Perceptions, Preferences and Experiences of Telemedicine among General Population in India: An Online Survey

by Poreddi Vijayalakshmi, PhD MSN RN

College of Nursing, National Institute of Mental Health and Neuro Sciences, Bangalore

George Delna, Nursing Intern BSc(N)

Madhu Diya, Nursing Intern BSc(N)

Eby Elan, Nursing Intern BSc(N)

Sunil Iyda, Nursing Intern BSc(N)

Jennifer Mary Gladies, Nursing Intern BSc(N)

College of Nursing, National Institute of Mental Health and Neuro Sciences, Bangalore

Reddy SaiYathin, MBBS

The Oxford Medical College, Hospital & Research Centre, Yadavanahalli, Bangalore

Reddy Sadananda, PhD MSW, MPhil

Assistant Professor, School of Social Sciences/Psychology, CHRIST University, Bengaluru

Citation: Vijayalakshmi, P., Delna, G.,  Diya, M., Elan, E., Iyda, S., Gladies, J. M., SaiYathin, R. &  Sadananda, R. (2023). Perceptions, Preferences and Experiences of Telemedicine among General Population in India: An Online Survey. Canadian Journal of Nursing Informatics, 18(1).  https://cjni.net/journal/?p=10874

Abstract

Background: Telemedicine is a fast-emerging health sector and the success of telemedicine depends on awareness and perceptions of the general population.

Aim: To explore the Indian general population perceptions, preferences, and experiences of telemedicine services in the midst of Covid-19 pandemic.

Methods: This was a descriptive online survey carried out amongst a conveniently selected general population (N=407) through a self-reported questionnaire.

Results: Our findings revealed that more than one fourth (28.2%) of the participants had engaged in a teleconsultation. A majority of the participants (41%) felt that telemedicine is a good option for the initial consultation and basic care. Further, most of the participants perceived that greater access to health care and avoiding overcrowding and hospital visiting hours were the main advantages of telemedicine.

Conclusion: The majority of the participants hold a favourable attitude towards telemedicine services. This can facilitate large-scale deployments of telemedicine services to bridge the healthcare gap between rural and urban areas.

Keywords: General Population, India, Perceptions, Telehealth, Telemedicine

Introduction

Globally, telehealth and telemedicine emerged as an innovative approach in offering appropriate health services during the Covid-19 pandemic. The World Health Organization defined Telemedicine as “the delivery of health care services by healthcare professionals using information and communication technologies” (WHO, 1998, p. 10). India, being a developing country faces a shortage of health care providers and healthcare infrastructure. Also, around 70% of the Indian population lives in remote and rural villages lacking access to healthcare services. In this context, telemedicine plays a great role in providing quality and affordable healthcare to people and is expected to bridge the health care gap between rural and urban areas ( Kustwar & Suman, 2020). The release of new Telemedicine Practice Guidelines on March 25, 2020, by the Ministry of Health and Family Welfare heralded a landmark development in implementing telemedicine services in India.

A review of the literature suggested that developed countries such as Denmark, Estonia, Germany, France, Italy, the Netherlands, Spain and the UK were successful in utilizing information technology in supporting the management of patients with chronic diseases (Lluch, 2013). However, the concept of telemedicine remains novel in developing countries (Combi et al., 2016; Hassibian & Hassibian, 2016). A review of literature on e-Health in sub-Saharan Africa (sSA) found that technical problems, poor internet and connectivity, participants’ selection biases, contextual issues, and lack of funds were the prominent challenges in adopting telemedicine services (Adeloye et al., 2017). Yet, the COVID 19 pandemic has provided an opportunity and a need to rapidly expand telemedicine services in developing countries (Bashshur et al., 2020; Das et al., 2020; Hollander & Carr, 2020).Telemedicine has become a promising approach for both patients and health care providers during the Covid-19 Pandemic which imposed restrictions on travelling and social distancing, to prevent the spread of the infection (Greenhalgh et al., 2020; Smith et al., 2020).

The success of telemedicine eventually depends on knowledge and understanding of the concept, skills acquired, and attitudes towards technology by health care professionals (Zayapragassarazan & Kumar, 2016) and the general population. Documented evidence shows that some research has been carried out to explore the general population perceptions on telemedicine across the world (Alboraie et al., 2021; Fares & Sehar-un-Nisa 2019; Haluza et al., 2016; Zahoor et al., 2020). Published research from India mainly focused on health care professionals’ awareness and attitudes towards telemedicine (Datta et al., 2021; Dongre et al., 2021; Garg et al., 2021; Malhotra et al., 2020; Poreddi et al., 2021). The government of India is committed to offering comprehensive health services to every corner of the country through telemedicine services which would be implemented at Health and Wellness Centers. In this situation, it is a important to evaluate the perceptions of the general population about the use of telemedicine services. In India, few studies have evaluated awareness and attitudes towards the use of telemedicine services among geriatric patients (Meher & Kant, 2014) outpatients (Naik et al., 2021), or rural people (Manisha, 2014) Hence, the present study was aimed to evaluate general population perceptions, experiences, and preferences of using telemedicine services.

Materials and methods

This was a descriptive online survey design using a convenience sample from the general population in India. The data was collected in the months of April and May 2020. A convenience nonprobability sampling technique was used in this study and the sample included individuals above the age of 18 years, with and/or without telemedicine experience, who were able to navigate Google Forms and complete the questionnaire.

The structured online questionnaire was developed based on the literature review. The first part of the online structured questionnaire included items related to socio-demographics (13 items) such as age, gender, education, background, marital status, ownership of a smartphone, accessibility of health care services, whether aware about telemedicine and e-health apps, source of information, etc. The latter part of the questionnaire included eight items to elicit attitudes, perceptions, and preferences towards telemedicine services during the Covid-19 pandemic. For example, participants’ opinion on telemedicine services, main advantages, and concerns regarding the use of telemedicine services, were collected. The questionnaire was validated for its content by experts from the nursing, social work, and psychiatry departments at the Institute. The data collection tool was piloted among a small group of individuals (n=50) to ensure proper wording and comprehension of the questionnaire.

Data collection and analysis

The survey link was circulated through email, WhatsApp and other social media which led to the structured questionnaire, published in English via Google Forms. The participants were self-directed to the survey by clicking the link, participation was voluntary, and no incentives were given for participation. The introductory part of the Google form included brief Information on the background, aim, objectives, procedures, voluntary nature of participation, and declarations of anonymity and confidentiality. The volunteer participants were requested to complete the questionnaire by clicking the link. A completed survey was automatically registered online. A total of 407 individuals completed the Questionnaire. The data were analysed using appropriate statistical software (SPSS 21 version) and the results were presented in tabular form. Descriptive statistics such as frequency, percentage, mean, and standard deviation were performed.

Ethical consideration

The researchers obtained formal permission from the concerned authority for data collection. The completion of the questionnaire by clicking the link was regarded as implied consent of the participants. As the questionnaire was completed online, the participants’ privacy and confidentiality were maintained.

Results

A total of 407 individuals participated in this study of whom 51% were men, aged below 35 years (85.2%), unmarried (76.4%) from urban background (60.9%) and postsecondary graduates (81.6%). A vast majority of them owned a smart phone (87.6%) and were aware of e-health and health care apps (89.7%). Most of the participants were aware of telemedicine through social media (35%) followed by health care providers (32%), television (20%), public campaign (8 %), posters (3%), and friends/others (2%) (Table 1).

Table 1: Socio-demographic details of the participants (n=407)

Regarding the use of telemedicine services, 28.2% of the participants had booked an appointment through telemedicine. Out of these 115 individuals, more than half of them (52.1%) were satisfied with the teleconsultation. While a majority (43.6%) of the participants were interested to have a teleconsultation, 13.7% of them were not aware of the process/technology of booking a telemedicine appointment. Though, 39.1% of the participants considered using telemedicine services to meet their health care needs, nearly half of the participants were unsure of using telemedicine services in the future. While 36% of the participants had a concern with the quality of healthcare, nearly one fourth of them worried about diagnoses made through telemedicine services. Most of the participants agreed that they have postponed hospital visits during the Covid-19 pandemic (60%) whereas 31% of the participants were not aware of telemedicine services prior to the Covid-19 pandemic. Nearly half of the participants (41%) felt that telemedicine is a good option for initial consultations and basic care. Further, most of them perceived that greater access to health care (35%) and avoiding overcrowding and hospital visiting hours (27%) were the main advantages of telemedicine. None the less, a majority (87%) in this study agreed that there is a need to implement telemedicine services in the country (Table 2).

Table 2. Participants’ views on telemedicine services (n=407)

Discussion

To the best of the authors’ knowledge, this was the first study in India that provided a snapshot of general population awareness, and perceptions towards the use of telemedicine services during the Covid-19 pandemic. The findings indicate that only 28.2% of the participants had experience with telemedicine consultations. However, nearly half of the participants (43.6%) were interested to consider telemedicine services and 87% of them accepted the need to implement telemedicine services in the country.

In the current digital information era, a high diffusion of Internet and smartphone use enables technology-based health communication activities among the general population (Lustria et al., 2011). Similarly, a majority of the participants in this study own a smartphone (87.6%) and were aware of e-health and health care apps (89.7%). These findings were in support of a US national survey which revealed that around 65% of phone users have downloaded at least one healthcare application (Krebs & Duncan, 2015). These findings also indicate a tendency of the general population towards the concept of health at hand (McGillicuddy et al., 2013). Social media usage has been shown to increase in the midst of the COVID-19 pandemic. Hence, unsurprisingly, most of the participants in the present study were aware of telemedicine services primarily through social media (35%) followed by health care providers (32%).

Telemedicine was found to be a more appropriate health care approach during the Covid-19 pandemic. However, only 58% of the participants in this study were aware of telemedicine. These findings were similar to earlier Indian studies carried out among the rural population (Manisha, 2014) and with outpatients. Also, a recent national survey carried out in the US revealed that a majority of the respondents (72%) indicated that they were not familiar with telehealth (Sykes, 2020).

With regard to use of telemedicine services, 28.2% of the participants in this study had an appointment through telemedicine. These findings corroborated with the findings of a national survey from a developed country, the US (Sykes, 2020). On the contrary, a survey revealed that 60.8% of outpatients had used telemedicine on or before the Covid-19 pandemic (Holtz, 2021). A recent survey in India also demonstrated similar findings among outpatients of a tertiary care centre which showed that 35.3% of patients had never encountered telemedicine before and 26.9% did not come across telemedicine even during the COVID-19 pandemic (Naik et al., 2021). On the other hand, these findings were somewhat dissimilar to a recent survey carried out among the general population in Egypt (N=686) which demonstrated usage of telemedicine among half of the participants (Alboraie et al., 2021).

In line with earlier studies (Sykes, 2020), in this study more than half (52.1%) of the participants who had encountered telemedicine services were satisfied. On the contrary, just more than a quarter of the outpatients (26.9%) rated their teleconsultation experience positively. The authors argued that these findings could be because of a lack of trust among the participants about the ability of telemedicine to compensate for in-person outpatient visits (Naik et al., 2021). In this study, 43.6% of the participants were interested in having a telemedicine consultation. These findings were comparable to earlier surveys carried out among general populations in Saudi Arabia and Egypt which showed a majority (80% & 60.8% respectively) of them were more likely to prefer telemedicine than traditional appointments (Alboraie et al., 2021; Alshammari & Hassan, 2019). Nonetheless, nearly half of the participants in this study were unsure of using telemedicine services in the future.

These findings could be attributed to a lack of awareness among the general population on how to utilize telemedicine services effectively. Also, 13.7% of the participants were not aware of the process/ technology of having a telemedicine appointment. In an online survey among Austrian adults (N=562), the participants perceived that the lack of technical prerequisites was one of the top-ranked barriers for implementing connected health services (Haluza et al., 2016). These findings suggested that it is critical to educate the general population in using digital health technologies. In addition, the government also should improve the infrastructure at health care facilities such as the availability of internet and computers, so that they can understand the utilization of new technologies which will help to increase the acceptance of telemedicine services (Meher & Kant, 2014).

Published evidence indicates that the three top-ranked advantages of telemedicine were better quality of healthcare, location-independent access to healthcare services, and better quality of life (Haluza & Jungwirth, 2015; Haluza et al., 2016). Similarly, nearly half of the participants in this study felt that telemedicine is a good option for initial consultations and basic care. Further, most of them perceived that greater access to health care (35%) and avoiding overcrowding and hospital visiting hours (27%) were the main advantages of telemedicine.

Reflecting on the participants’ concerns in using telemedicine services, our study revealed that 36% of the participants were worried about the quality of healthcare, privacy and diagnoses made through teleconsultation. These findings corresponded with the findings of a recent survey from a developed country which highlighted the participants’ concerns of misdiagnosis due to problems with communication, either because of technical issues or because of misinterpretation by the clinician (Sykes, 2020). These findings could be due to a lack of awareness about telemedicine among the participants. In line with earlier studies (Sykes, 2020; Zahoor et al., 2020), most of the participants (60%) in this study have postponed hospital visits during the Covid-19 pandemic. Similar to the findings of an earlier study, (Alboraie et al., 2021) a vast majority of the participants in this study felt that telemedicine is essential for delivering medical care to remote and underserved areas of healthcare. These findings indicate mostly positive attitudes of the general population towards the implementation of telemedicine services in the country.

Limitations

This was a feasibility study as the convenience sample was selected from only two states of the country. The data was collected using a self-reported online questionnaire which may introduce response bias. Also, we have included educated and computer literate participants. Thus, the findings of this study were not generalizable to the Indian population. Nevertheless, the main aim of this study was to assess a snapshot of prevailing perceptions on the use of telemedicine services in the context of Covid-19 pandemic. The findings may have important implications for issues such as the adoption of telemedicine, privacy, and the development and adaptation of strategies to meet the health care needs of diverse populations. Further, the findings and recommendations may be beneficial for policymakers to make appropriate decisions regarding the implementation of telemedicine services in India.

Conclusion

Our findings suggest that despite some apprehensions, the majority of the participants hold a favourable attitude towards telemedicine services. This can facilitate large-scale deployments of telemedicine services to bridge the gap between rural and urban areas in receiving appropriate health services. However, findings of this study further strengthen the need for education and awareness programs for the general population to encourage utilization of telemedicine services offered by the Ministry of Health and Family Welfare in India.

Acknowledgements

We are thankful to the participants for their valuable contribution.

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