This qualitative study was embedded within a larger study examining the use and effectiveness of exercise physiology services in Australia before and during the COVID-19 pandemic [5]. We used a qualitative description approach [10] to capture the client and AEP perspectives and experiences of exercise physiology services during the inaugural year of the COVID-19 pandemic (after January 25, 2020; the date of the first confirmed case in Australia).

Eligible participants for this study were adult (aged 18 years or older; capable of understanding and writing in English) clients who received and clinicians who delivered 1 or more exercise physiology sessions in Australia during the first year of the COVID-19 pandemic (June 2020 to June 2021). Purposive sampling was used to identify potential participants from a recent retrospective audit of AEP practices [5]. Participants were primarily sought through social media advertisements and correspondence released by the professional accreditation body Exercise & Sport Science Australia. Word-of-mouth referrals were obtained through the networks of study authors. Participants from all Australian states and territories were invited to participate. Potential participants were initially contacted via email by the project manager. Collectively, 9% (7/80) of clinicians and 8% (11/138) of clients agreed to participate. Recruitment ceased on the assessment by the interviewer that data saturation was reached. No reasons for refusal to participate were recorded and no participants withdrew consent following enrollment.

The data collection period spanned from January 20, 2021, to September 24, 2021. A total of 18 individual semistructured interviews were conducted via videoconference in the participants’ choice of setting (eg, home or workplace). A single interviewer (PJ; PhD, research fellow and AEP, and male) conducted all interviews. There were no established relationships between the interviewer and participants prior to study commencement. The interviewer introduced themselves as a member of the research team and disclosed all relevant study-based information regarding aims, funding, and participation.

Semistructured interviews followed an interview guide that listed a number of key questions developed by the interviewer (Multimedia Appendix 1). When necessary, the interviewer asked further questions to clarify or obtain additional information following responses to key questions. No repeat interviews were conducted, and all interviews were digitally recorded and transcribed verbatim by an external commercial transcription company (TranscribeMe). No field notes were made during or after the interviews. The mean (SD) duration of all interviews was 12.9 (3.3) minutes. Due to financial limitations, transcripts were not returned to participants for comment and correction.

Independent thematic analysis was formally conducted by one researcher (RCCB) using Microsoft Excel (Microsoft). These data were validated by another researcher (SEK). Each researcher independently familiarized themselves with all data and then extracted, coded, and tabulated meaningful sentences or phrases. Themes and subthemes were derived using deductive and inductive approaches and compared. These were guided by the approach of Braun and Clarke [11]. Consensus discussions were held digitally to consolidate themes and subthemes. When a consensus was not clear, a third researcher (PJ) arbitrated decisions on final themes. The trustworthiness of the data was assessed using four criteria: (1) credibility (data triangulation from multiple perspectives; with 2 researchers, RCCB and SEK, confirming themes), (2) transferability (rich details on the study methods with purposive sampling of participants), (3) dependability (data triangulation by 2 researchers, RCCB and SEK, with rigorous data collection techniques, procedures, and analyses), and (4) confirmability (debriefing, reflexivity, and meetings between RCCB, SEK, and NLM were conducted to establish analytic rigor). Dominant themes were cross-checked with exemplar quotes to confirm consistency. No participants were asked to provide feedback on the findings. Data saturation for both AEPs and clients was achieved prior to ceasing recruitment. Data saturation was determined when little or no new information was being garnered from interviews to address the research question [12,13].

The study was conducted in line with the National Statement on Ethical Conduct in Human Research (2007) and the Declaration of Helsinki. It was approved by Deakin University Human Ethics Advisory Group Health (90-2020-200512), and the findings were reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) [14]. All participants provided written informed consent prior to involvement in the study. Informed consent covered sensitive and private information. Participants engaged voluntarily in the research project and were able to opt up at any time. All participant data were deidentified prior to theme derivation.

Client and AEP demographics are shown in Table 1. A total of 11 clients and 7 AEPs participated in interviews, and 3 key themes with pertinent subthemes were identified (Figure 1 and Table 2). Experiences regarding overall access to exercise physiology services during the COVID-19 pandemic were often shared by both AEPs and clients.

The three main themes identified in this study of AEP and client experiences and perceptions of exercise physiology services during the COVID-19 pandemic were as follows: (1) telehealth enables access to services but limits the use of some clinical tools, (2) engagement and the “relational space” are limited by telehealth, and (3) technological challenges are pervasive in telehealth delivery of exercise services. Positive experiences included increased geographical reach and time or cost efficiency. Negative experiences stemmed from accessibility to equipment necessary for completing prescribed exercises and assessing or monitoring clinical outcomes, challenges with clinician-client rapport, inferior social engagement with peers and practitioners, and the presence of technological issues (system- and operator-based). This study adds to the current literature by providing insights into AEP and client perspectives on telehealth service delivery. This is especially important in the wake of the COVID-19 pandemic, where interest in digital health has been amplified.

We identified key positive themes relating to exercise physiology service provided during the COVID-19 pandemic. Specifically, both AEPs and clients acknowledged that telehealth delivery of services increased geographical reach and tended to be more cost- and time-efficient than in-person delivery. A 2021 report of Australian clients who used telehealth allied health services during the COVID-19 pandemic also identified positive experiences regarding time efficiency and increased geographical reach, yet conversely reported that multiple clients considered telehealth delivery poor value for money compared to in-person delivery [15]. Inconsistency regarding experiences of cost-efficiency likely stems from examining allied health services collectively, whereby hands-on treatments, such as manual therapy and podiatry services, are physically incompatible with telehealth delivery [15,16]. An analysis of financial costs associated with Australian exercise physiology services during the COVID-19 pandemic indicated that across a mean (SD) treatment duration of 11 (7) weeks, the cost of exercise physiology services solely delivered via telehealth was Aus $89.91 (US $59.71) less than that delivered in person only [17]. These apparent differences cost should be interpreted with caution, however, given the omission of effectiveness data and the disproportionate representation of National Disability Insurance Scheme clients. The positive experiences identified in this study support the notion that the continued use of telehealth delivery methods during the COVID-19 pandemic may benefit the provision of exercise physiology services due to remote access to services being valued. Accessibility to patient-centered health care is a key strategic imperative for the Australian government [18]. These results may indicate the value of telehealth exercise physiology services for the promotion of patient-centered health care.

Several negative experiences of exercise physiology services provided during the COVID-19 pandemic were also identified. Challenges pertaining to equipment accessibility, social engagement, and the use of technology were commonly identified by both AEPs and clients. Interestingly, the safety of telehealth delivery was not listed by clients or AEPs as a barrier to implementation. This finding contrasts with previous literature analyzing allied health professionals’ perceptions of telehealth exercise services, where safety and suitability of clientele were raised as a key consideration prior to implementation [19,20]. The challenges identified in this study were similar to those of a 2021 report of Australian clients and clinicians who used allied health services during the COVID-19 pandemic [9]. These include difficulties conducting some clinical assessments via telehealth and difficulties fostering the client-clinician relationship [15]. Furthermore, a recent qualitative analysis of telehealth allied health service delivery for clients with permanent disabilities reported similar challenges [9]. These challenges included inhibition of clinician feedback, difficulty fostering client-clinician rapport, and lack of access to resources [9]. Addressing challenges associated with the telehealth delivery of exercise physiology services is of known importance to facilitate uptake and effectiveness. For example, a recent systematic review examining the efficacy of exercise training for patients with chronic disease provided via telehealth delivery observed access and usefulness of technology as the main drivers of patient satisfaction [21]. Furthermore, both AEPs and clients perceived exercise physiology services via telehealth delivery as less effective than in-person delivery. This contrasts with recent findings determining that videoconferencing exercise interventions are at least as effective as in-person services for the improvement of exercise capacity and quality of life [21]. However, the context of videoconferencing exercise interventions included in this review differs from this study, with studies included being subjected to highly controlled clinical environments with objective data. This is fundamentally different from clinical exercise practice adapting quickly to COVID-19 pandemic–related public health restrictions.

The lack of social engagement expressed by clients in this study appeared to be influenced by the one-on-one nature of telehealth exercise physiology sessions delivered. Group-based videoconferencing may address some aspects of this issue but have additional considerations for delivery prior to implementation. While AEPs unanimously preferred in-person delivery and perceived that clients also preferred this modality, clients conveyed mixed opinions regarding which modality was superior for motivation to attend sessions. This suggests that there are a variety of factors that may influence modality preference (eg, time and digital literacy). Given the importance of a client-centered approach for achieving clinical outcomes, the value placed on a flexible mode of delivery by clients should be considered when designing exercise programs. This finding demonstrates the importance of co-designing exercise interventions between AEPs and clients for optimal uptake. Together, our observations and those from prior studies suggest that a range of barriers should be considered when using telehealth delivery of exercise physiology services.

The results of this study warrant consideration for ongoing and future exercise physiology telehealth services. To improve the reliability and quality of service, AEPs should ensure that universal telehealth requirements are met [22]. Of particular importance is the development of a skilled workforce competent in the administrative and operational aspects of telehealth practice. This includes the formulation of telehealth action plans (including strategies for issues with technology) for implementation by both administrative and clinical staff and the use of exercise assessment or prescription methods that lend themselves to delivery via telehealth. Examples may include validated patient-reported outcome measures and the application of telehealth-appropriate exercise programming that aligns with client goals and preferences. Further suggestions to improve practice include establishing expectations of sessions and access to support staff to facilitate telehealth sessions [9]. Prior to facilitation, evaluation processes should also take place on an individual level to assess client suitability for telehealth and preference for service modality [9,23]. Importantly, the co-design of solutions to client-perceived limitations of telehealth is warranted. Given that nationally funded AEP telehealth service uptake through Australia’s universal health care system (Medicare) is considerably low [24], and the government’s strategic imperative to provide more accessible patient-focused health care, the results of this study and consequent recommendations for practice should be considered prior to service implementation.

This study was strengthened by the inclusion of both AEPs and clients, which increased the ecological validity and generalizability of the lived experiences identified. The use of 2 independent data analysts who did not conduct the semistructured interviews further reduced the risk of bias during data analysis. The unique findings of this study complement previous literature, potentially contributing to the uptake and dissemination of telehealth in exercise services in Australia. The limitations of this study, however, should also be considered. First, all participants were recruited from the state of Victoria. This occurred even though participants from all states and territories were invited to participate. Second, financial restrictions precluded the return of transcripts and findings to participants for corrections and interpretation, respectively. As member checking is a component of assessing credibility, this has implications for the trustworthiness of the transcribed data and should be interpreted with caution. Third, the questions included in the interview guide of this study were designed to examine lived experiences and perspectives, rather than specifics regarding acceptability, barriers, and facilitators; therefore, future qualitative studies are necessary to evaluate and draw conclusions on these specific components of exercise physiology services during the COVID-19 pandemic.

The evaluation of perceptions and experiences of AEP and client lived experiences of exercise physiology services during the COVID-19 pandemic showed that despite pervasive technological challenges, telehealth delivery enabled access to services. Clinician-client rapport, social engagement, and the capacity to use dedicated equipment for exercise prescription and outcome assessment were viewed as negatives to telehealth service delivery. These findings imply that the co-design of solutions to client-perceived limitations of telehealth delivery is warranted. Shared client and AEP experiences highlight key considerations for the implementation of telehealth delivery into exercise physiology services to facilitate uptake and effectiveness.