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Despite the significant body of evidence on the efficacy and cost-effectiveness of internet interventions, the implementation of such programs in Portugal is virtually non-existent. In addition, Portuguese psychologists’ use and their attitudes towards such interventions is largely unknown.
The aim of this study was to explore Portuguese psychologists’ knowledge, training, use and attitudes towards internet interventions; to investigate perceived advantages and limitations of such interventions; identify potential drivers and barriers impacting implementation; and study potential factors associated to previous use and attitudes towards internet interventions.
An online cross-sectional survey was developed by the authors and disseminated by the Portuguese Psychologists Association to its members.
A total of 1077 members of the Portuguese Psychologists Association responded to the questionnaire between November 2018 and February 2019. Of these, 37.2% (N=363) were familiar with internet interventions and 19.2% (N=188) considered having the necessary training to work within the field. 29.6% (N=319) of participants reported to have used some form of digital technology to deliver care in the past. Telephone (23.8%; N=256), e-mail (16.2%; N=175) and SMS (16.1%; N=173) services were among the most adopted forms of digital technology, while guided (1.3%; N=14) and unguided (1.5%; N=16) internet interventions were rarely used. Accessibility (79.9%; N=860), convenience (45.7%; N=492) and cost-effectiveness (45.5%; N=490) were considered the most important advantages of internet interventions. Conversely, ethical concerns (40.7%; N=438), client’s ICT illiteracy (43.2%; N=465) and negative attitudes towards internet interventions (37%; N=398) were identified as the main limitations. An assessment of participants attitudes towards internet interventions revealed a slightly negative/neutral stance (Median=46.21; SD=15.06) and revealed greater acceptability towards blended treatment interventions (62.9%; N=615) when compared to standalone internet interventions (18.6%; N=181). Significant associations were found between knowledge (χ24=90.4;
This study revealed that most Portuguese psychologists are not familiar with and have no training or prior experience using internet interventions and had a slightly negative/neutral attitude towards such interventions. There was greater acceptability towards blended treatment interventions compared to standalone internet interventions. Lack of knowledge and training were identified as the main barriers to overcome, underlining the need of promoting awareness and training initiatives to ensure internet interventions successful implementation.
Advances in digital technology are transforming the current health care delivery paradigm, enabling health systems to overcome physical and organizational barriers and creating an opportunity to deliver accessible and convenient mental health care services at a distance [
Despite evidence of efficacy and potential usefulness, implementation of internet interventions in clinical practice has been peculiarly slow [
Previous studies have been performed to investigate psychologist attitudes toward internet interventions and categorize drivers and barriers to the adoption of such programs. Overall, findings suggest that therapist attitudes range from neutral and cautiously positive to generally positive [
In a study performed by Mora and colleagues [
Contrasting with these findings, a more guarded attitude was identified in other studies, and major concerns related to security and ethical and legal requirements have been reported as important barriers to adoption [
Technical barriers such as connection challenges and disruptions were also flagged as potential limitations of internet interventions, and a major concern reported in several studies [
Other important findings reported in previous research as influencing therapist attitudes relate to demographic and background factors (eg, age, gender, length of professional career, personal experience in using modern technologies) [
In Portugal, only one study addressed psychologist attitudes toward electronic psychological interventions (EPI). In the study, Neves et al [
In spite of the findings that psychologists’ attitudes toward internet interventions appear to be positive, there are variations between countries [
This study was conducted in the framework of the iNNOVBC (A Guided Internet-Delivered Individually Tailored ACT-Influenced Cognitive Behavioral Intervention to Improve Psychosocial Outcomes in Breast Cancer Survivors) project (ClinicalTrials.gov NCT03275727) [
Due to the scarcity of adequate instruments designed to evaluate the outlined issues in the target population, the Attitudes Toward Internet Interventions Survey (ATIIS) was developed. After a comprehensive literature review was performed, most relevant publications were identified and served as a basis for development [
The final version of the survey comprised 38 items assessing 4 main categories: (1) information relating to frequency of use of digital technology and internet interventions in practice (eg, use and frequency of use of digital technology, provision and prescription of internet interventions, contexts and purposes of use); (2) knowledge and training within the internet interventions field; (3) perceived advantages and limitations of internet interventions and potential barriers and challenges impacting implementation; and (4) attitudes toward internet interventions (eg, related to efficacy and efficiency; privacy, security and confidentiality; patient empowerment and increased disinhibition; therapeutic processes and alliance; and blended, complementary, and stand-alone interventions). The attitudes section was composed of 21 items aimed at capturing cognitive, affective, and behavioral predispositions of favor or disfavor [
Demographic and background items were added to the questionnaire to gather supplementary information (eg, age, gender, educational and professional background, professional experience, and theoretical orientation). The survey questions were asked in the form of dichotomous and multiple choice questions and in the form of 5-point (0=completely disagree to 5=completely agree) Likert scales. Since it was not expected for participants to be familiar with the concept of internet interventions, an explanation of the concept based on the definition by Barak et al [
An assessment of the validity of the attitudes section of the questionnaire resulted in 21 items clustering in two dimensions labeled as positive attitudes and negative attitudes. Reliability of the scale was also tested and considered excellent (α=.91). A detailed description of the psychometric properties assessment process of this scale and its results can be found below. A copy of the instrument is available in
Statistical analyses were divided into 4 steps and conducted using SPSS Statistics. First, descriptive statistics such as frequency distributions, measures of variability, and measures of central tendency were calculated to characterize the study sample and determine its face validity. These statistics encompassed demographic and background characteristics such as, age, gender, educational and professional background, professional experience (in years), and theoretical orientation.
Second, a psychometric properties evaluation process of ATIIS took place, and an exploratory factor analysis (EFA) based on the principal component analysis method using a varimax rotation was conducted to determine the factor structure of the questionnaire, perform scale purification, and determine the questionnaire’s construct validity. The whole study sample (1077) was used for this purpose. The Kaiser-Meyer-Olkin (KMO) test and a Bartlett test of sphericity were calculated to measure sampling adequacy (confirmed if KMO value greater than .5) and appropriateness of the extracted factors (significant at
Following this process, results pertaining to frequency of use of digital technology and internet interventions in daily practice, provision and prescription of internet interventions, contexts and purposes of use, perceived advantages and limitations of internet interventions, and potential barriers and challenges impacting implementation were analyzed. Although some of the questionnaire items contained multiple response options for which up to 3 response categories could be selected, only single response options (eg, percentage of psychologists using chat services) rather than combined response options (eg, percentage of psychologists using chat services and videoconference) were calculated in order to simplify the analysis.
Finally, psychologist attitudes toward internet interventions were examined using descriptive statistics, and chi-square analysis and post hoc tests were used to determine if demographic (eg, sex and age) and background factors (eg, academic background, work context, years of professional experience, theoretical orientation), knowledge, training, previous experience of use, recommendation, future use, and attitudes toward internet interventions would be associated and differed between participants holding extreme attitudes toward internet interventions.
The total sample comprised 1077 members of the OPP recruited between November 2018 and February 2019. Considering the number of psychologists registered as members at the time (21,214, data provided by T Pereira, OPP’s head of cabinet), response rate was 5.08%. Although we cannot determine the representativeness of the sample (OPP’s members demographic and background information is not available for consultation), demographic characteristics are similar to those published in the last census performed by OPP [
In our study sample, 91.6% (987/1077) of respondents were female, and age ranged from 20 to 77 years (mean 38.21; SD 9.49 years). Most participants held a license and/or master’s degree (722/1077, 67.0%), followed by postgraduate (273/1077, 25.3%), doctoral (75/1077, 7%), and bachelor’s degrees (7/1077, 0.6%). The majority of participants were active (986/1077, 91.6%) and worked primarily in private practice (270/1077, 25.1%), educational/research institutions (252/1077, 23.4%), and charities/nonprofit organizations (208/1077, 19.3%). Only 6.3% (68/1077), 4.4% (47/1077), and 1.6% (17/1077) of psychologists worked in the National Health Service (NHS) at primary, secondary and tertiary care, respectively. As for the length of time working within the field of psychology, the sample was evenly distributed, with 12.6% (136/1077) of professionals working for less than a year; 21.0% (226/1077) practicing psychology from 2 to 5 years, 17.3% (186/1077) working between 6 to 10 years in the field, 20.0% (215/1077) practicing between 11 to 15 years, 15.4% (166/1077) working from 16 to 20 years in this domain, and 13.7% (148/1077) practicing psychology for more than 21 years. Cognitive behavioral therapy was the most common theoretical orientation (56.0%, 603/1077), with psychodynamic (14.8%, 159/1077) and eclectic (13.5%, 145/1077) orientations being second and third.
In order to test the psychometric properties of the attitudes section of ATIIS, we explored its construct validity and reliability.
An EFA based on principal component analysis and using a varimax rotation was conducted with the purpose of finding the underlying latent factors of ATIIS and determining the questionnaire’s construct validity. The whole study sample (N=1077) was used in this analysis. A KMO=.93 confirmed the sampling adequacy, and a Bartlett test of sphericity, χ2210=8003.39 (
The initial EFA resulted in 4 factors with eigenvalues above a Kaiser criterion of 1. However, a scree plot analysis revealed inflexions compatible with the retention of two factors. Due to convergence with theory, two factors were retained for the final EFA. The initial model hypothesized that items would load on either a positive or a negative factor. Total variance explained by these two factors was 44.10% (unrotated solution: factor one 36.2% and factor two 7.97% or rotated solution: factor one 22.40% and factor two 21.73%), and items clustering on these two factors suggested that the questionnaire measures two dimensions, labeled as positive attitudes (range of factor loadings: .375-.712) and negative attitudes (range of factor loadings: .459-.708). Items with factor loadings above
ATIIS reliability was assessed via the computation of Cronbach alpha. ATIIS total scale revealed excellent (α=.91) internal consistency and its subscales, positive (.88) and negative (.82) attitudes, showed good internal consistency [
An examination of collected data indicated that 37.2% (363/978) of respondents were familiar with the concept of providing psychological support via the internet. Nevertheless, a narrower group reported knowing how these types of interventions work (218/978, 22.3%), and only 19.2% (188/978) were considered to have the necessary training to work in the field.
Around 29.6% (319/1077) of participants reported that they use or have used in the past some form of digital technology to provide support in the context of their practice. Of nonusers (758/1077, 70.4%), 61.7% (468/758) reported to be considering using it in the future. Telephone (256/1077, 23.8%), email (175/1077, 16.2%,) and short message service (SMS) or text message (173/1077, 16.1%) services were among the most used forms of digital technology, while chat services (66/1077, 6.1%) and unguided (16/1077, 1.5%) and guided (14/1077, 1.3%) internet interventions were much less used. However, 8.7% (94/1077) reported using videoconference services. Digital technology was mostly used by clinical and health psychologists (269/319, 84.3%), followed by educational psychologists (31/319, 9.7%). In most cases, digital technology was used as a complement to face-to-face interventions (288/319, 90.3%) rather than as a stand-alone interventions (31/319, 9.7%) for the purpose of treating mental health disorders such as anxiety or depression (205/319, 64.3%). Increasing accessibility to information and psychological care was reported as the main reason for using digital technology in practice by 54.5% (174/319) of respondents whereas only 0.6% (2/319) used it for research (see
Motivations for previous use of digital technology in psychological practice (n=319).
Motivation | Value, n (%) |
Increasing accessibility to information and psychological care | 174 (54.5) |
Lowering the costs of psychological interventions | 3 (0.9) |
Increasing adherence to psychological interventions | 61 (19.1) |
Monitoring treatment progress | 41 (12.9) |
Facilitating follow-up care | 26 (8.2) |
Managing crisis situations | 5 (1.6) |
Improving career prospects | 5 (1.6) |
Research | 2 (0.6) |
Other | 2 (0.6) |
Almost a fifth (19.1%, 206/1077) reported that they recommend or have recommended in the past to their clients accessing online services or resources with the aim of improving their emotional wellbeing and/or health status. Most frequently recommended resources were websites providing information about mental and/or somatic health (57.3%, 118/206), blogs, discussion forums and social networks (38.3%, 79/206), videoconference-delivered psychological interventions (29.1%, 60/206), and apps (28.2%, 58/206). On the other hand, online support groups (21.8, 45/206) and guided (13.1%, 27/206) and unguided (4.4%, 9/206) internet interventions were the least recommended. Only a minority of respondents (3.7%, 39/1077) provided or recommended internet interventions to their clients in a regular basis.
Considering the potential advantages of internet interventions, accessibility (860/1077, 79.9%), convenience (492/1077, 45.7%), and cost effectiveness (490/1077, 45.5%) of such interventions were considered the most important advantages. Conversely, ethical concerns (438/1077, 40.7%), client ICT illiteracy (465/1077, 43.2%), and client negative attitudes toward internet interventions (398/1077, 37.0%) were identified as the main limitations. Other advantages and limitations associated with internet interventions are presented in
Advantages and limitations associated with internet interventions (n=1077).
Characteristic | Value, n (%) | |
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Accessibility | 860 (79.9) |
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Convenience | 492 (45.7) |
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Economical (cost effectiveness and sustainability to health care systems) | 490 (45.5) |
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Reduced stigma associated with psychological support/confidentiality | 206 (19.1) |
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Privacy/anonymity | 164 (15.2) |
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Health equity | 142 (13.2) |
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Client empowerment | 131 (12.2) |
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Personalized health care | 89 (8.3) |
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None | 77 (7.1) |
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Scientific evidence | 43 (4) |
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Client information and communications technologies illiteracy | 465 (43.2) |
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Ethical | 438 (40.7) |
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Client attitudes toward internet interventions | 398 (37.0) |
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Information systems security | 386 (35.8) |
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Cultural | 271 (25.5) |
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Therapist attitudes toward internet interventions | 259 (24.0) |
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Health care systems not ready for implementation | 234 (21.7) |
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Cost and accessibility to digital technology | 144 (13.4) |
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Therapist information and communications technologies illiteracy | 96 (8.9) |
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Other | 82 (7.5) |
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Political (decision makers not interested in implementation) | 50 (4.6) |
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Economical (cost effectiveness and sustainability to health care systems) | 18 (1.7) |
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None | 18 (1.7) |
When questioned about the possibility of internet interventions presenting more disadvantages than advantages, only 24.5% (239/1077) of participants refuted this claim.
The main barriers to overcome in the implementation of internet interventions were related to limitations on the conceptual comprehension and implementation of self-help techniques by clients (676/1077, 62.8%), therapist perceptions of insufficient scientific evidence on the efficacy and cost effectiveness of internet interventions (670/1077, 62.2%), limitations on the adaptation of treatment protocols (665/1077, 61.7%), patient ICT illiteracy (516/1077, 47.9%), and low adherence both from patients (466/1077, 43.3%) and psychologists (437/1077, 40.6%) toward such programs. Negative attitudes presented both by clients (417/1077, 38.7%) and therapists (416/1077, 38.6%) were also considered an important obstacle to overcome in the implementation of internet interventions (see
Barriers to implementation of internet interventions (n=1077).
Characteristic | Value, n (%) | |
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Ability to comprehend concepts and learn self-help techniques | 676 (62.8) |
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Client information and communications technologies illiteracy | 516 (47.9) |
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Low adherence | 466 (43.3) |
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Negative attitudes | 417 (38.7) |
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Scientific evidence (efficacy and cost effectiveness) | 362 (33.6) |
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Costs and access to digital technology and information technology infrastructures | 211 (19.6) |
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Time consumption | 28 (2.6) |
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None | 21 (1.9) |
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Scientific evidence (efficacy and cost effectiveness) | 670 (66.2) |
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Adaptation of treatment protocols to the digital environment | 665 (61.7) |
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Low adherence | 437 (40.6) |
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Negative attitudes | 416 (38.6) |
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Clinician information and communications technologies illiteracy | 178 (16.5) |
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Costs and access to digital technology and information technology infrastructures | 91 (8.4) |
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Time consumption | 38 (3.5) |
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None | 20 (1.9) |
The median score on the ATIIS scale was 46.21 (SD 15.06), which corresponds to a slightly negative/neutral attitude toward internet interventions. Factors contributing to this predisposition relate to possible security (417/1077, 42.6%) and confidentiality (494/1077, 50.5%) breaches when using internet interventions, reported discomfort about dealing with sensitive information online (466/1077, 47.7%), perceived inaccuracy of remote psychological assessment processes (578/1077, 59.1%), perceived unsuitability of internet interventions for crisis management (473/1077, 48.4%), a disbelief on the possibility of establishing therapeutic alliance via the internet (356/1077, 36.5%), and a generalized perception of face-to-face interventions as being superior for client education/self-management skills development (702/1077, 71.8%) and mental disorders treatment (699/1077, 71.6%) compared with internet interventions. Absence of knowledge about the efficacy (561/1077, 57.4%) and efficiency (443/1077, 45.3%) of internet interventions and its impact on patient empowerment (461/1077, 47.2%) and a possible loss of control of the therapeutic process by clinicians (372/1077, 38.1%) also seem to influence this stance. Nevertheless, perceived convenience (473/1077, 45.6%) of internet interventions, encouragement of emotional expression in some cases (360/1077, 36.8%), facilitation of the follow-up process (440/1077, 45%), and the possibility of delivering blended (615/978, 62.9%) and pharmacotherapy complementary interventions (511/978, 52.2%) rather than stand-alone internet interventions (181/978, 18.6%) seem to balance attitudes regarding this matter.
Chi-square tests and post hoc analyses were performed to examine possible associations between demographic factors (sex, age), background factors (academic background, work context, years of professional experience, theoretical orientation), knowledge, training, recommendation, future use, previous experience of use, and attitudes toward internet interventions. Differences in responses between participants with or without prior experience of use and holding extreme attitudes toward these interventions were also evaluated. Percentiles (assumed here as the percentage of scores that fall below the scores of interest) were computed to categorize participant attitudes and identify those who held extremely negative (scores <Q1=36.03, 244; 25.1%) and extremely positive (scores >Q3=53.49, 242; 24.9%) attitudes toward internet interventions.
Chi-square analyses (see
Considering age, psychologists aged between 41 and 60 years were more likely to have used the telephone or internet to provide psychological support in the past, while psychologists aged 30 years and younger were less likely to have done it. Similarly, psychologists with less than 5 years of professional experience were less likely to have already used such interventions, whereas psychologists with more than 16 years of professional experience were more likely to have used internet interventions in the past. Work context also seems to impact the use of internet interventions. Participants working at the NHS and in private practice had a higher probability of using the internet and telephone to provide care. Working at public services, education/research facilities, and charities made it less probable participants had adopted these interventions.
Regarding self-reported knowledge and training on internet interventions, psychologists reporting moderate to high knowledge and training were more likely to have prior experience in implementing such programs than those whom reported little to no knowledge about internet interventions. Furthermore, having a psychodynamic theoretical orientation impacted use positively, making it more likely that psychodynamic psychologists had used internet interventions in the past than expected. No significant associations were found between other theoretical stances and internet intervention adoption.
Extreme attitudes toward internet interventions seem, as well, to have significantly impacted adoption. Psychologists presenting more negative attitudes toward these interventions were less likely to have prior experience using internet interventions than expected and when compared with psychologists holding more positive attitudes. Finally, prior experience implementing internet interventions significantly affected referrals and the possibility of psychologists recommending such programs to their clients. Psychologists with prior experience of use were more likely to recommend internet interventions and online resources with the purpose of improving their clients’ health status.
Factors associated to previous experience of use.
Characteristic | Previous experience of usea | Chi-square tests | ||||
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No | Yes | Chi-square | Cramér V Φc | ||
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≤30 | 207 (4.4) | 47 (–4.4) | — | — | — |
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31-40 | 323 (1.4) | 121 (–1.4) | — | — | — |
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41-50 | 152 (–3.5) | 95 (3.5) | — | — | — |
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51-60 | 59 (–4.2) | 52 (4.2) | — | — | — |
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≥61 | 17 (1.1) | 4 (–1.1) | — | — | — |
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Cognitive behavior therapy | 435 (1.4) | 168 (–1.4) | — | — | — |
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Psychodynamic | 99 (–2.4) | 60 (2.4) | — | — | — |
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Humanist | 25 (–1.6) | 17 (1.6) | — | — | — |
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Eclectic | 93 (–1.8) | 52 (1.8) | — | — | — |
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Systemic | 24 (1.5) | 5 (–1.5) | — | — | — |
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Other | 37 (0.1) | 15 (–0.1) | — | — | — |
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None | 45 (3.9) | 2 (–3.9) | — | — | — |
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National Health Service | 82 (–2.2) | 50 (2.2) | — | — | — |
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Private practice | 151 (–6.0) | 119 (6.0) | — | — | — |
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Public services | 59 (2.4) | 12 (–2.4) | — | — | — |
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Private companies | 22 (1.0) | 6 (–1.0) | — | — | — |
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Rehabilitation services/prisons | 21 (0.9) | 6 (–0.9) | — | — | — |
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Education/research institutions | 190 (2.0) | 62 (–2.0) | — | — | — |
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Charities | 164 (3.0) | 44 (–3.0) | — | — | — |
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Other | 69 (1.5) | 20 (–1.5) | — | — | — |
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≤1 | 122 (5.3) | 14 (–5.3) | — | — | — |
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2-5 | 172 (2.1) | 54 (–2.1) | — | — | — |
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6-10 | 129 (–0.3) | 57 (0.3) | — | — | — |
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11-15 | 151 (–0.1) | 64 (0.1) | — | — | — |
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16-20 | 96 (–3.9) | 70 (3.9) | — | — | — |
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≥21 | 88 (–3.1) | 60 (3.1) | — | — | — |
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Completely disagree | 145 (6.1) | 15 (–6.1) | — | — | — |
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Moderately disagree | 200 (3.6) | 52 (–3.6) | — | — | — |
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Neither agree nor disagree | 143 (0) | 60 (0) | — | — | — |
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Moderately agree | 172 (–5.1) | 119 (5.1) | — | — | — |
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Completely agree | 29 (–5.8) | 43 (5.8) | — | — | — |
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Completely disagree | 301 (7.4) | 54 (–7.4) | — | — | — |
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Moderately disagree | 188 (0.1) | 78 (–0.1) | — | — | — |
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Neither agree nor disagree | 115 (–0.8) | 54 (0.8) | — | — | — |
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Moderately agree | 65 (–6.2) | 71 (6.2) | — | — | — |
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Completely agree | 20 (–5.2) | 32 (5.2) | — | — | — |
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No | 649 (6.1) | 222 (–6.1) | — | — | — |
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Yes | 109 (–6.1) | 97 (6.1) | — | — | — |
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≤36.02 | 190 (2.9) | 54 (–2.9) | — | — | — |
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36.03-46.20 | 185 (2.0) | 60 (–2.0) | — | — | — |
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46.21-53.48 | 177 (1.2) | 64 (–1.2) | — | — | — |
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≥53.49 | 133 (–6.1) | 109 (6.1) | — | — | — |
aAdjusted standardized residual frequencies appear in parentheses after observed group frequencies. Original wording: I am familiar with the concept of providing psychological support via the internet. Rated on a 5-point scale: 1=completely disagree to 5=completely agree.
bOriginal wording: I believe to have the necessary training to provide psychological support via the internet. Rated on a 5-point scale: 1=completely disagree to 5=completely agree.
cOriginal wording: Have you ever recommended the use of internet-based psychological support or other online resources in order to improve a client’s health status?
The association of attitudes toward internet interventions with demographic and background factors, knowledge, training, recommendation, and future use was also assessed via chi-square analyses (see
Findings in these analyses primarily reflect the fact that psychologists without any knowledge, training, or previous experience using internet interventions are more likely to present more negative attitudes toward these interventions than expected. Conversely, psychologists reporting moderate to high knowledge, adequate training, and prior experience on the implementation of internet interventions were more prone to present favorable attitudes toward these interventions.
Additionally, participants having more positive attitudes toward internet interventions had a higher probability of recommending internet interventions and online resources to improve the health status of their clients and considering using such interventions in the future. Opposingly, participants presenting more negative attitudes toward internet interventions were less likely to recommend or contemplate using such interventions in the future. No demographic or background factors were significantly associated with attitudes toward internet interventions in this study.
Factors associated with attitudes toward internet interventions.
Characteristic | Attitudes | Chi-square tests | ||||||||||||
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≤36.02 | 36.03-46.20 | 46.21-53.48 | ≥53.49 | Chi-square | Cramér V | ||||||||
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Completely disagree | 63 (4.6) | 45 (0.9) | 32 (–1.5) | 20 (–4.0) |
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Moderately disagree | 68 (0.8) | 83 (3.3) | 60 (–0.4) | 40 (–3.8) |
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Neither agree nor disagree | 56 (1.0) | 50 (–0.1) | 56 (1.1) | 39 (–2.0) |
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Moderately agree | 49 (–3.8) | 57 (–2.6) | 81 (1.5) | 102 (4.9) |
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Completely agree | 8 (–2.8) | 10 (–2.2) | 12 (–1.6) | 41 (6.6) |
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Completely disagree | 109 (3.1) | 103 (2.2) | 86 (–0.2) | 55 (–5.1) |
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Moderately disagree | 64 (–0.5) | 64 (–0.5) | 77 (1.8) | 61 (–0.9) |
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Neither agree nor disagree | 41 (–0.1) | 43 (0.2) | 41 (0) | 41 (–0.1) |
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Moderately agree | 22 (–2.6) | 25 (–2.0) | 27 (–1.4) | 62 (6.0) |
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Completely agree | 8 (–1.6) | 10 (–0.9) | 10 (–0.9) | 23 (3.4) |
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No | 223 (4.8) | 204 (1.1) | 194 (–0.2) | 166 (–5.7) |
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Yes | 21 (–4.8) | 41 (–1.1) | 47 (0.2) | 76 (5.7) |
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No | 132 (10.5) | 65 (–0.1) | 44 (–4.2) | 20 (–6.1) |
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Yes | 58 (–10.5) | 120 (1.0) | 133 (4.2) | 113 (6.1) |
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aAdjusted standardized residual frequencies appear in parentheses after observed group frequencies. Original wording: I am familiar with the concept of providing psychological support via the internet. Rated on a 5-point scale: 1=completely disagree to 5=completely agree.
bOriginal wording: I believe to have the necessary training to provide psychological support via the internet. Rated on a 5-point scale: 1=completely disagree to 5=completely agree.
cOriginal wording: Have you ever recommended the use of internet-based psychological support or other online resources in order to improve a client’s health status?
dOriginal wording: Do you expect to use the internet or the telephone to provide psychological support in the future?
The aim of this study was to explore Portuguese psychologist knowledge, training, use, and attitudes toward internet interventions, investigate perceived advantages and limitations of such interventions, identify potential drivers and barriers impacting implementation, and study potential factors associated to use and attitudes toward internet interventions.
Results showed that most psychologists were not familiar with internet interventions and had no prior experience using digital technology in the provision of psychological support. Only a minority reported having the necessary training to work in the field. Nevertheless, more than half of nonusers contemplated using it in the future, mainly as blended and pharmacotherapy complementary interventions rather than stand-alone internet interventions. From those who had prior experience implementing such programs, the majority were clinical and health psychologists who used telephone, email, and SMS services as a complement to face-to-face interventions with the purpose of increasing access to information and psychological care when treating mental health disorders such as anxiety or depression. Guided and unguided internet interventions were rarely used in this context. These results are in line with previous studies [
Although accessibility, convenience, and cost effectiveness are considered important advantages of internet interventions by Portuguese psychologists, their attitudes toward such interventions tend to range from slightly negative to neutral, and a guarded stance is adopted when analyzing the topic. Similar findings were reported by Neves et al [
According to participants in this study, the main barriers to overcome in the implementation of internet interventions were related to limitations on the conceptual comprehension and implementation of self-help techniques by clients, insufficient scientific evidence on the efficacy and cost effectiveness of internet interventions, and difficulties in the adaptation of treatment protocols to the digital format. Although these may be in fact challenges to overcome in some domains, the high number of publications attesting to the efficacy and cost effectiveness of internet interventions based on established treatment protocols and promoting the use of self-help techniques by clients [
As in previous studies [
Another important aspect relating to the ethics and process of delivering psychological support via the internet that occasionally emerged in this research as potentially affecting implementation pertains to the deleterious effect internet interventions may have on psychological assessment, therapeutic alliance, and crisis management. Like in previous publications [
Last, negative attitudes presented both by patients and psychologists toward internet interventions were other important obstacles identified by participants in this research. The assessment of their attitudes exhibited in the context of this study confirmed this assertion. However, although only a few studies focused on the acceptability of internet interventions, the existing literature seems to point in the opposite direction [
Regarding potential factors associated with Portuguese psychologist use of internet interventions, a significant association was found between previous experience of use and age, years of professional experience, work context, theoretical orientation, attitudes, knowledge, training, and recommendation of internet interventions. Unexpectedly, digital native psychologists (aged 30 years and younger) and psychologists with less than 5 years of professional experience were less likely to have used internet interventions in the past when compared with their middle-aged (aged 41 to 60 years) and more experienced colleagues (16 or more years), a finding that is not justified by a delay entering the labor market, since most of our sample was active and no significant differences were found regarding work status between the different age groups. Furthermore, considering that no significant associations were found between age and attitudes toward internet interventions, this finding might be justified by seasoned psychologists feeling more in control of the therapeutic process and therefore more lenient toward setting rules and more willing to use innovative tools in their practice. Work context also seems to impact internet intervention adoption. Psychologists working at the NHS and in private practices were more likely to include digital technology in the therapeutic process than psychologists working at public services, education/research institutions, and charities. The shortage of mental health professionals [
Considering the prevalence of lifetime mental health disorders in Portugal is above 30% [
Several limitations must be considered when interpreting our findings. Despite ATIIS good psychometric properties, the fact that the two selected factors—positive and negative attitudes—only account for 44% of the variance explained suggests further research is necessary to understand what other factors might be attributable to psychologist attitudes toward internet interventions. Second, ATIIS online dissemination and the study sample self-selection might have introduced selection bias, limiting the generalizability of the obtained results. ICT illiterate psychologists as well as those presenting more negative attitudes toward internet interventions might not have participated in this study, lowering the response rate and biasing its results. Nevertheless, the study sample may be considered very large, and its demographic and background characteristics are similar to those published on the last census performed by OPP [
This study investigated the use and attitudes of Portuguese psychologists toward internet interventions and provided insight on the principal barriers hindering implementation in the country. Most Portuguese psychologists were not familiar with and had no training or prior experience using internet interventions. A slightly negative/neutral attitude toward internet interventions was captured, indicating that Portuguese psychologists are cautious toward these interventions and show greater acceptability toward blended treatment interventions compared with stand-alone internet interventions. Lack of knowledge and training are likely the main barriers to overcome for successful implementation and underline the need for awareness and training initiatives focusing not only on internet intervention efficacy and cost effectiveness but also on the practical, relational, technological, ethical, and regulatory requirements this treatment modality entails.
Attitudes Toward Internet Interventions Survey factor analysis (rotated component matrix).
Attitudes Toward Internet Interventions Survey
exploratory factor analysis
electronic psychological interventions
information and communication technologies
A Guided Internet-Delivered Individually Tailored ACT-Influenced Cognitive Behavioral Intervention to Improve Psychosocial Outcomes in Breast Cancer Survivors
Kaiser-Meyer-Olkin test
National Health Service
Portuguese Psychologists Association (Ordem dos Psicólogos Portugueses)
short message service
The authors wish to thank OPP for advertising the study to its members. The authors acknowledge the assistance of George Vlaescu in the acquisition of the data. CMS was funded by the Erasmus+ Program of the European Union.
This study was conceptualized and designed by CMS, EW, RS, and GA. CMS acquired the data, analyzed and interpreted the data, and wrote the manuscript. EW, RS, and GA revised the article for important intellectual content. All authors equally contributed to this study.
None declared.