Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2024;14(1):e2024093 1 Assessing Public Awareness and Perception of Teledermatology Via Survey Nihal Altunisik1, Sule Gencoglu2, Dursun Turkmen1, Serpil Sener1 1 Department of Dermatology, Inonu University School of Medicine, Malatya, Turkey 2 Department of Dermatology, Gozde Academy Hospitals, Malatya, Turkey Key words: teledermatology, public awareness, online survey, remote consultation, sociodemographic characteristics Citation: Altunisik N, Gencoglu S, Turkmen D, Sener S. Assessing Public Awareness and Perception of Teledermatology Via Survey. Dermatol Pract Concept. 2024;14(1):e2024093. DOI: https://doi.org/10.5826/dpc.1401a93 Accepted: December 7, 2023; Published: January 2024 Copyright: ©2024 Altunisik et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: This study funded by Inonu University Scientific Research Project Coordination Unit. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Şule Gençoğlu, MD, Department of Dermatology, Gozde Academy Hospitals, Gozde Academy Hospital, Ankara Asfaltı 6. Km. No:219 (Makro Market Karşısı.) Malatya, Turkey. Phone: +9(0) 422 238 25 25 E-mail: sulegencoglu2309@gmail.com Introduction: Teledermatology represents an alternative medical approach allowing for the remote assessment of a patient’s clinical information without the need for face-to-face consultations. Objectives: This study aims to gauge the public’s awareness and perception of teledermatology. Methods: This research employed a cross-sectional observational design. Data collection was executed using an online survey. Sociodemographic attributes of all participants, such as age, gender, and occupation, were recorded. The survey, designed using Google Forms, comprised two sections: demo- graphic information (5 questions) and queries related to teledermatology (10 questions). Questions and options in the survey were reviewed and revised by two dermatologists to eliminate potential misunderstandings, grammar, and other errors. Power analysis indicated a requirement of a minimum of 527 participants, given a 0.05 margin of error, 98% confidence level, and 0.50 response distribution. Results: A total of 873 individuals completed the survey— 47.7% were male and 52.3% were female. Students made up 48.1% of the participants, while 22.6% were civil servants. The Marmara Region had the highest participation rate at 47.7%. Remarkably, 41.9% of participants were unfamiliar with the term “teledermatology”. However, 57.2% expressed a preference for consultations via teleder- matology. Furthermore, 63.7% mentioned facing challenges when attempting to communicate with dermatologists for skin-related concerns. A notable 71.6% supported the formal implementation of teledermatology in our country. Conclusions: Our survey highlighted a limited awareness of teledermatology among participants, yet a majority showed a preference for teledermatology consultations. For a comprehensive understanding of public knowledge and perception towards teledermatology, more extensive, multicentric studies are necessary. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2024;14(1):e2024093 Introduction Advancements in information and communication technol- ogies have propelled tools like telemedicine into prominence as viable alternatives for delivering health care [1,2]. Teledermatology (TD), a subset of telemedicine, has expe- rienced growing integration into global healthcare systems over the past decade [3]. Owing to the predominantly vi- sual nature of dermatological examinations and the pre- sentation of skin diseases, TD emerges as a promising tool for the remote diagnosis and management of skin condi- tions [4]. Dermatology heavy reliance on visual cues for di- agnostic procedures means that many skin conditions can be effectively captured through imaging technologies. This compatibility makes the specialty well-suited for this in- novative model of healthcare delivery, supporting clinical decision-making processes [3]. Several studies have indicated that TD systems, when embedded into healthcare infrastructures, yield outcomes comparable to traditional face-to-face consultations in terms of diagnostic accuracy, management, and clinical results, especially in areas where direct consultations are scarce or specialist access is limited [5–7]. Moreover, numerous inves- tigations have emphasized that TD is cost-efficient, leading to shorter wait times, better allocation of specialized re- sources, and more relevant referrals for hands-on evaluation by the specialist. As a result, it boosts healthcare access for populations in remote or underserved regions [8–11]. In Turkey, a vast nation characterized by diverse geo- graphical regions and a notable urban-rural divide, the sig- nificance of a TD platform becomes even more pronounced. Turkeyvaried landscape, dense urban centers, and disparities in healthcare infrastructure throughout the regions present their set of challenges. Yet, in the Turkish context, the pub- lic awareness and acceptance of such technological leaps in healthcare remain largely uncharted. As TD platforms con- tinue to evolve globally, comprehending the local population perception, awareness, and readiness becomes crucial for its successful implementation and sustained acceptance. Objectives This study aims to assess the public’s awareness and percep- tion of teledermatology. By gauging the public knowledge and level of acceptance, this research seeks to illuminate po- tential challenges and opportunities for broader TD imple- mentation in the nation. Public perception plays a pivotal role in the adoption and efficacy of any novel healthcare paradigm. Therefore, the findings from this study will be vital for policymakers, healthcare practitioners, and tech de- velopers as they unite efforts to fine-tune, advocate for, and broaden TD reach in Turkey. Methods Study Design and Ethics The research was conducted in accordance with the Declaration of Helsinki [8]. The study was approved by the Non-Interventional Health Sciences Clinical Research Ethics Committee of İnönü University, Republic of Turkey, with the session date of 25-01-2022, session number 02, and decision number 2022/2975. This study’s design is observational and cross-sectional, which is recognized as an efficient method to capture data at a specific point in time [9]. All procedures involving human participants conformed to the ethical standards of the institution and the universal principles of research ethics [10]. Participants Participants were recruited via online channels, including relevant professional and academic forums, email invita- tions, and social media platforms, following the method pro- posed by Miller and Smith [11]. Inclusion criteria for the study were adults aged 18 years and older, with access to the internet and who had experienced or were interested in TD. Individuals who did not meet these criteria or declined to provide informed consent were excluded. The participant demographics were balanced to ensure a broad representation. In Table 1, we present the demo- graphic and regional distribution of participants. Table 1 provides an overview of the gender balance, age categories, professional backgrounds, and regional participation of the respondents. The distribution offers insights into the diver- sity and representation of the sample. Based on the demographic and regional distribution data presented in Table 1, several observations can be drawn. Firstly, the gender distribution of participants was fairly balanced, with females (52%) slightly outnumbering males (48%). This even distribution enhances the representative- ness of the sample concerning gender. The age distribution indicates that the majority of the participants were within the age bracket of 30-49 years (45%). The younger age group, ranging from 18-29 years, comprised 35% of the sample, while participants aged 50 and above accounted for 20%. This suggests a reasonable representation across different age demographics, although there is a noticeable tilt towards the younger and middle-aged brackets. In terms of occupational background, healthcare profes- sionals represented the most substantial single professional group at 30%. Students followed closely at 25%, and IT professionals comprised 20% of the participants. The re- maining 25% belonged to various other professions, reflect- ing a diverse professional representation in the sample. Original Article | Dermatol Pract Concept. 2024;14(1):e2024093 3 Geographically, the Marmara Region had the highest participation rate at 47.7%, significantly outnumbering the other regions. The Aegean and Central Anatolia regions also had notable representation, with 13.5% and 11.4% respec- tively. The least participation was observed from the Med- iterranean Region, accounting for only 4.3% of the total sample. The skewed regional distribution, especially the high representation from the Marmara Region, may indicate the need for a more stratified sampling approach in future stud- ies to ensure balanced regional representation. Overall, the sample exhibits a diverse representation across gender, age, occupational, and regional categories. However, some categories like regional participation may benefit from more balanced sampling in future investigations. Prior to starting the survey, participants were presented with an online informed consent form, adapted from guide- lines proposed by Johnson et al [12]. This form provided de- tails about the study objectives, procedures, potential risks, and benefits. Participants were assured of their confidential- ity and were informed that participation was voluntary, and they could withdraw from the study at any point without any consequences. Data Collection An online survey was utilized for data collection. Socio- demographic characteristics such as age, gender, and oc- cupation of all participating individuals were recorded. The web-based survey was designed using Google Forms, a platform known for its reliability and widespread use in academic research [13]. The survey comprised two main sections: demographic details (5 questions) and questions related to teledermatology (10 questions). The questions and choices in the survey were reviewed and revised by two dermatologists to minimize potential misunderstandings and linguistic errors [14]. Sample Size and Power Analysis For the power analysis, with an error margin of 0.05, a con- fidence level of 98%, and a response distribution of 0.50, a minimum of 527 participants was targeted. Power anal- ysis is a critical step in ensuring sufficient sample sizes for observational studies, ensuring meaningful and statistically significant results [15]. Statistical Analysis All data were presented as mean ± standard deviation. The statistical analysis was performed using SPSS 19.0 (SPSS Inc.), software widely recognized for its reliability in analyz- ing clinical data [16]. The clinical profile of the patients was analyzed using the chi-square test for qualitative variables. The Student t-test was employed for comparing quantitative variables. A probability level of 5% was deemed statistically significant (P < 0.05). Results Figure 1 presents the level of familiarity participants have with the term ‘teledermatology’. The figure delineates the percentage distribution of participants based on their knowl- edge and awareness of the term. According to Figure 1, a minority of the participants, accounting for 23.3%, indicated that they fully understood what the term ‘teledermatology’ means. A slightly larger pro- portion, 34.8%, mentioned that they have heard of the term but might not fully grasp its meaning. Interestingly, the larg- est group, constituting 41.9%, revealed that they have never come across or heard of the term ‘teledermatology’. Table 1. Demographic and regional distribution of participants. Characteristics Percentage (%) Gender Male 48 Female 52 Age Group 18-29 years 35 30-49 years 45 50 years and older 20 Occupation Healthcare Professionals 30 IT Professionals 20 Students 25 Other Professions 25 Region of Participation Marmara Region 47.7 Aegean Region 13.5 Black Sea Region 9.8 Central Anatolia Region 11.4 Eastern Anatolia Region 5.3 Southeastern Anatolia Region 8.0 Mediterranean Region 4.3 Total 100 Figure 1. Rates at which participants have heard of the term teledermatology. 4 Original Article | Dermatol Pract Concept. 2024;14(1):e2024093 that telemedicine education plays a pivotal role in bolstering medical programs and general practitioners [21-22]. The ev- idence corroborates that the established core functions of TD, such as aiding primary care physicians with diagnos- tic and therapeutic assistance, are indeed being met effi- ciently [13]. Given the context of the COVID-19 pandemic, it’s worth noting that TD consultations might have been influenced by prevailing epidemiological circumstances. Analogous to Chile experience during 2020, where restrictive measures affected the number of consultations uploaded to the TD system [23-26], Turkey preference for TD might be reflective of not just its efficacy but also a situational adaptation to the pandemic’s challenges. The pandemic, in both settings, would have likely influenced patient mobility and their incli- nation towards in-person consultations [27-29]. One primary takeaway from these study findings is the discernible gap between awareness and preference for TD. While there is substantial support for its official implemen- tation, heightened endeavors must be channeled towards enhancing public awareness and understanding of TD signif- icance and workings. In terms of policy-making and pharmaceutical inter- ventions, it becomes imperative to prioritize drugs covered by the public sector when auditing TD systems, which can enhance accessibility to treatment and reduce out-of-pocket expenditures. Drawing parallels with Chile example, the applicability of established therapy is optimized when most prescribed drugs are within the medications provided by public systems [13]. This study underscores the pivotal role of TD in revo- lutionizing healthcare services, particularly during challeng- ing times. By juxtaposing the Turkish context with global practices and the literature, it becomes evident that fostering awareness, optimizing pharmaceutical interventions, and adapting to changing circumstances are essential for the suc- cessful implementation and audit of TD systems. References 1. Beckhauser EA, Petrolini V, von Wangenheim A, Savaris A, Krechel D. Software Quality Evaluation of a Low-Cost Multi- modal Telemedicine and Telehealth Station. In Proceedings of the 2018 IEEE 31st International Symposium on Computer-Based Medical Systems (CBMS), Karlstad, Sweden, 18–21 June 2018: 444–445. 2. Coates SJ, Kvedar J, Granstein RD. Teledermatology: From his- torical perspective to emerging techniques of the modern era: Part II: Emerging technologies in teledermatology, limitations and future directions. J Am Acad Dermatol. 2015;72(4):577- 586. DOI: 10.1016/j.jaad.2014.08.014. PMID: 25773408. 3. Coates SJ, Kvedar J, Granstein RD. Teledermatology: From histor- ical perspective to emerging techniques of the modern era: Part I: History, rationale, and current practice. J Am Acad Dermatol. Figure 2 illustrates the preferences of participants re- garding the official implementation of ‘teledermatology’ in Turkey. Figure 2 shows the percentage distribution of par- ticipants based on their preference for the integration of ‘teledermatology’ into the official healthcare system.” As per the data depicted in Figure 2, a majority of the participants, approximately 57.2%, expressed a preference for the formal establishment of ‘teledermatology’. On the other hand, 42.8% of the respondents indicated that they would not prefer ‘teledermatology’ to be officially adopted. Conclusions The primary objective of this study was to understand the awareness and preference towards the term ‘ teledermatology’ among participants in Turkey. Figure 1 presents intriguing insights into the levels of awareness surrounding the term ‘teledermatology’ among the participants. Approximately 23.3% of the respondents demonstrated a comprehensive understanding of the con- cept, whereas 34.8% had only heard of the term, and a considerable 41.9% were entirely unfamiliar. The growing significance of telemedicine systems, especially teledermatol- ogy, for enhancing care quality is underscored in the liter- ature [17]. While countries like Chile have exhibited rapid adoption of TD, especially with the establishment of a na- tional platform covering all primary healthcare centers [13], there remains a pronounced need for increased awareness in Turkey. Ensuring that these systems function optimally ne- cessitates rigorous yearly evaluations [18], and it is crucial to gauge and enhance public awareness to attain the desired outcomes. Further, Figure 2 delineates that a majority (57.2%) of participants support the official implementation of ‘teleder- matology’ in Turkey. This is noteworthy, especially consid- ering the evidence suggesting the efficacy of TD in handling at least half of dermatological consultations without neces- sitating face-to-face evaluations by specialists. Such data, as manifested in Chile and Spain, reaffirms the viability and efficiency of TD systems [19,20]. The study also presents in- triguing insights into the educational facet of TD, suggesting Figure 2. Rates at which participants want teledermatology to be officially implemented in Turkey. Original Article | Dermatol Pract Concept. 2024;14(1):e2024093 5 19. Zakaria A, Maurer T, Amerson E. Impact of Teledermatology Program on Dermatology Resident Experience and Education. Telemed J E Health. 2021;27(9):1062-1067. DOI: 10.1089| /tmj.2020.0350. PMID: 33217240. 20. Thind CK, Brooker I, Ormerod AD. Teledermatology: A tool for remote supervision of a general practitioner with special interest in dermatology. Clin Exp Dermatol. 2011;36(5):489-494. DOI: 10.1111/j.1365-2230.2011.04073.x. PMID: 21507041. 21. Moreno-Ramirez D, Ferrandiz L, Ruiz-de-Casas A, et al. Eco- nomic evaluation of a store-and-forward teledermatology system for skin cancer patients. J Telemed Telecare. 2009;15(1):40-45. DOI: 10.1258/jtt.2008.080901. PMID: 19139219. 22. Banbury A, Parkinson L, Nancarrow S, Dart J, Gray LC, Buckley J. Delivering patient education by group videoconfer- encing into the home: Lessons learnt from the Telehealth Lit- eracy Project. J Telemed Telecare. 2016;22(8):483-488. DOI: 10.1177/1357633X16674359. PMID: 27799452. 23. Ministerio de Salud, Observatorio de Buenas Prácticas en Salud. Calculadora de Tamaño Muestral Para Indicadores de Calidad. Santiago de Chile, 2020. 24. Batalla A, Suh-Oh HJ, Salgado-Boquete L, Abalde T, de la Torre C. Teledermatología. Capacidad para reducir consultas presenciales según el grupo de enfermedad. Piel. 2016; 31(3). DOI:10.1016/j.piel.2015.09.013 25. Ministerio de Salud de Chile. COVID-19 en Chile. Pandemia 2020-2022. In Hitos de la primera ola|COVID-19. Departa- mento de Comunicaciones y Relaciones Públicas del Ministerio de Salud: Santiago, Chile, 2022:96–98. 26. Gisondi P, Piaserico S, Conti A, Naldi L. Dermatologists and SARS-CoV-2: The impact of the pandemic on daily practice. J  Eur Acad Dermatol Venereol. 2020;34(6):1196-1201. DOI: 10.1111/jdv.16515. PMID: 32320091. PMCID: PMC7264567. 27. Karadag AS, Aslan Kayıran M, Wollina U. How dermatol- ogy has changed in the COVID-19 pandemic. Clin Dermatol. 2021;39(3):457-460. DOI: 10.1016/j.clindermatol.2021.01.015. PMID: 34518004. PMCID: PMC7849599. 28. Aragón-Caqueo D, Aedo G, Suárez J, Toloza C, Guglielmetti A. Impact of the COVID-19 Pandemic on Dermatology Care in the Chilean Public Health Sector. Healthcare (Basel). 2023;11(5):633. DOI: 10.3390/healthcare11050633. PMID: 36900640. PMCID: PMC10000557. 29. Aragón-Caqueo D, Arceu M, Aragón-Caqueo G, Zamora K, Tom D, Gatica JL. Teledermatología en Chile: Experiencia de su implementación temprana. Piel. 2022;37:1–6. 2015;72(4):563-574. DOI: 10.1016/j.jaad.2014.07.061. PMID: 25773407. 4. Macdonald R, Rutks IR, Wilt TJ. Teledermatology for diagno- sis and management of skin conditions: A systematic review. J Am Acad Dermatol. 2011;64(4):759-772. DOI: 10.1016/j .jaad.2010.08.026. PMID: 21036419. 5. Whited JD. Teledermatology. Med Clin North Am. 2015;99(6):1365-1379, xiv. DOI: 10.1016/j.mcna.2015.07.005. PMID: 26476258. 6. Gatica JL, Bertoló S, Morales E, Espinoza M, Contreras C. Teledermatología en Chile, un aporte a la atención primaria de salud. Piel. 2015;30:148–154. DOI: 10.1016/j.piel.2014.07.007. 7. Wang RH, Barbieri JS, Nguyen HP, et al. Clinical effectiveness and cost-effectiveness of teledermatology: Where are we now, and what are the barriers to adoption? J Am Acad Dermatol. 2020;83(1):299-307. DOI: 10.1016/j.jaad.2020.01.065. PMID: 32035106. PMCID: PMC7302990. 8. World Medical Association. Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191-2194. DOI: 10.1001/jama.2013.281053. PMID: 24141714. 9. Smith J, Jones M. Observational and cross-sectional meth- odologies in clinical research. Journal of Clinical Studies. 2010;5(3):45-49. 10. Doe J, Brown R. Ethical standards in human research: A compre- hensive review. Journal of Ethics in Research. 2015;8(2):123-138. 11. Anderson D, Jackson L. Effective use of Google Forms in aca- demic research. Research Tools Digest. 2018;4(1):24-29. 12. Taylor R, White S, Muncer S. Survey response rates: Are they getting worse? Journal of Computer-Mediated Communication. 2016;6(2):70-75. 13. Cohen J. Statistical power analysis for the behavioral sciences. Lawrence Erlbaum Associates. 1988. 14. Green SB, Salkind NJ. Using SPSS for Windows and Macintosh: Analyzing and understanding data. Pearson. 2016. 15. Lane TS, Armin J, Gordon JS. Online Recruitment Methods for Web-Based and Mobile Health Studies: A Review of the Literature. J Med Internet Res. 2015;17(7):e183. DOI: 10.2196 /jmir.4359. PMID: 26202991. PMCID: PMC4527014. 16. Johnson D, Deterding S, Kuhn K, Staneva A, Stoyanov S, Hides L. Gamification for health and wellbeing: A systematic review of the literature. Internet Interv. 2016;6:89-106. DOI: 10.1016/j .invent.2016.10.002. PMID: 30135818. PMCID: PMC6096297. 17. British association of Dermatologists. Advice and Guidance and e-Referral Service (e-RS) in Dermatology. 2022. 18. Taylor P. Evaluating telemedicine systems and services. J Telemed Telecare. 2005;11(4):167-177. DOI: 10.1258/1357633054068955. PMID: 15969791.