families due to a fear of the child protection service in Norway. The fear of a connection between the Norwegian welfare system and the child protection service has also been reported in the literature (36). This resonates with literature reviews finding a medium effect size on minority status and cultural barriers as dropout predictors for psychosocial follow-up (35, 37). Thus, the adoption of digital solutions should prioritize the inclusion of diverse cultures.

The interviewees pointed out the lack of digital solutions incorporated into the Norwegian hospital, which could make it challenging to introduce a new digital solution for psychosocial follow-up for childhood critical illness survivors. Digital solutions for mental health have low uptake in healthcare despite the potential to decrease cost and increase accessibility (13). The interviewees mentioned the digital platform “HC And”, VR, and telehealth as successful examples of digital solutions that could inspire a solution for digital psychosocial follow-up and persuade skeptical stakeholders. Digital transformations in healthcare are traditionally considered slow because of healthcare’s complex organization, high amount of sensitive data to handle, high resistance toward digitalization, and low degree of user-friendly digital solutions (38). It is important to design, assess, and certify widely available training programs for health professionals to address their most essential needs in implementing digital mental health interventions in their practice (13, 14). Therefore, the digitalization process of a solution for digital psychosocial follow-up needs to be as long as necessary to train health professionals’ adaption. However, children’s current digital life with high digital skills, pinpointed by the interviewees, could make it easier to introduce them to digital solutions compared to the stakeholders in other age groups.

The interview findings pinpointed that the ongoing digitization of the entire hospital and the rapid digitization with video meetings during the COVID-19 pandemic can also aid in adapting digital solutions for psychosocial follow-up. The latter digitization process was beneficial for some children who are harder to reach physically, such as those with medical conditions that make social settings challenging, older children, and those living far from the hospital. This positive experience of telehealth as more accessible aligns with previous research about specific groups responding positively to the forced digitalization of psychosocial follow-up during the COVID-19 pandemic (39, 40). Qualitative research on health professionals’ experiences with digitalization during the COVID-19 pandemic also found that digital solutions could address communication challenges related to the transition between hospital and home that existed before the pandemic (41). Therefore, the present study adds to the current hope in psychiatry and psychology that this pandemic-driven digitalization process with telehealth could transform psychosocial follow-up (40, 42,43,44). Besides, exploiting the continuous development of child and adolescent psychiatry in hospitals can enhance children’s engagement in digitalization. This development can involve incorporating a hospital’s artifact in a digital solution for psychosocial follow-up for childhood critical illness survivors.

However, one interviewee pointed out that relationship-building can be worse with video communication compared to face-to-face for some children. These findings are consistent with similar research where health professionals are concerned about missing non-verbal cues in digital solutions (15, 26). Thus, digital psychosocial follow-ups should be hybrid solutions that also includes children who struggle with video communication.

Previous research regarding the health professionals’ and patients’ experience of the pandemic-driven digitalization of telehealth highlighted that telehealth mostly worked well if the patient and health professional had previously met face-to-face (40). Regarding web-based psychological treatments for adults, health professionals also preferred hybrid solutions (13). One interviewee also pinpointed the importance of a hybrid solution, stating that children’s screen time is already high and obsession with the digital world could cause them to forget real-world necessities.

This study’s single-site design may restrict the generalizability of the results to other hospitals. Conducting a multi-site study involving hospitals with varying psychosocial follow-up and digital situations could help explore the broader applicability of these findings. The present study concluded with six interviewees because the last interview yielded no new codes. This sample size aligns with Braun and Clarke’s recommendation of a minimum six interviewees for small research projects utilizing thematic analysis (45). Furthermore, prior qualitative health research has demonstrated that six interviewees could be sufficient to achieve saturation in thematic analysis (46, 47), particularly for expert interviews (48, 49).