Brief Report

Telemedicine for Peer-to-Peer PsychiatryLearning Between U.K. and Somaliland

Medical Students

Roxanne Keynejad, M.B.B.S., Faisal R. Ali, M.R.C.P.

Alexander E. T. Finlayson, M.R.C.P., Jibriil Handuleh, M.D.

Gudon Adam, M.D., Jordan S. T. Bowen, M.R.C.P., Andrew Leather, F.R.C.S.

Simon J. Little, M.R.C.P., Susannah Whitwell, M.R.C.Psych.

Objective: The proportion of U.K. medical students applyingfor psychiatry training continues to decline, whereas, in Somali-land, there are no public-sector psychiatrists. This pilot studyassessed the usefulness and feasibility of online, instant messenger,peer-to-peer exchange for psychiatry education between cultures.

Method: Twenty medical students from King’s College, London,and Hargeisa University (Somaliland) met online in pairs every 2weeks to discuss prearranged psychiatric topics, clinical cases,and treatment options, completing online evaluations throughout.

Results: Average ratings of the enjoyment, academic helpful-ness, and interest of sessions were 4.31, 3.56, and 4.54 (of a max-imum of 5), respectively; 83% would recommend the partnershipto a friend.

Conclusion: This partnership enabled students on both sides toexploit psychiatry-learning resources at the other’s disposal,outside the standard medical education context, illustrating thebenefits to medical students in dramatically different locations ofpartnership through telemedicine. This pilot study presents aninnovative, cost-effective, under-used approach to internationalmedical education.

Academic Psychiatry 2013; 37:182–186

This preliminary pilot study aimed to share knowledgeand experiences between medical students in Somali-

land and the United Kingdom, for psychiatry educationand cross-cultural exchange. Here, we assess the usefulnessand feasibility of online, instant messenger, peer-to-peer ex-change for education in psychiatry between cultures. Thereare no documented reports of psychiatry education of thiskind. Given the growing emphasis on global health andthe recruitment crisis in psychiatry (1), developing innova-tive, cost-effective technologies to stimulate medical stu-dents’ interest in this area is of increasing importance toacademic psychiatrists and medical educators worldwide.Somaliland is a self-declared independent state in the

north of Somalia. Its estimated population is 2.0–3.5 mil-lion, with an annual health budget of $750,000. There areonly two public inpatient psychiatric units in the country andno psychiatrists working in the public sector (2).King’s Tropical Health and Education Trust Somaliland

Partnership (KTSP) works to strengthen the healthcare sys-tem and improve access to care through mutual exchange ofskills, knowledge, and experience between Somaliland andKing’s College Hospital, U.K. (3). This includes teachingand examination support from U.K. psychiatrists to final-year medical students in Somaliland, who would not other-wise receive formal training in mental health.MedicineAfrica is a telemedicine portal, based on a social-

network structure, which facilitates online, case-basedtutorials in real time. It has previously been used for live dis-tance teaching in both Sierra Leone and Somaliland, wherepartners received reciprocal educational benefit (4). Onlinepeer-to-peer learning, exploiting e-learning technologies,offers students a more diverse medical education and in-creasing access to medical education resources worldwide

From St. Helier Hospital, Carshalton, UK (RK), University of Manches-ter, UK (FRA), University of Oxford, UK (AETF, SJL), Amoud UniversityMedical School, Somaliland (JH), University of Hargeisa, Somaliland(GA), MedicineAfrica; King’s Centre for Global Health, King’s CollegeLondon, UK (JSTB, AL), Institute of Psychiatry, King’s College London,UK (SW). Send correspondence to Dr. Keynejad; e-mail: roxanne.keynejad@gmail.comCopyright © 2013 Academic Psychiatry

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(5). A recent literature review found that new medical edu-cation technologies for psychiatry teaching are not wellstudied and require partnership approaches to integrate theminto curricula (6), although telepsychiatry is beneficial inenhancing exposure to isolated patient populations (7).

The logical framework (“logframe”) frequently used toevaluate development interventions consists of subdivisioninto precursors, inputs, processes, outputs, outcomes, andimpact (8). This study examines the outputs and outcomesof an educational intervention to support peer-to-peer learn-ing, in the context of a larger project of capacity-building inthe fragile state of Somaliland. This article describes a pre-liminary pilot project exploring whether an interventionsolely employing existing resources has scope for wideruse and scaling-up in medical education that is mutually,cross-culturally beneficial.

Method

Ten King’s College London (KCL) U.K. students werepaired with 10 Hargeisa University Medical School (Soma-liland) students through a partnership between the KCLPsychiatry Society and the KTSP. This was coordinatedby an intern in Hargeisa and a medical student in London.All students volunteered to participate in response to e-mailcommunications and lecture announcements advertising thepartnership. The small sample size was necessitated by lowuptake from KCL students, but was considered sufficient towarrant a preliminary pilot study.

Students were instructed to meet their partner for 1 hour,every 2 weeks, using online instant-messaging via thewebsite MedicineAfrica. Students were paired at random,without any criteria, including sex, since female students didnot object to having male partners. Each pair aimed to meeteight times, to discuss psychiatric topics. Students receiveda set of eight suggested themes for discussion, includingcultural perspectives and stigma, affective disorders, sub-stance misuse, and psychosis.

Students completed an initial questionnaire before thebeginning of the partnership, a short survey after each 1-hourmeeting, and a final evaluation questionnaire about the ex-perience (see Appendix 1, Appendix 2, and Appendix 3).Three Likert-scale questions were asked, the remainder beingqualitative. As a pilot study, this was considered most ap-propriate to explore participants’ views and experiencesand to determine what aspects of the partnership neededimprovement.

Consent to completion of anonymized questionnaires foruse in evaluation and research and full anonymizing of

clinical cases were explicit features of the Terms of Refer-ence that all students signed before beginning. All ques-tionnaire responses were fully anonymous. As part of theKTSP, MedicineAfrica evaluation, ethical approval camefrom the KCL Ethics Committee, and permission wasgranted by the Somaliland Medical Association and Min-istry of Health.

Results

Seven male and three female KCL students and five maleand five female Hargeisa University students, with a meanage of 25 years, participated. Of 18 initial questionnaires,44%were sixth-year students; 17%, fifth-year; 22%, fourth-year; 11%, third-year; and 6%, second-year. All Somalilandstudents had received psychiatry training from KTSP, toensure comparable levels of previous knowledge of psy-chiatry with U.K. students. Students hoped to learn aboutthe other country’s culture, history, people, medical models,psychopathology, and treatment. One U.K. student said: “Ihope to gain a wider knowledge of psychiatry—seeing itonly from a Western perspective is very blinkered.”

Thirty-six questionnaires were completed after meetings,with 64% by KCL students (N=23) and 36% by Hargeisastudents (N=13); one did not indicate affiliation. The aver-age duration of each meeting was 68 minutes. One pair didnot successfully meet. Of the remainder, 4.7 meetings werecompleted, on average, indicating that 57% of meetingswere reported by the questionnaire.

Grouping self-reported learning-points under commonthemes, 61% of respondents reported learning the similari-ties and differences between psychiatry in the two countries,including social, religious, and cultural attitudes and stigma;44% learned more about depression, posttraumatic stressdisorder (PTSD), and anxiety disorders; 39% learned aboutpharmacotherapy; and 33% learned about alternative cul-tural and religious explanations for psychiatric illness, aboutherbal, healing and Qur’anic therapies; 33% learned aboutkhat, cannabis, and other drugs of abuse and their effects onsociety, families, and health; 28% learned about the finan-cial challenges of public healthcare, the impact of the civilwar, and the rise of private healthcare in both countries. Acommon theme was how similarly psychiatric illnessespresent in both countries.

Table 1 summarizes students’ post-meeting evaluationresponses. When asked, “On a scale from 1 to 5, how muchdid you enjoy today’s session?” the average rating was 4.31,with 58% giving the maximum score of 5. When asked “Ona scale from 1 to 5, how much did you find this session

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academically helpful?” the average rating was 3.56, with39% giving the maximum score of 5. When asked “On ascale from 1 to 5, how interesting did you find today’ssession?” the average rating was 4.54, with 71% giving themaximum score of 5; 83% of respondents would recom-mend the partnership to a friend; 57% of respondents thoughtthey would keep in touch with their partner.In the final evaluation of their experience, 9 KCL students

out of 10who started, and only 3HargeisaUniversity studentsout of 8 who started completed questionnaires. All respond-ing students agreed that the topic themes providedwere usefulin helping them to structure their meetings, and 72% followedthem explicitly, although others found them too rigid.Those who met regularly felt they gained from the part-

nership. One KCL student commented:

I gained an understanding of the differences in the way that societyviews mental illness in Somaliland and in the U.K. I also learned a lotabout mental health issues that are less common in the U.K. (e.g., Khatabuse) and the inter-relationship between religion and mental healthcare provision in Somaliland. I had seen. . . ECT, which my partnerwas not familiar with, and so I could share what I had been taughtduring my psych rotation and vice versa... I learned a lot from her.

Only a small number of student pairs completed the fulleight meetings. Participants who did not complete the fullprogram identified problems, which included:

l Internet connection difficultiesl Traveling to access a computerl Participants not being committed at the outset and lack-ing motivationl Misunderstanding of how the partnership works throughMedicineAfrica

Logistical problems limiting full completion were thebiggest challenge to successful partnership. Time-delayscaused by slow internet connections prompted one studentto suggest a blog as an alternative format, whereas otherparticipants relished the personal and immediate instant-messaging format. In only one case was the language bar-rier considered to be a problem.

Students stated the that there was a clear benefit to usingMedicineAfrica, a bespoke tool for online clinical com-munication, rather than using existing communication for-mats such as e-mail or video-conferencing.Although students liked being able to read what others

had discussed, because the website made meetings openlyvisible online, many were unhappy that conversations werenot private. For future cohorts, the option to make a con-versation inaccessible to other users of the site was added,to preserve confidentiality.

Discussion

This preliminary pilot study explored the value and fea-sibility of pairing medical students in Somaliland and theU.K. for online telemedicine peer-to-peer psychiatry learn-ing. Post-meeting and evaluation questionnaires revealed thatthe partnership enabledmedical students to consolidate theircurricular psychiatry teaching and enhance their knowledgeof medicine in a differently-resourced environment. Stu-dents learned about perceptions of psychiatric illness ina different culture and shared their experiences of patients.High ratings of interest and moderate enjoyment and aca-demic helpfulness were given in spite of logistical problems.Medical students’ high computer literacy led to clear sug-gestions to improve the MedicineAfrica website, based onknowledge of other online communication forums.Challenges included low uptake of the partnership by

King’s College London students and low questionnairecompletion by Somaliland students, a significant limitationto be rectified in future cohorts, as the final evaluation isbiased in favor of KCL students’ experiences and preventsdirect comparison between student groups. It highlights theneed to better explain and reiterate the importance of com-pletion of all questionnaires to all students at the outset andthroughout.The proportion of U.K. medical students applying for

specialty training in psychiatry continues to decline, while, in

TABLE 1. Summary of Post-Meeting Evaluation Responses

Not at All(Rating: 1) (Rating: 2)

Somewhat(Rating: 3) (Rating: 4)

Very Much(Rating: 5)

RatingAverage

On a scale from 1 to 5, how much did youenjoy today’s session?

0.00% (0) 2.8% (1) 22.2% (8) 16.7% (6) 58.3% (21) 4.31/5 N=36

On a scale from 1 to 5, how much did youfind this session academically helpful?

13.9% (5) 8.3% (3) 25.0% (9) 13.9% (5) 38.9% (14) 3.56/5 N=36

On a scale from 1 to 5, how interesting didyou find today’s session?

0.00% (0) 2.9% (1) 11.4% (4) 14.3% (5) 71.4% (25) 4.54/5 N=35

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Somaliland, there are no psychiatrists working in the publicsector. This partnership stimulated interest in psychiatry byencouraging medical students to think about psychiatry out-side the standardmedical education environment,making useof a unique telemedicine learning format.

Although the small sample size, qualitative question-naires, and imbalanced response rates prevent these find-ings from being generalized, they provided a positive pilotinvestigation upon which to build a more rigorously im-plemented and evaluated partnership. In 2011, this was un-dertaken with a larger cohort, whose results are currentlybeing evaluated. Lessons learned from this pilot study in-clude the importance of regularly encouraging participantsto complete questionnaires, to maximize evaluation and au-dit of e-learning and ensure that balanced feedback is col-lected from both countries.

This partnership illustrates the potential benefits tomedical students in dramatically different locations of peer-to-peer learning through telemedicine. It presents an inno-vative, extremely cost-effective, and under-used approachto medical education. This project expands the scope of theKTSP health link beyond qualified clinicians, to the medicalprofessionals of the future.

APPENDIX1.Hargeisa–KingsCollege London (KCL)Psychiatry Partnership Starting Questionnaire

1. Which university do you study at?2. How old are you?3. Which year of Medicine are you currently in?4. If you have studied a previous degree before Medicine,

please state which subject you studied before.5. What do you know about medicine in Somaliland (if

you are a KCL student) or in the United Kingdom (ifyou are a Hargeisa student)?

If you are unsure, please guess.

6. What is your opinion of psychiatry?7. What do you know about psychiatry in Somaliland (if

you are a KCL student) or in the United Kingdom (ifyou are a Hargeisa student)?

What forms of treatment are used?What are the most common psychiatric diagnoses?How do patients present for treatment?What are the most common substances of misuse?

If you are unsure, please guess.

8. What are the common myths and misconceptions aboutmental health in your country?

If you are a student at Hargeisa University, what can yousay about post-conflict Somaliland and the current state ofmental health?9. What do you hope to gain from this partnership?

10. Would you consider a career in psychiatry? Why?

APPENDIX 2. Hargeisa-KCL Psychiatry Partnership:After-Meeting Short Questionnaire

1. Which university are you a student of?2. On what date did this meeting take place? How long did

your meeting last?3. Which meeting was this? (i.e., first, second, third, etc.)4. Please name three things you and your partner discussed

today.5. Please name three things you learned today6. On a scale from 1 to 5, howmuch did you enjoy today’s

session?7. On a scale from 1 to 5, how much did you find this

session academically helpful?8. On a scale from 1 to 5, how interesting did you find

today’s session?9. Please state one thing you would improve for next time.

10. What was your experience of the MedicineAfrica web-site like?

APPENDIX 3. Hargeisa-KCL Partnership EvaluationSurvey

1. How many times did you successfully meet with yourpartner for a session on MedicineAfrica?

2. What were the main things which you and your partnerdiscussed in the meetings you had?

3. Please comment on whether you used the topics we pro-vided as a framework for your meetings. Were they use-ful? What improvements should we make to the topics?

4. Please tell us what was great about this partnership.What did you gain, what did you learn, what couldyou offer your partner?

5. Some students were unable to meet their partner for allthe scheduled sessions. If this happened to you, pleasetell us what the problems were. What do we need tochange to overcome this type of problem when we startthis partnership again in the future?

6. Did the MedicineAfrica forum work as an appropriatemedium for your meetings? Is there anything we canchange to make it more user-friendly? Should we be

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using the site in a different way to make the most of thepartnership?

7. Would you recommend the partnership to a friend?8. If no, why not? (If you have any other feedback about

the partnership—what worked well, what needs to beimproved, and your ideas, please write them here. Willyou be keeping in touch with your partner in future?)

9. Please indicate your university10. Please state your age and your year of study.

References

1. Cutler JL, Alspector SL, Harding KJ, et al: Medical students’perceptions of psychiatry as a career choice. Acad Psychiatry2006; 30:144–149

2. Syed Sheriff RJ, Baraco AFH, Nour A, et al: Public–academicpartnerships: improving human resource provision for mentalhealth in Somaliland. Psychiatr Serv 2010; 61:225–227

3. Leather A, Ismail EA, Ali R, et al: Working together to rebuildhealth care in post-conflict Somaliland. Lancet 2006; 368:1119–1125

4. Finlayson AET, Baraco A, Cronin N, et al: An international,case-based, distance-learning collaboration between the U.K.and Somaliland, using a real-time clinical education website.J Telemed Telecare 2010; 16:181–184

5. Harden RM, Hart IR: An international virtual medical school(IVIMEDS): the future for medical education? Med Teach2002; 24:261–267

6. Hilty DM, Alverson DC, Alpert JE, et al: Virtual reality, tele-medicine, web and data processing innovations in medical andpsychiatric education and clinical care. Acad Psychiatry 2006;30:528–533

7. Miriam J, Szeftel R, Sulman-Smith H, et al: Use of tele-psychiatry to train medical students in developmental dis-abilities. Acad Psychiatry 2011; 35:268–269

8. Department for International Development: Guidance on Usingthe Revised Logical Framework (online); retrieved 06/12/2011;http://www.dfid.gov.uk/Documents/publications1/how-to-guid-rev-log-fmwk.pdf

ERRATA

In the November-December 2012 issue, the title of the article from Korszun A, et al., “Responseto Prabhakar et al. Letter” (Acad Psychiatry 2012; 36:500) should be “Response to Vahabzadehet al. Letter.”

In the November-December 2012 issue (Acad Psychiatry 2012; vol 36), two website listings wereincorrect: p. 480, the correct website for the APAOffice of HIV Psychiatry: http://www.psych.org./aids; p. 486, for information about substance use in patients with HIV: www.hiv-druginteractions.org/interactioncharts.aspx.

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