Review Reports - Beyond Access: Telehealth Readiness, Trust, and Early Use Among Jordanian Patients with Chronic Illness

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors conducted an exploratory qualitative study to understand how patients with chronic diseases in Jordan become activated, motivated, and ready to engage with telehealth services, especially during early adoption. They interviewed 14 adults, purposively selected from three hospitals, and analyzed the data using Braun and Clarke’s six-step thematic approach.

Their findings reveal a nuanced picture of patients’ experiences. Patients appreciated telehealth for its role in preserving independence and maintaining continuity of care. For many, it reduced reliance on family members for transportation and helped manage everyday life more smoothly. At the same time, readiness to use these services was shaped by a combination of structural, financial, and personal factors. While telehealth reduced travel costs and loss of income, patients still faced expenses for devices and internet access, highlighting an economic paradox for those with limited resources.

Family support emerged as a critical facilitator of engagement, yet low digital literacy, platform changes, and unstable internet connectivity posed significant challenges. Trust in telehealth was conditional, relying on patients’ perceptions of convenience, responsiveness, and reliability.

Overall, the authors argue that readiness to adopt telehealth is not purely an individual characteristic but is relational, structural, experiential, and conditional. They emphasize the need for hybrid care models that integrate family involvement and affordable digital technologies, enabling patients with chronic diseases to use telehealth sustainably for disease management.

The study is interesting and makes a valuable contribution to the literature.

Strengths:

The topic is relevant and timely, focusing on patients’ engagement with telehealth services.
The study is well-developed, with a broad perspective and a robust methodology.

Weaknesses:

Some aspects of presentation and editorial structure could be streamlined and improved to convey the message more clearly.

Specific Comments:

In the introduction, some passages are supported with references cited in cluster (see lines 59, 64, 66); the authors are encouraged to detail the contribution of each reference to clarify how previous studies inform their work.
Other sections of the introduction lack supporting references; for example, lines 96–102.
There is an excessive emphasis on the pandemic. Given that three years have passed since its conclusion, and four to five years since the acute phase, it is sufficient to mention it briefly at the beginning and then move forward.
Some parts of the methods section include elements (with many reference) that are more typical of an introduction than methodological description.
The methods are divided into multiple sections (eight), some of which are very brief, fragmenting the narrative. It is suggested to consolidate them according to a standard structure and support the study design flow with a flow chart to guide the reader.
Ethical aspects should be included in the backmatter regarding relevant approvals, while procedural details can then be referenced in the methods section.
Results are organized thematically. A brief justification for the choice of analysis should be included.
Section 3.2 contains long passages reporting comments, which can be tedious to read. Consider summarizing/inserting the information in a table and referring back to it for clarity.
The “Strengths and Limitations” currently included in the conclusions should be moved to the discussion section.
The conclusions should be made more effective, present a concrete look toward the future, and avoid including references, which are generally not recommended in this section.

Author Response

Comment 1: In the introduction, some passages are supported with references cited in cluster (see lines 59, 64, 66); the authors are encouraged to detail the contribution of each reference to clarify how previous studies inform their work.

Response 1: Thank you for this valuable comment. The Introduction has been carefully revised to address this concern. Specifically, we reduced the use of clustered citations and, where appropriate, relied on a single, most relevant reference to support each claim. In cases where multiple references were retained, we clarified the specific contribution of each cited study to better demonstrate how prior research informs the present work. These revisions have improved the clarity, precision, and transparency of the literature synthesis.

Comment 2: Other sections of the introduction lack supporting references; for example, lines 96–102.

Response 2: Thank you for this note. We added references to support the claim “Existing studies have focused mainly on emergency applications, specific disease groups, or provider-related barriers rather than the process of patient activation”.

Comment 3: There is an excessive emphasis on the pandemic. Given that three years have passed since its conclusion, and four to five years since the acute phase, it is sufficient to mention it briefly at the beginning and then move forward.

Response 3: Thank you for this insightful comment. The Introduction has been revised to reduce the emphasis on the COVID-19 pandemic. We now refer to it briefly as a contextual factor in the early expansion of telehealth and have removed redundant or extended discussion throughout the section. The revised text shifts the focus toward current and ongoing considerations in telehealth use, particularly in relation to chronic disease management and patient readiness. These changes have improved the timeliness and relevance of the manuscript.

Comment 4: Some parts of the methods section include elements (with many reference) that are more typical of an introduction than methodological description.

Response 4: Thank you for this important observation. The Methods section has been carefully revised to improve its focus and clarity. We removed or reduced background-oriented statements and excessive referencing that were more appropriate for the Introduction. Where necessary, such content was either relocated to the Introduction or condensed into brief, method-focused descriptions. In addition, we retained only key methodological references (e.g., for analytic approach and reporting standards) to ensure that the section clearly emphasizes what was done and how it was conducted. These revisions have streamlined the Methods section and aligned it more closely with methodological reporting standards.

Comment 5: The methods are divided into multiple sections (eight), some of which are very brief, fragmenting the narrative. It is suggested to consolidate them according to a standard structure and support the study design flow with a flow chart to guide the reader.

Response 5: Thank you for this helpful suggestion. The Methods section has been carefully revised to improve coherence and readability. Specifically, we consolidated the original subsections into a more streamlined and standard structure by merging related components (e.g., settings, participants, and sampling; data collection procedures; and trustworthiness with ethical considerations). This reduced fragmentation and improved the overall narrative flow.

Comment 6: Ethical aspects should be included in the backmatter regarding relevant approvals, while procedural details can then be referenced in the methods section.

Response 6: Thank you for this important suggestion. The manuscript has been revised accordingly. Formal ethical approval details, including the Institutional Review Board information and approval number, have been moved to the backmatter in accordance with journal requirements. The Methods section has been streamlined to retain only the procedural aspects of ethical conduct (e.g., informed consent, confidentiality, and participants’ rights), with a reference to the backmatter for full ethical approval details. These changes improve compliance with reporting standards and enhance the clarity of the manuscript structure.

Comment 7: Results are organized thematically. A brief justification for the choice of analysis should be included.

Response 7: Thank you for this helpful suggestion. A brief justification for the use of thematic analysis has been added to the Data Analysis section. Specifically, we clarified that thematic analysis was selected due to its flexibility and suitability for identifying and interpreting patterns in participants’ experiences and perceptions, which aligns with the exploratory aims of this study.

Comment 8: Section 3.2 contains long passages reporting comments, which can be tedious to read. Consider summarizing/inserting the information in a table and referring back to it for clarity.

Response 8: Thank you for this valuable suggestion. Section 3.2 has been revised to improve clarity and readability. We reduced the length and number of extended quotations by retaining only the most illustrative examples and summarizing repetitive content narratively. In addition, we developed a new table that presents an overview of the main themes, subthemes, and selected illustrative quotes. The text has been revised to refer to this table, providing a clearer and more structured presentation of the findings while preserving the depth of participants’ perspectives.

Comment 9: The “Strengths and Limitations” currently included in the conclusions should be moved to the discussion section.

Response 9: We thank the reviewer for this suggestion. The “Strengths and limitations” text has been moved from the Conclusions to the end of the Discussion (placed immediately before the Conclusion).

Comment 10: The conclusions should be made more effective, present a concrete look toward the future, and avoid including references, which are generally not recommended in this section.

Response 10: We thank the reviewer for this suggestion. We have revised the Conclusions to remove in-text references and to add concrete future research and implementation directions; please see the updated Conclusions

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript explores patient activation and readiness for telehealth adoption among individuals with chronic diseases in Jordan using a qualitative approach. The topic is appropriate as per scope of journal and time.

The comments for revision are as followed.

What is the novel contribution, particularly in relation to existing qualitative studies on telehealth adoption in low- and middle-income countries. Specify.
The rationale for focusing specifically on early-stage telehealth adoptionshould be better articulated.
The sampling strategy (n = 14) is appropriate for qualitative research; however, participant characteristics (age, disease type, digital experience)should be described in more detail.
The recruitment process from three hospitalsshould be clarified, including inclusion/exclusion criteria and potential selection bias.
The use of Braun and Clarke’s thematic analysisis appropriate, but details on coding procedures (e.g., number of coders, consensus process) should be provided.
The manuscript should include information on data saturationand how it was determined.
Reflexivity should be addressed; the authors should discuss researcher positionality and potential biasin data interpretation.
The role of family supportis highlighted; however, distinctions between supportive vs dependency dynamics should be explored.
Barriers such as digital literacy and connectivity issuesshould be contextualized within broader healthcare infrastructure in Jordan.
The discussion of trustin telehealth would benefit from a more nuanced analysis (e.g., trust in technology vs providers vs systems).
Policy and practice implications (e.g., hybrid care models, digital inclusion strategies) should be more concretely outlined.
Ethical considerations (e.g., informed consent, confidentiality) should be explicitly stated.
The conclusion is appropriate but could be strengthened by proposing specific, actionable recommendationsfor telehealth implementation in similar contexts.
The following recent studies are suggested to evaluate and add to the literature review of the manuscript: https://doi.org/10.1002/pon.70377, https://doi.org/10.1109/TMC.2025.3634422

Author Response

Comment 1: What is the novel contribution, particularly in relation to existing qualitative studies on telehealth adoption in low- and middle-income countries. Specify.

Response 1: Thank you for this important comment. We have clarified the novel contribution of this study in relation to existing qualitative research on telehealth adoption in low- and middle-income countries (LMICs). This was added at the end of the introduction section.

Comment 2: The rationale for focusing specifically on early-stage telehealth adoption should be better articulated.

Response 2: Thank you for this insightful comment. We have strengthened the rationale by clarifying why early-stage telehealth adoption is critical. Specifically, early experiences shape patients’ motivation, trust, and continued engagement, yet this phase remains underexplored compared to general utilization and satisfaction. This was added at the end of the introduction section.

Comment 3: The sampling strategy (n = 14) is appropriate for qualitative research; however, participant characteristics (age, disease type, digital experience)should be described in more detail.

Response 3: Thank you for this valuable comment. Participant characteristics (age, disease type, and telehealth experience) were partially described in the Results section and Table 2. We have now added a concise summary to further clarify variation in digital experience and enhance transparency.

Comment 4: The recruitment process from three hospitals should be clarified, including inclusion/exclusion criteria and potential selection bias.

Response 4: Thank you for this important comment. We have clarified the recruitment process across the three hospitals, detailed the inclusion and exclusion criteria, and acknowledged potential sources of selection bias to enhance transparency and methodological rigor.

Comment 5: The use of Braun and Clarke’s thematic analysis is appropriate, but details on coding procedures (e.g., number of coders, consensus process) should be provided.

Response 5: Thank you for this valuable comment. We have expanded the description of the coding process to clarify the number of researchers involved, the coding procedure, and how consensus was achieved, thereby strengthening the transparency and rigor of the analysis.

Comment 6: The manuscript should include information on data saturation and how it was determined.

Response 6: Thank you for this valuable comment. Data saturation was explained and determined.

Comment 7: Reflexivity should be addressed; the authors should discuss researcher positionality and potential bias in data interpretation.

Response 7: Thank you. We added a brief "Reflexivity and researcher positionality" subsection to Methods (Trustworthiness and Ethics). The Methods note included team composition (clinician, qualitative health researcher, research assistant), potential prior perspectives, and steps to limit bias (reflexive notes/journal, two independent coders with consensus and third‑coder arbitration, regular analytic reflexivity meetings, and an audit trail).

Comment 8: The role of family support is highlighted; however, distinctions between supportive vs dependency dynamics should be explored.

Response 8: Thank you. We expanded the analysis to differentiate supportive versus dependency dynamics of family involvement. This was added at the end of theme 3 and in the discussion section.

Comment 9: Barriers such as digital literacy and connectivity issues should be contextualized within broader healthcare infrastructure in Jordan.

Response 9: Thank you. We added a brief sentence in Results (end of Theme 2) linking participants’ reports of limited digital literacy and unstable internet to wider infrastructure constraints in Jordan. We also added a short paragraph in the Discussion (immediately after the paragraph beginning "However, this study complicates the assumption that telehealth is inherently accessible or affordable.") that contextualizes these barriers within uneven broadband coverage, device/data costs, and the need for system-level solutions (expanded broadband, subsidised devices/data, and telehealth integration).

Comment 10: The discussion of trust in telehealth would benefit from a more nuanced analysis (e.g., trust in technology vs providers vs systems).

Response 10: Thank you. We expanded the Discussion to provide a more nuanced analysis of trust, distinguishing trust in technology (usability, connectivity, data security), trust in providers (communication, clinical competence, relational warmth), and trust in systems (service integration, access, governance). We added a short paragraph in the Discussion (after the paragraph on conditional trust).

Comment 11: Policy and practice implications (e.g., hybrid care models, digital inclusion strategies) should be more concretely outlined.

Response 11: Thank you. We added a concise "Policy and practice implications" paragraph to the conclusions and implications. The text outlines hybrid care models with triage and telehealth‑readiness checks, recommends digital inclusion measures (subsidised devices/data, expanded broadband, community training), calls for improved platform usability and clinician training (including family involvement), and proposes monitoring telehealth equity and outcomes to guide policy.

Comment 12: Ethical considerations (e.g., informed consent, confidentiality) should be explicitly stated.

Response 12: Thank you. Informed consent and confidentiality is clearly indicated under the heading “Trustworthiness and Ethics).

Comment 13: The conclusion is appropriate but could be strengthened by proposing specific, actionable recommendations for telehealth implementation in similar contexts.

Response 13: Thank you for this important comment. The conclusion section was changed to “Conclusions and Implications”. It was rewritten by proposing specific, actionable recommendations for telehealth implementation in similar contexts.

Comment 14: The following recent studies are suggested to evaluate and add to the literature review of the manuscript: https://doi.org/10.1002/pon.70377, https://doi.org/10.1109/TMC.2025.3634422

Response 14: Thank you. One of these references was added to the literature.

Reviewer 3 Report

Comments and Suggestions for Authors

This study is well-structured and strong.

However there are some points that need attention.

First, the authors state a conceptual contribution, but it needs an anchoring in a theory. Think of something like the Technology Acceptance Model
Second, it is not clear why the participants are only 14, but the study mentions involvement of providers (N=48). Inconsistency in study sample
If the findings are from only 14 patients that is not enough to draw conclusions. You need at least 20.
The discussion for now repeats the findings. It lightly links the finings to the literature.
The thematic approach is strong but the authors can do better in the theme naming. Don't go narrative otherwise we are not talking thematic analysis anymore.

Author Response

Comment 1: First, the authors state a conceptual contribution, but it needs an anchoring in a theory. Think of something like the Technology Acceptance Model

Response 1: Thank you for this valuable suggestion. We have now explicitly anchored the study within the Technology Acceptance Model by adding a brief conceptual framing in the Introduction and integrating TAM into the interpretation of findings in the Discussion. We also clarified how our findings extend TAM by highlighting the relational, structural, and conditional dimensions of telehealth readiness. These revisions strengthen the theoretical contribution of the study while remaining consistent with its qualitative design.

Comment 2: Second, it is not clear why the participants are only 14, but the study mentions involvement of providers (N=48). Inconsistency in study sample. If the findings are from only 14 patients that is not enough to draw conclusions. You need at least 20.

Response 2: Thank you for this important comment. We would like to clarify that this paper reports only the patient component of a larger qualitative study that included both patients and healthcare providers (total N = 48). The findings presented in this manuscript are based on 14 patient participants, as the focus of this paper is specifically on patients’ experiences of telehealth readiness and early use.

Comment 3: The discussion for now repeats the findings. It lightly links the finings to the literature.

Response 3: Thank you. We revised the Discussion to reduce repetition, shift descriptive material to Results, and strengthen interpretive links to relevant literature and theory; tracked changes are provided.

Comment 4: The thematic approach is strong but the authors can do better in the theme naming. Don't go narrative otherwise we are not talking thematic analysis anymore.

Response 4: We thank the reviewer for this important suggestion. In response, we have revised all theme titles to ensure they are concise, conceptually grounded, and consistent with Braun and Clarke’s thematic analysis approach. Narrative-style theme labels have been replaced with shorter analytic headings to improve clarity, abstraction, and methodological rigor throughout the Results section and Table 3.