MEDINFO 2007
K. Kuhn et al. (Eds)
IOS Press, 2007
© 2007 The authors. All rights reserved.
Medical Students’ Knowledge and Perceptions of e-Health: Results of a Study in
Sri Lanka
Sisira Edirippuligea
, Rohana B. Marasingheb
, Anthony C. Smitha
, Yoshikazu Fujisawac
,
Walisundara B. Herathb
, M. T. M. Jiffryb
, Richard Woottona
a
Centre for Online Health, University of Queensland, Australia
b
Faculty of Medical Sciences’, University of Sri Jayewardenepura, Sri Lanka
c
Niigata University of Health and Welfare, Japan
Abstract
The present study investigates the knowledge, perceptions
and attitudes of medical students in Sri Lanka in regard to
e-health. We also examined the barriers which impede
them to develop knowledge and skills in e-health within
their medical curriculum. A questionnaire focusing on the
knowledge, attitudes and expectations of medical students
towards e-health was distributed to all final year students
(n=136) at the Faculty of Medical Sciences, Sri Jayewardenepura
University, Sri Lanka. Response rate was 74%.
43% of respondents stated that they were familiar with the
term e-health. 51% rated their knowledge of e-health
applications as minimal. 88% admitted that they had no ehealth
education or training of any kind. Over 80% of all
respondents thought that e-health had an important role to
play in the current and future health sector, particularly in
developing countries. Our survey revealed that respondents
had very poor access to computers and Internet use
was rare. 77% of respondents admitted that they were not
provided with systematic knowledge and skills in e-health
through their medical curriculum and identified the
absence of formal education in e-health as a serious short-
coming.
Keywords:
medical education, e-health, curriculum development,
developing countries
Introduction
The healthcare industry in general is under growing pressure
to provide services more efficiently and economically
[1]. As far as developing countries are concerned, problems
and issues associated with the health services are
even more daunting [2]. Extreme poverty has prevented
governments in developing countries from funding health
adequately resulting poor state of health in the populations.
Poor health infrastructure, inadequate facilities and the
shortage of healthcare professionals are characteristic features
of the health sector in developing countries. Rural
and remote communities – where the majority of the population
live in developing countries - are particularly
deprived of health services. Addressing health issues in
developing countries has become a global concern [3].
However, there is no quick remedy to health problems in
developing countries as the improvement of health infrastructure
and the increase of the number of health
professionals require long-term investments and policy
implementations [4].
In this context, e-health has been identified as one alternative
to provide improved services and specialist care in
developing countries [5]. The potential of e-health applications,
i.e. the delivery of health services across a distance
by using information and communication technologies
(ICT) is being recognised for its potential, especially for
the delivery of health services to rural and remote areas
[6]. International organizations such as the United Nations
(UN) and the World Health Organization (WHO) have
acknowledged e-health as a potential alternative to address
acute health needs in developing countries [7-8].
Among many other factors, the acceptance of e-health by
health professionals is extremely important if this new
modality of healthcare delivery is to become an integral
part of mainstream healthcare. Knowledge, acceptance and
enthusiasm to utilise e-health as an alternative way of service
delivery by healthcare professionals, particularly by
doctors would help facilitate the integration of e-health.
Needless to say, developing countries are one of the most
likely beneficiaries of e-health. Thus, knowledge and skills
in e-health and keenness to use this tool by local healthcare
professionals would undoubtedly help address at least
some of the existing problems.
There is a growing body of literature showing that e-health
has a role to play in contemporary healthcare [9-10]. Also
literature is evident that e-health is useful for developing
countries [11]. However, there is not many studies done to
investigate the level of knowledge among health professionals
[12]. A few studies show the level of IT knowledge
in medical students [13].
Sri Lanka is a developing country according to number of
indicators. Like other developing countries, health sector
in Sri Lanka has been challenged by various problems.
Total expenditure on health as a percentage of GDP in
2002 was 3.7% which is significantly lower than that is in
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industrial countries. Overall access to health facilities for
people in Sri Lanka is low. For example the number of
hospital beds per 1000 population constitutes 2.9. The
number physicians per 10,000 population is 4.11 [14].
Rural population in Sri Lanka constitutes 77% of the total
population [15]. The most complete hospital facilities and
highest concentration of physicians are in the urban areas,
while many rural and remote areas suffer severe scarcity of
health services. Thus the territorial disparity in health services
is a characteristic feature in the island (Table 1).
Emergency transport of patients especially in the countryside
is still at a rudimentary level.
Table 1 - Number of medical specialists in urban and rural
hospitals in Sri Lanka1
1
Source: Sri Lanka Government Health Web Portal, 2005,
(http://www.health.gov.lk/)
Aims
The objective of this present study was to evaluate the
knowledge, attitudes and perceptions of medical students
towards e-health since their preparedness is a key to the
success in implementing e-health in developing countries.
Methods
We designed and distributed a survey to assess the knowledge
and attitudes of medical students towards the broad
subject of e-health. The survey was distributed to all final
year medical students (136) studying at the Faculty of
Medicine, Sri Jayewardenepura University (SJU), Sri
Lanka. Questions were divided into the following sections:
demographic details, knowledge in e-health, relevance to
future practice, the use of computers and the Internet and
access to e-health education.
Results
Demographics
A total of 100 (74%) students completed the survey. 54%
of respondents were female. The majority of respondents
(about 91%) were between the age of 26-30 years and the
remainder were between 23-26 years of age.
Knowledge of e-health
Nearly half of all respondents (43%) admitted that they
were familiar with the term e-health. However, 51% of
respondents described their knowledge and skills related to
e-health as minimal while 22% were unsure. 86% of
respondents had had no exposure to e-health education
and/or training. 71% of respondents said they had never
read any literature on e-health.
Relevance of e-health
Questions were asked to examine the perceptions of the
students about e-health. About 86% of all respondents
admitted that e-health will have an important role to play
in the current and future health sector. Only 2% disagreed
with that statement while 11% were not sure. Again 86%
of respondents agreed with the fact that e-health will be
useful in their future practice. Only a very small number
admitted that e-health will have no use in their future practice.
78% of respondents admitted that e-health
applications will improve their services. Majority of
respondents (77%) believed that e-health would have particular
relevance to developing countries and 85% agreed
that e-health should be encouraged.
Use of computers and the internet
Several questions were asked to establish the knowledge
and skills of the participants in computing and the level of
the Internet use. The results of the survey showed that the
availability of computers and the Internet for students was
low. They admitted that the access to computers and the
Internet was limited both at home and at the university.
Only a very small number (3%) of students had frequent
access to computers and the Internet. The majority of students
(65%) used the Internet very rarely. Nonetheless a
large number of students admitted that they were comfortable
using computers and the Internet. Also 67% admitted
that they had formal computer education and training. The
majority of students expressed the desire to have better and
more frequent access to computers and the Internet.
Access to e-health education
41% of respondents admitted that they had received no satisfactory
knowledge of e-health through their medical
program while 36% were not sure. While 79% of respondents
suggested that e-health should be included in the
medical curriculum and 56% thought that e-health must be
offered as an elective. About 85% of survey participants
suggested that e-health course must include a practical
component to provide hands-on skills. More than half of
respondents (64%) expressed their willingness to study ehealth
at post-graduate level.
Participants of the survey also identified the lack of appropriate
educational programs, financial constraints, lack of
Speciality Urban Rural Total
Cardiologists 18 0 18
Neurologists 9 0 9
Psychiatrists 15 0 15
Pathologists 23 9 32
Dermatologists 10 1 11
Radiologists 29 6 35
Microbiologists 16 0 16
Occupational
therapists
46 1 47
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sufficient access to technology and traditional methods of
medical education as major barrier to develop systematic
knowledge and skills in e-health.
Discussion
There are no quick solutions to the complex problems in
the health sector in developing countries. Among others, ehealth
has been identified as one possible solution to
address some of these problems. Under right circumstances
new technologies can improve the quality of care
and efficiency of services. Governments as well as private
sector around the world have become aware of the potential
of new technology. But the enthusiasm of policy
makers and investments in infrastructure only cannot
enable e-health to enhance health services. The expansion
of knowledge and skills in e-health at grass-roots level
(among health professionals) and their acceptance of these
techniques are imperative factors for e-health to become
sustainable.
Our survey revealed that although the majority of students
were familiar with the term e-health their knowledge and
skill to practice this modality was extremely limited.
Indeed, the limited access to computers and the Internet is
a serious barrier in developing countries. Unlike in industrialised
countries, computers are still a luxury in the
developing world. Presumably this barrier has limited the
advantages they may gain from new technologies. This
limitation also represents a significant factor preventing
them from acquiring necessary knowledge and skills in ehealth.
The so called ‘digital divide’ is still a formidable
barrier to be overcome [16].
Despite the fact that students have limited access to computers
and the Internet, the majority of them are computer
literate. In fact, there is a growing interest in computers
and the Internet in the developing world [12]. The students
found that one of the main barriers for them to develop
appropriate knowledge and skills in e-health was the
absence of formalised e-health educational components in
the medical curriculum. There is a need to provide knowledge
about the fundamentals of e-health, basic concepts
and various applications with particular emphasis on lowcost
e-health modalities. Such education must also include
a practical component to provide medical students with
necessary hands-on skills. This preparation would enable
students to choose relevant applications in their own practice
suitable for their own circumstances.
Conclusions
Health systems in developing countries can be a potential
beneficiary of e-health applications. Not only local governments,
but also the international organisations such as
the UN and the WHO have identified the potential of ICT
to address the health needs of developing countries. Efforts
have been made to promote e-health in developing countries
by investing funds, initiating projects and introducing
technology and improving infrastructure.
However, in this effort, e-health education has been the
least attended area. The knowledge, acceptance and enthusiasm
of local health professionals, particularly doctors are
vital if e-health is to be a significant component of mainstream
healthcare. Cultivation of a positive attitude
towards e-health requires systematic education. Students
must be provided with a formalised e-health education
within their medial and health curriculum to establish
knowledge in basic concepts, terminology, various ehealth
applications, successes and failures in current practice.
Such education must also include a practical
component to provide hands-on skills.
Undoubtedly the impact of digital divide is still a serious
problem for developing countries. Concerted efforts must
Table 2 - Information and Communication technology distribution
Source: International Telecommunication Union, World Telecom Indicators 2002
Countries Main
telephone
lines per
100 persons
Residential
main lines
per 100
households
Monthly
subscriptio
n as % of
income per
capita
Personal
computers
per 100
persons
Internet
users per
10,000
persons
Internet
hosts per
10,000
persons
Low income
Lower middle income
Upper middle income
High income
World
Africa
Americas
Asia
Europe
Oceania
2.9
13.6
22.7
59.7
17.1
2.6
35.1
10.7
40.5
40.0
11.4
35.8
59.8
108.8
54.9
9.9
80.6
41.8
80.0
98.3
14.1
2.9
2.0
0.7
5.7
12.7
3.1
5.5
1.1
3.7
0.6
2.4
8.2
37.3
7.7
1.0
26.6
2.2
17.9
39.9
62.2
264.9
992.6
3992.9
820.8
84.9
2164.3
433.9
1804.5
2771.6
1.0
4.3
78.7
1484.2
232.6
3.4
1332.9
28.7
191.5
885.2
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be made to enhance the access to technology in these countries.
The potential of low-cost e-health applications in
developing countries is still untapped. In order to use lowcost
e-health modalities to their full capacity one must
have an appropriate knowledge in e-health and understanding
of local needs. Formalised e-health education
embedded into medical and health curriculum is needed to
enhance the knowledge and skills of local health profes-
sionals.
Acknowledgments
We thank the University of Queensland (New Staff Start-Up
Research Fund) for funding this research. We also thank the medical
students of Sri Jayewardenepura University for their
participation in the study.
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Address for correspondence
Dr Sisira Edirippulige
Centre for Online Health
University of Queensland
Level 3 Foundation Building
Royal Children’s Hospital
Herston Road HERSTON Q 4029
(Fax: +61 7 3346 4705)
Email: s.edirippulige@uq.edu.au
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