An assessment of the level of awareness of e-health among Saudi medical students

Background. Many studies are available in the literature about e-health in Saudi Arabia, however, data is limited to a few organizations and does not necessarily reflect the the current and potential use of e-health for health care organizations in the country. The aims of this study were 1)To determine the levels of knowledge, attitude and practice of medical students on e-health, and 2) To identify the predictors of e-health practice. Methods. A cross-sectional survey of 440 medical students at the college of medicine, King Saud bin-Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia, was conducted, during October/November 2019, using a previously validated questionnaire, to assess: (1) knowledge in three domains; e-health definition (13 statements), fields of application of e-health (8 statements), methods of using e-health (7 statements), (2) attitude toward using e-health (8 statements) and (3) reported practice of e-health in medical training (5 statements). A scoring system was used to calculate the total and percentage score of knowledge, attitude and practice for each student. Multiple regression analysis was applied to identify predictors of e-health practice. Significance was considered at p<0.05.

Conclusion. This study provides basic information regarding medical students' knowledge, attitude, and practice on e-health. More resources should be directed to elevate medical students' knowledge and to motivate them to practice e-health using the available tools.

Background
Information technology (IT) methods in healthcare are well known to provide clinicians with healthrelated information and tools, such as clinical decision supportive systems. These softwares are expected to improve patient care and minimize medical errors. [1]. In other words, the rising demand to improve the healthcare processes via technical products and services has led to a tremendous development of wireless technologies worldwide [2].
E-health has been discussed widely in literature, workshops, scientific meetings, and the popular press. At the end of 2011, studies on e-health accounted for 1,688 research data in PubMed, 18,600 in Google scholar, 2,420,000 in Yahoo search and 29,500,000 in Google.com [3]. Globally, the functions of e-health services have been expanding rapidly, with the aim to improve health, reduce costs of healthcare, increase equity and quality of healthcare, and improve communication between healthcare providers and patients [4].
There are many definitions of e-health, however no universal agreement is there on any of them [3].
Moreover, there remains a lack of consistency in the use of the e-health research [4]. A broad range of digital technologies and interventions used by stakeholders in many diverse settings have been described by e-health [5,6]. E-health was defined as internet-based health-related information seeking and developing to support health services locally, regionally, and globally [7].However, this definition was concerned with only patients seeking health information on the internet. E-health was defined by Shaw et al [8] as an emerging field in the intersection of medical informatics, public health, and business. The term characterizes not only a technical development, but also a state-ofmind, a way of thinking, an attitude, and a commitment for networked global thinking, to improve healthcare locally, regionally, and worldwide by using information and communication technology.
The World Health Organization recently defined e-health as "the combined use of electronic information and communication technologies (ICT) for health" [9]. This is an all-encompassing definition as it includes all aspects of health, from maintaining well-being to disease management.
In 2010, the World Health Organization called for more studies on e-health in developing countries [10]. E-health in Saudi Arabia is growing, as many organizational and individual initiatives have implemented e-health applications. Many studies are available in the literature about e-health in Saudi Arabia , however, data is limited to a few organizations and does not necessarily reflect the current and potential use of e-health for health care organizations in the country [34]. A descriptive analysis of the status of e-health in Saudi Arabia highlighted the national e-health initiatives such as the establishment of a new Master of Health Informatics degree program at King Saud bin-Abdulaziz University for Health Sciences (KSAU-HS) as an initiative to educate specialized professionals [11], with an e-health course to foster future professional development in this field in the country [15] and the role of the Saudi Association for Health Informatics (SAHI) in enhancing coordination among health information professionals [11]. In a survey to assess the level of usage of EHRs in gomernment-related hospital in Saudi Arabia, showed only 16% use [17], and the major chalenge facing full adoption of EHR in hospitals in Saudi Arabia was that most of physicians and nurses had negative attitudes toward EHRs relating to health information security and confidentiality concerns, lack of motivation or incentives to learn and use EHRs, and lack of sufficient training on using EHRs [17]. The aim of the present study was to determine e-health awareness among Saudi medical students at the college of medicine, King Saud bin-Abdulaziz University for Health Sciences

Study Subjects
The study population is the students of College of Medicine (COM-R), King Saud bin-Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia. COM-R admits Saudi national mainly and awards a bachelor of medicine to two educational streams. Stream 1 has secondary school graduates and follows what is known as the conventional program. Stream 2 allows holders of Bachelor of Science degrees. These students fol low what is known as the Graduate Entry Accelerated Program. This program is the first of its kind in the kingdom of Saudi Arabia and is designed to expedite the process of graduation by recognizing these students' previous learning, thus, helping increase market supply of physicians faster [12]. Medical students of both sexes, in both steams, during the study period will make the target of this study.

Study Design
A cross-sectional study to assess the levels of knowledge, attitude and practice of medical students on e-health in medical field. Students were contacted once.

Sample size and sampling technique:
Assuming a prevalence of 50% satisfactory level of knowledge of e-health among students, a confidence interval of 95%, and a margin of error of 5%, the estimated sample size was 384 students.
To compensate for non-response of 20%, a total of 460 questionnaires were distributed to students of different educational grades, using an equal allocation method of sampling.

Data Collection
A previously validated self-administered questionnaire [36] was utilized to assess awareness of medical students on e-health. Based on test re-test reliability, correlations for overall knowledge score, attitude score and practice score were: r = 0.89, r = 0.80 and r= 0.46 respectively. Internal consistency was high [Average Cronbach's α = 0.80].
Knowledge: Knowledge about e-health was assessed in terms of 3 domains: what is e-health (13 statements), fields of its application (7 statements) and methods of its use (6 statements). Factual statements were responded by "yes", "No" or "Do not know". Knowledge score was calculated as follows: 1 point for correct answer and 0 point for don't know & wrong answer. The total score in each domain for each student was calculated by summing scores for all responses, and the overall level of knowledge was assessed by summing scores for all reponses in the 3 domains, then a percentage score was calculated. This percentage score was categorized into satisfactory (>75%) and unsatisfactory (≤75%).
Attitude: Attitude towards e-health was assessed in terms of; interest in receiving e-health training, use of patient electronic medical records in health settings, use of internet in health service/research, does the use of computer by physician save time, should computer be used in all health centers, does the use of computer relieve pressure on hospital outpatients, how it is difficult to use the internet in the field of health. Attitudinal statements were responded to by "strongly agree", "agree", "not sure", "disagree" or "strongly disagree". Attitude score was calculated by using 5-point Likert scale ranging from 0 to 4 points; 4 points for strongly agree on positive attitude sentence, to 0 point for "strongly disagree". The total score for each student was calculated by summing scores for all responses, and then a percentage score was calculated. This percentage score was categorized into positive (>75%), neutral (50-75%) and negative(<50%) attitudes.
Practice of e-health: Practice of students was assessed as regards: participation in video conference, use of the internet for health related information, and use of patient electronic records, program, and. Statements related to practice will be responded to by "No" or "Yes". Practice score was calculated by giving a score 1 for practicing and 0 for non-practicing. The total score for each student was calculated by summing scores for all responses, and then a percentage score was calculated.
The questionnaire includes questions on personal characteristics and previous experience in computer use. The investigator distributed an anonymous self administered English based questionnaire inside an envelope, to ensure confidencialy, with a cover letter. Each envelope was handed to the student in his/her classroom. Students were expected to fill the questionnaire and return it in the envelope sealed with no identifiers. The cover letter served as the front page that explained the purpose of the study and invited the student to particpate voluntarily. Agreement to fill the questionnaire was considered as a consent.

Data analysis
SPSS software Ver. 25 was used for data entry and analysis. Descriptive statistics such as mean score and standard deviation, as well as frequency and percentages of all independent variables (age, gender, educational grade, etc…) were used. Responses were scored by frequency and percentage then converted to percentage mean scores, then transformed to qualitative data as mentioned previously. To predict the significant predictors of student's practice, multiple regression analysis was applied. Significance was considered at p-value <0.05.

Ethical Considerations
The survey was introduced to the students in an envelope, with a cover letter, explaining the aims of the study. Participation in the study was voluntary. The envelope was not recognized by the instructors. The cover letter assured the students that their feedback would not affect their academic evaluation. Agreement to participate was considered as a consent. The collection of data sheets was framed with confidentiality in a matter where the student's name, contact information, or badge number would not be identified or traced by anyone. This study was approved by the IRB of the

Results
A total of 440 medical students were surveyed for their levels of awareness of e-health, the majority were females (55.7%), of stream 1 (79.8%) and of families whose monthly income was more than 10,000 SR (82.8%). Those students were distributed nearly equally on the four educational grades. Table 1 shows the distribution of students according to their responses to factual statements on knowledge about e-health. With regard to the definition of e-health, the majority of students responded correctly to 11 statements, and incorrectly to 2 statements; they incorrectly agreed that e-health is "patient examination through the use of internet" (65%) and "organization of health care for patients, including surgical operations, via the internet" ( 58.6%). With regard to the fields of application of e-health, the majority of students correctly agreed on the follwing applications; clinical (80.5%), educational (89.5%), administrative (74.5%), policy-making ( 57.8%) and research (83.6%).  Table 1. Table 2 shows the responses of medical students to 8 attitudinal statements on using e-health.

Meanwhile
Generally speeaking, the majority of students responded positively to the statements. However, less than two-thirds of them agreed or strongly agreed that "doctor use of computer during patient interview saves time" (64.9%), and less than two-thirds disagreed that "the use of internet in the field of health is difficult"(63.2%). The percentage mean score of attitude towards the use of e-health was 82.32% (positive attitude). Nearly three-quarters of all students reported positive attitude to e-health use (73.4%), with only 2% of them who reported a negative attitude. Table 3 shows the forms of practice of e-health during medical training as reported by the medical students.Using electronic medical records and searching for health information ranked first (92.6% & 91.7% respectively), followed by using e-health in medical training (85.2%), while attending e-health traing programs and participation in visual communication came last (77.5% & 74.1% respectively).
The percentage mean score of overall practice was 84.27% (good level of practice). More than threequarters of medical students (78.4%) reported good practice, only 9.1% of them reported poor practice. Table 4 shows the results of a multiple regression analysis of e-health practice among medical students and the independent variables; gender, age, educational grade, stream type, monthly income attitude score and knowledge score. It shows that higher e-health practice score was significantly predicted by higher knowledge (t=2.219, p=0.027) and attitude (t=2.114, p=0.035) scores, after adjusting for other variables in the regression model.

Discussion
It is believed that the use of information and communication technologies (ICT) can be a potential alternative to address some of the daunting problems in healthcare sector in developing countries.
Knowledge, skills and acceptance of e-health by health professionals are essential attributes of a successful integration of this new tool. In a study on medical students in Sri Lanka [37], fifty one percent rated their knowledge of e-health applications as minimal, and 43% were familiar with the term e-health. This finding was comparable with the findings of our study, where only 43.6% of all students reported satisfactory level of overall knowledge about e-health. However, the fact that the Sri Lanka's study was conducted in 2007, while our Saudi's study was conducted during 2019, might affect the validity of comparison between the findings of these two studies. This lack of knowledge on e-health could be attributed to the absence of formalized e-health educational components in the medical curriculum. On the other hand, nearly three-quarters of all students reported positive attitude to e-health use, in our study. This finding was in agreement with the finding of a study in Sri Lanka [37], where over 80% believed that e-health had an important role to play in the current and future health sector, and another study in Bangladesh, where the majority of students believed the internet was useful for helping to make health decisions [38].
Medical educators recognize that electronic health record (EHR) proficiency is a skill required for students to succeed after medical school [39]. Medical students need hands-on experience documenting clinical encounters as well as entering orders to prepare for residency and become competent physicians. A 2012 survey of clerkship directors by the Alliance for Clinical Education and the University of Michigan Medical School also showed the limited scope of EHR use by students [40].
In the study of Sri Lanka, respondents had very poor access to computers and internet use was rare.
In Bangladesh study of e-health literacy among university students [38], the majority of students used the internet to find health information, although a little over half of students were competent in computer. However, in the present study, using electronic medical records and searching for health information, and using e-health in medical training were reported by almost all students, and attending e-health traing programs and participation in visual communication were reported by threequarters of students, with an overall good level of practice.
It has been reported that some factors such as; level of education [38,[41][42][43][44], electronic device use [38,43], advanced age [38,43] and gender [43] influenced the use of internet for health-related information [43]. In Bangladesh study [38], e-health literacy was found to be influenced by age, education and marital status, computer knowledge used to search for health information. In the present study, e-health practice score was significantly predicted by both the knowledge and attitude scores, after adjusting for age, gender , stream type, educational grade and family monthly income. This finding reflect the need for an educational e-health program for medical students.

Conclusions
Overall knowledge of students about e-health was less than satisfactory, while their attitudes were satisfactory and their practices were good. Students' practice of e-health was significantly predicted by their levels of knowledge and attitude on e-health. This study could provide basic information regarding medical students' knowledge, attitude, and practice on e-health.
More resources should be directed to elevate medical students' knowledge and to motivate them to practice e-health using the available tools. It would help policy makers and education planners in developing appropriate evidence-based strategies and curriculum in medical and health institutes for successful implementation and use of e-health systems. Implementation of formalized e-health educational copmponents in the medical curiculum is necessary, to provide knowledge about the fundamentals of e-health, basic concepts and various applications . Such education must also include a practical component to provide medical students with necessary hands-on skills. Educational simulations without prior EHR training help students develop EHR competence [45].

Availability of data and materials
Most of the data supporting our findings is contained within the manuscript, and all others, excluding identifying/confidential respondent data should, will be shared upon request.

Competing interest
The authors declare that they have no competing interests.

Author contributions
MAA and BD contributed to concept development, manuscript preparation and final writing, BD and AIA and SN contributed to concept development, research proposal writing and data collection, analysis and interpretation, and manuscript drafting. All authors read and approved the final manuscript.