key: cord-0334282-e9zhax3w
authors: Al Meslamani, Ahmad Z.; Al-Dulaymi, Raghad; El Sharu, Husam; Alwarawrah, Zaid; Ibrahim, Osama Mohamed; Al Mazrouei, Nadia
title: The Patterns and Determinants of Telemedicine Use during the COVID-19 Crisis: A Nationwide Study
date: 2022-05-28
journal: nan
DOI: 10.1016/j.japh.2022.05.020
sha: 9a4c3ca601a5665d010b9cdc6b5ab03cccbe42a4
doc_id: 334282
cord_uid: e9zhax3w

Objectives This study aimed to investigate consumers’ patterns, nature, and predictors of telemedicine utilization as well as consumers’ attitude toward this technology. Methods A quantitative, self-administered questionnaire was developed, validated, and delivered randomly to adults living across the United Arab Emirates between January, 2021 and January, 2022. The questionnaire included questions about categories of telemedicine used, purpose of use, challenges encountered during the use of telemedicine, and reasons for not using telemedicine technology. We adopted a proportionate random sampling technique to recruit participants by three ways: social media, phone calls, and face-to-face. Results The final dataset included 1584 participants, of which 496 (31.3%) used telemedicine during the COVID-19 pandemic. The most common reasons for not using telemedicine during COVID-19 was having no idea that telemedicine exists (38.3%, 417/1088) or having no idea how to use it (33.5%, 365/1088). Telemedicine users reported that that telepharmacy (89.7%), teleconsultation (78.2%), and telediagnosis (23.0%) were the most frequently used telemedicine services during the COVID-19 crisis. Of the 496 telemedicine users, 469 (94.6%) reported using telemedicine for seeking a pharmacist advice about medication instructions, 422 (85.1%) for ordering non-prescription drugs, and 401 (80.8%) for seeking a physician advice. those with high activity on social media were less likely to be associated with telemedicine users versus non-users. Discussion While telepharmacy has been increasingly used by consumers, more attention is needed to fix its limitations and improve patient safety. Conclusion This study shows a positive attitude and a general acceptance of telemedicine services among the UAE population. Some socio-demographic and clinical characteristics were significantly associated with the use of telemedicine during the pandemic.

accelerated to meet the unpresented challenges in healthcare delivery. In the United States, a multimillion-dollar 48 telemedicine program was launched by the Federal Communications Commission (FCC) , 1 and more regulations to 49 encourage stakeholders implementing active telemedicine services during the pandemic were issued , 2 In Canada, 50 COVID-19 necessitated the active incorporation of telemedicine services to urban healthcare , 3 In Australia, the use 51 of telemedicine during the pandemic was advanced by legitimizing telemedicine practice, strengthening the 52 relationship between consumers and practitioners, and secure resources 4 Several private companies in Spain 5 and the 53 United Kingdome 6 supported local health authorities in rolling out telemedicine for healthcare facilities and personnel.

The United Arab Emirates (UAE) had issued the first telemedicine framework in 2013, which comprised the 55 regulatory guidelines for six major elements; telediagnosis, telecounselling, telemedical interventions, 56 teleconsultation, teleprescribing, and telemonitoring . 8 At the early beginning of the pandemic, the UAE responded 57 quickly through a series of innovative solutions. First, the Remote Care Platform for digital care was launched 58 . 8 Second, "doctor for every citizen" service was extended to include all residents of the UAE . 9 This service offers a 59 free medical consultation through videoconferencing. Third, the guidelines for telemedicine practice were 60 continuously updated . 10 The largest healthcare company in UAE, Abu Dhabi Health Services Company (SEHA), 61 indicated that teleconsultation and teleprescribing accounted for 9.0% and 10.0% of all the total outpatient 62 consultations and prescriptions, respectively . 11 In Abu Dhabi, the findings of a cross-sectional survey showed that video consultations were a significant predictor for physicians' confidence toward treating acute cases during COVID-telemedicine during and beyond the pandemic, 13 a little is known about the experience of adults with the use of we aimed to investigate factors that influence future use of telemedicine.

73 This cross-sectional study was conducted in seven UAE emirates (Abu Dhabi, Dubai, Sharjah, Ajman, Umm Al-74 Quwain, Fujairah, and Ras Al Khaimah) using a self-administered, online questionnaire over a year (from January, 75 2021 to January, 2022). All Adults (≥18 years) who were residents in the UAE, spoke Arabic or English, and 76 competent enough to complete the questionnaire without assistance, met the inclusion criteria for the study. On the 77 other hand, adults who were critically ill or were mentally incompetent were excluded from the study. According to

Raosoft sample size calculator 14 , the minimum recommended sample size was 384, considering a population size of 79 8,240,361, a 5% margin of error, and a 95% confidence interval. Nevertheless, to meet the study aims in providing a 80 nationwide assessment of telemedicine services during COVID-19, we aimed to collect responses from 1600 eligible 81 participants. The STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting 82 guideline for cross-sectional studies was adopted and followed as a protocol for conducting this study.

This study used a structured questionnaire, which was developed through a five-step process. First, the main 85 investigator extensively reviewed the literature 12,15-19 , , and drafted the first version of the questionnaire in the English 86 language. Second, the research team gathered through a virtual meeting and discussed the structure and flow of the 87 questionnaire. Ambiguous questions were clarified, duplicates were removed, and questions with inaccurate 88 information were corrected. Third, the main investigator invited an expert in health informatics who was a system 89 developer, a general practitioner (GP) with telemedicine experience, and a community pharmacist who were 90 operationalizing telepharmacy services to attend a virtual meeting to validate the content of the questionnaire. During 91 the meeting, the panel members were asked to grade each item in the questionnaire on a scale of 1 to 10 for clarity, 92 relevance, and appropriateness . 20 The overall means of clarity, relevance, and appropriateness were 8.51 S.D.±1.67, 93 9.34 S.D.±2.07, and 8.27 S.D.±1.14, respectively. Additional amendments and comments recommended by the panel 94 members were also considered. Fourth, the validated version of the questionnaire was translated into Arabic language 95 by three bilingual linguistics who used forward and backward translation technique 21 . Finally, the research team 96 performed a pilot test to assess reliability and comprehensibility of the study questionnaire. The pilot test included 35 97 participants (5 from each Emirate) who were asked to complete the questionnaire and report any questions or words 98 that hinder the understandability of the questionnaire. The responses were imported into the Statistical Package for consistency of the questionnaire items, was calculated. The primary outcome of this test was alpha (α) coefficient, comprised 13 questions designed to collect general information about participants (age, gender, nationality, 106 educational level, martial status, monthly income, medical insurance coverage, comorbidity, social media activity, 107 smoking status, participant's need for monthly prescription, and COVID-19 infection status), in the second section (5 108 questions), all participants were firstly asked whether they used telemedicine during the COVID-19 crisis or not.

Those who were telemedicine users, were asked about categories of telemedicine used, purpose of use, and challenges 

(28.6%). When we asked those who did not use telemedicine services during the COVID-19 crisis about their decisions 175 (N=1088), 38.3% reported that they had no idea that telemedicine exists, 33.5% indicated that had no idea how to use 176 telemedicine services, and 23.8% were uncertain about telemedicine clinical effectiveness (Figure 2) . Furthermore, services were not covered by their medical insurance.

Approximately sixty-seven percent of the respondents strongly agreed or agreed that using telemedicine during the 181 COVID-19 crisis was necessary ( Table 3) . Forty percent of the participant strongly disagreed or disagreed with 182 preferring to visit hospitals or clinics during the COVID-19 crisis. Roughly the same frequency (~41.6%) were 183 satisfied with the telemedicine services provided during the pandemic. Around half of the participants agreed or 184 strongly agreed that they would seek telemedicine services in the future. Nevertheless, only 33.5% strongly agreed or 185 agreed that they had changed their opinions regarding telemedicine services.

The findings of this study showed significant correlations between some of the attitude items (Table 4) . First, 187 individuals who agreed more on the necessity of telemedicine during the COVID-19 crisis were more willing to 188 continue using telemedicine services in the future and are probably more disposed to change their opinions regarding 189 the use of these services. Preference for seeking regular healthcare services was negatively correlated with satisfaction 190 with telemedicine. Specifically, individuals who preferred to seek regular healthcare services were less likely to be 191 satisfied with telemedicine services provided during the pandemic. Additionally, satisfaction with telemedicine 192 services was positively correlated with the intention to use telemedicine in the future; participants who were satisfied 193 with telemedicine services were more likely to state that they would continue to use these services in the future.

There were significant differences between telemedicine users (N=496) versus non-users (N=1088) for the socio-196 demographic characteristics (Table 5) . Participants who had age above 70 years (AOR = 1.56; 95%CI,1.16-1.86; health visits between June and November 2020 used telemedicine, which is similar to our respondent group . 26 the US during the pandemic and found a significant association between reimbursing digital visits and high-quality 235 telemedicine experiences. The need for physical examination was another major issue raised by our respondents. A 236 previous study showed that patients tend to be less confident in their physician's diagnosis when there is no physical 237 examination. This can be encountered by implementing strategies to improve patients' telehealth experiences such as 

There are several limitations to this study. First, the study design is observational cross-sectional, with attitudes and 260 patterns of telemedicine use assessed at a certain timeframe. People's perceptions of this service, however, may change 261 over time. As a result, it would be beneficial to continue investigating people's willingness to use telemedicine in the 262 future and post-COVID-19. Second, there is a risk of methodological bias related to the self-reporting nature of the study. People might tend to exaggerate their use of telemedicine to seek approval or social desirability. Therefore, it those at home. This may induce bias given that not all the study population are exposed to data collection. While we 267 aware of the limitation of this data collection technique, this may lay the ground for future comprehensive public 268 survey.

Overall, this study showed a positive attitude and a general acceptance of telemedicine services among the UAE 271 population. Age, gender, college education, medical insurance, monthly prescription, diabetes, immune diseases, and 272 activity on social media were all strong predictors of telemedicine use during COVID-19. The lack of awareness with 273 telemedicine was one of the most prominent reasons reported by our respondents for not using this service.

Policymakers play an essential role in developing educational programs that promote the range of telemedicine 275 services to improve patients care during these challenging times. The findings of this study will guide future research 276 to investigate the barriers and the continuing use of telemedicine after the pandemic. J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 

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31, 33. Ernsting, C. et al. Using Smartphones and Health Apps to Change and Manage Health Behaviors: A