In Study 1, external inhibiting and facilitating conditions were identified which had an impact on attitudes toward video therapy adoption and its intended future use. In Study 2, the modified model of the Unified Theory of Acceptance and Use of Technology (UTAUT) explained 58.8% of the variability in therapist's Behavioral Intention to Use digital media. Here, Performance Expectancy was a significant predictor.
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the use of digital media in speech and language therapy became part of the service during the COVID-19 pandemic
This resulted in a need for empirical studies on the use and acceptance of digital media technologies
to determine users&#x00027; requirements and concerns regarding the newly mandated technologies
in order to support its expansion in education and training going forward
&#x0201C;Acceptance&#x0201D; has been previously identified as an important aspect behind successful technology adoption
two online questionnaire studies were conducted to explore how technology use is accepted among speech and language therapists in Germany
Methods: Study 1 involved a questionnaire about video therapy with 15 question groupings
examining technology acceptance and competence
707 complete responses were included in the analysis
Study 2 involved a different questionnaire
examining technology acceptance and digital media in therapy
79 individuals participated in the second survey
Study 1 data were analyzed to identify unifying factors underlying respondent attitudes and was followed up with a logistical regression; Study 2 data were analyzed with multiple linear regression
external inhibiting and facilitating conditions were identified which had an impact on attitudes toward video therapy adoption and its intended future use
the modified model of the Unified Theory of Acceptance and Use of Technology (UTAUT) explained 58.8% of the variability in therapist&#x00027;s Behavioral Intention to Use digital media
Performance Expectancy was a significant predictor
Conclusions: Both studies investigated facilitating and inhibiting factors for the implementation of digital media including video therapy in future speech therapy services
Results demonstrated that the use is accepted in therapy
optimal conditions&#x02014;both institutional and individual&#x02014;are needed to enable digital participation for therapists and patients
trainers should focus on the functional aspects of the technologies to be used
in order to positively influence Performance Expectancy in a targeted manner and thus increase the therapists&#x00027; intention to use digital technology in therapy
which in turn promotes patients&#x00027; digital participation
ICT represents a very diverse toolkit (<a href="#B80">Starke and Leinweber, 2019</a>); for example
in the broad variety of software applications (apps)
sometimes by supplementing it&#x02014;e.g.
when a group of people sitting in a caf&#x000E9; discuss a video playing on someone&#x00027;s phone&#x02014;or sometimes completely substituting it&#x02014;e.g.
when the same group of people are half a world apart discussing the video while on a messaging forum
Apps can also remove communication barriers
such as social distancing; they can serve as learning aids
language apps; they can facilitate unlikely connections
job-seeker apps; they can support motivation
it had not been nationally implemented as standard practice in Germany
to improve patient usage and therapeutic outcomes
the positive and negative factors influencing therapists must be clearly understood
Thus a clear understanding of the challenges facing therapists can inform educational institutions of any systematic gaps in understanding
Acceptance, as defined above, is a latent construct (<a href="#B46">Jockisch, 2010</a>), which is why models are used to explain which facets make up the construct and which factors influence it; one such model is the Unified Theory of Acceptance and Use of Technology (UTAUT) (<a href="#B96">Venkatesh et al., 2003</a>)
This model was used in Study 2 of this paper
to also consider Facilitating Conditions (FC) as a direct predictor of Behavioral Intentions to Use (BIU)
four supplementary UTAUT concepts (impact of peers
self-efficacy and attitude) are each presented below
the Attitude of Colleagues (AoC) is a relevant supplemental factor
Familiarity with the use of digital media in the direct work environment can have a positive influence on the acceptance of the technology
This is the factor addressed by the model supplement Digitality at Work (DaW)
This construct has been termed the Self-Assessment of Digital Competencies (SAoDC)
Basic UTAUT-model extended by four variables (Study 2)
Despite the modifications, the UTAUT follows a relatively simple premise. <a href="#B96">Venkatesh et al. (2003)</a> assume that the intention to use technology
More recently, <a href="#B38">Hastall et al. (2017)</a> criticized such technology acceptance models for ignoring the dynamic and multi-determined process of using technology; this critique is of particular relevance to Study 1
they claimed that the attention to the developmental process of technologies
the view of human motivation on technology
the social influences on individuals and the differences between individuals using technologies were all inadequately considered
they discussed three approaches through which technology adoption can be promoted: (1) a realistic view about decision-making processes of individuals
(2) sufficient knowledge about different stages of technology adoption
organizational and situational determinants
This results in three dimensions&#x02014;individual-related factors
Individual-related factors encompass approach behaviors and avoidance behaviors
both behaviors can arise simultaneously in a given situation
while the therapist supports the patient verbally during the exercise
the patient needs a hands-on situation to fully engage
can express as external supportive or inhibitive influences on video therapy
Technology-related factors encompasses the technology itself
software incompatibility) and rewarding aspects (e.g.
All factors have implications on the adoption and acceptance of digital media in health care
If technology is assessed and accepted as useful and necessary for professional life
then people are also prepared to deal with future innovations and iterations
and to review and expand their own competencies to match
it becomes possible to include digital participation as a fundamental goal of SLT work
This results in a need for empirical studies on the use
acceptance and adoption of digital media in SLT in order to be able to determine needs with regard to the expansion of competencies in education and training
the current two studies were designed to examine the acceptance of these technologies by German speech and language therapists
Study 1 focuses on positive and negative factors which correlate with the therapist&#x00027;s future use of video therapy and it interprets which factors may thus influence successful implementation of video therapy
Study 2 examines factors influencing the therapists&#x00027; intention to use digital media in SLT in the future and identifies factors that influence this intention
By identifying supporting and inhibiting factors based on different theoretical assumptions and models
these studies build together to inform the development of training and professional education
to ensure and expand the targeted use of digital media in the future
these studies would also improve and sustain the future digital participation of patients
The following research questions were investigated by Study 1:
What factors correlate with the prospective adoption of video therapy by speech and language therapists
What constructs underlie the attitudes of users toward technology acceptance and technology competence in the context of SLT
An initial questionnaire, made up of 52 question groupings (see Measure below), was developed at the University of Applied Sciences and Arts (German: HAWK Hildesheim/Holzminden/G&#x000F6;ttingen) in early 2020. The survey was hosted online from June 3rd to July 1st, 2020, on the online freeware SoSciSurvey website (<a href="#B53">Leiner, 2019</a>)
The data were stored on the SoSciSurvey server until the end of the data collection period
then they were transferred to the university&#x00027;s own server until June 30th
Persons outside the project team and temporary staff have no access to the data
Recruitment was conducted through the German Federal Association of Speech and Language Therapy (Deutscher Bundesverband f&#x000FC;r Logop&#x000E4;die e.V.)
Respondents were asked to participate if they were providing speech and language therapy in an outpatient setting in Germany at the time of the survey
The participants were informed about the study contents and data privacy and gave their informed consent
From 841 online responses, 25 were excluded due to denied informed consent (n = 22), invalid data (n = 2) and a profession outside of SLT (n = 1). Subsequently, an inconsistency check was made to proof data validity (<a href="#B74">Schrepp, 2016</a>)
a time-related test and a content test were made
an additional 109 participants submitted substantially incomplete responses
and were therefore excluded from the analysis
707 participant responses were included and analyzed in this study
Participants&#x00027; demographics in Study 1
The original questionnaire consisted of 52 question groupings (forced-choice
as inclusion criteria (2 question groupings)
Sociodemographic data (7 question groupings)
Resources used for videoconferencing (7 question groupings)
Current implementation of videoconferencing (21 question groupings)
Adoption of videoconferencing in future health care delivery (9 question groupings)
General feedback to the questionnaire (1 question)
The questions were created in accordance with literature about technology use in SLT (e.g., <a href="#B61">Molini-Avejonas et al., 2015</a>; <a href="#B70">Pitt et al., 2018</a>; <a href="#B92">Tyagi et al., 2018</a>; <a href="#B55">Leinweber and Schulz, 2019</a>)
Each grouping was structured as a question with multiple response options
&#x0201C;in which contexts have you used video therapy&#x0201D;
Answers consisted of closed multiple choice options
&#x0201C;individual therapy&#x0201D;; &#x0201C;group therapy&#x0201D;; &#x0201C;individual counseling&#x0201D;; &#x0201C;group counseling&#x0201D;; &#x0201C;other (text field)&#x0201D;
Respondents could select any and all responses that were relevant
These question groupings were then recoded into unique binary questions for the statistical analysis (see below)
The questionnaire used will be published in a separate article
In preparing the data used for the regression
five of the adoption questions were deemed appropriate and were combined for the dependent variable; these related to: regarding usefulness of video therapy (VT)
whether VT is as successful as in person therapy and whether VT affects the relationship with the patient
Seven of the question groupings concerning technology acceptance (TA) and eight groupings concerning technology competence (TC) were selected for independent variables
The same TA and TC question groupings were then used in the factor analysis
All calculations were performed with the IBM SPSS program version 27 (<a href="#B43">IBM Corp, 2020</a>)
All multi-answer question groupings were dummy-coded into individual binary response questions
to facilitate the use of stronger statistical analyses
To examine what influences the prospective adoption of video therapy by speech and language therapists
as the dependent variable was found to be significantly non-normally distributed and could not be sufficiently rectified via standard correction methods
a statistically weaker but more robust logistical ordinal regression was performed
To form the dependent variable, the five questions regarding the participants&#x00027; views on video therapy adoption (mentioned above in Measure) were recoded into positive (&#x0002B;1), negative (&#x02212;1) and neutral (0) and summed together to form a general &#x0201C;Opinion of Video Therapy&#x0201D; variable (see <a href="#T2">Table 2</a>)
ranging from &#x0002B;5 (all positive) to &#x02212;5 (all negative)
This resulted in a single variable with a distribution that could be statistically analyzed
Question responses informing the independent variable &#x0201C;Opinion of Video Therapy&#x0201D;
the regression included all binary recoded question items from the factor analysis (89 individual question items in all)
Question groupings representing video therapy acceptance and competence in Study 1
Although the data were not all perfectly normally distributed
due to the robust nature of the analysis and the use of binary independent variable items
the data was deemed to be acceptable for the analysis
A preliminary factor analysis was originally conducted which was limited to 25 iterations; the resultant Scree plot identified four primary factors before tailing off
thus the final factor analysis was limited to four factors
This four factor analysis is presented in the Results section
To investigate the technology acceptance of speech and language therapists
The constructs Attitude of Colleagues (AoC)
Self-Assessment of Digital Competencies (SAoDC)
and Attitude and Affect toward the Use of Digital Media (AUDM) were included as additional variables
The following research questions were investigated by Study 2:
To what extent are speech and language therapists intending to use ICT in therapy in the future
predict speech language therapists&#x00027; Behavioral Intention to Use digital media in therapy
The development of the used online questionnaire took place in the department of Inclusive Education for speech
and communication needs at the University of Bremen (Germany)
The survey period ran from mid-July to November 2020
The questionnaire was made available via LimeSurvey (Limesurvey GmbH)
Respondents were asked to participate if they were providing SLT in an outpatient setting in Germany at the time of the survey or had done so prior to the COVID-19 pandemic
Use of digital media or delivery of video therapy during the COVID-19 pandemic did not constitute inclusion criteria
Recruitment was conducted through German SLT associations and networks as well as personal contacts of the authors
Participants were informed of the study content and were required to provide informed consent before beginning the survey
Participation could be discontinued at any time during the survey
The data is stored on the university server and will remain stored until 2030
and only project-internal employees will have access to it
Respondents&#x00027; demographics in Study 2
The majority of respondents (64.6%) were self-employed in their own practice
Nearly one-third were not self-employed/employed (31.6%)
two freelancers working on a fee basis (2.5%) and one student worker (1.3%) participated in the survey
a theory-based questionnaire was created to examine technology use
personal experiences regarding technology use in everyday work
The questionnaire also included a general part with questions on socio-demographic information
The data used for the presented study came from the questionnaire section on technology acceptance and the experience with digital media use
Different items were used to query technology acceptance. 14 of the items used were German translations and modifications of the adapted UTAUT items validated by <a href="#B86">Teo (2009</a>, <a href="#B87">2010)</a>, which have their origin in <a href="#B96">Venkatesh et al. (2003)</a>. They are shown in the <a href="#T5">Table 5</a>. All items were Likert items which were summarized in 5 Likert scales following past literature (<a href="#B37">Harpe, 2015</a>)
The five response options were: 0 = does not apply at all; 1 = mostly does not apply; 2 = undecided; 3 = mostly applies; 4 = applies fully
Technology acceptance items used in Study 2
The internal consistency of the 14 used UTAUT items was determined by Cronbach&#x00027;s alpha. With a value of &#x003B1; = 0.892, internal consistency was high (<a href="#B21">Cortina, 1993</a>)
The internal consistencies were also calculated for the individual Likert scales of the four predictors of the UTAUT model which also turned out to be high: PE &#x003B1; = 0.890; SI &#x003B1; = 0.813; FC &#x003B1; = 0.899
The value for EE was acceptable: &#x003B1; = 0.769
In addition to the UTAUT items, a total of 25 items were developed for the constructs of Attitude of Colleagues (AoC), Digitality at Work (DaW), Self-Assessment of Digital Competence (SAoDC), and Attitude and Affect toward the Use of Digital Media (AUDM) and included in the questionnaire. The items on these constructs were developed from theory and generated as Likert items (<a href="#B37">Harpe, 2015</a>) according to the used UTAUT items
Items used for the four additional influence variables in Study 2
Internal consistency was also checked for these individual scales: SAoDC &#x003B1; = 0.851; DaW &#x003B1; = 0.818; AoC &#x003B1; =0.841; AUDM &#x003B1; =0.918
These constructs also showed a high value in terms of internal consistency
All calculations were performed with the program SPSS program version 26 (<a href="#B42">IBM Corp, 2019</a>)
To examine technology acceptance in the form of Behavioral Intention to Use (BIU) among therapists
the calculations and considerations of the mean and dispersion measures of the single variables of UTAUT and the new constructs were performed
To answer the second question, the respective items of the variables were summarized using their mean values as in other studies on the UTAUT. The recommendations in using the averaged values of Likert scales as interval scaled data were fulfilled (<a href="#B37">Harpe, 2015</a>)
the response values of the respondents were used (age in years
Multiple linear regressions in a three-block hierarchy (forced entry) were used to test the influence of the different independent variables on BIU
All assumptions for the analysis were fulfilled
In order to take into account the possible influence of the variables age and work experience
these were also included in the regression calculations
Due to the low participation of males (n = 4)
the correlations between all individual variables included were checked
The variable Attitude of Colleagues (AoC) was then excluded from further calculations as it did not show any correlations with the dependent variable BIU or the other predictors
In the first block of the multiple linear regression
age and work experience (WE) were included in the model
the established predictors of the UTAUT&#x02014;PE
SI and FC&#x02014;were included to check the basic model
For 12 of the 79 respondents not all values were available
because at the time of the survey they were not undergoing any therapies and therefore certain data were not feasible (n = 11) or there were missing values in a part of the included items (n = 1)
the data of 67 persons could be used for this analysis
Since collinearity between the predictors Performance Expectancy (PE) and Attitude and Affect toward the Use of Digital Media (AUDM) was found in the last model
AUDM was excluded in a new model calculation to avoid distortions of the model
the same statistical procedure was followed as just mentioned
it was not possible to conduct a multiple regression analysis as planned
due to the significant deviations from normality of the independent variable
which therefore violated the assumptions necessary for multiple regression
An ordinal logistic regression was therefore conducted
Significance was determined at the standard p &#x0003C; 0.05
The &#x02212;2 Log Likelihood model was significantly significant (&#x003C7;2 = 447.775
indicating that the full model was a significant improvement in the predictive capacity of the full model over the intercept only model
p = 1.00) and Deviance (&#x003C7;2 = 1,107.218
Goodness of Fit tests indicated that the model was a good fit for the data
The regression results indicate a variety of factors which correlate with the adoption of video therapy in the future. Overall, 14 items contributed significantly to the model&#x02014;see <a href="#T8">Table 8</a> for details
increased difficulty in any category was associated with a reduced likelihood of a higher adoption score
a lack of prior experience [&#x02212;0.849
p = 0.029] and a perceived limitation of methods [&#x02212;0.811
p = 0.028] all significantly reduced a respondent&#x00027;s opinion of video therapy
perceived benefits like health protection of patients [1.461
p = 0.009] all significantly increased a respondent&#x00027;s opinion about video therapy
Significant response items identified for video therapy adoption in Study 1
A reported perception of increased preparation time [0.978
p = 0.005] actually improved respondent opinion
as did the reduced travel time for patients [0.557
Motivation also seemed to influence respondent opinions&#x02014;respondents with increased motivation [0.756
however those who sought professional help to fix technical problems time [&#x02212;0.841
p = 0.025] and those who gave up on video therapy when faced with technical problems time [&#x02212;1.268
p = 0.028] had a reduced opinion of video therapy
Rotation matrix to the factor analysis of 14 question items in Study 1
With regard to the acceptance of the use of digital media within therapy
a heterogeneous picture emerged among the German therapists
The Behavioral Intention to Use (BIU) scores ranged from 0.5 to the maximum achievable 4 points
The average for the entire group is 2.92 (SD = 0.895)
which is within the range of &#x0201C;mostly applies&#x0201D; on the Likert scale used
To what extent do Performance Expectancy (PE)
predict speech and language therapists&#x00027; Behavioral Intention to Use (BIU) digital media in therapy
Descriptive measures of the variables included (Study 2)
In terms of the included moderator variables of age and work experience (WE), there were isolated significant correlations found. Age correlated significantly with work experience (WE), Behavioral Intention to Use (BIU), Performance Expectamcy (PE) and Effort Expectancy (EE), while WE also correlated significantly with EE. All correlations are shown in <a href="#T11">Table 11</a>
Correlations between the included variables (Study 2)
Model 3, which included all of the variables, explains 58.8% of the variability. The elucidation of variability was increased by including the variables Digitality at Work (DaW) and Self-Assessment of Digital Competencies (SAoDC) into the UTAUT-model but not significantly. <a href="#T12">Table 12</a> provides an overview of the multiple linear regression results
Results of the multiple linear regression (Study 2)
The generalizability of the models is given
The F-statistic shows highly significant values (p &#x0003C; 0.001) for model 2 as well as model 3
so both models (basic UTAUT and extended UTAUT) predict BIU significantly
<a href="#T13">Table 13</a> shows the regression coefficients of model 3 (extended UTAUT)
Linear model of the predictors of BIU (Model 3; Study 2)
Performance Expectancy (PE) is a significant predictor of Behavioral Intention to Use (BIU) in German speech language therapists
There was no evidence of multicollinearity
no case had an excessive influence on the model and the normal distribution of the residuals was given
All significant items had at least a moderate impact on the outcome variable here
implying that all four factors are relevant for a successfully implemented adoption of video therapy technology
with supportive behavior and avoidance behavior combining to influence an individual&#x00027;s attitude
Factor 4 included items based on environment-related factors, in particular the barriers preventing video therapy adoption that stem from geographical factors. Literature has constantly noted that challenges to video therapy adoption in Germany often include technical difficulties, such as unstable internet connections, service availability or continuity problems (<a href="#B10">Bilda et al., 2020</a>; <a href="#B52">Lauer, 2020</a>; <a href="#B75">Schwinn et al., 2020</a>)
an unstable internet connection or intermittent connection failure can make video therapy difficult or even impossible
In many speech and language therapy sessions
as the assessment of linguistic or facial aspects can only be accurate with good image and sound quality
The four presented factors, when taken together, can help to inform those who wish to implement video therapy successfully. Firstly, parties who wish to implement video therapy as a regular and reliable healthcare service should aim to maximize adoption-facilitating conditions, like the personal and emotional benefits to patients and therapists; simultaneously they should aim to minimize rejection-facilitating conditions (<a href="#B97">Wade et al., 2014</a>)
for example by supplementing individual experience with quality training and by supporting therapists in their time investment
All of this requires substantial knowledge about the patients and therapists to bring together
Digitality at Work (DaW) showed the highest mean value
This can be explained by the video therapies performed during the COVID-19 pandemic
These were temporarily the only possibilities to offer therapy for many patients and were therefore integrated in most practices
as shown by Facilitating Conditions&#x00027; (FC) low average score
This is consistent with the results of the first study
For the purpose of identifying the impact of different influencing factors
six possible influencing factors (four original UTAUT and two supplementary) were included in the full analysis of study 2 along with age and work experience (WE)
Performance Expectancy (PE) and Effort Expectancy (EE)
while WE correlated significantly with age and EE
The correlation between age and WE is not surprising
as older speech and language therapists typically have more WE than younger therapists
there appears to be an interaction effect of age and WE in parts of the model
In their meta-analysis, <a href="#B25">Dwivedi et al. (2019)</a> were able to demonstrate a direct influence of attitude on BIU
they found that attitude partially mediated the effects of all UTAUT-predictors on behavioral intention as well
between PE and Attitude and Affect toward Use of Digital Media (AUDM)
This evidence supports the inclusion of attitude as a mediator in future studies
If speech language therapists consider the use of digital media as beneficial for their work
the intention to use digital media in the future increases
Social influence (SI) on BIU has also been highlighted previously, particularly among women (<a href="#B62">Morris and Venkatesh, 2000</a>; <a href="#B88">Teo and Noyes, 2014</a>)
Given the very high proportion of female therapists
both in this study and in the field in general
this factor should not be underrated; however
due to this high ratio among the respondents
this study could not isolate the SI effect from the sex effect
The included variables Self-Assessment of Digital Competencies (SAoDC) and Digitality at Work (DaW) could additionally improve the prediction of BIU in the model
a significant direct influence on the BIU could not be proven for the present sample
Comparable constructs of both studies underlying the attitudes of users toward technology acceptance and technology competence in the context of SLT
This highlights the importance of education in the industry going forward
The implementation of the aforementioned content and factors faces the additional challenge in Germany that there are different training paths (e.g.
speech language therapists or academic speech therapists)
the authors provide concrete factors to consider and ideas for implementation that can be applied in all education and training contexts of speech language therapy
Further education and training should also focus on dealing with questions on Performance Expectancy (PE)
as this could promote a positive Behavioral Intention to Use (BIU)
Therapists should receive information and gain experience in this context
which would show them how ICT can improve and support the fulfillment of individual tasks in therapeutic work
focusing on the benefits and opportunities that the technology can bring to the therapy situation itself
To ensure that the technologies being taught
will be meaningfully incorporated into the therapists&#x00027; repertoires
educators should focus in particular on the deeper functional aspects with a high proportion of practical exercises
Possible approaches could include the use of case studies or therapy videos in which the use of ICT is exemplified
collegial case consultations with a focus on ICT-supported therapy
which brings the use of ICT into the trainees&#x00027; focus
education and training could include formats for exchange between speech and language therapists
positive experiences can be shared with peers
awareness can be raised and people can also benefit from the experiences of others
The challenge of purchasing and maintaining suitable hardware and software is also financial
these costs have been shouldered predominantly by the practices themselves or the individual therapists
this was largely concentrated in the use of video therapy; the use of apps or educational software in therapy did not significantly change over the COVID-19 pandemic period
These factors could be considered in future investigations
Maximizing facilitation triggers and reducing inhibiting conditions should be the intention
for an optimal health service delivery to patients
A better digital participation for patients is only possible if technology acceptance in speech and language therapists increases by the described possibilities of individual-related
social and environment-related as well as technology-related factors and therefore allows a satisfying health technology adoption in SLT
The results of both studies presented here are based on an online survey of therapists
The samples were obtained from SLT professionals working in outpatient settings in Germany
so it was consciously accepted that therapists working in other contexts
both studies used an online questionnaire for the survey
which means that it cannot be ruled out that therapists were more likely to participate who had a minimum level of affinity for and competence in technology
a certain bias in the results cannot be discounted
Due to the pandemic situation and the associated restrictions at the time of the studies
This could be due to the methodological limitations
or due to the structure of the questionnaire questions selected
but this limits the connections that can be drawn with the three factors (individual-related
environment-related and technology-related factors) derived from the technology adoption approach of other models
Because of the occasional proven correlations between age/work experience and other variables there seems to be moderating effects in parts of the model
These effects should be investigated in more detail in future studies
two additional factors derived from theory had to be excluded from the final analysis (Attitude of Colleagues and Attitude and Affect toward the Use of Digital Media)
This was the only way to ensure a methodologically adequate procedure
it was possible to obtain initial indications regarding the technology acceptance among SLT professionals in Germany
which can be used for future studies in this area
First hints for possible supporting factors emerge
which can be applied for practice and planning of further education and training
The raw data supporting the conclusions of this article will be made available by the authors
This study was approved by the committee for research ethics of the University of Applied Sciences and Arts (HAWK) Hildesheim/Holzminden/G&#x000F6;ttingen
all participants were informed about the study contents and data privacy and gave their informed consent
No data was collected without prior consent
all participants of Study 2 were informed about the study content and data privacy on the first page of the online-survey and gave their informed consent
The survey itself and its evaluation were anonymous
and it was not possible to draw conclusions about the respondents at any time during the survey or the evaluation
MB and AW performed the statistical analysis from Study 1
BA and AS designed Study 2 and oversaw data collection
BA performed the statistical analysis from Study 2
All authors contributed to writing the manuscript
Grant support for the Study 1 was received from the German Federal Association of Speech and Language Therapy (Deutscher Bundesverband f&#x000FC;r Logop&#x000E4;die e.V.) for research to SW
We would like to thank the therapists who gave their time to respond to the questionnaires and Nele V&#x000F6;cks and Judith Kr&#x000E4;mer for preparing data analysis of Study 1
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations
Any product that may be evaluated in this article
or claim that may be made by its manufacturer
is not guaranteed or endorsed by the publisher
The Supplementary Material for this article can be found online at: <a href="https://www.frontiersin.org/articles/10.3389/fcomm.2023.1176827/full#supplementary-material">https://www.frontiersin.org/articles/10.3389/fcomm.2023.1176827/full#supplementary-material</a>
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<a name="B71" id="B71"></a> Pre&#x000DF;ler
PhonoLo: digitaler Begleiter durch die Phonologie-Therapie
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Unified Theory of Acceptance and Use of Technology
Borgetto B and Starke A (2023) Technology use in speech and language therapy: digital participation succeeds through acceptance and use of technology
Received: 28 February 2023; Accepted: 27 September 2023; Published: 24 October 2023
Copyright &#x000A9; 2023 Leinweber, Alber, Barthel, Whillier, Wittmar, Borgetto and Starke. This is an open-access article distributed under the terms of the <a rel="license" href="http://creativecommons.org/licenses/by/4.0/" target="_blank">Creative Commons Attribution License (CC BY)</a>
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&#x0002A;Correspondence: Juliane Leinweber, <a id="encmail">anVsaWFuZS5sZWlud2ViZXJAaGF3ay5kZQ==</a>; Birte Alber, <a id="encmail">YmlydGUuYWxiZXJAdW5pLWJyZW1lbi5kZQ==</a>
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Saint Mel’s parish held the traditional Processione del Cristo Morto e dell&#8217;Addolorata (Procession with the Dead Christ and Our Lady of Sorrows)
Close to a thousand people walked and prayed from St
following the statues of the dead Christ and Our Lady of Sorrows thorough the streets of Flushing and Whitestone
It was the 57th annual Good Friday Procession in the Whitestone-Flushing area
The Borgetto Cultural Association hosted the event
greeted the faithful of their parishes as well as many other from around the diocese who usually come to St
Mel’s every year to participate in this traditional devotion
the participants prayed the Sorrowful Mysteries of the Rosary in Italian led by Father Italo Barozzi
the president of the Borgetto Cultural Association
officially welcomed the new members and handled them the association pins that Father Barozzi had blessed at the beginning of the ceremony
the statue of Christ was taken down from the cross and put in the processional coffin to start the procession
A group of teenage girls carried the statue of Christ from the cross to the coffin
The Processione del Cristo Morto e dell&#8217;Addolorata at St
Mel’s closely follows the traditions of the procession usually held in the town of Borgetto in Sicily
the original hometown of many families of the parish
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delegated by the District Anti-Mafia Directorate of the Public Prosecutor's Office of Palermo
has implemented the arrest order of a crime suspect ordered against seven suspects
active in the Palermo territories of Partinico
Borgetto and Torretta and held responsible
crimes of mafia association and other related crimes
The operation is part of a broader investigative and executive context which saw the involvement of investigators from the State Police and the Federal Bureau of Investigation in a complex and detailed investigation launched on members of the Gambino family of New York and some Italian representatives of the same association still active in Sicily
at the same time as the execution of the detention order against the 7 suspects in the province of Palermo
the competent FBI branch of New York carried out similar restrictive measures against a further 10 subjects
under investigation for criminal association
The joint operation saw FBI special agents and investigators from the Central Operations Service
the Palermo Flying Squad and the local Sisco in the field
assisted by specialized personnel from the Crime Prevention Departments
started in April 2021 and supported by the consolidated collaborative relationship between the Central Operational Service and the FBI
were progressively corroborated by a constant information-investigative exchange and by a series of cross-border observation services implemented on the axis Palermo-Rome-New York
the investigative findings have demonstrated the ultraactivity of the Partinico mafia mandate
historically linked to the boss Vito Vitale whose rise to the top
was supported by Totò Riina's "Corleonesi"
the criminal profile of some senior elders of the "Torretta" mafia family which had already emerged in the background of the historic investigations better known as "Pizza Connection" and "Iron Tower"
also the role of some prominent members of La Cosa Nostra Americana (LCA) linked to the well-known boss Frank Calì
murdered for trivial reasons in March 2019
the solidity of the existing relationships between the two cliques on the US-Italy axis was ascertained
the American interest in the organizational affairs of the Sicilian Cosa Nostra emerging and a series of dynamics linked to the regency of the mandate also coming to light mafioso from Partinico
the findings developed on the foreign front by the Federal Bureau of Investigation have documented a varied series of extortionate conduct carried out in the construction site sector of the Big Apple by today's recipients of the restrictive measures ordered in the USA
also benefiting from the labor of the local metropolitan gangs
It is in this context that some of the suspects of Italian origin have also evoked previous episodes of extortion against restaurateurs of Sicilian origins based in New York
the impulse and intermediation action ensured in Sicily by the major local mafiosi
capable of exerting pressure on the relatives of the same victims still residing in the Partinico district area
The connection between Lca and the Sicilian "cosa nostra" was therefore also substantiated by the transposition into the USA of the extortion "method" suggested by an elderly boss from Partinico
where the American suspects were convinced of the opportunity of settling for smaller sums and abandoning the bloody actions delegated to the aforementioned gangs
with the aim of retaining the extortionists in the advantageous prospect of a "softer" and lasting subjugation
today's suspects have demonstrated that they maintain an accentuated ability to control the territory
also revealing a series of dynamics connected to the management of a thriving drug trafficking and the conduct of predatory crimes "authorized" by the local regent 
On the occasion of the joint execution of the planned restrictive measures - which took place simultaneously in New York and Palermo starting from the early hours of today (4.00 am in New York and 10 am in Italy) - the reciprocal use of Italian investigators was also envisaged and Americans
who intervened as "observers" on the opposing operational scenarios
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and its Brotherhood of Christ and Our Lady of Sorrows conducted its annual Good Friday procession from St
Mel’s contingent were Fathers JunHee Lee and Italo Barozzi
In speech-language pathology, there is a constant need to make evidence-based decisions based on the patient's needs and goals, speech-language pathologist's clinical expertise, and external evidence. During the COVID-19 pandemic, it was possible for the first time in Germany to implement video-based telepractice in the outpatient care of speech-language pathology. This study aimed to find out how evidence-based decisions are made in video-based telepractice and what forms of evidence are used.
Speech-language pathologists who were working in outpatient services recorded their video-based telepractices for the research project. Five recorded video-based telepractices were transcribed using a simple transcription system and video interaction analysis was used to analyze the video recordings based on grounded theory methodology.
Volume 8 - 2023 | <a class="ArticleLayoutHeader__info__doi" href="https://doi.org/10.3389/fcomm.2023.1176473">https://doi.org/10.3389/fcomm.2023.1176473</a>
Introduction: In speech-language pathology
there is a constant need to make evidence-based decisions based on the patient&#x00027;s needs and goals
speech-language pathologist&#x00027;s clinical expertise
it was possible for the first time in Germany to implement video-based telepractice in the outpatient care of speech-language pathology
This study aimed to find out how evidence-based decisions are made in video-based telepractice and what forms of evidence are used
Methods: Speech-language pathologists who were working in outpatient services recorded their video-based telepractices for the research project
Five recorded video-based telepractices were transcribed using a simple transcription system and video interaction analysis was used to analyze the video recordings based on grounded theory methodology
Results: Interactions between patients and speech-language pathologists are characterized by evidence-based decisions that can be observed
Speech-language pathologists make decisions based on their clinical expertise
There is little evidence of negotiation between patients and speech-language pathologists to make joint decisions
Results showed that speech-language pathologists do not explicitly name external evidence to justify their decisions to patients
Shared decision-making is encouraged by a participative interaction between patients and speech-language pathologists
there was a predominant paternalistic interaction in which the speech-language pathologists made decisions on their own
To represent the decision-based interactions between patients and speech-language pathologists in a video-based therapy session
Discussion: Evidence-based and shared decision-making are important in speech-language pathology to provide patient-centered treatments
The exchange of information between the patient and the speech-language pathologist is important in order to make joint decisions based on these different levels of knowledge
the patient becomes an active participant in the digital treatment
Further research should reconstruct the implicit (possible) use of external evidence
video-based telepractice was allowed to be provided as a telemedical service in an outpatient speech-language pathology (SLP) service for the first time in Germany
The implementation of video-based telepractice was an opportunity to maintain access to SLP service and thus reduce gaps in therapy due to reduce in-person contact
SLPs and patients needed to decide whether continuing therapy via video-based telepractice was feasible with the available technical resources and privacy considerations
This article examines how decision-making occurs in patient-clinician interactions with patients of different ages and clinical indications in video-based telepractice to examine the possibilities of a successful digital participation for people with special needs
It focuses on how patients and clinicians are involved in decision-making and what components characterize a decision-making process
Decision-making processes in SLP should involve multiple forms of evidence to make informed decisions in patient care
Evidence-based practice (EBP) &#x0201C;is the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services&#x0201D; (<a href="#B8">Cochrane, 2011</a>). EBP in SLP has been described as being guided by three core components (<a href="#B1">ASHA, 2004</a>, <a href="#B3">2023</a>; <a href="#B13">Dodd, 2007</a>; <a href="#B14">Dollaghan, 2007</a>):
The best available evidence from systematic research is called external evidence
current best evidence or external scientific evidence
The knowledge and experience of SLPs and their professional and communication skills needed in the therapy process to make shared decisions is referred to as clinical expertise
evidence concerning the preferences of a fully informed patient
or evidence internal to clinical practice in the literature
which can lead to uncertainty for therapists in evidence-based decision-making
Therefore, the advanced EBP model (<a href="#B3">ASHA, 2023</a>) defines three components
the &#x0201C;patient&#x00027;s and caregiver&#x00027;s perspective&#x0201D;
which includes the patient&#x00027;s values
it includes &#x0201C;evidence (external and internal)&#x0201D;
where external evidence refers to best current scientific literature and internal evidence refers to information from subjective observations or objective measurements about patients gathered during the treatment process
the &#x0201C;clinical expertise&#x0201D; refers to e.g.
knowledge from education or critical thinking from professional experience
Decision-making processes should be based on EBP
Decisions must be made throughout the therapy process (e.g.
There are two well-known concepts of decision-making: evidence-based decision-making and shared decision-making
Emphasis is on a reflective approach to the sources of information (e.g.
health systems) on which decisions are made
SDM focuses on the social interaction among all parties involved in the decision and all the associated knowledge bases and forms of interaction
Both concepts, EBDM and SDM, serve to ensure that patients receive high quality care that is based on the best available evidence. While EBDM focuses on the incorporation of diverse evidence into decisions (<a href="#B3">ASHA, 2023</a>), SDM aims to ensure that patients are fully informed so that they can share decisions with professionals (<a href="#B17">Elwyn et al., 2010</a>, <a href="#B18">2012</a>). In a systematic review, <a href="#B40">Stacey et al. (2017)</a> show that SDM results in
and more actively involved in the decision-making and care process
1179) assume that &#x0201C;pragmatic and contextual reasoning&#x0201D; emerges from workplace conditions and influences decision-making processes
The aforementioned literature focus on the various components of EBP and factors that influence clinical decision making in in-person service
it became possible for the first time in Germany to offer and perform video-based therapy in outpatient SLP
a temporary special permit was granted to offer video-based telepractice to people with certain disorders (e.g.
Because (evidence-based) decision making in SLP is a relevant topic in literature and research
it is relevant to investigate how different forms of EBP and other factors influence SLPs&#x00027; decision-making processes in video-based telepractice
The research question of the study was: how do decision-making processes occur between patients and SLPs in video-based telepractice in outpatient service
and what components of evidence do they take
The aim of the study was to conduct the first analysis of video-based telepractice in outpatient SLP services during the COVID-19 pandemic in Germany
Of particular interest was how evidence-based decision-making was realized
a qualitative research design was chosen to answer the research question in a methodological appropriate manner
This paper reports on data collected within the research project &#x0201C;Videotherapie in der ambulanten logop&#x000E4;dischen Versorgung&#x0201D; (ViTaL). The research ethics committee of the University of Applied Sciences and Arts Hildesheim/Holzminden/G&#x000F6;ttingen (HAWK) approved this study. The data represented in this study are based on a video interaction analysis (<a href="#B50">Tuma et al., 2013</a>)
five recorded video-based telepractices were analyzed to describe how evidence-based practice
Outpatient SLPs were recruited by newsletter, social media, homepage, etc. of the Deutscher Bundesverband f&#x000FC;r Logop&#x000E4;die e.V. (dbl) (the official national professional association of logopedics in Germany) and other research networks (e.g., working groups, students, alumni) (<a href="#F1">Figure 1</a>)
SLPs were asked to record their video-based telepractices
Process from recruitment to case selection
nine interested SLPs were introduced to the entire project and its requirements
They were given a written description of the project
and the privacy policy to participate in the project
there was a version for the SLPs and a version for the patients
As the purpose of the study was to explore the decision-making process in video-based telepractice in outpatient service
the only criterion for recruiting patients was that their synchronous therapy had to be video-based
No other inclusion criteria were communicated to SLPs to recruit patients
The reason for this is that it was not possible to assess whether SLPs and patients would be willing to record the video-based telepractice because it was a new medium and some of the use of it was still uncertain
SLP1 and SLP3 are students in their 6th semester of seven semesters of studying at a university
they observe SLP services and increasingly assume the role of therapist or co-therapist under the supervision of their teachers
practical experience and critical reflection takes place from the beginning of the study in order to obtain their state license to work as a SLP at the end of the 6th semester
it can be assumed that the selected students are novices in the learning process of developing an understanding of EBP and skills for implementation of evidence-based decision making
The SLPs recorded the video-based telepractices either with the videoconferencing software they used (ZOOM: SLP1, SLP3, SLP4, SLP6, SLP7, and SLP8) or with the free software OBS (<a href="http://www.obsproject.com/de">www.obsproject.com/de</a>) if the telepractice could not be recorded with the videoconferencing software (e.g.
Each SLP received a link and password e.g.
to upload the video files to the HAWK&#x00027;s password-protected cloud
One SLP (SLP4) was unable to upload the video files to the cloud because of a very weak Internet connection
These video files were encrypted on a USB flash drive and were sent by postal service
MB received the USB flash drive and uploaded the video files to the cloud
All video files were stored in the HAWK cloud by MB under anonymized labels
As more video recordings were provided than could be analyzed, 5 video recordings from different SLPs and patients were selected. Consideration was given to the principle of qualitative research to select cases for data analysis that represent the diversity of individuals, settings, or behaviors (<a href="#B30">Maxwell, 2013</a>)
Purposeful case selection was also guided by identifying variations in the typical population and then systematically selecting cases that represented the most important variations
Minimum and maximum variations were also considered
The selected cases (e.g., interview passages, video recordings) must be particularly rich in detail (<a href="#B7">Breidenstein et al., 2013</a>)
the video recordings provide a detailed account of the therapy that took place and the interactions between patient and therapist
video recordings were selected in which decision-making processes (e.g.
demonstrating different exercise options) or decisions made (e.g.
determining the exercise modification) were evident
the results of making decisions with or without giving reasons (SLP1 to SLP8) and of negotiating and deciding together (SLP1
Due to existing shared decision-making processes
The video recording of SLP6/P6 was selected for maximum contrast
It did not show any negotiation and decision making processes between the patient and the SLP
student/6th semester) was excluded from the data analysis because the video-based telepractice was recorded with an external camera
which severely limited the sound quality and thus the intelligibility of the patient&#x00027;s verbal communication
the external camera focused the patient&#x00027;s image on the screen
so that the therapist&#x00027;s nonverbal communication was barely visible and thus could only be analyzed to a limited extent
The transcripts were as detailed as necessary to address the research question and objectives of the study
were used in the transcription to represent social interaction
delayed audio and video transmission) and the reactions of the SLP and patients were transcribed
No video recordings were excluded from data analysis due to technical difficulties (e.g.
The selection of cases follows the principle of contrast. The cases represent the spectrum of possibilities by showing as much variance as possible (<a href="#B7">Breidenstein et al., 2013</a>)
the cases are intended to represent the spectrum of speech and language therapy
The principle of minimum and maximum contrast is the guiding principle
In order to represent the investigation field as broadly as possible
similar cases and very different cases were selected
Information from patients and therapists sociodemographic questionnaires was used
Based on available sociodemographic data of patients and SLPs
5 individual cases were selected to represent the heterogeneity of patients and SLPs
work experience ranged from academic training (3 years) to 29 years
and working focus ranged from no focus in academic training to a focus in
and symptoms included fluency disorders (stuttering
The video recording of the youngest patient (P3) was chosen so that the age contrast with P2 (60 years old) and P4 (78 years old) would be maximum
Selection criteria included patients&#x00027; symptoms to reflect the numerous symptoms and treatment methods
and the number of previous video-based telepractices to reflect the frequency of use and experience with video-based telepractice
both students with little professional experience and both treating a patient (P1
SLP4 and SLP5 with more professional experience
different professional status and adults with language disorder (P2)
neurogenic speech disorder (P4) and voice disorder (P5)
children with speech and language disorders) was excluded because
she is a practice owner with a similar working experience (18 years)
SLP8 was excluded because she worked in an outpatient practice
was of the same age and had the same work experience (as SLP2)
and had a working focus on developmental language disorders (as SLP5)
She also had a child with a total number of previous telepractice of 10 (similar to P1 and P3)
Events (e.g., situations, people) that the participants themselves identified as particularly important (<a href="#B7">Breidenstein et al., 2013</a>)
participants were informed through the study information and online study presentation that decision making and decisions made during the delivery of video therapy would be analyzed
They made their own decisions about which video-based telepractice to record with which patients
and then they decided which video recordings to make available to researchers
This was not influenced by the researchers
the SLPs were able to select the video-based telepractices of the patients that they considered to be most relevant
The reasons given by the participants for the selection of the patients and their recorded video-based telepractice were the consent of the patients or their relatives
Based on the research question and the purpose of the study
sequences were selected and analyzed by the researchers in which explicit decision-making by SLPs and patients and the negotiation of decisions in video-based telepractice were evident
Criterions such as representativeness, frequency, and everydayness can also be used to select cases (<a href="#B7">Breidenstein et al., 2013</a>)
Sociodemographic data of the patients and the SLPs
Case selection can also focus on the unusual, the unexpected, and the misunderstood. Analyzing situations that cause confusion makes it possible to focus on the differences between the culture of the participants and the cultural self-evidence of the observer (<a href="#B7">Breidenstein et al., 2013</a>)
The researchers&#x00027; assumption that SLPs give reasons for their decisions led to a search for sequences of decisions in which no reasons were given
It turned out that all the video recordings showed sequences in which the SLPs did not give reasons for their decisions
this did not become a criterion for case selection
a decision made by the SLP to perform the exercise was corrected by her after P2 asked several times
this video recording was selected for analysis
such as patients disagreeing with the SLP&#x00027;s decisions
or a negotiation process not being completed due to technical difficulties
did not occur in any of the 23 video recordings
All of the recorded telepractice sessions are equivalent to a 45-min therapy session
The SLPs were located in a therapy room in the outpatient clinical practice (SLP1
the start of the video-based telepractices was defined when the SLPs enter the digital space of the videoconferencing software
The end was defined when the patients and SLPs say goodbye (SLP1
SLP4) or when they are interrupted due to technical problems (SLP5)
all video-based telepractices demonstrated treatment sessions
The participating SLPs used various hardware (e.g.
The synchronous therapies were always performed using audio and video transmission
Various features of the videoconferencing software (e.g.
screen sharing) were used to show digitally recorded home practices or videos
The video feature was often used to display therapy materials in front of the camera for the other person to see
Due to the limited capacity of the internet
such as audio and video transmission interruption occurred
therapists and patients agreed to use the chat function of the videoconferencing system if the audio transmission was severely delayed and they could no longer understand each other
or to ignore the poor video transmission and concentrate on the audio transmission
Another way of handling technical malfunctions was for therapists and/or patients to log back into the videoconferencing system
It is important to note that the patients and SLPs were largely familiar with the technical use of videoconferencing software at the time the video-based therapies were recorded
social interaction via a videoconferencing system was unfamiliar to the SLPs as well as to the patients and their families compared with social interaction in in-person therapies
It should also be noted that all patients were in the &#x0201C;intervention&#x0201D; phase of therapy and were receiving individual therapies
The interpretive video interaction analysis was realized in two steps: within-case analysis and cross-case analysis
reflection of self-perception and perception of others
completion of an exercise or instruction of a new exercise were categorized as nonverbal and verbal communication
minimum and maximum contrast sequence comparisons could be determined during the course of the video-based telepractice for subsequent fine analysis
sequences with decisions with and without explanation
or sequences in which a decision is negotiated between the patient and the SLP vs
sequences in which a decision is predetermined by the SLP
sequences in which decisions are negotiated between the patient and the SLP
or sequences in which the SLP explains a decision and the explanations are based on the therapist&#x00027;s experience or on the approach of the therapy method
These marked sequences were then reviewed and discussed with the other members of the team (SW
As a result of all five within-case analyses
four sequences with decision processes (negotiation
weighing arguments) and 26 sequences with explanations and 61 with decisions without explanations were identified as relevant for further analysis
The sequences ranged in length from 1:24 min to 9:37 min
A blank line was inserted after each sequence in the analysis protocol
This separates the sequences from each other
Initial Coding and coding categories&#x02014;exemplary extract of the analysis
This also took place in the comparative approach of the grounded theory methodology (<a href="#B43">Strauss and Corbin, 1996</a>; <a href="#B22">Glaser and Strauss, 1998</a>; <a href="#B12">Dietrich and Mey, 2018</a>)
actions and interactions in which decisions or decision-making were analyzed in individual cases and which were similar in content were now compared across cases
or specifying the target action with or without reasoning (SLP)
The contrast was in the different contexts (e.g.
Typical courses of interaction were reconstructed in a differentiated way
sequences of interactions with a similar context were compared (e.g.
teaching self-awareness to patients who had never received in-person therapy
consolidation of speech modification techniques)
The cross-case analysis of similar interactions aimed to describe the temporal sequence and structure of the interaction between the patients and the SLPs
This was to reconstruct across cases how decisions are made or how decision-making occurs in video-based telepractice
The results indicated that SLPs maintain strategies for a common basis of interaction during video-based telepractice
Nonverbal and verbal communication as part of social practices was limited by the resulting delays in audio or video transmission
SLPs and patients used various technical interaction strategies
or to ignore the limited image transmission
they re-established a common basis for interaction
hand gestures; pauses in fluent speech) that SLPs and patients used to maintain their interactions were demonstrated
It was noticeable that patients and SLPs sometimes could not see each other
It was not maintained when practice materials were held in front of the video camera
or when patients looked down while writing or reading and talking to the SLP
or when the SLP explained something to them
By analyzing the data, it could be reconstructed that the decision-making process is strongly influenced by the social interaction between the patient and the SLP. A paternalistic interaction or participative interaction between patients and SLPs characterizes decision making in video-based telepractice (<a href="#F3">Figure 3</a>)
The descriptive characterization of the two styles of interaction applies to the social interactions in video-based telepractice in outpatient SLP services analyzed in this qualitative study
Characteristics of decision-making in video-based telepractice
A paternalistic interaction by the SLP was most evident when structured treatment (e.g.
A more participative interacting was observed in the video-based telepractice
where different individual exercises were combined (e.g.
The analysis showed that the patient&#x00027;s age
had less influence on the decision-making than the style of interaction
it became clear that negotiation to decide how to perform the next exercise (Case 3: 2 sequences; Case 5: 1 sequence) occurred in both Case 3 (SLP: 22 years/P3: 6 years) and Case 5 (SLP5: 53 years
both SLPs give a similar number of decisions without giving reasons (SLP3: 11; SLP5: 12) and decisions with giving reasons (SLP3: 2; SLP5: 5)
Although both cases are maximum contrasts in terms of age
no difference in decision making could be found
The cross-case analysis also revealed that in all cases there were more decisions without reasoning given (SLP1: 14
SLP5: 12) than decisions with reasoning given (SLP1: 8
This is done in patients with different symptoms (e.g
voice disorder) and with different total treatment time: from 1 month (P2) to 6.5 years (P1)
The SLP&#x00027;s paternalistic interaction characterized social interactions
by &#x0201C;determine target action&#x0201D; within a therapy sequence or by &#x0201C;determine home practice.&#x0201D;
SLP2: (holds an image card in front of the camera) &#x0201C;What is important to me today is that you also tell me the generic term
it&#x00027;s still a bit difficult (removes image card
looks at screen) to find a generic term for everything in this category
the generic term is especially important to me today
(holds an image card in front of the camera
SLP2 is not visible (3) SLP2 removes image card
P2: &#x0201C;This is (2) uh one (3) u::ch&#x0201D;
SLP2: (holds an image card in front of the camera
looks at screen) &#x0201C;That is always so difficult to find the (1) the generic term.&#x0201D;
SLP2: &#x0201C;That&#x00027;s what I explained to you before
that everything got a bit mixed up because of the stroke (2) and we&#x00027;re trying to sort it out now
which you also have to do as home practice from time to time
it can be seen how the SLP2 determines the target action without asking the patient how relevant the goal of the exercise is for him
She does not respond to his nonverbal and verbal signals (e.g
but justifies why this target action is necessary based on the cause and symptoms of the disease
The target action and goal are predetermined by the SLP and there is no negotiation or modification of the exercise
SLP also mentioned their clinical expertise and experience
The focus was on the correct execution of the actions
and the clinical expertise of the SLPs determined the therapeutic approach
SLP1 asks for the patient&#x00027;s self-assessment of his use of speaking technique using specific criteria and also self-assesses his use of speaking technique using the same specific criteria (quote 2)
(1) subtract&#x0201D; [applies speaking technique] (laughs)
SLP1: &#x0201C;I&#x00027;m going to ask you again for the criteria and you can just give a thumbs up (shows it) or thumbs down (shows it)
SLP1: &#x0201C;Was it long enough?&#x0201D;
P1: &#x0201C;Yes.&#x0201D; (he stretches up his right thumb)
with the &#x0201C;s&#x0201D; I think you can be much louder than with the &#x0201C;m&#x0201D;
(1) and how was the transition to the vowel
yes.&#x0201D; (he stretches up his right thumb)
but just long enough so that you still have enough air for the rest of the word
She does not link the evaluation of his speaking to his wishes for therapy
SLP partly justified their decisions by referring to the patient&#x00027;s therapy goal or to previous successes or difficulties in practicing
The SLPs often did not explain to the patients and the continuously present (P3: mother) or partially present (P2: wife) relatives why a target action had to be repeated
or they decided to start a &#x0201C;new target action.&#x0201D;
A participative style of interaction was evident in the video-based telepractice when the SLPs asked the patients to rate their perception of the vocal quality or their effort during &#x0201C;perform target action&#x0201D; (quote 3)
(2) is the breathing more stimulated than before?&#x0201D;
P5: &#x0201C;It is mainly that it sticks so much here (the left hand to the lower right costal arches) (.) yes
such a sticky feeling is (.) it&#x00027;s almost like that
so it&#x00027;s less here (.) in the abdomen (.) the further feeling is than so more back here
which I feel is very pleasant.&#x0201D; (both hands are in the lumbar region)
then let&#x00027;s do a little stretching exercise one more time
SLP5 asks the patient how she assesses her breathing (quote 3)
This requires the patient to be able to perceive
describe and assess herself and her breathing
SLP5 confirms the patient&#x00027;s self-assessment and
provides a new target action that relates to the patient&#x00027;s self-awareness
She uses the patient&#x00027;s self-awareness to continue voice therapy
negotiations took place between the patients and the SLPs about
&#x0201C;repeat action&#x0201D; or &#x0201C;extended practice.&#x0201D; In these more participative interactions
patients&#x00027; self-assessments were used as starting points for modified action or new target actions
When interacting with patients in this way
SLPs brought their clinical expertise and experience
as well as specific knowledge from previous therapy sessions with each patient
The shared dialogues and patient self-assessments allowed the SLPs to flexibly adapt interventions to the current needs
everyday communication situations and the individual living environments of the patients on a situation-specific basis
Shared decision-making processes took place
after the self-assessment of the previous implementation and documentation of homework by the patient (P1) or by the mother (P3)
the patient respectively the mother and the SLP discussed and decided how to implement home practice more often in the future (P1) and how to use popular and existing games at home (P3)
further exercise actions were discussed together
taking into account preferences (P3) and physical self-awareness (P5) in the decision-making process
Negotiations in the decision-making process took place in participative interactions
The data analysis revealed that SLPs rarely explicate their internal decision-making process and thus rarely explain or justify their decisions to patients and relatives
it is not clear to others on what professional basis the decisions were made
to &#x0201C;correct&#x0201D; the patient&#x00027;s target actions or to &#x0201C;finish action&#x0201D; and &#x0201C;determine new target action.&#x0201D; When SLPs justified their decisions
on the implementation of the therapy method) and to previous experience with the patient (e.g.
The SLPs justified their decisions in participative and paternalistic interactions with the patients and relatives
The internal evidence and the client perspectives were expressed in different degrees of explicitness
No explicit inclusion of current external evidence (e.g.
scientific evidence) could be reconstructed when analyzing video-based telepractice
Based on the results of the within-case and of the cross-case analyses, a process model was developed which illustrated how patients and SLPs interact during a video-based telepractice session (<a href="#B4">Barthel et al., 2021a</a>). Three phases characterize video-based telepractice sessions: (1) situational, content-based arriving, (2) interactive, process-based treatment, and (3) situational, content-based closure (<a href="#F4">Figure 4</a>)
Figure 4. Process model of patient-therapist interactions (P: patient, SLP: speech-language pathologist) (<a style="color:grey;" href="#B4">Barthel et al., 2021a</a>)
The visible and audible interactions in each phase and the resulting interaction process throughout the therapy session are based on decisions made by the SLP and the patient
decisions relate to content related structural aspects of speech and language therapy
such as the therapy method or the transfer of practice as the next therapy step
decisions refer to the concrete interactionist situation
such as &#x0201C;determine target action,&#x0201D; &#x0201C;confirm target action,&#x0201D; &#x0201C;request self-assessment,&#x0201D; and &#x0201C;determine home practice
The various decisions all lead to continuous practicing in the &#x0201C;interactive
They maintain the process-based interaction between patient and SLP
With the introduction of video-based telepractice during the COVID-19 pandemic
SLPs needed to rapidly transition their outpatient service from in-person to video-based therapy
The study examined the decision-making that occurs in the interactions between patients and SLPs in a video-based telepractice
It focused on the components that characterize a decision-making process
The availability of technical equipment (e.g.
the availability of videoconferencing systems (e.g.
and the existing skills to use the technical equipment and functions of the digital applications enabled patient&#x00027;s digital participation in health care
the health care in outpatient SLP services could continue without interruption due to restrictions during the COVID-19 pandemic
to distinguish between clinical opinion and clinical expertise and to understand their influence on the clinical decision-making process
There was no evidence of patient refusal or questioning of the clinical process during the participative interactions in video-based telepractice
this could lead to more content and goal-related justifications by SLPs and more communicative negotiation processes between patients and SLPs
Why patients did not inquire about the content of the practice
could be due to the fact that only practices they were already familiar with were performed
that the explanations and the nonverbal and verbal specification of the target action were understandable
or that this pattern of interaction had consciously or unconsciously developed due to the previous number of therapy sessions
The results of the present study are consistent with international findings (e.g., <a href="#B9">Coleman et al., 2015</a>; <a href="#B38">Rangarathnam et al., 2015</a>; <a href="#B52">Wales et al., 2017</a>; <a href="#B45">Sutherland et al., 2018</a>; <a href="#B32">McGill et al., 2019</a>; <a href="#B46">Theodoros et al., 2019</a>; <a href="#B54">Weidner and Lowman, 2020</a>) that show video-based telepractice can be delivered to individuals with different communication disorders (e.g.
voice disorders) and clinical conditions (e.g.
Parkinson&#x00027;s disease) of different ages
One way that people with communication disorders across the lifespan can digitally participate in healthcare is via video-based telepractice as a digital form of outpatient SLP service
Speech and language telepractice is considered necessary in the German health care system
to counteract physical distances and limited mobility
to integrate the evidence-based transfer of therapy content more strongly into the patients&#x00027; lives
Video-based telepractice is necessary to meet the advancing digital healthcare
The process model focuses on the social interactions between patient and SLP and their decisions in video-based telepractice. A limitation is that continuously or partially present relatives are not explicitly listed in the phases of the process model (<a href="#F4">Figure 4</a>) and in the styles of interaction (<a href="#F3">Figure 3</a>)
Since relatives are an important resource in SLP
the involvement of relatives should be focused on in order to describe their role in decision-making processes in a more differentiated way
in all phases of therapy and depending on the age of the patients
Their interactions could be mapped in an extended model to concretize decisions related to how relatives are guided for &#x0201C;home practice&#x0201D; or how they are integrated into &#x0201C;perform target action.&#x0201D; This could reveal similar or different decision-making processes as well as styles of interaction of the SLPs
and the family members were using the video-based telepractice for at least six therapy sessions
It is reasonable to assume that during this time
interactions were implicitly and/or explicitly developed that influenced decision-making in video-based telepractice
How social practices of decision-making occur in other phases of the therapy process (e.g.
what patterns of decision-making occur in group therapy
and how little experience with social interactions in video-based telepractice affects decision-making are not answered by the study
the process model can only map individual therapy in the treatment phase
In this video-based observational study with a cross-sectional design
it was not possible to reconstruct how nonverbal and verbal pragmatic communication factors (e.g.
gestures) depend on the relationship between patients and SLPs
or on symptoms of the communication disorder
and in turn influence decision-making processes
This refers both to the access and use of digital applications and to the participative style of social interactions in digital care
The use of different qualitative and quantitative methods of data collection and analysis in different research designs can address the complexity of video-based in outpatient SLP service (e.g.
ICF orientation) and decision-making processes
This can be used to gain further essential insights into the conditions and patterns of interaction in evidence-based decision-making processes in video-based telepractice and also in SLP in general
internal and external evidence and clinical expertise in interactive decision-making needs to be elicited from the perspectives of SLPs and patients and made explicit for use in treatment
To concretize the sources of knowledge of SLPs
it would be relevant to know which sources of knowledge influence the interne evidence and clinical expertise
It would be interesting to determine whether and how
or the expertise of colleagues are incorporated into clinical decision-making processes
A decision-making process in which the patient ultimately made the decision about how to proceed with practicing was not analyzed in the video interaction analysis
It was not founded that SLPs were asking patients to make a choice between different practice options or intensities
It would be interesting to find out in which situations and for which content patients make the final decision and SLPs leave the final decision to the patients
It would also be interesting to find out what patients and families want to know from their perspective in order to make an informed decision
Qualitative research methods would be appropriate to explore the views
It would also be interesting to know when and how decisions are influenced when synchronous video and in-person therapies take place during the course of therapy
This could provide knowledge about the role of patients and the competencies of SLPs in order to shape the future of evidence-based and digital SLP in Germany
The datasets presented in this article are not readily available because it is not possible to anonymize the recorded video-based teletherapies. Due to privacy and ethical concerns, the data cannot be made publicly available. Further inquiries can be directed to the corresponding author. Requests to access the datasets should be directed to MB, <a id="encmail">bWFyaWEuYmFydGhlbDJAaGF3ay5kZQ==</a>
and JL contributed to conception and design of the study
MB wrote the first draft of the manuscript
MB and JL contributed to manuscript revision
All authors contributed to the article and approved the submitted version
The Deutscher Bundesverband f&#x000FC;r Logop&#x000E4;die e.V
(dbl) (the official national professional association of logopedics in Germany) funded this study
The handling editor PJ declared a shared committee with the author JL at the time of review
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Received: 28 February 2023; Accepted: 30 November 2023; Published: 15 December 2023
Copyright &#x000A9; 2023 Barthel, Wittmar, Borgetto and Leinweber. This is an open-access article distributed under the terms of the <a rel="license" href="http://creativecommons.org/licenses/by/4.0/" target="_blank">Creative Commons Attribution License (CC BY)</a>
&#x0002A;Correspondence: Maria Barthel, <a id="encmail">bWFyaWEuYmFydGhlbDJAaGF3ay5kZQ==</a>
&#x02020;ORCID: Maria Barthel <a href="https://orcid.org/0000-0002-3682-6555">orcid.org/0000-0002-3682-6555</a> Silke Wittmar <a href="https://orcid.org/0000-0003-0886-6872">orcid.org/0000-0003-0886-6872</a> Bernhard Borgetto <a href="https://orcid.org/0000-0001-7465-3061">orcid.org/0000-0001-7465-3061</a> Juliane Leinweber <a href="https://orcid.org/0000-0002-5655-7882">orcid.org/0000-0002-5655-7882</a>
The Italian-American Catholic community of Whitestone was graced with the presence of the Sacred Image of Our Lady of Romitello for a visit to St
The image is the sacred Madonna of Our Lady of Sorrows from the town of Borgetto in Sicily
turned out in droves to venerate the image
“It is an image that has been venerated for several centuries,” said Bishop Nicholas DiMarzio
“It’s very important to the people from Borgetto
as they venerate Our Lady under this title.”
which was only the second time the Italian church and government allowed for the icon to travel to the U.S
The first time occurred in the 1980s to St
which at the time housed the highest concentration of Borgetto in the diocese
“There are many more Borgetto that live here in the United States than are left in Borgetto in Italy,” said Msgr
“They came for a better life; they found that better life
but their love and devotion always remains with their miraculous image of Our Lady
She’s the one they pray to in bad times and good
They see it as a visit of the Blessed Mother
and it means a great deal to them to see this image in the church.”
– two Passionist priests from the Sanctuary of Romitello in Borgetto – accompanied the image as it made its way from Aeroporto di Palermo
where the image was unveiled and placed upon a float for a mile-long street procession of nearly 500 people up 154th Street to St
complete with a police escort and the “Association G
Catanzaro,” the 30-piece concert band of Borgetto
The image was then placed behind the altar
A rite of reception was held the first night
president of the Borgetto Cultural Association; and Father DiMariano
“I believed this day would arrive,” Giambrone said
Luke’s and other surrounding churches lined the aisles for a chance to venerate the Madonna up close
All present received a prayer card with the image along with a cotton ball that had been rubbed on the glass protecting the image
“For me it’s something unbelievable…beautiful,” said Claudia Morelli
Luke’s for 35 years whose family comes from Rome
“I’m very emotional because I love the Blessed Mother
very happy that the Blessed Mother is with us.”
special Masses in English and Italian were held as well as confessions
blessings and house visits by the Passionist priests
Archbishop Michele Pennisi of the Diocese of Monreale – the home diocese of Borgetto – celebrated a special Mass at St
followed by another street procession with the image
Tosi said he was privileged and honored to welcome the sacred image to his parish and community
“I think it’s very appropriate that the image of Our Lady of Romitello should come to St
not because there are so many descendants of Borgetto here in our parish and in our neighboring parishes but also because tradition tells us that St
Luke had a very warm and loving relationship with the Blessed Mother,” he said
Luke was an artist who composed the first painting of the Blessed Mother – also a fitting touch to the image’s visit
Mel’s parish honored “the most popular saint of the world” – St
Auxiliary Bishop Raymond Chappetto was the main celebrant of a Mass in Italian at the parish March 16
came into the church at the start of the entrance procession
the Italian community is very strong,” Bishop Chappetto said
“It’s one of the largest Italian communities that we have in the diocese and they have a great devotion here to St
so I’m very happy to be here tonight with them.”
Joseph is very deep in Italy and among Italian-Americans
but certain traditions related to this devotion come from specific Italian regions and towns
Mel’s there is a large number of Italian immigrants and first-generation Italian-Americans
and some families are originally from a town near Palermo that has become famous for its celebrations in honor of St
Mel parishioner whose parents came to America from Borgetto
“There are a lot of [other] towns that do this too
the community built the altar in the church’s undercroft in the traditional style
All the key elements were there – three tiers representing the Three Persons of the Holy Trinity
with the Holy Child in his arms at the top of the altar
the food on the altar is shared with family and friends
but originally it was collected primarily to give to the poor people in the town
“The tradition is that you choose three children from a poor family,” said Georgakopoulos
“People donate money and the money is split evenly among the children
They also buy the food in threes – everything you could think of
Bishop Chappetto said: “Tonight we want to stress the importance of St
Joseph in the life of the Church and in the plan of salvation
He is a very important figure in the life of the Church
he is a very good provider for the Holy Family and we want to provide for our families as well.”
Mel’s has become popular among the Italian-Americans in the Diocese of Brooklyn and beyond
“I grew up with the tradition because I’m Sicilian,” Scaturr said
“It’s good to see here in the United States that the tradition continues with our families and our children
You have people that celebrate here at the same time they celebrate [St
“In our town it’s a big tradition because people make promises to St
Bishop Chappetto blessed the bread baskets by the statue of St
The second part of the celebration then took place around the St
The conversation was animated and mostly in Italian
The whole celebration had the feeling of a big family reunion
participants took home bags with loaves of bread that the bishop had blessed at the end of Mass
this was one of the highlights of a very busy week
“This is one of three Masses in honor of St
McClancy High School yesterday in Italian to honor St
and then on Monday night at my own parish in Flushing
Bishop Chappetto knew about the celebration of St
“In my family we had a great devotion to St
Joseph and I am happy that tradition still continues and that I can be part of it.”
Close to 1,000 Italian-Americans participated in the annual Good Friday street procession in Whitestone
the evening program began for the first time at St
Addolorata del Romitello and the Confraternita del Cristo Morto e dell’Addolorata organized the procession
Italian-Americans brought the devotion from their hometown of Borgetto
our roots and I want this to carry on,” said Gino Romero
vice president of the Borgetto Cultural Association
This was Romano’s first year chairing the procession
and his main goal was to involve younger parishioners and families
“I want the younger generation into this so I reached out to my daughters
my grandchildren – everybody – to see where our roots are from
“I raised my kids to believe in Jesus Christ and they have to keep doing that with their kids,” he said
Four generations of the Romano family joined in the line of march following a standing-room-only service of Stations of the Cross
led in Italian by Father Italo Barozzi from St
and also great faith and popular piety,” said Father Barozzi
The important thing is to be able to transmit this to them so that tomorrow they will remember the customs of their youth
They stood in silence as men and women climbed a wooden staircase
and took down a statue of Christ from a wooden crucifix on the front lawn
Romano removed the nails and crown of thorns
which his grandson Gino carried on a satin pillow
and women carried the statue to the glass coffin
parishioners from Our Lady of the Blessed Sacrament
and even some people from Brooklyn and Long Island
“This is a tradition for me and my family for many
Azopardi said Good Friday wouldn’t be the same for her without taking part in this procession
which was organized by Steve Giambrone and the Comitato Festa Di Maria S.S
And while the faces and details have changed since she was child
the faith that first inspired this tradition still burns in the hearts of those who continue it today
I used to be one of the little boys carrying the cross,” said Sal Casabianca
who recently moved back to the old neighborhood
He spotted familiar faces and friends’ parents in the crowd
but was most excited to see that young men and women were there to breathe new life into this custom of faith and culture in the community
the lack of established enforcement mechanisms has left the judgement largely symbolic
combined with the fact that China takes claim over most of the South China Sea
demonstrates China&#8217;s potential unwillingness to back down from issues related to maritime sovereignty
as their capacity to enforce their claims and engage in negotiations is overshadowed by China&#8217;s dominance
and raises the possibility of military tensions and conflicts
Minor conflicts like the Sino-Filipino boat collision may exacerbate the complex security context
in which the actions of both parties can be misinterpreted and lead to a larger conflict
international laws are not very successful in mitigating such conflicts since China demonstrates a disregard for maritime legislation
which in turn imposes no real penalties on the Chinese government
a major violation of state sovereignty in the South China Sea would only put pressure on the international system and exacerbate global conflict
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