The Role of Telemedicine Centers and Digital Health Applications in Home Care: Challenges and Opportunities for Family Caregivers

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

While the underlying idea is valuable, the current presentation of the findings is not suitable for academic reporting. I recommend rewriting the Results and Discussion sections to improve clarity, coherence, and relevance.

• Please explain clearly how the systematic literature review was conducted. In particular, describe the number of articles identified at each stage—after the initial title and abstract screening and after the full-text review. It would also be helpful to include a diagram (e.g., a PRISMA flowchart) to illustrate the selection process.
• The search strategy includes the terms ‘telemedicine’, ‘telehealth’, and ‘digital health application’. How do you define ‘digital health applications’ in this context? Are there additional key terms that should be included to ensure a comprehensive search? Please justify your choices, especially given the broad and evolving nature of digital health terminology.
• Could you please justify the sample size for both the quantitative and qualitative components of the study?
• The results and discussion section is currently very long and fragmented, and many subsections repeat similar ideas. From a reader’s perspective, the findings appear disconnected and difficult to follow. Could you please revise these two sections by synthesising related findings, reducing repetition, and presenting the results in a more concise and coherent structure?

The theoretical framework in the introduction is not clearly presented. Please identify the relevant literature and rewrite this section.

Comments for author File: Comments.pdf

Author Response

Comment 1:

While the underlying idea is valuable, the current presentation of the findings is not suitable for academic reporting. I recommend rewriting the Results and Discussion sections to improve clarity, coherence, and relevance.

Response 1:
Thank you for the comment, this has been addressed. The Results and Discussion sections have been comprehensively revised to improve clarity, coherence, and academic rigor. The findings related to digital health applications in the context of telemedicine are now presented in a more structured and focused manner, with a clearer distinction between results and their interpretation.

Comment 2:

Please explain clearly how the systematic literature review was conducted. In particular, describe the number of articles identified at each stage—after the initial title and abstract screening and after the full-text review. It would also be helpful to include a diagram (e.g., a PRISMA flowchart) to illustrate the selection process.

Response 2:
Thank you for the comment, this has been addressed. The methodology of the systematic literature review has been expanded to clearly describe the number of articles identified and excluded at each stage of the screening process, including title/abstract screening and full-text review. In addition, a PRISMA flow diagram has been included to visually illustrate the study selection process for research on digital health applications and telemedicine.

Comment 3:

The search strategy includes the terms ‘telemedicine’, ‘telehealth’, and ‘digital health application’. How do you define ‘digital health applications’ in this context? Are there additional key terms that should be included to ensure a comprehensive search? Please justify your choices, especially given the broad and evolving nature of digital health terminology.

Response 3:
Thank you for the comment, this has been addressed. The term “digital health applications” is now clearly defined within the manuscript and conceptually distinguished from telemedicine and telehealth. Furthermore, the search strategy has been refined and expanded by including additional relevant keywords, with a clear justification provided to reflect the broad and evolving terminology in the field of digital health.

Comment 4:

Could you please justify the sample size for both the quantitative and qualitative components of the study?

Response 4:
Thank you for the comment, this has been addressed. The sample sizes for both the quantitative and qualitative components of the study are now explicitly justified. The manuscript explains how the chosen sample sizes are appropriate for drawing meaningful conclusions regarding the use, acceptance, and perceived impact of digital health applications in a telemedicine context.

Comment 5:

The results and discussion section is currently very long and fragmented, and many subsections repeat similar ideas. From a reader’s perspective, the findings appear disconnected and difficult to follow. Could you please revise these two sections by synthesising related findings, reducing repetition, and presenting the results in a more concise and coherent structure?

Response 5:
Thank you for the comment, this has been addressed. The Results and Discussion sections have been substantially condensed and reorganized. Related findings on digital health applications have been synthesized, repetitive content has been removed, and the overall structure has been streamlined to enhance coherence, readability, and thematic consistency.

Comment 6:

The theoretical framework in the introduction is not clearly presented. Please identify the relevant literature and rewrite this section.

Response 6:
Thank you for the comment, this has been addressed. The theoretical framework in the introduction has been revised and more clearly articulated. Relevant literature and theoretical models related to the implementation, adoption, and use of digital health applications in telemedicine have been integrated to strengthen the conceptual foundation of the study.

Comment 7:

Overall, the structure looks very difficult for me to follow as a reader. Based on your mixed method, you can bring the results together. Then include discussion and other relevant paragraphs. For example, you used the term 'conclusion' several times, which is very confusing. Another point, for example, lines 216-22, lines 222-234, and lines 234-245, can be written in a paragraph.

Response 7:

The subsections relating to the conclusion in the results have been removed. Thank you for pointing this out.

Comment 8:

Line 56-57: You have mentioned the theoretical backgrounds, but it is not clear what you have tried to explain; there are existing theoretical models that could be applicable if necessary

Response 8:

The theoretical background has now been explained in more detail.

Comment 9:

Could you please explain why you have started doing a systematic literature review in this study, which is also another major work? You can do it; in that case, you need to be very specific and follow the guidelines. You need to synchronise your mixed-method results with the systematic literature review. I have also noticed that you have used a digital health application in the search strategy, which differs from telehealth; if not, please explain.

Response 9:

The background of the literature reference has been presented in more detail in the article.

Comment 10:

How does one qualitative case study justify your sample size?

Response 10:

The use of a single case study is not intended to reflect the entire group of family caregivers, but rather to serve as an example to illustrate the advantages of using telemedicine technologies and, above all, the connection to a telemedicine center.

Reviewer 2 Report

Comments and Suggestions for Authors

Currently, telemedicine centers and digital health applications play a significant role in home care in more developed societies. The article's topic is therefore highly relevant.

Here are some recommendations for improvement:

1- Although the article is well-written, it sometimes repeats some topics/ideas. It is therefore advisable to minimize these repetitions.

2- To avoid making the article too "dense" to read, tables or graphs with the data (including its processing) should be shown, which is perfectly easy to do since the SPSS data processing software was used.

3- As the authors mention, 58 participants is too few, but only 18 caregivers of family members using the technologies (telemedicine, health applications, etc.) is even more critical to the reliability of the data and consequently the results obtained.

This last item is difficult to improve, except with a new data collection and respective processing. Leaving that one aside, at least the previous two are recommended for improvement.

Author Response

Comment 1:

Currently, telemedicine centers and digital health applications play a significant role in home care in more developed societies. The article's topic is therefore highly relevant. Although the article is well-written, it sometimes repeats some topics/ideas. It is therefore advisable to minimize these repetitions.

Response 1:
Thank you for the comment, this has been addressed. Repetitive content across the manuscript has been carefully reviewed and reduced. Overlapping ideas related to telemedicine and digital health applications in home care have been consolidated to improve readability and ensure a clearer and more concise presentation of the findings.

Comment 2:

To avoid making the article too "dense" to read, tables or graphs with the data (including its processing) should be shown, which is perfectly easy to do since the SPSS data processing software was used.

Response 2:
Thank you for the comment, this has been addressed. Additional tables and figures have been included. These visualizations support a clearer interpretation of findings related to the use of telemedicine and digital health applications in home care settings and reduce textual density.

Comment 3:

As the authors mention, 58 participants is too few, but only 18 caregivers of family members using the technologies (telemedicine, health applications, etc.) is even more critical to the reliability of the data and consequently the results obtained.

Response 3:
Thank you for the comment, this has been addressed. We fully agree that the limited sample size, particularly the small number of caregivers using telemedicine and digital health applications, represents a significant methodological limitation. Unfortunately, it was not feasible to increase the sample size without conducting a new data collection. This issue has therefore been acknowledged and discussed in the Limitations section, including its potential impact on the reliability and generalizability of the results.

Reviewer 3 Report

Comments and Suggestions for Authors

I found the manuscript very novel and interesting. However, there are several limitations that the authors must address.

The small sample size (n = 58) and single case study restrict how far the findings can be generalized beyond this context; the authors should explicitly frame the results as exploratory and consider emphasizing the need for replication with larger, more diverse samples.

Recruitment via training courses and caregiver education programs likely favors more motivated and digitally open participants; the authors must discuss this sampling bias and, where possible, compare basic characteristics of participants with non-participant caregiver populations.

Telemedicine and DiGA use are largely self-reported, which may introduce recall and social desirability effects; it would be helpful to complement self-reports with objective usage data (e.g., app logs) in future work.

The description of the questionnaire development is solid, but the psychometric evaluation is limited to Cronbach’s α; the authors should consider adding factor-analytic evidence (e.g., construct structure, item loadings) to strengthen measurement validity.

The quantitative analysis focuses mainly on descriptive statistics and simple tests; the authors must consider using multivariable models (e.g., logistic or linear regression) to control for confounders such as age, education, and caregiving intensity.

The case study is rich but based on a single caregiver perspective, which narrows the interpretive scope; it would be helpful to clarify that the case primarily illustrates mechanisms and hypotheses rather than providing representative evidence.

The concept and functions of the telemedicine center (TMZ/TCC) are central but sometimes described in general terms; the authors must sharpen the operational definition (services, staffing, workflows) so that the structure can be better understood and potentially replicated.

Technology types and DiGAs are grouped broadly (monitoring, reminders, teleconsultation), but differences between concrete solutions remain somewhat vague; it would be helpful if the authors clarified whether certain classes of tools are particularly effective for specific clinical pictures (e.g., dementia vs. cardiovascular disease).

Barriers such as data protection concerns and technical complexity are mentioned but not systematically quantified or ranked; the authors should consider adding a clearer overview (e.g., frequency or severity ratings) to guide priority areas for intervention and training.

The link to established theoretical frameworks (e.g., TAM, UTAUT2) is noted in the methods but less visible in the results and discussion; it would be helpful if the authors more clearly mapped key findings back to specific constructs (e.g., effort expectancy, performance expectancy, facilitating conditions).

The implications for practice and policy are mostly focused on training and information campaigns; the authors must expand on structural recommendations for telemedicine centers (e.g., funding models, integration with primary care, standards for digital literacy support) to make the contribution more actionable for health system planners.

Comments on the Quality of English Language

Satisfactory

Author Response

Comment 1:

The small sample size (n = 58) and single case study restrict how far the findings can be generalized beyond this context; the authors should explicitly frame the results as exploratory and consider emphasizing the need for replication with larger, more diverse samples.

Response 1:
Thank you for the comment, this has been addressed. The findings are now explicitly framed as exploratory, and the need for replication with larger and more diverse samples is highlighted.

Comment 2:

Recruitment via training courses and caregiver education programs likely favors more motivated and digitally open participants; the authors must discuss this sampling bias and, where possible, compare basic characteristics of participants with non-participant caregiver populations.

Response 2:
Thank you for the comment, this has been addressed. Potential sampling bias related to the recruitment strategy is now acknowledged and discussed in the Limitations section.

Comment 3:

Telemedicine and DiGA use are largely self-reported, which may introduce recall and social desirability effects; it would be helpful to complement self-reports with objective usage data (e.g., app logs) in future work.

Response 3:
Thank you for the comment, this has been addressed. The reliance on self-reported data is now noted as a limitation, and future studies are recommended to include objective usage data.

Comment 4:

The description of the questionnaire development is solid, but the psychometric evaluation is limited to Cronbach’s α; the authors should consider adding factor-analytic evidence (e.g., construct structure, item loadings) to strengthen measurement validity.

Response 4:
Thank you for the comment, this has been addressed. The limited psychometric evaluation is acknowledged, and further validation is suggested for future research.

Comment 5:

The quantitative analysis focuses mainly on descriptive statistics and simple tests; the authors must consider using multivariable models (e.g., logistic or linear regression) to control for confounders such as age, education, and caregiving intensity.

Response 5:
Thank you for the comment, this has been addressed. The analysis is now framed as exploratory.

Comment 6:

The case study is rich but based on a single caregiver perspective, which narrows the interpretive scope; it would be helpful to clarify that the case primarily illustrates mechanisms and hypotheses rather than providing representative evidence.

Response 6:
Thank you for the comment, this has been addressed. The illustrative and hypothesis-generating purpose of the case study is now clearly stated.

Comment 7:

The concept and functions of the telemedicine center (TMZ/TCC) are central but sometimes described in general terms; the authors must sharpen the operational definition (services, staffing, workflows) so that the structure can be better understood and potentially replicated.

Response 7:
Thank you for the comment, this has been addressed. The operational description of the telemedicine center has been clarified.

Comment 8:

Technology types and DiGAs are grouped broadly (monitoring, reminders, teleconsultation), but differences between concrete solutions remain somewhat vague; it would be helpful if the authors clarified whether certain classes of tools are particularly effective for specific clinical pictures (e.g., dementia vs. cardiovascular disease).

Response 8:
Thank you for the comment, this has been addressed. Differences between technology types are now described more clearly, including their relevance for specific clinical conditions.

Comment 9:

Barriers such as data protection concerns and technical complexity are mentioned but not systematically quantified or ranked; the authors should consider adding a clearer overview (e.g., frequency or severity ratings) to guide priority areas for intervention and training.

Response 9:
Thank you for the comment, this has been addressed. Barriers are now more clearly summarized and discussed in terms of their practical relevance

Comment 10:

The link to established theoretical frameworks (e.g., TAM, UTAUT2) is noted in the methods but less visible in the results and discussion; it would be helpful if the authors more clearly mapped key findings back to specific constructs (e.g., effort expectancy, performance expectancy, facilitating conditions).

Response 10:
Thank you for the comment, this has been addressed. Key findings are now more explicitly linked to relevant theoretical constructs.

Comment 11:

The implications for practice and policy are mostly focused on training and information campaigns; the authors must expand on structural recommendations for telemedicine centers (e.g., funding models, integration with primary care, standards for digital literacy support) to make the contribution more actionable for health system planners.

Response 11:
Thank you for the comment, this has been addressed. The implications section has been expanded to include structural and policy-related recommendations.

Comment 12:

https://doi.org/10.3390/healthcare11091268
The author must review and add this manuscript. 

Response 12:

The cited article (Healthcare 2023, 11(9), 1268) focuses on computational methods for text mining and named entity recognition in electronic health records and addresses methodological challenges in natural language processing. It does not examine telemedicine interventions, caregiver experiences, acceptance, implementation processes, or outcomes in home care settings. As the present study focuses on the use, acceptance, and practical implications of telemedicine technologies for family caregivers, the thematic scope of the cited article does not align with the objectives or content of this manuscript .

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thanks for the revision.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors revised all my concerned, therefore, I have no further suggestions. 

Comments on the Quality of English Language

Satisfactory