Setting
The study was conducted in Norway, a Northern European country with universal health coverage providing both specialist and primary health care including mental healthcare services [
21]. Almost 65,000 children and adolescents receive specialist mental health care yearly in Norway, with outpatient care being the dominant treatment option [
22]. The latest numbers from 2021 show that most adolescents receiving specialist mental health care in Norway either had a mental or behavioural disorder, chapter F in the ICD-10 coding (57%) or had symptoms and signs involving cognition, perception, emotional state and behaviour, part of chapter R in the ICD-10 coding, (40%) [
22,
23].
In Norway, all citizens can access the national digital patient portal (
www.helsenorge.no), and some healthcare services have their own digital patient portal solutions in addition. Patient portals offer a range of features, including access to information from one’s electronic health record such as test results and medical notes, prescriptions refill requests, appointment booking, asynchronous patient-provider communication, and online consultations.
Until the age of 12, parents normally have access to most information shared in their child´s patient portal. From the age of 12, adolescents get more rights in determining the information they will share with their parents [
24,
25]. From the age of 16, which is the age of majority under health regulations in Norway, adolescents can access all their information in their patient portal [
26,
27].
Recruitment and participants
The eligibility criteria were adolescents aged 12 years or older currently receiving or had received treatment in the last three months at one of four different specialist child and adolescent mental healthcare clinics in Norway. The clinics were purposefully chosen to cover the various parts of Norway.
Eligible participants were identified by administrative staff at the clinics, who also wrote the patients’ names and addresses on pre-packed envelopes. The envelopes contained an information letter and consent form, the questionnaire, and a prepaid return envelope. After three weeks, a reminder was sent to all participants, asking them to disregard the request if they had already responded.
Data collection
For participating adolescents aged 12 to 15, consent from both parents was required for their child´s participation. Consequently, for adolescents between ages 12 and 15, the questionnaire had to be answered on paper and returned by mail as no electronic solution existed that allowed for the practice of double parental consent. Adolescents aged 16 years or older, i.e., above the age of majority according to health regulations in Norway, were able to consent themselves. Therefore, adolescents aged 16 years or older could choose to either answer the questionnaire on paper or scan a QR code and answer the questionnaire digitally.
The questionnaire used in this study primarily included validated scales and questions from previously published studies on patient portal use. It was piloted on three adolescents aged 12–17, two of whom had prior experience with mental health care. Feedback from the participants of the pilot was used to make refinements and ensure clarity. The questionnaire began with a definition of a patient portal:
“A patient portal is an app or website that provides digital access to healthcare services. It may give you access to information from your health record that your healthcare providers have shared with you, such as test results and visit summaries. It may also provide features like appointment scheduling and the ability to contact healthcare providers for ongoing treatment. An example of a patient portal that is accessible to all residents in Norway iswww.helsenorge.no.
Additionally, many general practitioners also use various types of patient portals.”
The adolescents aged 16 years or above, or their parents for those younger than 16 years, consented to the linkage of their questionnaire answers to data from the Norwegian Patient Registry (NPR), which included information on their contacts with specialist mental health care and their registered ICD-10 diagnoses.
Measures
The question measuring interest in using patient portals was based on a Belgium study [
28], and read as follows:
“Please indicate how strongly you agree or disagree with the following statements: I am interested in using a patient portal”. Participants could select one of the following response options: “Strongly agree”, “Agree”, “Disagree” or “Strongly disagree”. The responses were then recoded into a binary variable, categorising “Interested” for answers “Strongly agree” or “Agree” or “Not interested” for “Disagree” or “Strongly disagree”.
Patient activation was assessed using the validated Norwegian version of the Patient Activation Measure (PAM®-13) [
29]. It comprises 13 statements to which participants indicate their level of agreement on a four-point Likert scale, transformed to a score ranging from 0 to 100. The PAM®-13 has been employed in studies on eHealth interventions [
30], patient portal use [
31], and patient populations from the age of 12 [
32]. The scores were categorised into four levels: level 1 (score 0–47), level 2 (score 47,1–55,1), level 3 (score 55,2–72,4) and level 4 (score 72,5-100) [
33,
34].
Self-reported overall health was assessed using a single question:
“In general, how would you rate your health?” with the following five response categories: “Excellent”, “Very good”, “Good”, “Fair” and ”Poor” [
35,
36]. Self-reported health has previously been used to evaluate general health in various studies of adolescents, including adolescents in the Nordic countries [
37,
38].
Depressive symptoms were assessed using the Patient Health Questionnaire-8 (PHQ-8), which is a validated adaptation of the original PHQ-9 developed for diagnosing and assessing depression. The PHQ-8 has also been used on adolescents and in Norwegian studies [
39‐
43]. The PHQ-8 consists of eight items, and participants were asked to indicate the extent to which certain symptoms had bothered them for the last two weeks using the following response options: “not at all”, “several days”, “more than half the days” and “nearly every day”. The total score of the answers ranged from 0 to 24 and was categorised into four levels: minimal or mild depressive symptoms (0–9), moderate depressive symptoms [
10‐
14], moderately severe depressive symptoms [
15‐
19] and severe depressive symptoms [
20‐
24].
The questionnaire also included one domain from the eHealth Literacy Questionnaire (eHLQ), a questionnaire consisting of seven domains, that has been validated in Danish and previously used in a Norwegian context [
44‐
46]. The domain “Using technology to process health information” included five questions and was used as a measure of eHealth literacy. Participants were asked to indicate their level of agreement on a 4-point ordinal scale ranging from “strongly agree” to “strongly disagree”. The average score was calculated and then categorised into quartiles, as there is no universally established used cut-off for this domain.
Specialist mental health care contacts were counted as either: below 10, between 10 and 30, or above 30 contacts, within the last 12 months. This includes all activities and encounters where the patient was present, such as consultations, online consultations, and telephone contact between the provider and the patient. However, the code for indirect patient contact was excluded. The ICD-10 diagnoses were grouped into the two chapters most commonly used in Norwegian specialist mental health care for adolescents: “Mental and behavioural disorders” (Chapter F) or “Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified” (Chapter R) [
22]. Adolescents with more than one diagnosis were categorised according to their primary diagnosis.
Socio-demographic information was self-reported and included age, gender with three categories (female, male and other), the participants’ school or daytime activity, and parents’ highest education.
Sample size
This study was part of a larger quasi-experimental study that aimed to assess the difference in PAM-13 scores between users and non-users of a comprehensive patient portal. The power calculation for the larger study showed that 588 adolescents were needed to observe a difference of at least 4 points between groups, with a standard deviation of 15, an alpha of 0.05, a power of 80%, and an allocation ratio of 1:3. We managed to obtain information on 623 adolescents, and they were invited to account for non-responses.