Attitudes towards video consultation for telepsychiatry services among psychiatrists during the COVID-19 pandemic: An observational study

1. Introduction

Telepsychiatry broadly refers to systems of providing mental health care from a distance (Jh et al., 2006; Mucic, 2008; Saeed et al., 2012). Despite consistent demonstration of usefulness of telepsychiatry (Yellowlees et al., 2012), few settings have integrated telepsychiatry into existing systems (Naskar et al., 2017).

In the context of the ongoing COVID-19 pandemic, telepsychiatry can be utilised as an effective modality for psychotherapeutic interventions, with the added advantage of limited physical contact (Yellowlees et al., 2012). However, the implementation of telepsychiatry would be largely based on the willingness, acceptance and prior experience of service providers (Bashshur, 1995; Bashshur et al., 2013). Interestingly, though studies have shown good acceptance by patients, several studies note that acceptance among doctors is usually lower (Jh et al., 2006; Mucic, 2008; Saeed et al., 2012). In view of the multiple proven advantages of telepsychiatry, it is of clinical interest to better understand the attitudes of health care providers towards this health care delivery modality. Though few studies have examined this question (Hilty et al., 2009; Mucic, 2008; Saeed et al., 2012), to the best of our knowledge, there are none in the Indian context. This study aims to address this lacuna as well as provide valuable inputs for acceptance of telepsychiatry services among psychiatrists in the context of the COVID-19 pandemic.

2. Methods

We conducted a cross sectional observational study at a tertiary care psychiatric facility in South India. We recruited all members of teaching faculty as well as post graduate trainees after obtaining informed consent. We obtained clearance from the institutional review board and ethics committee. The assessments allowed for anonymous responses and for confidentiality. The data collection form (attached as a supplementary file) was divided into four sections, namely, Section A- included details about socio-demographic and clinical data, Section B- Vellore Instrument to Assess Attitude to Telepsychiatry (VIAAT) to assess attitudes to telepsychiatry, Section C included endorsement of the ‘overall statements’ and Section D on the perceived strengths and weaknesses of telepsychiatry.

VIAAT consisted of twenty declarative statements, which participants were asked to endorse on a numerical scale (1 indicating complete disagreement and 10 indicating complete agreement). We used a theoretical framework with the following factors to derive the statements used in the questionnaire: (a) clinical care, (b) technology, (c) patient acceptance, (d) legal complications. The statements were drafted in a manner that higher levels of endorsement could be taken as an indicator of a better attitude towards video consultations. A Total Attitude Score was calculated by adding scores on twenty statements. Total attitude score was dichotomized at 140 (70 % of a possible 200) into ‘high’≥140 and ‘not high’ <139 TAS.

3. Results

Seventy-two doctors actively working in the Department of Psychiatry in a tertiary care centre attached to a general hospital were included in the study. One person refused consent; there was no statistically significant difference between participants and non-participant on age, sex and years of experience. The majority of participants were less than 40 years of age, female, and postgraduate trainees. Most had no prior experience with video consultation and agreed that COVID-19 changed their perception of video consultations.

The psychometric properties of the instrument were calculated and were good, Cronbach alpha for the questionnaire was 0.916; Cronbach alpha for all subscales was more than 0.8. Split half reliability method demonstrated a high correlation coefficient of 0.89. Four factors were identified using latent variable analysis (impact on clinical care, confidence in use of technology, perceptions about patient acceptance, and legal perspectives), which mapped the theoretical constructs of the instruments. The eigen values of impact on clinical care, confidence in use of technology, perceptions about patient acceptance, and legal perspectives were 4.58, 4.29, 3.20 and 1.77 respectively; they explained 22.94 %, 21.48 %, 15.99 % and 8.87 % of the variance respectively.

The mean total attitude score was 136.7, 46.5 % (n = 33). The total attitude score did not show significant associations with age, designation or years of experience in psychiatry. Males had a significantly higher mean total attitude score than females and were more likely to have a ‘high’ total attitude score (OR 1.88; 95 %CI = 1.12–3.15). Table 1 details total attitude score as well as subscale scores by age, designation and gender. Among the subscales of the score, males and females showed significant differences only in the technology subscale with males having a significantly higher mean score. There were significant differences between faculty and postgraduates in mean scores in the patient acceptance subscale with faculty having a significantly higher mean score.

Table 1.

Details total attitude score as well as subscale scores by age, designation and gender (n = 71).

	Total Attitude score mean (SD)	Clinical Care mean (SD)	Technology mean (SD)	Patient Acceptance mean (SD)	Legal Complications mean (SD)
Whole sample	136.7 (25.6)	46.1 (8.9)	34.9 (7.6)	43.4 (12.1)	12.2 (4.45)
Age
> 40 years	138.7 (13.1)	46.8 (4.7)	37.8 (4.0)	40.7 (7.5)	13.3 (3.8)
<40 years	136.3 (27.7)	45.9 (9.6)	34.2 (8.1)	44.1 (12.9)	11.9 (4.6)
Gender
Men	143.5*(27.4)	48.5 (7.9)*	35.6 (7.6)	46.5 (13.2)	12.8 (4.7)
Women	131.1*(22.9)	44.1 (9.2)*	34.3 (7.6)	41.0 (10.6)	11.6 (4.1)
Designation
Trainee	133.7 (28.7)	45.8 (10.4)	33.4 (8.3)*	42.6(13.2)	11.9(4.5)
Faculty	140.6 (20.6)	46.6 (6.7)	37.0 (6.2)*	44.4 (10.5)	12.5 (4.4)

^*p value < 0.05.

Participants were asked to endorse the statement ‘Overall, I would recommend video consultations to my patients’ on a numerical scale from 1 to 10 with 1 indicating complete disagreement and 10 indicating complete agreement. The mean score of the sample was 7.65 (SD = 1.80). Bivariate analysis showed a significant association only with gender; with males having significantly higher mean scores than females (8.12 vs. 7.25, p value = 0.025). Multivariate analysis was done using linear regression with all the individual statements in section II, age and gender as independent variables. Endorsement of the statement ‘Overall, I would recommend video consultations to my patients’ was significantly associated only with endorsement of the statement ‘I am confident in using technology’ (p value = 0.03, r square = 0.26). Gender was not significantly associated in multivariate analysis. Analysis of the frequencies of selected strengths and weaknesses by gender, age and designation showed that technological problems (84.5 %) and legal liabilities (76.1 %) were the most commonly selected weaknesses. Social distancing (95.8 %) and better accessibility to care (91.5 %) were the most commonly selected strengths of video consultations.

4. Discussion

Respondents seemed to have a good overall attitude towards video consultations in this sample of psychiatrists who mostly had no past experience with video consultations, but were imminently expecting to. The COVID-19 pandemic, and the constraints of physical consultations in this context seems to have been a significant factor in changing attitudes towards video consultations.

Technology seemed to be the most important factor influencing attitudes with multivariate analysis showing that self-rated comfort in using technology was the only factor independently associated with doctors’ stated intention to recommend video consultations as a modality to their patients. Differences in attitude scores between males and females also seemed to operate by way of technological factors with males and females showing significantly different scores in only the technology subscale of the questionnaire. ‘Technological problems’ was also the commonest felt weakness of video consultations in this sample. This is in keeping with findings in multiple studies across the world, with increased relevance in developing countries (Ashfaq et al., 2021; Gaggioli et al., 2005; Haimi et al., 2018; Kamal et al., 2018; Ly et al., 2017). However, comfort in using technology can be viewed as a factor amenable to modification.

While several studies demonstrated better attitudes among younger and more junior doctors that could be reflective of contextual and institutional factors (Gaggioli et al., 2005; Waschkau et al., 2020), in our study, age or designation did not significantly influence total attitude score, though, interestingly, postgraduate trainees and younger respondents were significantly less optimistic about patient acceptance of video conferencing compared to their seniors.

Though this study has inherent weaknesses due to its cross sectional, single centre design, we believe it provides valuable data in the context of few studies looking at the field of telepsychiatry in a low resource setting. This study indicates that an investment into increasing doctors’ confidence in using the technology involved in the process of video conferencing could significantly improve attitudes towards the modality and ease its implementation in real world settings. Sessions geared specifically towards this outcome could be a valuable addition to telepsychiatry programmes in similar settings, though further studies in the area are warranted.

Financial disclosure

This study was funded using institutional funds (FLUID grant).

Declaration of Competing Interest

We have no conflicts of interest to declare.