Utilization of Telehealth Services in Libya in Response to the COVID-19 Pandemic: Cross-sectional Analysis

Background: Health care systems in transitional countries have witnessed unprecedented challenges related to adequate and continuous health care provision during the COVID-19 pandemic. In many countries, including Libya, institutions and organizations have begun to implement telehealth technology for the first time. This serves to establish an alternative modality for direct physician-patient interviews to reduce the risk of COVID-19 transmission. Objective: This study aimed to assess the usability of telehealth services in Libya and to provide an overview of the current COVID-19 scenario. Methods: In this cross-sectional study, an anonymous web-based survey was administered to Libyan residents between April and May 2020. Participants were contacted through text messaging, emails, and social media. The survey items yielded information on the sociodemographic characteristics, availability and accessibility of health care services, effects of the COVID-19 pandemic on health care services, mental health status, and the feasibility and application of the telehealth system. Results: We obtained 2512 valid responses, of which 1721 (68.5%) were from females. The participants

The emergence of the COVID-19 pandemic has posed unprecedented challenges on health care systems in many countries, resulting in the cancellation of surgical procedures, closure of clinics, and an increase in the burden on health care services from patients with COVID-19 who require careful consideration and more care [5][6][7].In response to this disruption, many countries have started implementing strategies to reduce the risk of disease transmission and to provide adequate health care services, especially among individuals with chronic diseases who need more care [8][9][10][11].
Therefore, many countries have started using telehealth services; that is, advanced technologies such as video, audio, and other means to provide health care services and promote the well-being of individuals while being physically distant from the health care provider [12][13][14].Telehealth services offer several advantages to both patients and health care providers.The benefits of this system among patients include a shorter waiting time, a reduced need to travel long distances from their homes for health consultations, total avoidance of transport, and a reduced risk of infection, especially during the COVID-19 pandemic.The telehealth system offers several advantages to health care workers, including a marked reduction in patient interaction, the ability to assess patients with different diseases, the ability to perform follow-up evaluation and record outcomes, and a reduction in stress related to the COVID-19 pandemic.
The Libyan health care system operates primarily through public health centers and primary care centers, at which health services are provided at no cost.However, this manner of health care provision lacks sophisticated and advanced health services.In addition, a large number of private centers provide paid health services that may confer more advantages over traditional public health care services.However, these expensive private care services might represent a barrier to care provision among many Libyan residents.Although some large companies provide health insurance to their employees, such as policies that cover the main services provided by private health care centers, this provision is limited to a very specific portion of the population.
The Libyan health care system was not prepared for the COVID-19 pandemic.Hospitals and health care workers in Libya need better training and more resources to combat the pandemic, and there have been shortages of personal protective equipment, a lack of health services, and few prepared intensive care units [15,16].These difficulties, along with the current ongoing civil war, pose challenges on the Libyan health care system, resulting in a high demand for urgent and determined action [17].
Many institutions and organizations have initiated telehealth programs for the first time during the COVID-19 pandemic in Libya to help patients avail of health care services and consultations without the need to visit hospitals and to reduce the risk of COVID-19 transmission.Since this is the first time telehealth services have been introduced in Libya, their usability by the Libyan population and their health-related effects need to be assessed, and the challenges faced by health care authorities and organizations in implementing these new strategies need to be determined.In this study, we aimed to assess the usability of telehealth services in Libya and to provide an overview of the current COVID-19 scenario.

Participant Recruitment
In this cross-sectional study, we distributed an anonymous web-based survey among Libyan residents between April and May 2020 via text message, email, and social media platforms.The inclusion criteria were that participants should be Libyan residents aged over 18 years.Incomplete questionnaires with >30% missing data were excluded from the analysis.We marked essential questions with the "required" function to ensure high quality of the data collected.

Measurement Tool
The web-based survey was conducted in accordance with the Checklist for Reporting Results of Internet E-Surveys [18].The first section of the survey included questions on demographic characteristics such as age, gender, social status, economic stability, residential status, smoking status, and general health.The second section of the survey comprised questions on the availability and accessibility of health care services, including the distance travelled to access nearest health care facility and the time taken to reach it, mode of transport available, and ability to cover medical costs.The third section comprised questions related to the effects of the COVID-19 pandemic on health care services.A subsequent section contained questions on mental health status, screening symptoms of anxiety and depression using the self-administered 9-item Patient Health Questionnaire (PHQ-9) [19,20], wherein a score of ≥15 was considered the threshold for depression.The 7-item Generalized Anxiety Disorder scale [21] was used to assess anxiety, with a score of ≥15 as the threshold for anxiety.The final section of the questionnaire assessed the usability of telehealth in accordance with the Telehealth Usability Questionnaire devised by Parmanto et al [22] and validated by Zhou et al [23].The telehealth questionnaire was translated to Arabic by two independent translators using the forward-backward translation method.Any discrepancy in the translated versions was resolved through further discussion until consensus was reached.The translated XSL • FO RenderX questionnaire was piloted with 30 participants, and the internal consistency was determined from a Cronbach α of .74 in the translated Arabic version.The telehealth usability survey included 3 items on the usefulness of telehealth, 3 items on the ease of use and learnability, 4 items on interface quality, 4 items on the quality of interaction, 3 items on reliability, and 4 items on satisfaction.Each of these items was scored on a 3-point Likert scale (0=agree, 1=neutral, 2=disagree).

Statistical Analysis
Descriptive statistics are presented as frequency and percentage values.Continuous variables are presented as mean (SD) values.We performed a chi-square test to investigate associations between basic study characteristics and gender.Statistical analyses were performed using SPSS software (version 25.0, IBM Corp).A P value of ≤.05 was considered significant

Ethical Considerations
The study was approved by the Bioethics Committee of the Biotechnology Research Centre (Tripoli, Libya; 109.3-2020).
Participants provided written informed consent and their anonymity was maintained.

Accessibility of Health Care Services
Most participants reported an adequate level of ease in accessing health care centers, with 715 (28.5%) responding with "very easy" and 1299 (51.7%) responding with "easy."Regarding their mode of transport, almost half of the participants (n=1140, 45.4%) reported driving their own car, and 1097 (43.7%) hired a taxi or a private driver.In addition, 989 (39.4%) respondents reported that it took them 15-30 minutes to reach a health care facility, whereas 804 (32%) reported that they needed less than 15 minutes to reach their nearest facility.Furthermore, 1407 (56%) participants reported that they could consult with a specialist physician within 2 days, whereas 1558 (62%) reported that they could not access their medical records or files.
Most participants (n=1546, 61.6%) found it difficult to cover the costs of medical care.More than half of the participants (n=1429, 56.9%) reported that they avoided seeking medical care for the fear of being financially burdened.Some participants (n=1225, 48.7%) reported difficulties in availing of emergency health care services.Most participants (n=2171, 86.4%) agreed that the working hours of clinics needed to be extended; however, approximately 1264 (50.4%) reported that it was easy to interact with physicians and nurses during health care counseling, and the remaining 1248 (49.6%) participants responded with "neutral" or disagreed with the statement, "Interactions with nurses and doctors are easy."The findings of the assessment of the accessibility of health care services are summarized in Table 2.

Impact of the COVID-19 Pandemic on the Participants' Health
Only 90 (3.6%) participants agreed that the lockdown had affected their health, while most participants (n=2207, 87.9%) disagreed with that statement.Most participants (n=1264, 86.8%) disagreed with the statement that the lockdown had psychological effects.However, 1531 (60.9%) participants were worried about being afflicted with COVID-19, and 1974 (78.6%) were worried about their family members becoming infected.Table 3 provides an overview of the effects of COVID-19 on the survey participants.

Mental Health Outcomes
In total, 454 (18.1%) participants had scores of ≥15 on the PHQ-9, which indicates that they had symptoms of depression.Furthermore, 382 (15.2%) participants had scores of 20-27 on the PHQ-9, which indicated a high likelihood among these participants to experience symptoms of depression.In addition, 372 (14.8%) participants had scores of ≥15 on the 7-item Generalized Anxiety Disorder scale, which indicates that they had anxiety symptoms.

Telehealth Usability
Approximately half of the survey respondents agreed on the usefulness of telehealth services during the COVID-19 pandemic.In addition, more than half of the study participants reported that it was easy to avail of telehealth services and trusted this type of health care service.More than half of the study participants (n=1435, 57.1%) reported that they felt comfortable seeking the telehealth services, and 1389 (55.3%) reported that the system was easy to understand.Furthermore, 1354 (53.9%) participants reported that they could easily communicate with physicians through the telehealth system.However, only 1018 (40.5%) participants reported that communication with physicians was easier through the telehealth system than through other traditional methods.Regarding the reliability of the system, 1034 (41.2%) participants reported that the efficiency of the system was similar to that of in-person physician consultations, while 1175 (46.8%) participants responded with "neutral" to this statement.Additionally, 1439 (57.3%) participants felt comfortable communicating with physicians through the telehealth system, while 1545 (61.5%) reported that the system provides an effective means of communication when availing health care services.More than half of the participants (n=1383, 55.1%) felt satisfied with the telehealth system and were willing to use it in future.Table 4 provides an overview of the participants' perception of the usability of telehealth services during the COVID-19 pandemic.

Principal Findings
This study aimed to assess the accessibility, applicability, and feasibility of telehealth services in Libya during the COVID-19 pandemic.Most study participants reported being able to access health care facilities.However, most participants found it difficult to cover the cost of the health care services, and more than half of them avoided seeking these services owing to the difficulty in covering their costs.Our study participants reported high levels of telehealth usability and applicability.More than half of the participants (n=1435, 57.1%) reported feeling comfortable using telehealth services, 1389 (55.3%) reported that the system was easy to use, and 1354 (53.9%) reported an enhanced level of interaction with health care providers.Furthermore, 1018 (40.5%) participants reported that communication with physicians was better through the telehealth system than through traditional health care methods, while 1034 (41.2%) reported that the telehealth services were equally as efficient as in-person health care services.In addition, our participants experienced moderate levels of symptoms of anxiety (n=372, 14.8%) and depression (n=382, 15.2%).
Regarding the accessibility of the telehealth services, most participants did not report any difficulty in in reaching health care facilities or arranging an appointment with a specialist.However, the participants reported difficulties in accessing their laboratory findings and hospital records, which may be influenced by the unavailability of electronic health records in XSL • FO RenderX most hospitals and the unavailability of laboratory facilities in several major hospitals, where patients have to visit another facility to obtain the results of laboratory tests.

Comparison With Previous Studies
Our results suggest that the telehealth system potentially provides an alternative to traditional health care services, especially during the COVID-19 pandemic, concurrent with Mclean et al [24] who reported no difference in outcomes between traditional and telehealth services.Telehealth services offer more flexibility in securing appointments and are more comfortable for individuals living far from health care facilities, especially cancer patients or individuals with chronic diseases who might be at increased risk of severe COVID-19 [25,26].However, further development of telehealth services is needed to supply the demand for several specialties that require a specific eHealth-based health care infrastructure [27].A recent study from China [28] reported that telemedicine and telehealth services were effective and feasible and allowed for substantial improvement in health care services for patients with COVID-19.Another study from China [29] on the role of internet hospitals in the COVID-19 pandemic reported that telehealth services and internet hospitals can offer essential support in controlling the pandemic by reducing the cross-infection risk, thus curbing the spread of COVID-19.However, several barriers and challenges regarding the implementation of internet hospitals remain, and further studies with large samples are required to focus on testing specific prototype internet hospitals [30].
Another example of the efficiency of telehealth services is based on individuals with diabetes; telemedicine has been reported to substantially improve health-related outcomes among individuals with diabetes [31].Another study that used big data and artificial intelligence approaches for diabetes care supported this finding [32].
Our study provides an overview of the mental health status of the Libyan population.Mental health services constitute a major application of telehealth, with several smartphone apps yielding positive outcomes during self-management of depression [33].The demand for these interventions is high, given the current state of mental health during the COVID-19 pandemic, and telehealth facilitates follow-up evaluation of patients with psychiatric disorders without the need for hospital visits.On-demand mental health telehealth systems have shown promising outcomes in reducing the symptoms of depression [34].
Several challenges are associated with the implementation of telehealth services in Libya.The first issue relates to finances.The government and health care authorities need to provide support for telehealth services and provide funding opportunities to help new organizations and health care centers change their traditional approaches for care provision to a remote system to reduce the risk of COVID-19.This is critical because Libya is faced with a financial crisis, and it would be difficult for Libyan residents to cover the cost of such expensive health care services.Second, Libyan residents have been facing problems with electricity provision and internet access over the last few years.
It would be majorly challenging to implement these services during the civil war when internet connectivity is troublesome.
Another issue that needs to be considered in Libya is the protection of patient confidentiality and the ability to devise methods that protect the personal and clinical data of patients.Our study clearly highlights this issue; 1558 (62.0%) participants reported that they could not access their health reports.However, it is also concerning that several private telehealth services are providing care without any formal agreements or specific policies to protect patient data or let patients access their own health records.Therefore, further studies should address this issue and focus on data protection and on providing patients easy access to their health data.

Strengths and Limitations
This study has several strengths.First, to our knowledge, this study is the first to validate the Telehealth Usability Questionnaire as an instrument in Arabic.Second, this study is the first to provide an overview of the usability of telehealth and the health status of the Libyan population.Third, our study included a large sample of 2512 individuals with complete data and assessed several health-related issues with a special emphasis on accessibility and the mental health status of the Libyan population.Furthermore, to our knowledge, this study is the first to assess the usability of telehealth services during the COVID-19 pandemic in a transitional, resource-limited country.Our study furthers the current understanding of the usability of telemedicine in transitional, resource-limited countries, and our results support the implementation of telehealth programs despite certain potential challenges associated with them.
The study has several limitations that should be addressed in future studies.First, it was a cross-sectional survey carried out during the COVID-19 pandemic simultaneously with the introduction of telehealth services, and some participants may not have used telehealth services during this period.Second, we did not assess internet connectivity and electricity provision, which are potential factors affecting the ability of some communities to access telehealth services; these factors need to be addressed in future studies.Third, this study was an online cross-sectional survey, and most participants were young and without major comorbidities or chronic diseases; therefore, we may have overestimated the usability of these services because older individuals may face more challenges in using these technologies and may require more assistance.Therefore, further studies are required to assess elderly individuals and those with special needs and to investigate how telehealth systems could be implemented for these specific groups of patients.Fourth, we used self-reported scales, which may have increased the risk of bias.We also used a 3-point Likert scale for the Telehealth Usability Questionnaire; this may have influenced our findings.

Conclusions
Telehealth services can substantially replace in-person consultations and prevent nosocomial infections in Libya during the COVID-19 pandemic.Our study provides an overview of the accessibility and usability of telehealth services, and our results suggest that telehealth services help reduce the workload XSL • FO RenderX of physicians and direct contact with patients during the COVID-19 pandemic.Our results support the implementation of telehealth services; however, further studies are required to focus on the protection of patient confidentiality and personal data.

Table 1 .
Baseline demographic characteristics of the study population (N=2512).

Table 2 .
Accessibility of health care services among the study participants (N=2512).

Table 3 .
Effects of the COVID-19 pandemic on the health of the study participants (N=2512).

Table 4 .
Usability of telehealth services among the study participants (N=2512).