Patient Perceptions on Telepsychiatry as an In-Consult Alternative During COVID-19 Pandemic: Peruvian Adaptation of the Telehealth Usability Questionnaire

Abstract

Objective:

To identify the perceptions of the patients who received alternative care by telepsychiatry at the Cayetano Heredia Hospital (HCH).

Methods:

This research consisted of two phases: (1) transcultural adaptation of the Telehealth Usability Questionnaire (TUQ) with three experts and (2) application of the questionnaire in 183 patients from psychiatry in HCH. Nonparametric tests were used to determine the association between variables.

Results:

We applied 20 questions to 60 men and 123 women, with a median age of 45. The ease of using the virtual consultation service, the comfort with its use, and the general satisfaction had a score of 6 out of 7 and are associated with the number of devices that patients have and their degree of education. The usefulness, communication by virtual means, and the solution of technical problems had scores higher than 6, being considered acceptable by the patients. Willingness to have a teleconsultation again was high and was associated with patient satisfaction with the consultation.

Conclusions:

Most patients were satisfied with telepsychiatry via telemonitoring during the COVID-19 pandemic. The usage of validated tools such as TUQ might be included as part of evaluations of new telemedicine services.

Introduction

Telemedicine has been used historically in crisis times and pandemics since its beginnings. The telegraph was used during the American Civil War. The telephone has been used since the 1900s by physicians. The radio was used during the First World War in Alaska and Australia¹ and during the Vietnam War to bring psychological support.² In Peru, its use started during the cholera epidemic in 1991, when the Ministry of Health and nongovernmental organizations utilized the radio, television, and the written press to give cleaning measures and feeding habits.³

During COVID-19, the Peruvian government declared an obligatory quarantine for every citizen, with exceptions for those requiring health care needs as an urgency or emergency.⁴ Since May 2020, medical care has been offered by telemedicine according to the Ministerial Resolution N° 309-2020.⁵ At Cayetano Heredia Hospital (HCH), telemonitoring was implanted and consisted of the follow-up of their patients using the virtual modality.⁴ Under this new medical care, the continuity of user medical care was authorized.

Developed countries have more experience in telepsychiatry before the COVID-19 pandemic, and it is seen that this medical care conserves the effectiveness of in-person therapy and does not affect the patient–physician relationship.^6,7 Furthermore, the satisfaction of the medical consultations, according to the actual literature, depends on different factors such as the perceived usefulness, family and friend's opinions, the patient's attitude, and the patient's previous knowledge of technology.^6,8 On the contrary, it is believed that variables such as older age and disabilities might hinder the use of virtual medical consultations.⁹

During the COVID-19 pandemic, telemedicine has increased around the world from 7.1% to 85.5% in countries such as the United States.¹⁰ In Europe, the acceptance of telepsychiatry was 80.2% during the pandemic.¹¹ The factors that determined the type of medical consultation elected were diverse, such as the patient's age¹² and the transportation time to the face-to-face medical visit.¹³ In developing countries, the low acceptance was determined by illiteracy, ignorance toward the digital software, difficulties in developing an adequate patient–physician relationship, and the difficulty to detect body language by the physicians.^14,15

Because of the recent massive implementation of telepsychiatry in medical consultations in Peru, there is no literature on the success or failure of its implementation. This study aimed to identify the different perceptions of the patients from the psychiatry service attended by telemonitoring while obtaining data on patient satisfaction with its associated factors.

Materials and Methods

PHASE A: TRANSCULTURAL ADAPTATION OF THE TELEHEALTH USABILITY QUESTIONNAIRE

The Telehealth Usability Questionnaire (TUQ) was developed by Parmanto et al.¹⁶ It consisted of 21 items from different aspects of telemedicine using a Likert scale from 1 to 7 (totally disagree and totally agree as anchors in the extremes of the scale). The questions are classified according to the usability factors: usefulness, ease of use and learnability, interphase quality, interaction quality, reliability, satisfaction, and future use. Later, Torre et al. adapted, translated, and validated the TUQ in Spanish in Argentina.¹⁷

Three experts (two health professionals with a master's in biomedical informatics and one psychiatrist with a master's in clinical epidemiology) away from the study participated in the adaptation of the TUQ to the sociolinguistic variations of Spanish in Peru. Each one received the original survey in English and the validated version in Spanish. Then, they completed in a table where they pointed out each question if: (1) corresponded to the variable indicator, (2) contributed to measure the proposed indicator and, (3) allowed to classify the subjects in the established categories. Finally, the investigators reunited the completed tables by the experts to elaborate the final questionnaire.

PHASE B: QUESTIONNAIRE APPLICATION

An instrument that consisted of two parts was constructed (see Supplementary Material S1). The first part recollected general information of the patients and the second one was composed of the new adapted questionnaire from Phase A.

A sample size of 183 patients was determined and a convenience selection was carried out between the patients who went to the hospital to pick up the medical prescription after the medical consultation by telemonitoring. The inclusion criteria were all the continuing patients older than 18 years who were attended in the psychiatry service and the exclusion criteria were patients with active psychotic symptoms, intellectual disability, and all the patients who required psychiatric medical care by emergency. The patients who accepted to participate in the study first signed an informed consent and then filled the instrument. Additional information about the patients and the physician who provided the medical consultation was not collected.

DATA ANALYSIS

The data were analyzed with STATA 16. Cronbach's alpha coefficient was performed to test internal consistency. For the description of the categorical variables, frequencies and percentages were used. For the quantitative variables, median and ranges were used due to a lack of normal distribution analyzed by the Shapiro–Wilk test. For the bivariate analysis, nonparametric tests were used. For the comparison between groups, tests such as U from Mann–Whitney and Kruskal–Wallis were used. To determine the ordinal relationship between two variables, the test of Spearman's correlation was used.

ETHICAL CONSIDERATIONS

This study was approved by the Universidad Peruana Cayetano Heredia and the HCH Institutional Review Boards. Confidentiality of the data obtained was guaranteed.

Results

PHASE A

The original version and the Argentine validation of TUQ were reviewed together with the tables of expert validation. It was decided to remove item 10 (“This system is able to do everything I would want it to be able to do”) because in our context there is no specific platform for telemonitoring but rather common ways such as phone calls or video calls (via WhatsApp or Zoom) were used. That is why also both interface quality and interaction quality factors were changed to comfort with the virtual service and communication, respectively. In addition, a study performed in HCH in 2019 showed that 36% of the patients understood medical terminology.¹⁸ Thus, we opted to change the term “telemedicine” to “virtual medical consultation” to reach a better comprehension from the participants.

PHASE B

One hundred eighty-three (n = 183) patients participated in the study, the female-to-male ratio being almost 2:1. All the usability components had an internal consistency higher than 0.7. In the ease of use and learnability indicator, an increase of 0.1 was observed in the Cronbach's alpha if question 6 was deleted. The same occurred with questions 13 and 14 and their respective indicators (Table 1).

Table 1.

Internal Consistency of the Telemedicine Usability Questionnaire—Peruvian Adaptation

INDICATOR	ITEMS	CRONBACH COEFFICIENT ALPHA	CRONBACH COEFFICIENT ALPHA WITHOUT THE QUESTION
Usefulness	1. Access to health care services	0.7515	0.6376
	2. Time of transport saved		0.7237
	3. Resolution of health care needs		0.6340
Ease of use and learnability	4. Access to medical consult	0.8407	0.7499
	5. Comprehension of steps to get a medical consult		0.7163
	6. Perception of benefit		0.8647
Comfort with the virtual service	7. Comfort with phone/video calls	0.8513	0.7571
	8. Liking for telepsychiatry		0.7791
	9. Simplicity of the virtual consult process		0.8335
Communication	10. Microphone	0.8343	0.7708
	11. Sound		0.8027
	12. Effectively communicating their expression		0.7347
	13. Equivalence to in-person consult		0.8472
Reliability	14. Interaction interruptions	0.7583	0.7741
	15. Technical problem solutions		0.5821
	16. Failures during the consult		0.6388
Satisfaction	17. Comfort with the medical consult	0.8949	0.8836
	18. Acceptance of virtual consults		0.8424
	19. Willingness to use virtual consults again		0.8650
	20. General satisfaction		0.8653

The participants' characteristics according to sex are detailed in Table 2. The median age was 45 (18–94) years. According to the education degree, 7 (3.83%) people did not have any type of formal education (high school) and 3 of them had a disability. About the place of precedence, 58 (31.69%) patients lived in the same district where the hospital was located.

Table 2.

Participant Data

	MALE ( n = 60, 32.79%)	FEMALE ( n = 123, 67.21%)
Degree of instruction
No education	1 (1.67)	6 (4.88)
Incomplete primary and middle school	1 (1.67)	12 (9.76)
Completed primary and middle school	3 (5.00)	13 (10.57)
Incomplete high school	6 (10.00)	10 (8.13)
Completed high school	25 (41.67)	32 (26.02)
Incomplete technical school	1 (1.67)	1 (0.81)
Completed technical school	0 (0.00)	6 (4.88)
Incomplete bachelor's	8 (13.33)	14 (11.38)
Completed bachelor's	14 (23.33)	28 (22.76)
Postgraduate	1 (1.67)	11 (0.81)
CONADIS
Yes	9 (15)	16 (13)
No	51 (85)	107 (87)
District of residence
San Martin de Porres	23 (38.33)	55 (44.72)
Los Olivos (4 km from hospital)	10 (16.67)	18 (14.63)
Independencia (6.5 km from hospital)	5 (8.33)	13 (10.57)
Cercado de Lima, Comas, Rimac (12 km from hospital)	12 (20.00)	20 (16.26)
Puente piedra, Carabayllo, San Juan de Lurigancho, Ventanilla (16 km from hospital)	6 (10.00)	11 (8.94)
San Isidro, Miraflores (22 km from hospital)	0 (0.00)	4 (3.25)
La Molina (30 km from hospital)	1 (1.67)	0 (0.00)
Outside of Lima	3 (5.00)	2 (1.63)
Type of consult
Phone call	52 (87)	105 (85)
Video call	4 (7)	15 (12)
Both	4 (7)	3 (2)
Number of devices with webcam
0	16 (27)	36 (29)
1	30 (50)	53 (43)
2	7 (12)	20 (16)
3	3 (5)	10 (8)
4	3 (5)	0 (0)
5	1 (2)	2 (4)
6	0 (0)	1 (2)
7	0 (0)	0 (0)
8	0 (0)	1 (2)

The most frequent telemonitoring modality was phone calls (n = 157, 85.79%), followed by video calls (n = 10, 10.38%). Only 7 (3.83%) patients received both. About the available devices with camera web, the majority possessed only one device (n = 83, 45.36%), followed by the ones that did not have any (n = 52, 28.42%). The education degree was related to the fact of possessing at least one device (p = 0.0001). The number of devices that the participants had was also related to the education (p = 0.0016) (Table 3).

Table 3.

Number of Electronic Devices According to Degree of Instruction

DEGREE OF INSTRUCTION	ELECTRONIC DEVICES (MEDIAN)	MIN	MAX
No education	1	0	2
Incomplete primary and middle school	0	0	2
Completed primary and middle school	1	0	2
Incomplete high school	0	0	2
Completed high school	1	0	4
Incomplete technical school	1	1	1
Completed technical school	1	1	3
Incomplete bachelor	2	0	8
Completed bachelor's	1	0	5
Postgraduate	2	1	3

Figure 1 shows the distribution of the answers according to each question of the questionnaire. Next, the results are shown according to the proposed indicators.

Fig. 1.

Distribution of questionnaire response.

Usefulness

In the usefulness indicator, 146 (79.78%) patients reported better access to health services thanks to the psychiatric consultations by telemonitoring, 164 (89.62%) people considered that this modality saved transportation time, and 133 (73.08%) perceived that it helped solve all their health necessities. Health access perception was associated with the residency district according to the Kruskal–Wallis test (p = 0.0067), being higher in the farther districts. The participants who received mixed medical consultations reported to have better access to health (p = 0.0394). There was no association between age and the modality of medical consultation used (p = 0.5148).

Ease of use and learnability

According to the ease of use and learnability indicator, 80.33% (n = 147) reported that it was easier to understand the steps to access the virtual medical consultation. The benefit perception was 77.05% (n = 141). These last two increased with the number of available devices (p = 0.0156 and p = 0.001, respectively) (Fig. 2). No education level was found to increase the ease of understanding about the steps to access virtual medical consultations (p = 0.145). No difference was found in the perceived benefit with telemonitoring between the participants who has CONADIS cards (the Peruvian equivalent of a disability ID card) and the ones who did not have (p = 0.4166). The benefit of virtual care was better perceived in mixed medical consultations and video calls compared with phone calls (p = 0.0281). This variable increased with education degree (p = 0.0031) (Fig. 3).

Fig. 2.

Number of electronic devices according to perceived benefit, ease of access to the consult, and comfort.

Fig. 3.

Degree of instruction according to access to the virtual consult and comfort with the virtual consult.

Comfort with the virtual service

In comfort with the virtual system indicator, 132 (72.13%) were comfortable with phone/video calls, 118 (64.48%) liked the telemonitoring modality, and for 145 (79.23%) it was simple the virtual process. The comfort with calls was higher in patients with more devices (p = 0.003) and with higher education degree (p = 0.0001) ( Figs. 2 and 3 ). Seven patients without formal education with greater comfort and facility than expected, according to the tendency, were reported. This last group had a median of 1 device and only 2 people did not have any devices with webcam. The proportion of patients who liked using the virtual platform for their medical consultations was 64.5% (n = 118).

Communication

Most of the participants did not report problems. A total of 74.32% (n = 136) did not report problems with the microphone and 85.32% (n = 152) did not report sound problems. A total of 66.67% (n = 122) felt comfortable expressing themselves during the virtual medical consultation and 56.91% (n = 103) reported equivalence between the virtual consultation and the face-to-face medical visit. The participants with more devices also stated fewer difficulties when talking and listening to the physician.

Reliability

One hundred thirty-five participants (75%) did not have interruptions during the medical consultation. It was asked if they had technical problems during the telemonitoring and 56 did not report of any. A total of 67.22% perceived an adequate solution to these. Also, it was asked about the issues during all the medical care processes (medical consultation plus prescription pickup). A total of 71.20% considered an adequate resolution to these issues. Fifty-eight participants did not have any issues, so they answered “N/A.” There were no differences in the resolution of issues in the virtual consultation service according to sex (p = 0.6891), residency district (p = 0.3992), modality of consult (p = 0.1013), or physical disability of the patient (p = 0.2784).

Satisfaction and future use

In the satisfaction indicator with telepsychiatry, 133 (73.08%) patients reported being comfortable with the physician attention and it tended to be higher with the increase of the electronic devices. Also, it was seen that the participants who had more devices (p = 0.046) and a higher education degree (p = 0.0096) presented greater comfort with the physician service during the virtual medical consultation. A total of 75.96% considered that virtual medical consultations were acceptable and 78.69% considered having again a virtual medical consultation. One hundred forty-two (77.60%) participants were satisfied with the virtual medical consultations. Also, it was determined that satisfaction with the service was associated with the future use of telemedicine (p = 0.0001).

Discussion

In this study, 183 patients were asked about the different aspects of virtual medical consultation that they received from the service of psychiatry at HCH and the TUQ was transculturally validated. Cronbach's alpha of the usability components confirmed a good internal consistency. Although no specific system exists for ambulatory services at HCH, item 6 was not removed because the perception of the benefit from the patients would not be evaluated. In the same way, the communication indicator included, as one of the principal variables, the similarity with the in-person modality,¹⁶ which would not have been known if item 13 was removed. Although item 14 was not essential to measure the reliability indicator, we considered it useful to understand the possibility of adopting it as an alternative care modality after the pandemic.

When applying the survey, we found out that patients with mixed medical consultation had greater satisfaction, contrary to the finding by Guinart et al. where there was a greater acceptance toward telemedicine with video calls.⁶ Severe et al. reported a tendency where younger people younger than 44 years preferred medical care by video calls, while people older than 45 years preferred phone calls.¹² In our study, no significant difference was found.

Phone calls were the type of call with a higher score in a resolution of health issues, while video calls were the ones that had a higher equivalent with a real medical consultation. It should be noted in our population sample that those who received medical care by video calls were few. Besides not being explored, a possible explanation could be the additional cost that implies using mobile data when Wi-Fi is not available, the low velocity for the data exchange, or the lack of skills managing applications for video calls.

Regarding the transportation time saved with telemedicine, there was no difference according to the characteristics of the patients because all the participants gradually perceived this benefit. Our finding was similar to others reported in the literature.^8,21 The general satisfaction that was found in the population sample (six out of seven) was high, in part, because people have a higher predisposition to adapt to new situations in the COVID-19 context.^7,22 According to Bidmead et al., other factors that are associated with satisfaction are the management of technology and the physician–patient relationship.²² This matches with our findings, as the comfort with the virtual service increased with the number of devices (Fig. 2).

The comfort of the patients with telepsychiatry might have been facilitated by the patient–physician relationship as it was already established in the previous in-person visits.²³ The relationship with the physician influences more than the management of the illness in the perception of the patients about the medical care²⁴; that is why patient satisfaction alone cannot be used to assess the overall quality of the consultation.

One of the biggest challenges for its implementation, according to Treisman and cols, is the difficulty to manage technology.²⁴ Another difficulty for telepsychiatry observed in the third world countries is the low education degree.¹⁴ In our population, it was observed that people with a higher degree of education have greater comfort and ease of access to virtual consultations, a similar finding found by Holtz in a study on telemedicine before and after the pandemic.⁷ It is known that factors such as the aesthetics of the used platforms and the control of the user can influence the facility of its use.²⁵ It is also believed that people with a greater education degree in Peru possess more purchasing power for electronic devices and when having multiple devices, they have more options to choose the virtual communication modality that they prefer and then to have more experiences.

On the contrary, it is deduced that the facility to access the medical consultation does not increase significantly with the education degree due to the multiple ways available to access to the medical consultation (p = 0.1455). We recommend taking this factor into account for future investigations.

When evaluating satisfaction, medical consultation access, and comfort with the virtual system, no difference was seen between the patients with the CONADIS card, referring to the participant who had a disability, and the ones that did not. This finding is the opposite to what is expected because it has already been described the major barriers of infrastructure such as the internet, communication to people with disabilities, and the need of help when managing technological devices.⁹ Our hypothesis is that, because the people evaluated had only physical and noncognitive disabilities, they had no difficulties accessing virtual consultations. In addition, we believe that there were no infrastructure problems because all the participants lived in urban areas.

However, there were few participants in the study with CONADIS cards, probably because of the difficulty to mobilize to the hospital to pick up the prescription personally. It is believed that this could improve with the implementation of an electronic prescription and medication pickup places near the residency of the patients.

Most participants did not have technical issues; when having them, the resolution was efficient. This could be due to the use of common applications; this was different in studies with a specialized teleconsult system that requires software learning to maintain the security and confidentiality of the virtual medical consultation. The technical issues were usually associated with the stability of the call and the audio, as much as by the physician as by the psychiatrist. The same results were found in other studies.^6,8,25

About the question of the possibility of future use, most participants responded satisfactorily (five to seven points). In other studies, the fact that convenience is one of the most important factors is emphasized, that is why patients decide to have again a virtual medical consultation.^8,11,13,26 In our study, we found out that participants who lived farther away from the hospital had a higher preference for virtual medical care, similar to what was found by Reed et al., who determined that patients who were 30 min away by car from the in-person medical visit or the patients who had to pay parking ticket were more susceptible to choose the virtual modality instead of the face-to-face medical consultation.¹³ There was an elevated desire to have again a virtual consultation, which was related to the satisfactory experience of the service.

Some studies suggest that patients who have never used this type of medical care are recalcitrant before the medical consultation; however, after having one in the virtual modality, the desire for future use increases, especially when there is a good patient–physician relationship and general satisfaction.^19,27

Due to the characteristics of our population sample and the acceptance found, we consider that the virtual modality for medical care can be implemented permanently alongside the in-person medical visit to increase the offer of medical care to psychiatric patients. In addition, the perceptions from patients toward telepsychiatry should be continuously evaluated, as it is described that it tends to be higher in the beginning stages of its implementation and it tends to decrease over time.²⁵

Most of our participants will use this service once again in the future. Our results of patients who were willing to use the service again in the future are higher compared with the results from Guinart et al. (78.68% vs. 64.2%). Considering that our results are because most of the participants reported saving transportation time, while in the other study, less than half of their participants reported this benefit.⁶ Another factor that facilitated the satisfaction with telepsychiatry was the mobilization restrictions during the COVID-19 pandemic,^{6,7,9
–11,14} because in this context, people prefer the virtual modality to prevent COVID-19 infection,²⁰ also adding to the lack of vaccination in the country.

Limitations

The limitations of the study were that the questionnaire did not collect data on the diagnoses of patients, and therefore, it was not possible to know if some diagnoses carried a greater benefit with the use of telemedicine compared with others. It is suggested to evaluate the satisfaction of the patients and the effectiveness of the treatment in future studies, to amplify the knowledge about the achievements of telepsychiatry. In addition, the number of teleconsultations that the patients had before they answered the questionnaire was not collected since these could only be obtained directly from the attending physician or by the hospital system through telephone annexes. This factor could influence the perception of the ease of use and learnability of the system.

Conclusions

Most patients who continued their attentions through telepsychiatry via telemonitoring at HCH during the COVID-19 pandemic were satisfied with this new service according with the results of TUQ. Therefore, its use could be maintained in the future for periodic controls in patients with chronic disorders and in psychopharmacological maintenance therapies. Thus, the stability of symptoms would be verified without the need to travel to health centers, and medication dispensing would be programmed following refill requests or prescription renewals.

Other specialties have not been unaware of the inclusion of telemedicine. As in any implementation, not only the technological aspects should be analyzed, but also with instruments that measure patient satisfaction. Therefore, validated tools such as the adapted version of TUQ of this study should be included as part of the evaluations in new Peruvian telemedicine services.

Footnotes

Acknowledgments

This article corresponds to the thesis presented by Fiorella Rosas and Alonso Gayoso for the degree of Doctor of Medicine on August 11, 2021, at Universidad Peruana Cayetano Heredia (Repositorio Institucional: ).

Authors' Contributions

All the authors contributed to the generation of the article and have reviewed its final content.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Material S1

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Supplementary Material

Please find the following supplemental material available below.

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