Assessment of Self-Perceived Knowledge in e-Health Among Undergraduate Students

Abstract

Objective:

Growing research evidence shows the value of e-health in healthcare delivery. While efforts are made to implement e-health in mainstream healthcare, relatively modest attention has been paid to develop e-health knowledge and skills in health practitioners. Using a pre–post design, in this study, we aimed to examine self-reported knowledge and perception changes associated with an e-health course offered to university undergraduate students in Australia.

Methods:

Pre- and postsurveys were used to examine self-reported knowledge and perception changes relating to e-health among undergraduate students. All students enrolled in an e-health course (n = 165) were asked to complete an identical survey in the first and last week of the semester.

Results:

The response rates were 53% (n = 87) for the presurvey and 52% (n = 85) for the postsurvey. For all items, changes in self-reported knowledge and perception were statistically significant in pre/post median scores and dichotomized negative/positive proportions.

Conclusions:

Students believed the course helped them to improve their knowledge regarding key aspects of e-health. It is important to design an e-health curriculum targeting competencies to provide necessary knowledge and skills to help students practice e-health in their professional careers.

Introduction

The use of information and communication technologies (ICTs) in health and medicine is growing quickly. It is often said that ICTs are making significant changes in the way health and medicine have been traditionally practiced and ICT innovations are expected to transform the future of healthcare and medicine.^1
–3 According to the World Health Organization definition, e-health is the use of ICTs to provide enhanced health services to communities.⁴

Over the last three decades, many studies have investigated the feasibility, effectiveness, economics, and acceptability of e-health. The literature contains examples across almost the entire range of clinical disciplines.⁵ Some research has shown that when used in the right circumstances, e-health can lead to positive clinical outcomes and cost savings for patients and health systems.^6,7 Regardless of the growing evidence, integration of e-health into routine practice of health and medicine has been slow and patchy. Among other factors, the lack of systematic e-health education and training (E&T) for current and future health and medical practitioners has been identified as a reason for slow adoption of e-health.^8
–10

There has been a noticeable lack of interest in promoting E&T in e-health.^9
–11 A number of reasons may have contributed to this situation. The lack of recognition of the required skills and competencies in e-health and their relevance to contemporary healthcare practice has been an important factor.⁹ A study has also pointed out that the lack of expertise in E&T is a key barrier.¹² According to others, the absence of clear pathways for professional careers relating to e-health may have discouraged educational institutions to promote e-health E&T.¹³ In addition, there is an assumption that modern-day health and medical practitioners have adequate knowledge and understanding of the technology to use it in their practice without specialized training. Technologies such as the Internet and mobile phones undoubtedly have become part of day-to-day life for many people. This is particularly true with the young generation growing up with new technologies. This may have been a reason for the lack of enthusiasm to teach them e-health formally.

In this study, using a pre–post design, we set out to understand the changes in self-reported knowledge and perceptions of undergraduate students regarding e-health who enrolled in an e-health elective course.

Methods

Participants

Participants of this study were students who were enrolled in an e-health course offered at the University of Queensland, Brisbane, Australia. The title of the course is Introduction to e-Healthcare (HLTH 2000). This is an undergraduate course, which is offered as an elective subject. Students from a range of undergraduate programs who are eligible to take elective subjects enrol in this course. Typically, this course is taken by undergraduate students in health disciplines. All students enrolled in the e-healthcare course in semester 1, 2015 (n = 165), were invited to take part in this study.

Design

We used a pre/postsurvey to assess changes in students' self-reported knowledge and perceptions about e-health. An identical survey was used in the first and last week of the semester. E-mail reminders were sent to encourage participation. The surveys were hosted on Survey Monkey (www.surveymonkey.com). This study was approved by the Ethics Committee of the University of Queensland (#2015000115).

Description of the e-Healthcare Course

The Introduction to e-Healthcare course is designed to offer students the knowledge and understanding about basic theoretical and clinical aspects of e-health. The course is 13 weeks in duration and organized into three modules (module 1, weeks 1–3; module 2, weeks 4–10; and module 3, weeks 11–13; Table 1), with a new topic introduced each week. This course is delivered entirely online using the Blackboard e-learning platform (Blackboard, Inc., London).

Table 1.

Introduction to e-Healthcare: Course Structure

MODULE	WEEKS	TOPIC
1	1	Clarifying terminology relating to the subject area: Students are guided to familiarize themselves with multiple terms used in the field, identify distinct features of terminologies, and understand the definitions of e-health, telemedicine, telehealth, m-health, and other related terms.
	2	Introducing the history of e-health: Students are guided to identify key historical milestones in the development of the field of e-health.
	3	Identifying key factors facilitating e-health: Students are encouraged to contemplate on various technological and nontechnological factors driving e-health.
2	4	Understanding basics principles of health informatics: Students are guided to understand the basic conceptual principles governing the rationale for health information management and health knowledge. Students are encouraged to consider emerging methods of generating, storing, and accessing information and potential challenges posed by the use of digital technology in health information management.
	5	Understanding the potential of CDSS and their role for enhancing patient care: Students will explore the novel CDSS and current evidence for their effective use.
	6	Identifying trends in health information search online: Students are encouraged to consider emerging methods of health information access using the Internet and the pros and cons of such methods.
	7	Understanding home telehealth: Students learn about a range of novel methods to provide healthcare services for patients at home, including home telehealth, remote monitoring, and smart homes.
	8	Understanding m-health: Students are guided to understand the use of mobile devices to provide healthcare services. Students review a range of examples from both developed and developing countries.
	9	Learning about e-health applications for supporting critical care and disaster situations: Students learn about the potential of e-health in a disaster situation. A range of examples are reviewed.
	10	Learning about future directions in e-health: Students learn about current and emerging technologies that may impact on healthcare services. Examples of such technologies include online social networks, Internet of Things, and online social networks.
3	11	Understanding issues and challenges pertaining to e-health: Students are encouraged to think about various barriers to use the full potential of e-health. Students are challenged to propose solutions to address these issues.
	12	Learning about the status of global e-health adoption: By reviewing various examples, students learn about key e-health implementation globally and factors for their success (or failure).
	13	Knowing the status of adoption of e-health in Australia: Students learn about major e-health initiatives in Australia and their future perspectives.

CDSS, clinical decision support systems.

Students are provided weekly learning materials, including text-based study guides, 30-min online lectures, 10-min video material, and 2 research articles relevant to the topic of the week. In addition, each week, students are required to participate in a moderated online discussion forum to discuss relevant points highlighted by the course coordinator. For each topic of the week, problem-based learning scenarios are provided to stimulate critical thinking and encourage online peer discussion. Students are invited to provide their own experiences and reflect on the potential relevance of e-health in their future professions.

Students must complete three assessment tasks: (1) a multiple-choice test at the end of module 1, (2) an infographic presentation in the form of a poster on a chosen topic relating to e-health at the end of module 2, and finally (3) a scenario-based e-health needs assessment exercise at the end of module 3.

Survey Instrument and Data Collection

Survey questions were developed by the authors. We piloted the survey with five students and used the comments received from the pilot survey to refine the questions and to develop the final version of the survey. The final survey comprised questions about participant characteristics (year of study, major); participants' self-appraised knowledge about e-health (10 Likert item questions; Table 2); and (iii) participants' perceptions about e-health (4 Likert item questions; Table 3). The survey took about 10–15 min to complete.

Table 2.

Survey Questions Relating to Participants' Self-Rated Knowledge of e-Health

1	How would you rate your knowledge of e-health in general?
2	How confident are you to provide a definition of e-health?
3	How do you rate your ability to differentiate the terms e-health, telehealth, and telemedicine?
4	How confident are you about your knowledge in e-health applications?
5	How do you rate your knowledge about e-health activities in Australia?
6	How confident are you about your knowledge in e-health activities globally?
7	How do you rate your knowledge regarding ethical, privacy, and confidentiality issues relating to e-health?
8	How confident are you about your knowledge regarding the drivers of e-health?
9	How do you rate your knowledge about major barriers to e-health?
10	How confident are you about your knowledge relating to establishing e-health?

Five-point Likert item response was used (very low, low, neutral, high, and very high).

Table 3.

Survey Questions Relating to Participants' Perceptions of e-Health

1	Do you agree that e-health is beneficial for the parties involved in healthcare?
2	Given the opportunity, I am confident to use e-health.
3	I am confident that e-health is relevant to my future profession.
4	I am keen to use e-health in my future professional practice.

Five-point Likert item response was used (strongly disagree, disagree, neutral, agree, and strongly agree).

Data Analyses

Participants' response rate, year of study, and majoring field were summarized. Converging bar charts were used to visualize changes in self-rated knowledge and perception responses between the pre and post time points. A Wilcoxon signed-rank test was used to compare median pre/post question responses. Responses were then dichotomized (negative/positive) and Fisher's exact statistics calculated to examine changes in proportions. Neutral responses, which could indicate indifference or insufficient information to form an opinion, were excluded. Within each of the knowledge and perception scales, items were summed and compared using unpaired Student's t test. To assess internal consistency, Cronbach's alpha, including the effects of removing an item, was computed for each of the knowledge and perception scales for both the pre- and postsurveys. All tests were conducted at an alpha level of 0.05. Analyses were conducted using Stata, version 14 (StataCorp, College Station, TX).

Results and Materials

One hundred sixty-five (n = 165) students were enrolled in the course and invited to participate in the study. The response rates were 53% (n = 87) for the presurvey and 52% (n = 85) for the postsurvey. In both surveys, the majority of participants were in the third year of their undergraduate studies (Table 4). Most students were enrolled in health or science majors (Table 5).

Table 4.

Year of Undergraduate Study

YEARS	PRESURVEY, n (%)	POSTSURVEY, n (%)
1	9 (11)	10 (12)
2	18 (21)	16 (19)
3	52 (61)	54 (64)
4	6 (7)	5 (6)
No response	2 (2)	0
Total	87	85

Table 5.

Number of Participants by Majoring Field

MAJORING FIELD	PRESURVEY, n (%)	POSTSURVEY, n (%)
Public health	21 (24)	22 (26)
Biomedical sciences	23 (26)	19 (22)
Occupational therapy	18 (22)	19 (22)
Audiology	4 (5)	5 (6)
Business, commerce, and finance	4 (5)	4 (5)
Nutritional science	8 (9)	1 (1)
Speech pathology	3 (3)	4 (5)
Physiotherapy	1 (1)	3 (4)
Molecular biology	1 (1)	1 (1)
Physiology	1 (1)	1 (1)
Zoology	1 (1)	1 (1)
No response	2 (2)	5 (6)
Total	87	85

Changes in Self-Reported Knowledge

For all items comprising the knowledge scale, there was a statistically significant difference in pre/post median scores and dichotomized negative/positive proportions. In each case, the median was higher and positive proportion was larger in the postsurvey than the presurvey (Supplementary Figs. S1–S10; Supplementary Data are available online at www.liebertpub.com/tmj). There was a statistically significant pre and post difference in the scale overall (p < 0.001).

Changes in Perceptions

There was a statistically significant difference in pre/post median scores and dichotomized negative/positive proportions for perceptions of benefits of e-health (Supplementary Fig. S11) and confidence to use e-health items (Supplementary Fig. S12). For the question relating to relevance of e-health to participants' future profession, there was no statistically significant difference in pre/post median or dichotomized proportions, although the strongly agree proportion increased from 42.5% (pre) to 63.1% (post), suggesting that participants generally felt that e-health was relevant to them (Supplementary Fig. S13). For the question relating to participants' keenness to use e-health for future professional practices, there was a statistically significant difference in the median, favoring the postsurvey. While the dichotomized pre/post proportions were not statistically significantly different, the strongly agree proportion increased from 32.2% (pre) to 55.3% (post) (Supplementary Fig. S14). There was a statistically significant pre/post difference in the scale overall (p < 0.001).

Internal Consistency

Cronbach's alpha for the knowledge scale was 0.904 (pre) and 0.834 (post); for the perception scale, it was 0.684 (pre) and 0.886 (post). For the knowledge scale, the effect of removing an item did not increase alpha, suggesting good internal consistency. For the perception scale, in the presurvey, removing the perceptions of benefits question resulted in a minimal increase in alpha to 0.705.

Discussion

The key objective of this study was to examine the changes in self-reported knowledge and perceptions about e-health in university undergraduate students enrolled in an elective e-health course. One key motivation to conduct this study was an anecdotal perception that future health and medical professionals may have adequate knowledge about e-health and they understand the relevance of e-health in their future professional practice and therefore they do not need formal education in e-health. This perception may be one of the reasons why little attention has been paid to teach e-health systematically worldwide.

This study showed that e-health knowledge of students before commencing a course of study was very low. Students also had a poor understanding about the relevance of e-health in their future practices. This study has shown that after learning 13 topics relating to e-health, not only did students' knowledge significantly improve but their perceptions relating to the relevance of e-health for their future practice also improved.

Professional knowledge and skills are not static; they change and evolve due to various factors demanding professionals to acquire new knowledge and skills to fulfill their professional practices successfully. Changes in the marketplace, government regulations, and emergence of new technologies are some important factors that may influence the need for new knowledge and skills in professional practice.^14,15 Identification and recognition of required knowledge and skill sets are important steps toward the workforce development.^16
–18 Pedagogical theories suggest that systematic E&T is a key method of delivering relevant knowledge and skills required for professional practice.^19,20

The integration of ICTs in healthcare, as in other fields of human activities, has made significant changes in the way traditional healthcare is practiced. Today, the health workforce has to use ICTs for various tasks, including clinical, health administration, education, and research. Logic dictates that the health workforce must have relevant knowledge and skills to perform those tasks.

Evidence suggests that e-health may offer a range of benefits to various stakeholders. The review by Bashshur et al. shows that e-health provides reductions in hospital admissions/readmissions, length of stay, emergency department visits, and mortality.²¹ Research has shown the relevance of e-health in population health. E-health has been successfully used for health promotion, disease prevention, and surveillance.^22,23 Many governments and health systems have introduced e-health services and some have become large and well integrated, such as the Ontario Telemedicine Network in Canada²⁴ and Veterans Affairs Telehealth in the United States.²⁵ Some governments have made important policy changes to encourage and incentivize the use of e-health. For example, the Australian federal government introduced reimbursement for certain video-based consultations involving general practitioners, specialists, aboriginal health workers, nurse practitioners, and midwives.²⁶ In the United States, 46 states and Washington, District of Colombia, provide reimbursement for some video-based consultations under their Medicaid program, which supports the healthcare costs of those on low incomes and those living with certain disabilities.¹¹ Alongside the increase in use of e-health, a flourishing industry of medical, technology, and clinical service businesses has grown. It is difficult to reliably estimate the size of the market. One group of analysts suggested that it could be as large as USD $43.4 billion by 2019,²⁷ while another group were more conservative in their estimate of USD $36.3 billion by 2020.²⁸

Regardless of the growing evidence and interest in e-health, little effort has been made to build a workforce that has appropriate competencies and skills.²⁹ Lack of systematic E&T has often been noted as a key barrier to integrate e-health in mainstream healthcare practice.^9,13,30 A study reviewing the current level of educational opportunities in e-health at the tertiary level in Australia showed that currently there is no relevant content relating to e-health within the curriculum. The study emphasized that the lack of formal recognition of e-health by healthcare organizations and governing bodies has been a key barrier for developing relevant knowledge, skills, and competencies in the healthcare workforce. The study concluded that currently teaching and assessment of future clinical health professionals do not ensure that Australia will have a clinical workforce that is adequately empowered to work with e-health.⁹

As previously mentioned, a range of factors have contributed to the lack of interest in promoting e-health E&T. One such factor may also be the assumption that due to widespread technology use, today's health students may have sufficient knowledge and appreciation regarding e-health. However, this study showed that undergraduate students aspiring to be future health and medical practitioners have no e-health knowledge. Thus, it is misleading to think that current and future health professionals would acquire e-health knowledge because they live in a technology-immersed society. E-health as a unique academic discipline must be taught in a systematic manner targeting defined learning outcomes. Depending on the healthcare professional group, learning outcomes may vary. Health and medical educators must identify the e-health competency needs so that the curriculum can address these learning outcomes. It is important to actively promote e-health E&T by recognizing the relevance of e-health in professional practice. Specific knowledge, skills, and competencies relevant to e-health must be identified and healthcare governing bodies must place mechanisms for accreditation of such competencies. These measures may help educational institutes to develop and offer appropriate E&T programs in e-health. As early as 1990, Greenes and Shortliffe³¹ posed the argument that the horizontal integration of e-health into healthcare practices requires the integration of e-health into medical education.³² Yet, after nearly 25 years, the issue of E&T needs in e-health still remains to be addressed.

We would like to acknowledge several limitations in this study. This study tested students' self-reported knowledge and perceptions rather than the actual knowledge changes due to the e-health course content. In future studies, it is important to assess the effect of the e-health content taught by the course to make changes in students' knowledge. Another limitation was the inability to match the pre and post responses to undertake paired analysis. While the response rate in pre- and postsurveys was quite similar, due to the anonymity of the surveys, we were unable to test knowledge changes in individual participants.

The strength of this study is that the study was carried out in a practical setting where knowledge and perceptions of students aspiring to become health and medical professionals were examined. This is also the first study to examine the effect of an e-health course on knowledge of undergraduate students in a higher education setting.

Conclusions

The perception that modern-day students have adequate e-health knowledge and therefore require no formal education in e-health is possibly incorrect. Our study showed that undergraduate students who aspired to become future health professionals had poor knowledge regarding e-health. The e-health course helped improve their knowledge in the subject. Well-designed educational programs targeting key knowledge and skills in e-health will help advance the e-health workforce.

Footnotes

Acknowledgments

The authors gratefully acknowledge the support of the students enrolled in the e-Healthcare course (HLTH 2000) during this study.

Disclosure Statement

No competing financial interests exist.

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