Smartphone and medical application use among dentists in China

Background With the development of information technology, an increasing number of healthcare professionals are using smartphones and mobile medical applications (apps) in their clinical practice. The objective of this study was to survey the use of smartphone-based medical apps among dentists in China and determine dentists’ perceptions of such apps. Methods All data were collected using anonymous questionnaires. The questionnaires for this cross-sectional study were randomly sent to dentists by email, and 379 dentists responded. Dentists’ demographics and perceptions of WeChat, QQ (the most popular social media apps in China) and other medical apps were assessed; the questionnaire including questions on the purpose, frequency, daily use, and opinion of the apps they used. Questions were answered using a Likert scale (1 = strongly agree, 2 = agree, 3 = not sure, 4 = disagree, and 5 = strongly disagree). Results A total of 379 valid responses were received; the respondents had a median age of 33.6 years old (63.3% female). All subjects (100%) owned a smartphone, and all of them installed and used WeChat or QQ in their clinical practice. Only 76% of subjects installed medical apps (other than WeChat and QQ) on their smartphones. Male dentists were more likely to install medical apps than female dentists (p < 0.05). With increasing age, the percentage of dentists who installed medical apps decreased (p < 0.001). The frequency and daily use were higher for WeChat and QQ than for medical apps. Medical apps were positively perceived, with dentists reporting that they recommend these medical apps to their peers (Likert score: 1.67 ± 0.68). Conclusion Medical apps were perceived to have a positive impact on clinical practice, education and patient care in dentistry by providing relevant medical information. However, there will still be much room for improvement in the future.


Background
With the development and decreasing costs of information technology, an increasing number of people are becoming internet users worldwide. Data show that the number of internet users in the world was nearly 4,536, 248,808 by June 30, 2019 [1]. There are 2,300,469,859 internet users in Asia, representing 54.2% of the world. To date, mobile devices (such as mobile smartphones and tablets) are the main tools for accessing the internet. Smartphones have become handheld computers rather than mobile communication devices because of their powerful computing function, spacious memories, large screens and open operating systems. The tremendous improvements of smartphones has encouraged the development of various third-party applications (apps) that can be used on smartphones [2][3][4][5]. An app is a small specialized and customizable program that can provide various functions and services for users. There are numerous apps, including medical apps, available for use on smartphones. In addition to the general public, an increasing number of healthcare professionals are using medical apps in their clinical practice [2]. In the current information society, medicine has undergone remarkable advancements. Many studies have surveyed the use of smart devices or medical applications among physicians [6][7][8]. In dental fields, we only found similar studies on the use of medical applications or mobile learning technology among dental students around the world [9][10][11][12]. However, such research in dentists is limited, especially in China.
From the data available regarding the number of internet users worldwide it is reasonable to assume that Asia (especially China) will be a large market for smartphones and applications. Therefore, the aim of our study was to examine the current use of smartphone-based medical apps among dentists in China and determine the dentists' attitudes toward these apps. We aimed to provide readers with a better understanding of (1) the popularity of smartphones and medical apps among dentists in China, (2) the factors influencing dentists' use of medical apps, and (3) dentists' purposes for using such medical apps and attitudes towards them. With the data from this study, we hope computer scientists or dental healthcare professionals can design, improve and develop more convenient and useful smartphone-based applications according to current dentists' opinions. We also hope to help the dentists who have not used medical apps to select the proper apps to assist their clinical work.

Related work
Many studies conducted surveys regarding the use of smart devices or medical applications among physicians or medical students ( Table 1). The aim of this study was to survey the use of smartphone-based medical apps among dentists in China and determine the dentists' perceptions of such apps.
In 2012, Orrin et al. performed a prospective, nationwide email survey evaluating the use of smartphones and smartphone apps among providers at medical centers recognized by the Accreditation Council for Graduate Medical Education (ACGME) in the United States of America (USA) [8]. A total of 3306 unique responses from 1397 residents, 524 fellows, and 1385 attending physicians were received in the study. Greater than 85% of respondents used a smartphone. Over half of the respondents reported using apps in their clinical practice. The most commonly used app types were drug guides, medical calculators, coding and billing apps and pregnancy wheels.
Karl et al. conducted an online survey on smartphoneand medical-related app use among medical students and junior doctors in the United Kingdom (UK) in 2012 [11]. A total of 79.0% of medical students and 74.8% of junior doctors owned a smartphone. On average, apps were used for between 1 and 30 min per 24 h for students and 1-20 min per 24 h for doctors.
In 2018, Rikesh et al. assessed smartphone use among UK surgical doctors [7]. A total of 341 participants were surveyed. A total of 93.5% of participants owned a smartphone, with 54.2% of those owning medical apps and 86.2% using their device to access online medical resources. A total of 79.3% stated that they would be willing to use their smartphone for clinical use.
Payal et al. performed an assessment of digital literacy and the use of smart phones among Central Indian dental students [13]. Out of 260 students, 250 were internet users. A total of 94.23% of students owned a smartphone, and 46.53% of students had at least one app related to dentistry on their smartphone device. A total of 89.23% of students were keen for the implementation of e-learning in their curriculum.

Questionnaire and procedures
Considering that WeChat and QQ are the most popular social media apps in China, we investigated their use in dental clinical practice separately. The medical apps investigated in our study were a series of apps that are associated with clinical practice (other than WeChat and QQ).
The study questionnaire consisted of several parts (supplementary files). Part 1 collected dentists' demographic data, including age, gender, workplace, medical rank, whether a smartphone was used, and brand of smartphone. Part 2 investigated the use of WeChat and QQ in dentists' clinical work, including whether or not they used WeChat and QQ for work-related activities, and the purpose, frequency and daily use time of these apps. Part 3 surveyed the use of medical apps in dentists' clinical work, including whether medical apps were installed, how many apps were installed, and the purpose, frequency and daily use time of these medical apps. Part 4 assessed the dentists' perceptions of smartphone-based medical apps. Part 5 assessed the impact of medical apps on clinical practice. Responses to questions in parts 4-5 were based on a 5point Likert scale: 1 = strongly agree, 2 = agree, 3 = not sure, 4 = disagree, and 5 = strongly disagree.
The questionnaire was sent to 1500 dentists by email; we received 390 replies (response rate of 26%). The questionnaire was reviewed by an expert panel for content validity and reliability. Eleven dentists only responded to the questions in part 1, so we did not include their questionnaires in the analysis. Of the remaining 379 subjects, 91 dentists expressed that they did not install any medical apps except WeChat or QQ, and they did not answer the questions in part 4 and part 5. Therefore, we only analyzed the remaining 288 dentists' perceptions of these medical apps. The flow diagram outlining the collection of eligible questionnaires for this study is shown in Fig. 1.

Statistical analysis
Data were analyzed using SPSS statistical software (version 17, SPSS, Inc., Chicago, IL, USA). Subject characteristics are presented as frequencies (percentages). Quantitative Likert scale data are presented as the mean ± standard deviation. A chi-square test was used to examine the difference in owning a medical app among different groups. A p value of < 0.05 was considered significant.

Demographic characteristics of surveyed dentists in China
A total of 379 valid responses were received. The median study subject age was 33.6 years old (range: 19-59 years old), and 240 (63.3%) subjects were female. A total of 168 (44.3%) subjects worked in public hospitals, and 211 (55.7) subjects worked in private hospitals or clinics. Additionally, 47.2% of subjects were resident dentists, 40.4% were dentists in charge, and 12.4% were senior or associate senior dentists. All subjects (100%) owned a smartphone. The most popular brands of smartphones were Apple (46.2%) and Huawei (34%, Table 2).

The use of WeChat or QQ in dentists' clinical work
All participants installed WeChat or QQ on their smartphones, and they all used WeChat or QQ in their clinical practices. Participants reported that their main purposes for using WeChat or QQ in clinical practice were acquiring medical information (84.2%), communicating with peers (83.6%) and communicating with patients (77.6%). The frequency of using WeChat or QQ in clinical practice was reported to be at least once a day (73.6%), at least once a week (20.8%), or less than once a month (5.5%, Table 3). The time of daily usage is shown in Table 3; 25.9% subjects used WeChat or QQ in their clinical practice for more than 60 min per day, 19% subjects reported their daily use time was 21-30 min, 17.4% subjects reported their daily use time was 11-20 min.
The use of medical apps in dentists' clinical work A total of 288 (76%) subjects had medical apps (other than WeChat and QQ) installed on their smartphones, and 91 (24%) subjects did not have any medical apps installed, as shown in Table 4. Male dentists were more likely to install medical apps than female dentists (chisquare = 6.702, p < 0.05). With increasing age, the percentage of dentists who had medical apps installed decreased (chi-square = 45.3.3, p < 0.001). However, dentists' workplace and medical rank were not significantly associated with the installation of medical apps (chi-square = 1.670, p = 0.196; chi-square = 5.466, p = 0.065, respectively, Table 5). Among the 288 subjects, the average number of medical apps installed was 2.62 ± 1.73 (range: 1-12). Most subjects (71.5%) reported that they had 1-5 medical apps installed on their smartphones, and only 0.5% of subjects had more than 10 medical apps installed on their smartphones ( Table 4). The frequency and daily use (in minutes) of these medical apps among dentists is shown in Table 6. A total of 46.5% of subjects used medical apps at least once a day, 42.4% of subjects used them at least once a week, and 11.1% used them less than once a month. Among those who reported daily use, most reported 11-20 min of usage (31.6%) per day, followed by 11-10 min (29.2%) and 21-30 min (15.6%). Only 5.2% of subjects reported that they used medical apps more than 60 min per day ( Table 6). The top three purposes for using medical apps were reviewing medical knowledge (63.6%), reading medical news (36.4%), and reading medical journals (27.9%, Table 7).

Perceptions of smartphone-based medical apps and their impacts on clinical practice
The majority of subjects strongly agreed or agreed that they are looking to obtain more medical apps in the future (1.52 ± 0.69), that they would recommend these   Table 8).

Discussion
In recent decades, the technologies of mobile communication, mobile wireless internet and mobile devices have been widely used in many areas of human life. In this context, customized and multifunctional mobile apps (including medical apps) have flourished tremendously. Studies have shown that an increasing number of medical staff installed medical apps on their smart devices (including smartphones and tablets) and used them   frequently [2]. However, few studies have assessed the use of such medical applications among dentists. Therefore, in this study, we first performed such research in China. By using anonymous questionnaires, we collected data on the use of smartphone-based medical apps among dentists in China. We found that all participants (100%) in our study owned a smartphone, and the rate was slightly higher than many other similar studies (ranging from 82 to 99.3%) [14][15][16][17][18]. The most popular brands of smartphones were Apple and Huawei (a Chinese Android smartphone), and this result was consistent with another study [18]. All subjects had WeChat or QQ (the most popular social media applications in China) installed on their smartphones and used them in clinical practice. In 2016, Li et al. investigated the effect of WeChat on the compliance and duration of treatment in orthodontic patients in China. The authors found that use of this app    could reduce the treatment duration and bracket bond failure and improve clinic attendance in orthodontic patients [19]. Additionally, in our study, we found that 73.6% of subjects used these apps at least once a day, and only 5.5% of subjects used them less than once a month. A total of 25.9% of subjects reported that they typically used them in clinical practice more than 60 min per day. As we can see, the use of such social media apps (for purposed including acquiring medical information, communicating with peers and communicating with patients) is very common among dentists in China.
Only 76% of the participants (n = 288) installed a medical app (other than WeChat and QQ) on their smartphones. Though the rate was lower compared with the installation of WeChat and QQ, the number was still in agreement with many studies in other areas of the world [14,15,20]. Our study found that there were significant differences in whether medical apps were installed by gender and age. This finding was supported by many studies, in which young physicians were more likely to use medical apps than old physicians [7,14]. In our study, male dentists were more likely to use medical apps than females. Males are more interested in Internet technology and software in China, which could explain this observed phenomenon.
The average number of installed medical apps was 2.62, which was relatively small. According to the data regarding frequency and daily use of these medical apps, only 46.5% of subjects used medical apps at least once a day, and only 5.2% of subjects reported that they used medical apps more than 60 min per day. Compared with the use of WeChat or QQ in China, we found that the use of medical apps among dentists in China was not very prevalent. Compared with US and British healthcare professionals with a use rate of over 90%, our sample of dentists still showed a relatively lower medical app use [21,22].
Most of our subjects agreed or strongly agreed that they are looking to obtain more medical apps in the future and recommend these medical apps to other peers, which could reflect their affirmation and expectation towards medical apps. Most subjects agreed or strongly agreed that medical apps are essential tools for undergraduate medical studies and supplement medical textbooks. These findings were in agreement with several other studies that assessed the use of medical apps among dental students or junior doctors in many other regions around the world [9][10][11][12][23][24][25][26][27]. Although dentists thought medical apps could improve education among students, they reported disagreement or uncertainty with regard to whether medical apps are superior to medical textbooks or medical apps can replace medical textbooks. Most of them agreed that there are dangers in using medical apps for patient care. As we know, the accuracy of the information in a medical app is very important. If users make their clinical decision based on inaccurate or outdated information in medical apps, there could be serious consequences. Many studies have been conducted to assess the quality and accuracy (including expert involvement and medical evidence adherence) of these medical applications in the past few years [28][29][30][31][32][33][34]. The expert involvement rate of these applications ranged from 9 to 67%, and the adherence rate ranged from 0 to 87% [28]. Therefore, establishing appropriate regulatory procedures is extremely urgent. We believe that government health authorities (such as the Food and Drug Administration in America [35], the Medicines and Healthcare Products Regulatory Agency in England [36], Health Canada in Canada [37] and corresponding authorizes in other countries) could play a key role. To regulate these medical apps well, government health authorities could draft relevant guidelines that should be followed by app developers.
Regarding the effect of medical apps on clinical practice, dentists in China strongly agreed or agreed that these medical apps could allow faster access to medical information (1.90 ± 0.54). However, regarding the other aspects of the effect, Chinese dentists' attitudes were less positive than those reported in a similar study [14]. From the results above, we found that current medical apps in dentistry did well in providing relevant medical information in China and received positive reviews from Chinese dentists. However, on the other hand (i.e. outside of improved clinical decision making; saving time; help in making differential diagnoses; performing useful medical-related calculations; faster access to evidencebased medical practices/cases; and providing reliable sources of clinical skills, knowledge, and common laboratory reference values), medical apps did not meet the needs of dentists well. Therefore, in the future, there will be much room for improvement.

Conclusion
In conclusion, the use of smartphones and some social media apps (WeChat or QQ) is very common among dentists in China. The use of medical apps is also prevalent. These medical apps received positive reviews because most dentists reported that they would want to obtain more medical apps in the future and recommend these medical apps to other peers. These medical apps could allow dentists faster access to medical information in their clinical practices. However, there is still much room for improvement in patient care in the future (such as assisting with diagnoses and determining treatment options). According to this study, we found that there are many advantages of medical apps, including reviewing medical knowledge, reading medical or journals, acquiring clinical skills, communicating with patients/colleagues, and preparing presentations or examinations. In general, medical apps could be a good assistant for dentists in clinical practice. We believe that there will be an increasing number of dentists using medical apps in the future. Of course, patients would also benefit from these apps. However, there are still some disadvantages or risks of medical apps, such as data security, virus attack, inaccurate content, and lack expert involvement, to which we should pay attention. Therefore, establishing appropriate regulatory procedures is extremely important. We think the following tips could help [38]. First, the app stores should carefully examine any medical apps that would like to be published online. Second, the content and information in medical apps should be peer reviewed by relevant medical professionals. Third, a reliable assessment system or method for these medical applications should be established. An assessment or score of medical apps could help users select more appropriate apps for their purposes. Finally, we think the involvement of government health authorities is most important. We believe that the risks of using medical apps could be reduced by following these methods.

Limitations
There were some limitations in our study. First, our sample size was relatively small. We need a larger sample size to confirm our findings on medical app use among dentists in China in the future. Nevertheless, our results are in agreement with many similar studies conducted in other regions around the world and provide preliminary information. Second, our study only examined dentists' perceptions of medical apps. Further studies should be conducted to examine dental patients' use and perceptions of medical apps to examine how medical apps affect their oral healthcare. Third, our study did not investigate the potentially negative impacts of medical app use. Because the issue of patient safety and privacy has been proposed in recent years, we should focus on these issues in further investigations.

Abbreviations
Apps: Applications; ACGME: Accreditation Council for Graduate Medical Education; USA: United States of America; UK: United Kingdom