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Tunis Med
Tunis Med
Tunis Med
La Tunisie Médicale
0041-4131
2724-7031
Tunisian Society of Medical Sciences

Article
Assessment of knowledge and perceptions of Tunisian psychiatrists regarding telepsychiatry
Assessment of knowledge and perceptions of Tunisian psychiatrists regarding telepsychiatrySamaâli Samir 11
Hakiri Abir 22
Bouallaguia Azza 22
Amri Ghassen 22
Ghachem Rym 22
1. Faculty of medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
2. Psychiatry department B, Razi hospital, University of Tunis-El Manar, Manouba, Tunisia
6 2023
05 6 2023
102 6 360365
2022
https://creativecommons.org/licenses/by-nc-nd/4.0/ This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 Unported License. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-nd/4.0/
RESUME

Introduction: La télémédecine est désormais un pilier essentiel de l'évolution des soins de santé à l'échelle mondiale. En Tunisie, les défis du système de santé, exacerbés par la pandémie de COVID-19, ont souligné l'urgence d'adopter des solutions novatrices.À cet égard, la promulgation du décret-loi présidentiel n° 318/2022 le 8 avril dans le Journal Officiel de la République Tunisienne représente une avancée significative dans la réglementation de la télémédecine.Objectif: Évaluer les connaissances des psychiatres et pédopsychiatres tunisiens de la télémédecine, son cadre juridique et leurs représentations à cette nouvelle pratique médicale. Méthodes: Une étude transversale descriptive a été menée à 8 mois de la parution du décret présidentiel. L’enquête a eu lieu en ligne à travers un questionnaire électronique conçu sur la plateforme Google Forms. Résultats: Au total, 68 participants ont été inclus dans cette enquête. Le nombre médian d’année professionnelle était de 5±7 ans. Parmi les participants, 82% exerçaient en psychiatrie et 18% exerçaient en pédopsychiatrie. La majorité d’entre eux (62%) ne connaissaient pas les différents actes de la télémédecine et 57% des médecins n’étaient pas informés de l’existence du décret-loi. La majorité des médecins (74%) ont estimé nécessaire d’avoir une formation académique sur la télémédecine. La majorité des médecins (84 %) ont émis un avis favorable sur l’adhésion à la télépsychiatrie, indépendamment du sexe (p=0,69), du statut professionnel (p=0,512), de la spécialité (p=1), du nombre d’années d'expérience (p=0,83), et du secteur d’exercice (p=1).Conclusion: Malgré un niveau de connaissance faible en matière de télémédecine, la présente étude a mis en évidence un intérêt des psychiatres à l’intégration des technologies d’information et de la communication dans leurs pratiques cliniques.

ABSTRACT

Introduction: Telemedicine has become a fundamental pillar of the evolution of healthcare worldwide. In Tunisia, the challenges of the health system, amplified by the COVID-19 pandemic, have highlighted the urgency to adopt innovative solutions. In this regard, the publication of Presidential Decree No. 318/2022 on April 8 in the Official Journal of the Tunisian Republic represents a significant advance in the regulation of telemedicine. Aim: To assess the knowledge of Tunisian psychiatrists and child psychiatrists regarding telemedicine, its legal framework, and their perceptions of this new medical practice. Methods: A descriptive cross-sectional study was conducted 8 months after the issuance of the presidential decree. The survey was conducted online through an electronic questionnaire on Google Forms. Results: A total of 68 participants were included in this survey. The median number of professional years was 5±7 years. Among the participants, 82% worked in psychiatry and 18% worked in child psychiatry. The sector of practice was public in 69% and private in 31% of cases. Most of them (62%) did not know about the different telemedicine acts, and 57% of doctors were unaware of the existence of the presidential decree. The majority of doctors (84%) expressed a favorable opinion regarding the adoption of telepsychiatry, regardless of sex (p=0.69), professional status (p=0.512), specialty (p=1), years of experience (p=0.83), and practice sector (p=1). Conclusion: Despite a low level of knowledge regarding telemedicine, the study highlights the interest of the participants in integrating telepsychiatry into their clinical practices.

Mots clés

Télémédecine
Psychiatrie
Connaissance
Statut légal
Perception
Tunisie
Keywords

Telemedicine
Psychiatry
knowledge
Legal status
Perception
Tunisia résuméIntroduction
La télémédecine est désormais un pilier essentiel de l
évolution des soins de santé à l
échelle mondiale
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pmc1. INTRODUCTION

The advancement of Information and Communication Technologies (ICT) has brought about a significant transformation in the healthcare sector, reshaping the delivery of medical services. In 1997, the World Health Organization (WHO) defined telemedicine as "the part of medicine that uses the telecommunication transmission of medical information (images, reports, audio and video recordings) in order to obtain a remote diagnosis, expert opinion, continuous patient monitoring, or therapeutic decisions" (1). This mode of medical practice gained particular prominence during the COVID-19 pandemic (2).The concept of digital health, particularly telemedicine, is not new in Tunisia. On May 15, 1996, the National Telemedicine Committee was established to promote this innovative practice. As early as October 1996, a connection was established between La Rabta Hospital and Paul Brousse Hospital in Paris, marking the beginning of the integration of telemedicine into the strategic information technology plan of the Tunisian Ministry of Health (3).However, despite these initial advancements, the legal framework for telemedicine in Tunisia began to be defined more recently. Law 2018-43 of July 11, 2018, amending Law 91-21 of March 13, 1991, established the legal framework governing the practice and organization of medical and dental professions, thus marking a significant step in regulating telemedicine in the country (4, 5). In March 2020, the National Council of the Order of Physicians of Tunisia granted an exceptional authorization for teleconsultation in Tunisia, which was temporary until the end of the pandemic. This measure allowed physicians to use remote consultations, telecommunications, video conferences, as well as to renew prescriptions for chronic conditions (6).To specify the application details of this practice, Presidential Decree No. 318/2022 was published in the Official Journal of the Tunisian Republic on April 8, 2022 (7). Telepsychiatry is the application of telemedicine in the field of mental health. It is considered one of the oldest applications of telemedicine, with the first teleconsultation experiments initiated in the United States in 1958 (8). In the Tunisian context, an emerging trend characterized by rising demand for telemedicine among patients is observed. However, this evolution is hindered by the existence of an incomplete legal framework, further compounded by a lack of understanding of this framework. The potential risk arising from this situation is an increase in the misuse of teleconsultation among healthcare professionals. Despite limited reported experience with telemedicine practice, there is no data regarding the adoption of this emerging medical practice among Tunisian psychiatrists (9, 10). The objective of this work was to assess the knowledge of Tunisian psychiatrists and child psychiatrists regarding telemedicine, its legal framework, and their perceptions of this emerging medical practice.

2. METHODES

Study design

We conducted a descriptive cross-sectional study. The study period spanned a month and a half, from November 15, 2022, to December 31, 2022.

Study participants

The inclusion criteria for this survey covered Tunisian psychiatrists and child psychiatrists practicing in Tunisia, regardless of their affiliation with the public or private sector, and those who consented to participate in the survey. Psychiatrists and child psychiatrists practicing abroad were not included. Exclusion criteria included doctors from other medical, surgical, or biological specialties, as well as medical interns and externs.

Study procedure

The survey was conducted online using an electronic questionnaire developed on the Google Forms platform. The questionnaire was designed in French and comprised 34 questions : 10 questions on sociodemographic and professional data, 13 questions on knowledge related to telemedicine and its legal framework, and 9 questions regarding the interest in telepsychiatry in general and in the Tunisian healthcare setting in particular. There was also a question about willingness to embrace telepsychiatry and another question about the interest in specific academic training on telemedicine. During the questionnaire elaboration, our team relied on the decree law and the specificity of our psychiatric healthcare system, as well as data obtained from the literature on the application of telemedicine in psychiatry. We reached out to the executive board of the ATPEP ‘’Association Tunisienne de Psychiatres d’exercice privé’’ , who supplied us with an email list of private practice psychiatrists and child psychiatrists. Additionally, we acquired email lists of psychiatry and child psychiatry residents, as well as hospital-university psychiatrists and child psychiatrists, through the National College of Psychiatry and Child Psychiatry. The questionnaire was distributed via email to a total of 391 doctors.

Statistical analysis

Data entry and analysis were conducted using SPSS software version 26. We calculated simple frequencies and percentages for qualitative variables. Means, extreme values (minimum and maximum), and standard deviations were determined for quantitative variables. In the absence of normality, medians and interquartiles were calculated. Comparisons of percentages for independent series were performed using Pearson's chi-squared test. In cases where this test was not valid, the bilateral Fisher exact test was used. The significance level was set at 0.05.

Ethical considerations

All participants were informed of the study's objectives, the anonymity of participation, and the option to refuse to respond to the questionnaire. The study was approved by the ethics committee of Razi Hospital (RP B01-2023).

3. RESULTS

Sample Size

During data collection, Out of 391 physicians contacted via email, 70 participants responded to the questionnaire, which corresponds to 17.9% of the physicians contacted via email. Among these participants, two psychiatrists were practicing abroad at the time of the study and were therefore excluded. In total, 68 participants were included in this survey.

Sociodemographic and Professional Characteristics

The majority (78%) of the doctors were female, with a median age of 5 ± 7 years. Among the participants, 82% practiced in adult psychiatry, and 18% specialized in child psychiatry. Half (50%) of them were junior doctors (residents). The predominant practice sector was the public sector (91%). A patient traveling more than 100 kilometers round trip for a medical consultation was found in 91% of doctors. Geographic distance was identified as the main reason for the cancellation of a medical consultation (60%) (Table 1).

Evaluation of knowledge of telemedicine and its legal framework among participants

Among the 13 knowledge-related questions, only four received correct responses from more than 50% of the participants (Q1, Q3, Q8, and Q13). More than half of the respondents (62%) were unaware of the different telemedicine acts. More than two-thirds of the participants (73%) claimed to know the definition of teleconsultation, and 57% were unaware of the existence of Presidential Decree No. 318/2022 regarding the practice of telemedicine in Tunisia. Only 21% of them knew that there were telemedicine best practice recommendations. The majority of doctors (74%) believed it was necessary to have academic training in telemedicine (Table 2).

Utility and representation of telemedicine in the Tuni- sian psychiatric healthcare setting

According to 88% of doctors, telepsychiatry is useful to integrate into the Tunisian healthcare system, and 94% believed that telepsychiatry can facilitate access to healthcare. The interest in telepsychiatry practice in public hospitals was observed in 79% of doctors. Telepsychiatry is considered an alternative solution to address the underdevelopment of liaison psychiatry by 82% of the participants. Telepsychiatry can be implemented in various contexts, including patient monitoring (97%), addiction treatment (74%), and cognitive-behavioral therapies (88%). Furthermore, 81% of doctors believed that telepsychiatry presents a higher risk of medico-legal issues compared to traditional psychiatry (Table 3).

Adoption of Telepsychiatry

The majority of participants (84%) expressed a favorable opinion on telepsychiatry. No associations were found between the adoption of telepsychiatry and sex (p=0.69), physician status (p=0.512), specialty (p=1), years of professional experience (p=0.83), and practice sector (p=1) (Table 4).

4. DISCUSSION

Knowledge related to telemedicine Although all participants were already aware of the definition of telemedicine, more than half of them had not heard of the existence of the presidential decree-law related to the practice of telemedicine in Tunisia and therefore, they were unaware of its legal framework. This lack of knowledge reflects the limited dissemination of the law and the lack of information among Tunisian doctors about the legal framework for the practice of telemedicine. This result can partly be explained by the professional characteristics of the studied population, particularly the fact that junior doctors, due to their academic status, have not yet considered integrating telemedicine into their daily professional practice.Additionally, the period between the publication of the decree law and our survey was relatively short (8 months), which may also contribute to this result.A lack of knowledge was also found among surveyed doctors regarding the different modalities of telemedicine, except for teleconsultation, which 73% of them claimed to know. This result can be explained by the fact that teleconsultation is the most frequently used and widespread telemedicine act in psychiatry (8).The decree-law on telemedicine is divided into four chapters with 29 articles, covering general provisions, areas of application, general conditions of practice (including authorizations, technical requirements, exercise guarantees, and payment methods), and final and transitional provisions. In psychiatry, teleconsultation, which involves providing medical consultations remotely, and teleexpertise, which allows a physician to seek the opinion of competent colleagues, are the two main acts of telemedicine. To perform a telemedicine act, a physician must enter into a contract with the platform, approved by the professional order (if a private sector physician) or the Ministry of Health (if a public sector physician). The decree-law raises new legal risks for all stakeholders, including physicians performing the act, physicians consulted, and information support providers (7). Despite the publication of the Presidential Decree, which represents a significant advance in the regulation of telemedicine, the decree-law is currently awaiting the publication of application texts. These texts will provide more detailed guidance on implementing the law. Lack of knowledge could lead to misuse and abuse in a non-legal framework. The majority of doctors stated that it is necessary to have training in telemedicine. Training is considered a key driver for the expansion of telemedicine and overcoming barriers to its implementation. An example of this is the strategy adopted in the United States. To successfully integrate telemedicine into the American healthcare continuum, courses have been included in medical education curricula to effectively use telemedicine technologies in students' future careers (11).

Representation of telepsychiatry and its usefulness in the Tunisian Healthcare System The usefulness of integrating telepsychiatry into the Tunisian psychiatric healthcare system was recognized by 90% of cases. This emerging medical practice can find its place in both the public and private healthcare sectors. It could facilitate access to care for certain patients in geographically remote areas.Moreover, telemedicine could be a key player in reducing the distribution inequalities of psychiatrists in Tunisia, given that the density of these professionals was relatively low, at 2.81 psychiatrists and child psychiatrists per 100.000 inhabitants in 2017, with some regions having fewer than one psychiatrist per 100.000 inhabitants (12). Similarly, due to the absence of liaison psychiatry services in many Tunisian hospitals, telepsychiatry presents itself as a solution to improve access to mental healthcare in the country (13).In the present study, interest in telepsychiatry has been observed in various areas of mental health, including patient monitoring and emergency situations, regardless of age. According to 75% of participants, remote consultation could be beneficial for the elderly. Currently, an increasing number of controlled trials demonstrate the effectiveness of telepsychiatry in treating specific mental disorders, such as depression and anxiety, as well as in managing suicidal crises (14). For some patient groups, the distance created by telepsychiatry can be seen as an advantage as it can encourage their engagement in mental healthcare, especially for patients with phobias or for elderly individuals who may face obstacles such as reduced mobility, transportation issues or social isolation (15, 6). The effectiveness of psychiatry extends beyond traditional psychiatric treatment methods and also involves some recent psychotherapy methods. An example is cognitive-behavioral therapy (CBT) in the treatment of social phobia. In a recent meta-analysis including 42 articles, the results concluded that internet-based CBT is effective in managing social phobia, with no significant difference compared to traditional CBT practice (17). Adherence to telepsychiatry In this study, the majority of doctors expressed a favorable opinion about their adoption of telepsychiatry, indicating a positive perception of using ICT in their clinical practice. This result aligns with a recent study conducted by Albarrak et al. in Saudi Arabia to assess perceptions of telemedicine, where surveyed doctors were willing to adopt it in their daily practice. The main obstacles to using telemedicine mentioned in the study were the lack of proper training and coordination between ICT experts and clinicians (18). Furthermore, the interest in telemedicine in psychiatry was evident, regardless of the doctor's status, years of practice, practice location, and specialty. Among the doctors who supported telemedicine, 47% were juniors, and 53% were seniors. This suggests that familiarity with digital technologies is not a determining factor for telemedicine adoption, as senior doctors are just as interested as junior doctors. Similarly, our study showed that the adoption of telepsychiatry is not determined by specialty, as the majority of surveyed child psychiatrists expressed a favorable opinion. Some characteristics related to child psychiatry interviews suggest that the interest in telepsychiatry in child psychiatry may be limited due to the need for mediation in play and motor skills, the requirement for specific educational materials (toys, drawings, modeling clay), and the analysis of a child's movements in the room. In a study conducted among Norman psychiatrists on telepsychiatry practice, child teleconsultation was the least considered in comparison to those oriented toward adolescents, adults, and the elderly (19). These data remain controversial, as other studies have highlighted the advantages of teleconsultation for the child population, and some programs dedicated to this population have shown their feasibility, especially for neurodevelopmental disorders (20, 21).Despite the interest generated by telepsychiatry, 81% of doctors expressed concerns about their potential exposure to medico-legal issues related to this developing practice (22). This observation underscores the importance of academic training focused on legal aspects and the responsibilities of those involved in this emerging practice. Relevance and limitations of the study To our knowledge, this is one of the first Tunisian studies that assess the knowledge of Tunisian doctors, particularly psychiatrists, about telemedicine. The main value of this work lies in evaluating the perceptions of mental healthcare professionals regarding telemedicine a few months after the publication of the decree-law regulating its practice. Thus, this study provides primary data on the level of knowledge and interest that psychiatrists and child psychiatrists have in this new medical practice.However, this work has some methodological limitations. Firstly, the participation rate was low, with only 17.9% of the target population taking part, and the sample size does not adequately represent all Tunisian psychiatrists and child psychiatrists, including those from both the private and the public sectors. Additionally, the evaluation process lacked objectivity and did not utilize a validated psychometric tool. Given the absence of an appropriate tool, we designed a questionnaire specifically for this study.

CONCLUSION

Despite a lack of knowledge about telemedicine and its legal framework, our survey suggests that there is interest in this emerging practice among Tunisian psychiatrists. To address this knowledge gap, it would be necessary to implement specialized training programs in telemedicine to improve doctors' understanding of this new practice. This training could cover theoretical knowledge, various modalities, technical aspects, and recommendations for best practices in telemedicine to help future practitioners effectively use ICT for remote care.
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References

WHO Group Consultation on Health Telematics A health telematics policy in support of WHO’s Health-for-all strategy for global health development: report of the WHO Group Consultation on Health Telematics, 11-16 December, Geneva, 1997 World Health Organization 1998
Ohannessian R Duong TA Odone A Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action JMIR Public Health Surveill 2020 6 2 e18810 32238336
Elmatri A Télémédecine en Tunisie: liaisons avec les pays européens, arabes et africains 4th International Conference: Sciences of Electronic, Technologies of Information and Telecommunications 2007 Mars 2007 Disponible sur : http://www.setit.rnu.tn/last_edition/setit2007/T/2.pdf
République tunisienne Loi n° 2018-43 du 11 juillet 2018, complétant la loi n° 91-21 du 13 mars 1991, relative à l’exercice et à l’organisation de la profession de médecin et de médecin dentiste Journal Officiel 2018 17 Juillet 2018
République tunisienne Loi n° 91-21 du 13 mars 1991, relative à l’exercice et à l’organisation des professions de médecin et de médecin dentiste Journal Officiel 1991 15 mars 1991
Conseil National de l’Ordre des Médecins Communiqué du Conseil National de l’Ordre des Médecins. A propos de la Télémédecine 15 mars 2020 Disponible au lien URL : http://www.ordre-medecins.org.tn/fr/
République tunisienne Décret Présidentiel n° 2022-318 du 8 avril 2022, fixant les conditions générales d’exercice de la télémédecine et les domaines de son application Journal Officiel 2022 17 avril 2022
Brown FW A survey of telepsychiatry in the USA J Telemed Telecare 1995 1 1 19 21 9375114
Zgueb Y Bourgou S Neffeti A Amamou B Masmoudi J Chebbi H Psychological crisis intervention response to the COVID-19 pandemic: A Tunisian centralised Protocol Psychiatry Res 2020 289 113042 32387792
Mleyhi S Ziadi J Ben Hmida Y Ghédira F Ben Mrad M Denguir R La télémédecine et les réseaux sociaux dans la gestion des ECMO à l’ère de COVID-19: l’expérience Tunisienne Ann Cardiol Angeiol 2021 70 2 125 128
Brown FW A survey of telepsychiatry in the USA J Telemed Telecare 1995 1 1 19 21 9375114
Charfi F Ouali U Spagnolo J Belhadj A Nacef F Saidi O Melki W Highlighting successes and challenges of the mental health system in Tunisia: an overview of services, facilities, and human resources. J Ment Health 2023 Feb 32 1 166 174 33583305
Mishkin AD Cheung S Capote J Fan W Muskin PR Survey of Clinician Experiences of Telepsychiatry and Tele-Consultation-Liaison Psychiatry. J Acad Consult Liaison Psychiatry 2022 Jul-Aug 63 4 334 344 34793997
Astruc B Henry C Masson M Intérêt de la télé-psychiatrie pour la prise en charge des patients : enjeux et questions d’une pratique nouvelle. Ann Méd-Psychol Rev Psychiatr 2013 171 2 61 64
Bouchard S Paquin B Payeur R Allard M Rivard V Fournier T Delivering cognitive-behavior therapy for panic disorder with agoraphobia in videoconference. Telemed J E-Health Off J Am Telemed Assoc 2004 10 1 13 25
Desbordes M Nebout S Grès H Guillin O Haouzir S La télémédecine en psychiatrie du sujet âgé : enjeux et perspectives. NPG Neurol - Psychiatr - Gériatrie 2015 15 89 270 273
Romijn G Batelaan N Kok R Koning J van Balkom A Titov N Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders in Open Community Versus Clinical Service Recruitment: Meta-Analysis. J Med Internet Res 2019 21 4 e11706 30994462
Albarrak AI Mohammed R Almarshoud N Almujalli L Aljaeed R Altuwaijiri S Assessment of physician’s knowledge, perception and willingness of telemedicine in Riyadh region, Saudi Arabia. J Infect Public Health 2021 14 1 97 102 31060975
La télémédecine en psychiatrie : pratiques et représentations chez les psychiatres normands.
Doyen CM Oreve MJ Desailly E Goupil V Zarca K L’Hermitte Y Telepsychiatry for Children and Adolescents: A Review of the PROMETTED Project. Telemed J E-Health Off J Am Telemed Assoc 2018 24 1 3 10
Kommu JVS Sharma E Ramtekkar U Telepsychiatry for Mental Health Service Delivery to Children and Adolescents. Indian J Psychol Med 2020 42 5 Suppl 46S 52S 33354063
Salem NH Ouelha D Gharbaoui M Saadi S Khelil MB Aspects médico-légaux relatifs à la Télémédecine en Tunisie dans le contexte de la pandémie du Covid-19. Tunis Med 2020 98 6 423 433 33479958
