|Year : 2019 | Volume
| Issue : 7 | Page : 897-905
Healthcare-related smartphone use among doctors in hospitals in Kaduna, Nigeria – A Survey
Department of Medicine, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria
|Date of Acceptance||14-Mar-2019|
|Date of Web Publication||11-Jul-2019|
Dr. H Yahya
Department of Medicine, Barau Dikko Teaching Hospital, Kaduna State University, PO Box 9727, Kaduna
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The use of smartphones is now ubiquitous in developed countries and many studies have documented their use as a point of care tool, for communication and for reference purposes among various categories of doctors. In Africa and in Nigeria, fewer studies have been conducted and these have been confined to medical students, Interns and resident doctors. Aims and Methods: The aims of our study were to examine ownership, frequency and pattern of use and problems encountered in the use of smartphones among all category of doctors in hospitals in Kaduna, Nigeria. Results: A 20-item structured questionnaire was completed by 326 doctors from public and private/faith-based hospitals (aged 23 – 70 years, median 34, two thirds male). All but one respondent owned a smartphone and 99% reported using these during their work in hospital. The following activities were the most frequently performed (at least once a day) using smartphones: Check details about a disease (48.7% of respondents), Medscape (45.9%), voice/text to colleague (45.3%), check differential diagnosis (39.1%), Social Media (37.9%), check drug interactions (34.9%), find indications for use of drugs (34.3%), and use of drugs in special circumstances (33.8%). Younger doctors (less than 40 years) and particularly Interns/NYSC doctors and doctors within 10 years of graduation, were significantly more likely to perform above-mentioned activities. 86% of respondents graded their phones as very useful or invaluable. Perceived lack of time and unreliable internet were the most commonly reported barriers to optimal use. Conclusion: Smartphone use in hospitals among doctors in Kaduna is universal and is mainly for point of care, communication and reference purposes.
Keywords: Doctors, healthcare, hospitals, smartphones
|How to cite this article:|
Yahya H. Healthcare-related smartphone use among doctors in hospitals in Kaduna, Nigeria – A Survey. Niger J Clin Pract 2019;22:897-905
| Introduction|| |
Smartphones are small, pocket-sized computer devices running advanced operating systems with wireless and internet connectivity, Global positioning system (GPS), accelerometers, as well as the traditional call and messaging capabilities. Their use has risen exponentially all over the world in the last five years  including Nigeria where smartphone penetration is currently estimated at 30%. This has been made possible by the availability of very good but low cost phones and availability of cheaper, more widespread  and more reliable internet connectivity. This has resulted in the increasing use of internet-dependent communication methods such as email, messaging applications such as WhatsApp, social media applications such as Facebook, search engines such as Google, and a plethora of downloadable, standalone software applications (apps).
The modern smartphone's  markedly increased processing power, varied screen size, higher resolution and the availability of a vast collection of apps covering all aspects of medicine  has the potential to make these electronic devices invaluable tool in the modern doctor's arsenal.
The use of smartphones in hospitals in developed countries is widespread and many studies ,,,,,, have documented their use and impact among doctors in various specialties for communication and consultations with colleagues and supervisors, and sometimes patients, for access to point-of-care information (drug and medical references) and monitoring purposes in the clinic and the bedside, for education (e-books and e-journals), for research, and for telemedicine, but few studies have been conducted in Africa and Nigeria. Where studies have been done, they have involved only a limited category of doctors. For instance, In Ghana, smartphone use was studied only in House Officers, in Botswana, smartphone use was studied among doctors in training, and in Nigeria, smartphone use was studied only among fifth and sixth year medical students  and resident doctors in training; no study has been conducted among a wide category of doctors who care for the most patients.
The aims of our study were to assess the extent of ownership of smartphones among doctors working in hospitals in Kaduna, Nigeria, examine the frequency and pattern of healthcare and education-related use of these devices and document any perceived barriers and concerns to such use and suggestions to remedy them. It is hoped that this will aid in designing and implementing educational programs and other endeavors to ensure increased and optimum use of these devices and their functionalities for better patient care.
| Materials and Methods|| |
The study was a cross-sectional study of doctors working full time in all (54) public, private and faith-based hospitals in Kaduna metropolitan area using total population sampling. A total of 472 doctors were requested to complete a pre-tested, 20-item, structured questionnaire between August and September 2017 (see appendix) which was constructed by the authors based on anecdotal evidence and the study of relevant literature. Paper questionnaires were administered to participants in their work places after permission was obtained from the heads of the various institutions. Hospitals were identified based on information from the Department of Hospital Services, Ministry of Health and Human Services, Kaduna State and the Guild of Medical Directors, and the number of doctors working there was obtained from heads of the hospitals. Doctors were defined as medically qualified persons who were registered with the Medical and Dental Council of Nigeria (MDCN). Newly qualified doctors (House Officers or Interns and doctors serving in the mandatory one-year National Youth Service Scheme – NYSC – which comes immediately after internship) were also included in the study. The study was approved by the Human Research Ethics Committee of Barau Dikko Teaching Hospital, Kaduna, Nigeria (Protocol number: 17-0015-2). Participation in the study was voluntary and respondents who chose to fill the anonymous questionnaires were considered to have given informed consent. No honorarium was given. Statistical analysis was performed using SPSS version 22 for Windows (IBM Corporation, 2013). Chi squared was used to assess the significance of differences between groups. A P value of < 0.05 was considered significant.
| Results|| |
Demographic characteristics of participants
The demographic characteristics of study participants are summarized in [Table 1]. There are about 326 medical practitioners completed and returned the questionnaires out of a total 472 invited to participate, giving a response rate of 69.1%. Respondents' ages ranged from 23 to 70 years with a median of 34. Two-thirds of them were male. Two-thirds of respondents were below the age of 40 and almost 60% had been qualified within the previous 10 years. Almost 80% of respondents had attained only the basic medical or dental degree. A third of respondents were general practitioners while 42% where either residents in training in the various specialties or were fully qualified specialists. More than three quarters of respondents worked primarily in public health hospitals.
Smartphone ownership and use in hospital
All but one respondent owned a smartphone and most of the phones (78.6%) had the Android operating system installed; 10.1% had iPhones which run iOS. All but three respondents who owned smartphones (99.1%) reported using their phones to aid their work in hospital.
Pattern of smartphone use in hospitals – Healthcare-related activities and educational purposes
In assessing the frequency and pattern of use of smartphones, we requested doctors to indicate for what they might use their phones for. Doctors who reported using their phones several times a day or at least once a day were categorized as using that function “a lot”, those who used the phone about two or three times a week or at least once a week were considered “sometimes” users while those who used it only one or two times a month were considered “infrequent” users. The users who never used any given functionality or app were classified as “not at all”. Checking details about a disease condition was the most frequent reason for using smartphones by doctors in Kaduna – almost half of respondents reported using their phones “a lot” for this activity [see [Figure 1]]. Medscape app (WebMD LLC, 2011), which has a drug formulary, was the most frequently used drug app by respondents – 45.9% used it at least once a day and a further 22% used it at least once a week. Emdex  and BNF  – other drug reference apps similar to Medscape - were used much less frequently. A large number of respondents also used their phones to make work-related calls or send text messages to their colleagues or patients, use social media, check for differential diagnoses of diseases or check indications for use of drugs, drug interactions, or use of drugs in special circumstances (pregnancy, lactation etc.). The web browser (Google chrome, internet explorer etc.) was by far the most common way respondents accessed educational material on their phones – more than three quarters did so at least once a day [Figure 2]. Wikipedia  was used at least once a day by more than half of respondents. A dedicated textbook app and PDF books were also common sources of educational materials for respondents.
|Figure 1: General pattern of healthcare-related smartphone use in hospitals in Kaduna (figures are in percentages)|
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|Figure 2: General pattern of smartphone use in hospitals – educational purposes (figures are in percentages)|
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Although female doctors represented only a quarter of our study population as in the rest of the country, there were no significant gender differences in the frequent (at least once a day) use of these smartphone functionalities except in the use of a camera [Male: 60/189 (31.7%) VS Female: 10/65 (15.4%), P = 0.001], YouTube [Male: 63/172 (36.6%) VS Female: 8/48 (16.7%), P = 0.009] and PDF Books [Male: 104/185 (56.2%) VS 23/62 (37.1), P = 0.009]. Younger doctors (age less than 40) were significantly likely to use the following functions more frequently than older doctors (age more than 40): Look up for indications of use of drugs [75/176 (42.6%) VS 24/83 (28.9%), P = 0.035], Medscape [(113/178 (63%) VS 23/71 (32.4), P = 0.000], web browser [167/195 (85.6%) VS 63/90 (70.0), P = 0.002], and Wikipedia [106/161 (65.8%) VS 34/71 (47.9%), P = 0.010]. They were significantly less likely to use a camera [37/166 (22.3%) VS 30/81 (37.0%), P = 0.015] and a calendar app [25/87 (28.7%) VS 22/46 (47.8%), P = 0.029]. Compared with doctors working in private or faith-based hospitals, doctors in public hospitals were significantly more likely to use YouTube [55/78 (70.5%) VS 16/45 (35.6%), P = 0.0001] and call/text to colleagues [120/234 (51.3%) VS 24/65 (36.9%), P = 0.041] more frequently. There were no significant differences in the frequent use of smartphone functions between general practitioners on one hand, and specialists or specialists in training, on the other. Interns/NYSC doctors were significantly more likely to call/text colleagues, use Medscape, or Emdex or look up indications for general use of drugs or drugs in special circumstances than other doctors [see [Table 2]]. They were also significantly more likely to use a web browser, Wikipedia, E-Books or PDF Books to look for information, and telemedicine to seek assistance from colleagues. Similarly, doctors qualified less than 10 years were significantly more likely to use most healthcare and education-related activities compared with those who qualified longer [see [Table 3]].
|Table 2: Pattern of healthcare and education-related smartphone use in hospital by Intern/NYSC doctors compared to other doctors for activity performed at least once a day|
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|Table 3: Pattern of healthcare and education-related smartphone use in hospital by doctors qualified less than years and those qualified 10 years or over for activity performed at least once a day|
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Overall usefulness of smartphones in healthcare in hospitals, problems encountered and concerns for use
The respondents were requested to grade the usefulness of their phones as (a) not useful at all (b) occasionally useful (c) very useful or (d) invaluable (“can't do without it”). Overall, 234/322 (72.7%) of respondents considered their smartphones to be very useful in the healthcare setting, while 13.4% believed their smartphones were invaluable to their work. Only 39/322 (12.1%) and 6/322 (1.9%) considered their smartphones to be occasionally useful or not useful at all, respectively. This perception was similar irrespective of gender, place of work (public versus private or faith-based hospitals) and among general practitioners and specialists or specialists in training. The respondents younger than 40 years were, however, significantly more likely to consider their smartphones as very useful or invaluable than those aged 40 or above [182/204 (89.2%) VS 84/104 (80.8%), P = 0.041]. Similarly, newly qualified doctors (interns and NYSC doctors) were significantly more likely to judge their phones very useful or invaluable than other doctors [75/81 (92.6%) VS 202/241 (83.8%), P = 0.049] as were doctors who qualified within 10 years [168/184 (91.3%) VS 99/125 (79.2%), P = 0.002]. When respondents were asked whether they felt to be using their smartphones as much as they could, overall, less than half answered in the affirmative. Female doctors [22/74 (29.7%) VS 110/238 (46.2%), P = 0.012] and doctors qualified 10 years or more [45/125 (36.0%) VS 86/131 (65.6%), P = 0.0001] were significantly less satisfied with the use of their phones than male doctors and doctors qualified less than 10 years, respectively. Specialists or specialists in training were also almost significantly less likely to judge their phone use as adequate compared to general practitioners [48/87 (35.6%) VS 50/104 (48.1%), P = 0.052]. Respondents were asked about problems they encountered while using their phones in the course of their work in hospital. Having to see many patients and not having enough time was reported by almost 60% of respondents and was the most frequent barrier to optimal use of their phones in hospital. A reliable internet connection and internet connection fees were also given as barriers to optimal of use of phones by 44.2% and 23% respondents respectively. Doctors working in public hospitals are significantly more likely to cite lack of reliable internet as impediment to full use of their smartphones than those working in private hospitals [124/257 (48.2%) VS [20/69 (29%)] (P = 0.004). Similarly, interns and NYSC doctors were highly significantly likely to attribute unreliable internet access as a barrier to full use of their smartphones than other doctors [48/82 (58.3%) VS 96/244 (39.3%)] (P = 0.003). Also, compared to doctors qualified 10 or more years, doctors qualified for less are significantly more likely to point to unreliable internet connection as a barrier to full use of their phones [89/326 (27.3%) VS 48/326 (14.7%)] (P = 0.0001). Up to half of all respondents were concerned use of phones in the hospital might lead patients to think they did not pay much attention and more than 40% were worried about being distracted by use of their phones. Concern about reliability of the information obtained, although low overall (14.4%), is highly significantly more prevalent among those: a) aged less than 40 years compared to those who were 40 years of age or older years [39/206 (18.9%) VS 7/105 (6.7%)] (P = 0.004], b) general practitioners compared to specialists or specialists in training [18/107 (16.8%) VS 11/137 (8.0%)] (P = 0.036), c) interns/NYSC doctors compared to other doctors [18/82 (22.0%) VS 29/244 (11.9%)] (P = 0.025) and d) doctors qualified within 10 years compared to other doctors [36/326 (11.0) VS [9/326 (2.7)] (P = 0.0001).
Suggestions about improving use of smartphones in hospitals
An overwhelming majority of respondents (80.4%) believed providing free, reliable internet connection would improve use of smartphones in hospitals. Subsidizing internet connection fees was the next most frequent suggestion made to improve use (51.8%). Providing a dedicated smartphone application suitable for use in hospital and regular educational programs were also a common solutions offered, each reported by about 46% of respondents.
| Discussion|| |
We found that virtually all the doctors who participated in our study owned a smartphone and used it as aid during their work. This ownership is equivalent to those of developed countries ,,,,, and is likely a consequence of the availability of smartphones at prices as low as NGN25,000 (USD70) for Android phones, which constituted the majority of the phones used by doctors as in the general Nigerian population; the more expensive iPhone made up only just about 10% of phones used but provides identical applications, functionalities and user experience to Androids. Smartphones are now considered as important as the stethoscope in the doctor's diagnostic arsenal.
Our study shows that doctors used their smartphones, irrespective of their area of work, mostly as a point of care tool to look for details or guidelines about a disease condition, check differential diagnosis of a disease, determine when a drug might be used for a particular condition or how it might interact with other drugs or its use in special circumstances such as in pregnancy, lactation or in renal or hepatic impairment and is similar to findings of smartphone use among doctors worldwide.,,,,,,,,,, These points of care information might be available through a search engine but is found more easily in a dedicated app which may be specialty specific but the general apps are the most popular. For example, Medscape  - a mainly drugs reference app but which also has a medical calculator, an extensive compendium of diseases of all organ systems including medical emergencies, and a vast multimedia collection of procedures which doctors might wish to undertake – is used by more than two thirds of respondents at least once a week. Similar drug reference apps are much less used: Epocrates (Epocrates Inc. 2010) provided the basic information about drugs but requires a yearly subscription of USD175 (NGN63,000) to access other resources such as details about diseases or differential diagnosis – functionalities that are available entirely free in Medscape which can be downloaded and used offline. As a consequence, Medscape has been downloaded more than 5 million times in the Android Play Store while Epocrates has been downloaded only about 1 million times. Emdex  (Essential Medicines Index) app, an electronic version of the long-established, printed drugs reference index in Nigeria is also much less used probably because it became available recently and is limited in many respects compared to Medscape; Medscape's drug formulary, however, is based on the US pharmacopoeia. A well-developed local app containing relevant local content will serve doctors and other health practitioners in Nigeria better.
The communication with colleagues either through voice or text message was used by more than three quarters of doctors at least once a week and is in keeping with its use elsewhere.,,,,,,,, Social media use (Facebook etc.) was also common (38% of respondents used this frequently to share information, get answers to problems and for networking) and is similar to reports in other countries ,, and has been extensively reported in the literature. WhatsApp – a free, secure, cross-platform, primarily messaging (but now also increasingly used as social media), which has been downloaded more than a billion times in the Play Store, and allows sharing and exchange of text, voice, images, videos, internet link to various resources - is now becoming widely used by doctors to communicate, share, and take point-of-care decisions among individual doctors and among teams as they care for patients in various specialties such as internal medicine, surgery, radiology and pathology. In developed countries it is rapidly replacing the traditional pager system. Ellanti et al. reported that in a 6-month study of an orthopedic WhatsApp Group use among medical staff, mostly residents and interns, the vast majority of messages sent (92.7%) were related to patient care and included updates on new admissions, results of investigations, progress of inpatients and their treatment options. They found that this was faster and more efficient than the traditional telephone and pager system used in the hospital. There are concerns such as confidentiality and other issues regarding use of social media in healthcare settings; this has been well reviewed by Ventola. To address these issues, the British Medical Association and the Australian Medical Association have recently issued guidelines to doctors on how best to use social media.,
Smartphone use in hospital for educational purposes using a web browser, Wikipedia, PDF or a dedicated e-book app or YouTube was also very high among our respondents and is likely made possible by ease of access of material as well the larger, high resolution screens of modern phones. Easy access to reference material via a smartphone has been shown to enhance patient care in studies in many countries.,,,,,,,, Smartphone ownership appears to be as widespread among other major professional groups such as engineers, lawyers, businessmen and architects as in doctors although there are differing levels and patterns of use depending on the profession.,,,
Our study found that most doctors consider their smartphones to be very useful in hospital irrespective of age, gender or place of work as is found elsewhere,,,,,,,,, but younger doctors in general, and interns/NYSC doctors and doctors qualified within the previous 10 years in particular, were significantly more likely to judge their phones more useful than other doctors and this is probably because of disparity in knowledge and experience as medical practitioners as documented elsewhere. There is clearly a room for improvement in the use of smartphones as less than half of our respondents felt they were using their phones as much as they could.
The most frequently cited impediment to optimal use of smartphone in our study is lack of time related to perceived heavy workload. Quick and easy access to relevant point of care information, as would be provided by a dedicated app that contains curated material and that takes cognizance of the local environment may remedy this situation as has been shown in studies from the UK  and Botswana  and as has been suggested by almost half of our respondents.
Although doctors in our study used their smartphones frequently to access point of care information, up to half of respondents were concerned that this use might be perceived negatively by patients. Explaining the purpose of use to patients will ameliorate this anxiety.
Concern about being distracted was also high (40%) among our respondents and there are reports that distraction among healthcare workers has led to medical errors due to mistakes and omissions. Anxiety about the reliability of information, although low, was more frequent and significant among newly qualified doctors and general practitioners and this can be remedied by developing an app that brings together sources and links to reliable information which hospitals, other institutions and doctors' associations can subscribe to and make available to staff members at no or limited cost.
A reliable internet connection was cited as a barrier to adequate use of smartphone by more than 40% or respondents; this has been cited as a problem even in rich developed countries. We have noted patchy and unreliable internet connection in various parts of our own hospital and this most likely applies to other institutions as well. Applications that allow download and offline use of resources would go a long way in remedying this problem. Such applications could be updated from time to time whenever internet connectivity becomes available. The cost of internet access does not seem to be a major barrier to use of phones as it is cited as an impediment to phone use by less than a quarter of respondents.
Specific limitation of the study
Our study findings may not be applicable to doctors in rural areas where internet access is likely to be limited.
| Conclusion and Recommendations|| |
Our study has shown that smartphone ownership among doctors in Kaduna, Nigeria is universal and is used extensively to access point of care information, communicate with colleagues and derive reference material that would aid patient care. Although most doctors, especially newly qualified and those qualified within the previous ten years, found smartphones to be very useful, many were unsatisfied with their level of use because of time constraints and availability of reliable internet connection which can be remedied by developing a dedicated and curated app containing accurate and reliable information which is accessible offline and which is relevant to doctors practicing in Nigeria. Such app can be made available through doctors' organizations or hospital or other healthcare institutions at no or limited cost. There are regular courses and seminars about the utility of information technology in general, and smart portable devises like smartphones and tablets in particular, would also enhance optimal use of these devises by doctors. Medical school curricular should also include or strengthen courses about use of information technology.
Financial support and sponsorship
Personal resources of author.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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