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Evaluating the Effect of a Telepsychiatry Educational Program on the Awareness, Knowledge, Attitude, and Skills of Telepsychiatry Among Spanish Psychiatrists during COVID-19 Pandemic

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Introduction

Telepsychiatry (TP) is the branch of telemedicine that allows the delivery of mental health care from a distance through technology, often using videoconferencing, involving a range of services including psychiatric evaluations, therapy (individual therapy, group therapy, family therapy), patient education, and medication management.1–3

Although TP has been working in one form or another for over 60 years, it has been gaining prominence since the 1990s, fully accepted by mental health professionals in the 2000s, and since then it has been considered as effective as face-to-face care, with clinical practice guidelines being available.4 TP facilitates access to medical care for those patients who live in rural areas or who have some difficulty of any kind in getting to the hospital.

In Spain, a growing number of health services based on telemedicine have been implemented in recent years as a complement (not substitute) to conventional services. However, the dissemination of this technology is still limited and slow, with many more projects being tested than finally implemented in the health sector.5 However, it has been necessary to wait until the onset of coronavirus disease (i.e., COVID-19 pandemic), for TP transformation from a niche practice to a standard way of psychiatric clinical practice.6 TP is here to stay as those services that have converted their face-to-face appointments into virtual appointments have found a number of benefits, including overall user satisfaction, reduced time wasted by eliminating travel, the possibility of continuing to receive care despite confinement and maintaining the economic activity of a clinic, advantage that the physician can be teleworking, and flexibility in choosing the best time to be seen.7–9

The ultimate success of TP will depend on many factors including the knowledge and understanding of the concept, skills acquired, the attitude toward technology, greater number of hours of experience of clinicians, and working environment for psychiatrists.10,11

The Spanish Society of Psychiatry is a private nonprofit organization established in 1958 that includes more than 1,200 Spanish psychiatrists. Its aim is to lead Spanish psychiatry; promote the study and development of psychiatry, and its scientific and technical progress, care, teaching, and research at all levels and areas of its competence; promote information and psychiatric training of the general practitioner and participate in the training of the specialist; and contribute, by advising and promoting research to improve the practice of psychiatry.

In this context, and taking into account the challenges in mental health care created by COVID-19 pandemic, characterized by calls for social distancing and concerns about the mental health effects of the pandemic, the Spanish Society of Psychiatry developed an online Practical Course of Telepsychiatry offered free of charge to its members with the aim of filling the educational gap in this matter among psychiatry professionals in Spain and promoting knowledge of the technology, methods and practical skills.

Since assessment needs to be part of an ongoing evaluation cycle intended to keep the curriculum fresh, educationally sound, and achieving its intended objectives, the main objective of this study was to assess the changes in awareness, knowledge, attitude, and willingness to accept and provide TP services among the Spanish psychiatrists after their participation in an online educational intervention of practical TP.12

Materials and Methods

STUDY SAMPLE AND DESIGN

A quasi-experimental online design with pre-intervention and immediate post-intervention test was used in this study, conducted from October to December 2020. Until the current COVID-19 pandemic, TP had hardly been used in routine clinical practice in Spain. The Spanish Society of Psychiatry developed a practical online TP course carried out by psychiatrist with expertise in the field with the aim of covering the educational gap among mental health professionals in Spain, reaching more than 80% of its members (1,277 psychiatrists) and providing them with training in TP and logistical support.

INTERVENTION

The online educative intervention comprised 22 teaching hours along 14 topics that included the evolution and history of TP and its impact on psychiatric care; its benefits and limitations in clinical practice; TP technical considerations; its legal, safety, and ethical aspects; the path to implementation; the practice of TP in rural/remote places; in primary care; in residencies for the elderly; in child and adolescent mental health care; clinical research in TP; and training and communication in TP practice.

INSTRUMENT

The telemedicine—awareness, knowledge, attitude, and skills (AKAS) questionnaire was originally designed and validated by Zayapragassarazan10 as a self-reported questionnaire consisting of six sections: (1) information about the personal and professional background of the respondent; (2) awareness level about telemedicine, through 12 statements with graded response on a three-point scale ranging from 0 to 2 that is, “0” for “don’t know,” “1” for “heard of it,” and “2” for “know about it”; (3) knowledge level with respect to telemedicine, through 11 statements to be answered in either “Yes” or “No,” giving a score of “1” for “Yes” and “0” for “No”; (4) attitude toward telemedicine, through 11 statements with a graded response on a five-point Likert scale ranging from 0 to 4 that is, “0” for strongly disagree, “1” for disagree, “2” for undecided, “3” for agree and “4” strongly agree; (5) skills in telemedicine, through 12 statements with a graded response to each statement on a four point scale ranging from 0 to 3 that is, “0” for “unskilled,” “1” for “learner,” “2” for “mediocre” and “3” for “expert”; and finally, (6) an open ended section that allowed the respondents to express their opinions and other comments related to the area of research. Our adapted version only changed the word telemedicine by TP. The completion of the questionnaire twice, before and after the educational intervention, was mandatory requirement to obtain the corresponding educational credits. All the participants signed an informed consent to participate in the project.

DATA ANALYSIS

Data collected were statistically analyzed using the Statistical Package for Social Sciences (SPSS, version 25.0). The raw scores were calculated for awareness, knowledge, attitude, and skills sections of AKAS. The normality of the entered data was checked by the Kolmogorov–Smirnov test and Fisher’s measures of skewness and kurtosis. Mean and standard deviation (SD) were used to describe and summarize continuous variables while frequency expressed in percentages was used for categorical variables. Mean scores of AKAS were computed at the pre-intervention and at the end of educative intervention (post-intervention). Raw scores for the AKAS sections were converted to percentage considering that the scores equal to and <49% were considered as low with respect to AKAS, the scores between 50% and 70% were considered as average and the scores equal to and above 71% were considered as high. The change of scores and percentages between pre and post-intervention in AKAS sections analyzed was investigated using Chi-square test, paired t-, and analysis of variance (ANOVA) test with statistically significant level set at p ≤ 0.05.

Results

A total of 213 psychiatrists enrolled in the online course of practical TP and filled pre-intervention AKAS questionnaires. Of these, 152 completed the course and filled the post-intervention questionnaires. Table 1 shows the distribution of participating psychiatrists according to their sociodemographic variables. The sample initially consisted mainly of women (59%), younger than 40 years (61.9%), working in public sector (71.4%), in hospitals without TP units (81.7%), with a mediocre computer and internet knowledge (67.6%), and never attended any training course in TP (87.8%).

Table 1. Distribution of the Psychiatrists Who Participated in Online Course of Practical Telepsychiatry (n = 213)
  GLOBAL n (%)
Gender
 Male 87 (40.8)
 Female 126 (59.2)
Age group
 <30 years 58 (27.2)
 31–40 years 74 (34.7)
 41–50 years 34 (16.0)
 51–60 years 31 (14.6)
 More than 60 years 16 (7.5)
Work sector
 Private 23 (10.8)
 Public 152 (71.4)
 Both 38 (17.8)
Job category
 Psychiatry resident 67 (35.1)
 Psychiatrist 121 (56.8)
 Head of section 9 (4.2)
 Head of service 16 (7.5)
Teaching activity
 No 80 (37.6)
 Yes 133 (62.4)
Assistance activity
 No 10 (4.7)
 Yes 203 (95.3)
Research activity
 No 102 (47.9)
 Yes 111 (52.1)
Computer and internet knowledge
 Beginner 22 (10.3)
 Mediocre 144 (67.6)
 Advanced 47 (22.1)
Have you attended any training course in Telepsychiatry?
 No 187 (87.8)
 Yes 26 (12.2)
Does your hospital have a telepsychiatry unit?
 No 174 (81.7)
 Yes 39 (18.3)

Along Tables 2–4 the results on the AKAS questionnaire are depicted. Table 2 shows mean and SD for questionnaire sections scores of the overall sample and sub-samples before and after the educative intervention. At pre-intervention, it should be noted that female participants self-reported significant lower scores in skills (F = 4,758, p = 0.030), older participants self-reported higher values in awareness score (F = 6,192, p = 0.0001), and psychiatry residents self-reported significant lower values of awareness than psychiatrists (F = 9,358, p = 0.003). In Table 3 the levels of AKAS among the sample before and after the educational intervention are described.

Table 2. Mean and Standard Deviation for Awareness, Knowledge, Attitude, and Skills Sections Scores of the Overall Sample and Sub-Samples Before and After the Educative Intervention
PARAMETERS SCORE RANGE n (%) AWARENESS (MIN 0–MAX 24) KNOWLEDGE (MIN 0–MAX 11) ATTITUDE (MIN 0–MAX44) SKILLS (MIN 0–MAX36)
PRE POST PRE POST PRE POST PRE POST
Overall 213 (100) 18.1 ± 4.9 22.2 ± 2.6 7.7 ± 1.3 8.8 ± 0.5 32.7 ± 6.4 36.7 ± 5.9 28.8 ± 7.4 29.6 ± 6.5
Psychiatrists 146 (68.5) 16.6 ± 5.0 22.3 ± 2.9 7.7 ± 1.4 8.8 ± 0.5 32.8 ± 6.1 36.7 ± 5.9 28.6 ± 7.6 29.6 ± 6.5
Residents 67 (31.5) 18.1 ± 4.9 22.1 ± 1.9 7.7 ± 1.2 8.8 ± 0.6 32.6 ± 6.4 36.8 ± 5.2 29.3 ± 7.0 29.3 ± 6.5
Male 87 (40.8) 17.8 ± 4.6 21.8 ± 3.6 7.8 ± 1.4 8.9 ± 0.4 32.8 ± 7.5 36.6 ± 7.6 30.1 ± 7.7 31.5 ± 6.2
Female 126 (59.2) 18.1 ± 4.9 22.5 ± 1.7 7.6 ± 1.3 8.7 ± 0.6 32.7 ± 5.4 36.7 ± 4.4 27.9 ± 7.1 28.3 ± 6.4
Age <30 years 58 (27.2) 16.5 ± 5.2 22.0 ± 1.9 7.5 ± 1.3 8.8 ± 0.4 32.6 ± 6.9 37.2 ± 4.6 29.2 ± 7.8 30.4 ± 6.1
Age 31–40 years 74 (34.7) 17.2 ± 5.3 21.8 ± 3.7 7.6 ± 1.5 8.7 ± 0.6 32.0 ± 5.8 35.3 ± 7.2 30.1 ± 6.5 30.1 ± 6.1
Age 41–50 years 34 (16.0) 20.0 ± 2.7 23.0 ± 1.1 7.8 ± 1.3 8.8 ± 0.7 34.7 ± 5.6 39.4 ± 3.8 28.0 ± 7.9 30.1 ± 6.9
Age 51–60 years 31 (14.6) 20.1 ± 3.3 22.5 ± 2.1 7.7 ± 1.0 8.8 ± 0.5 32.7 ± 6.6 36.0 ± 5.9 25.9 ± 8.2 26.9 ± 6.9
Age >61 years 16 (7.5) 20.4 ± 5.1 23.0 ± 1.6 8.3 ± 1.3 8.9 ± 0.3 32.8 ± 6.4 36.7 ± 5.9 28.2 ± 8.1 28.4 ± 7.9

Table 3. Different Levels of Awareness, Knowledge, Attitude, and Skills of the Sample Before and After the Educational Intervention
DEGREE AWARENESS KNOWLEDGE ATTITUDE SKILLS
LOW ≤49% AVERAGE 50–70% HIGH ≥71% LOW ≤49% AVERAGE 50–70% HIGH ≥71% LOW ≤49% AVERAGE 50–70% HIGH ≥71% LOW ≤49% AVERAGE 50–70% HIGH ≥71%
PRE 26 12.2%) 36 (16.9%) 151 (70.9%) 4 (1.9%) 79 (37.1%) 130 (61.0%) 10 (4.7%) 70 (32.9%) 133 (62.4%) 30 (14.1%) 62 (29.1%) 121 (56.8%)
POST 1 (0.7%) 3 (2.0%) 148 (97.4%) 0 (0%) 4 (2.6%) 148 (97.4%) 3 (2.0%) 12 (7.9%) 137 (90.1%) 13 (8.6%) 46 (21.6%) 93 (61.2%)

Table 4. Effect of the Educational Intervention on Awareness, Knowledge, Attitudes, and Skills About Telepsychiatry in Psychiatrists Participating (Paired Sample t Test)
  MEAN SD SEM 95% CI OF THE DIFFERENCE t df SIG. (TWO-TAILED)
LOWER UPPER
Awareness total score PRE–POST −4.27 4.35 0.353 −4.97 −3.57 −12.09 151 0.000
Knowledge total score PRE–POST −1.12 1.42 0.115 −1.35 −0.891 −9.72 151 0.000
Attitude total score PRE–POST −3.38 5.55 0.450 −4.27 −2.49 −7.49 151 0.000
Skills total score PRE–POST −0.612 4.20 0.341 −1.29 0.062 −1.79 151 0.075

At pre-intervention, the awareness level shows that 12% of the participants have low level of awareness, 17% have average level, and 71% have high level; the knowledge level shows that only 2% of the participants have low level of knowledge of TP, 37% have average, and 41% have high level; concerning the attitude level, 5% of the respondents have low level of attitude toward TP, 33% possess an average level and 62% possess high level; and, according to the skill of TP, 14% do not have adequate skills, 29% possess average skills, and 57% have adequate skills. Table 4 shows the effect of the telepsychiatry educational intervention on the results of the AKAS questionnaire. There was a statistically significant increase in the awareness, knowledge, and attitudes scores but no in skills about TP. Figure 1 shows box plot graphics with pre- and post-AKAS questionnaire sections values where it is possible to demonstrate the improvement among the participants, especially in the first two scales (Awareness and Knowledge).

Fig. 1.

Fig. 1. Box plot graphics showing pre- and post AKAS questionnaire sections values. AKAS, awareness (A), knowledge (B), attitude (C), and skills (D).

Discussion

The COVID-19 pandemic has made the practice of psychiatry more challenging than ever. Calls for social distancing and concerns about the mental health effects of the COVID-19 pandemic have renewed considerable attention to TP as way of delivery of psychiatric assessment and care.13

Although TP had already demonstrated that it is comparable to face-to-face services in terms of efficacy and satisfaction, having even gone so far as to suggest that it might be preferable for some specific patients, concerns about rapport, privacy, safety, and technological limitations have limited the expansion of the more widespread application of TP.1,14–17 The global health crisis posed by the COVID-19 pandemic can serve as an opportunity to promote, among many mental health professionals, awareness and knowledge of the possibilities offered by the digital era.18 However, at present, psychiatrists need more formal training in technology to understand risks, benefits, and limitations of this technology-based treatment.19

The present study reveals that, before the educational intervention, the AKAS with regard to TP among our sample of Spanish psychiatrists are much higher than those evidenced with the same instrument, considering telemedicine, among the faculty members working in selected medical colleges in India or Italian physicians using another questionnaire.10,20 This is a positive starting point. Our work indicates (as do other review articles) that the degree of patient satisfaction with these techniques is similar to that obtained in face-to-face interviews.21 However, we must not forget that our respondents are mental health professionals self-selected by being interested in increasing their competence in TP who have voluntarily enrolled in the course and their initial attitudes would very likely be more positive. Understanding the AKAS toward TP among the broader groups of Spanish psychiatrists will require additional research with different methodology.

The effect of the educative intervention produced significant improvements in the domains of awareness, knowledge, and attitudes toward TP in psychiatrists participating. However, no significant change was observed in the skills domain about TP. The four-step model in teaching practical skills, which adopts a very behaviorist approach to learning and that has been traditionally used in medicine, involves: (1) real life demonstration; (2) trainer talk through; (3) learner talk through; and (4) learner do.22 Psychiatrists participating in the educational intervention have the opportunity to watch a recording of a TP procedure that could replace steps 1 and 2 but have no possibility to progress through steps 3 and 4. We consider that this situation was responsible for the lack of evolution in this domain since providing opportunities for the trainee to practice is vital, as is regular critical scrutiny of performance, coupled with constructive feedback.23 Future editions of the course should take this consideration into account to stimulate greater use of TP.

Moreover, the group that showed most interest in training in TP were women, younger than 40 years, working in the public sector and in hospitals without TP units. Therefore, it seems that this may be the target group for future training programs. Interestingly, young psychiatrist even if they do not yet have TP units implemented in their hospitals, they show a desire to learn. Such findings should encourage professional societies to develop training courses in this field. Finally, it is worth to note that in this study we have used self-report measures to assess improvements in AKAS, but future studies will have to investigate whether these changes extrapolate to an improvement in the use of TP tools.

Professional societies, as the Spanish Society of Psychiatry, play an essential role in the education, training, and setting and raising standards in the specialty. The Spanish Society of Psychiatry is highly committed to supporting the members throughout continuing medical education that have a direct impact in their daily practice. In this line, the online Practical Course of Telepsychiatry described in this study is an example.

Acknowledgments

The authors would like to gratefully acknowledge the collaboration of Spanish Society of Psychiatry and Dr. Zayapragassarazan for providing and authorizing us to use the “Telemedicine – Awareness, Knowledge, Attitude & Skills (AKAS) Questionnaire” (registration no.: L-79809/2018 dated December 27, 2018; diary no.: 14776/2018-CO/L; copyright office Government of India). IG thanks the support of the Spanish Ministry of Science and Innovation (MCIN) (PI19/00954) integrated into the Plan Nacional de I+D+I and cofinanced by the ISCIII-Subdirección General de Evaluación y el Fondos Europeos de la Unión Europea (FEDER, FSE, Next Generation EU/Plan de Recuperación Transformación y Resiliencia_PRTR); the Instituto de Salud Carlos III; the CIBER of Mental Health (CIBERSAM); and the the Secretaria d’Universitats i Recerca del Departament d’Economia i Coneixement (2017 SGR 1365), CERCA Programme/Generalitat de Catalunya.

Disclosure Statement

LGR has received grants and served as consultant, advisor or CME speaker for the following identities: Angelini, Casen Recordati, GSK, Novartis, Pfizer, Janssen Cilag, and Lundbeck, Lundbeck-Otsuka. IG has received grants and served as consultant, advisor or CME speaker for the following identities: Angelini, Casen Recordati, Ferrer, Janssen Cilag, and Lundbeck, Lundbeck-Otsuka, Luye, SEI Healthcare outside the submitted work.

Funding Information

No funding was received for this article.

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