8 IX September 2020

https://doi.org/10.22214/ijraset.2020.31509
 International Journal for Research in Applied Science & Engineering Technology (IJRASET)
ISSN: 2321-9653; IC Value: 45.98; SJ Impact Factor: 7.429
Volume 8 Issue IX Sep 2020- Available at www.ijraset.com

Assessment of Knowledge, Attitude, and Practice of

Telemedicine in India
Trupti Khade1, Dheeraj Kalra2
1
Medical Data Analyst, Vasta Bio-informatics Pvt Ltd, Navi Mumbai, India
2
Head of the Department - Public Health Dentistry, Y.M.T. Dental College and Hospital, Navi Mumbai, India

Abstract: This cross-sectional study is aimed to systematically access the knowledge, attitude, the practice of telemedicine by
conducting population surveys during the COVID pandemic. The 20 items questionnaire was circulated to survey 404 people
from the general population in Mumbai and Navi Mumbai, India who completed the questionnaire online from 5th April to 20th
April 2020. The mean age of the respondents was 27.96 + 7.99. The inferential statistics suggest that though the knowledge of
telemedicine among the sample population stands at 47.5%, the use of this service is a mere 15.8%. p<0.05, α error at 5%, and β
error at 20%, giving power to the study as 80%. The attitude towards using Telemedicine in times of a pandemic is highly
positive, on the other hand, preference for in-person consultation is higher in normal circumstances. The reason is limited
information. Having hit by the most overwhelming pandemic of all times, the promotion of Telemedicine amongst the Indian
population is timely.
Keywords: Telemedicine, Assessment, Knowledge, Attitude, Practice

I. INTRODUCTION
The 2019 novel coronavirus (2019-nCoV) or the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as it is now called,
is rapidly spreading from its origin in Wuhan City of Hubei Province of China to the rest of the world.1 So much so that, the World
Health Organisation has declared an international emergency – a global pandemic.2 Healthcare workers being at the forefront in
fighting this pandemic, are amongst the highest-risk population.3 Along with this, a doctor's office is considered to be the highest
source of infection. To protect both, healthcare workers and patients, the need for telemedicine arises more than ever before.4
The World Health Organization (WHO) defines Telemedicine as, "The delivery of healthcare services, where distance is a critical
factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for
the diagnosis, treatment, and prevention of disease and injuries, research and evaluation and for the continuing education of
healthcare providers, all in the interests of advancing the health of individuals and their communities."5
As the complementary theory of strategy for strengthening health systems, emphasizing the role of current environmental and
technological improvements in the lives of people, the use of telemedicine to access healthcare is gaining attention.
Technology must play a central role if a considerable improvement in quality and improvement in the healthcare system is to be
achieved. Along with which, one of the major probes in leaning towards telemedicine now, in the event of the most overwhelming
pandemic of all times – the Covid-19, the importance of telemedicine will be felt even harder by all the healthcare workers and the
patients for the security of themselves. Thus, there's a dire need for patients having enough knowledge about telemedicine and being
comfortable using it.

A. Background
Historically, telemedicine can be traced back to the mid to late 19th century with one of the first published accounts occurring in the
early 20th century when electrocardiograph data were transmitted over telephone wires. Telemedicine, in its modern form, started in
the 1960s in large part driven by the military and space technology sectors, as well as a few individuals using readily available
commercial equipment. Examples of early technological milestones in telemedicine include the use of television to facilitate
consultations between specialists at a psychiatric institute and general practitioners at a state mental hospital, and the provision of
expert medical advice from a major teaching hospital to an airport medical center.5

1
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/
2
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen
3
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7306961/
4
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7437610/
5
https://www.who.int/goe/publications/goe_telemedicine_2010.pdf

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 International Journal for Research in Applied Science & Engineering Technology (IJRASET)
ISSN: 2321-9653; IC Value: 45.98; SJ Impact Factor: 7.429
Volume 8 Issue IX Sep 2020- Available at www.ijraset.com

Recent advancements in and increasing availability and utilization of, ICTs by the general population have been the biggest drivers
of telemedicine over the past decade, rapidly creating new possibilities for health care service and delivery. This has been true for
developing countries and underserved areas of industrialized nations. The replacement of analog forms of communication with
digital methods, combined with a rapid drop in the cost of ICTs, has sparked wide interest in the application of telemedicine among
health-care providers, and have enabled health care organizations to envision and implement new and more efficient ways of
providing care. The introduction and popularization of the Internet have further accelerated the pace of ICT advancements, thereby
expanding the scope of telemedicine to encompass Web-based applications (e.g. e-mail, teleconsultations, and conferences via the
Internet) and multimedia approaches (e.g. digital imagery and video). These advancements have led to the creation of a rich tapestry
of telemedicine applications that the world is coming to use.5

B. Objective
The objective of this study is to access the knowledge of telemedicine, the attitude and preference towards and its usage. The
motivation for this study was the at-risk population of the healthcare workers and the patients to the coronavirus. COVID-10 being
an infectious disease, healthcare workers, patients, and the doctor's office are the high-risk population and place. In such a situation,
shifting towards the use of technology for the betterment of public health and reducing the risks is substantial. Though telemedicine
is no longer a new technology, the usage of this service is highly limited. This study aims at understanding this inconsistency and
proposing certain solutions for improvement.
1) The potential of Telemedicine: Technology has the potential to boost the standard of health care and to form it accessible to
more people. Telemedicine may provide opportunities to form health care more efficiently, better coordinated, and closer to
home. Research about telemedicine continues to be relatively new, but it's growing. As an example, studies have shown that
both telephone-based support and telemonitoring of important signs of individuals with coronary failure reduced the danger of
death and hospitalization for failure and improved quality of life. 6
2) Reasons Telemedicine Is Now More Important Than Ever
Virtual care has offered a lifeline during a world health crisis. The platform’s sudden growth could have permanent implications.
a) It Protects Medical Personnel and Patients from contagious diseases
b) It Increases Healthcare Access in Senior Living Communities and rural population
c) It Helps Conserve Supplies and Bed Space
d) It Supports Medical Specialties
e) It Brings Care and accessibility to Populations in Need7

II. MATERIAL AND METHODS

A. Design
The study is an online survey conducted in 2 provinces in India. Social networks like Facebook, Instagram, and WhatsApp have
been the major platforms for the circulation of the questionnaire.

B. Data Collection
The survey data was circulated randomly amongst the general population from 20 years to the elder population to know their views
on telemedicine and their knowledge regarding the same. A sample size of 404 was selected and the survey was circulated over the
web via google forms. The questionnaire contained 20 questions, divided into 3 sections; knowledge-based, attitude-based, and
practice-based. 3 of the questions were open-ended while rest 17 were closed-ended questions. To ensure the respondents feel free
to answer, their name was not required. Age was kept to be the only personal parameter.
The practice section covered many aspects of telemedicine practices such as services used, the person used for. Questions were kept
open-ended and a couple of them were yes/no questions.
The attitude questionnaire included eight questions based on the Nominal scale. This questionnaire aimed mainly on studying the
attitude of the population towards efficiency and psychology towards telemedicine. Yes, answers were considered as a positive
attitude. The data collection process took 15 days. (5th March – 20th March).

6
https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/telemedicine/art-20044878
7
https://healthtechmagazine.net/article/2020/05/6-reasons-telemedicine-now-more-important-
ever#:~:text=It%20Helps%20Conserve%20Supplies%20and,within%20a%20care%20delivery%20setting.

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 International Journal for Research in Applied Science & Engineering Technology (IJRASET)
ISSN: 2321-9653; IC Value: 45.98; SJ Impact Factor: 7.429
Volume 8 Issue IX Sep 2020- Available at www.ijraset.com

C. Data Analysis
Data entry, data checking, and data analysis were done with Microsoft Office Excel Sheet (version 2010, Microsoft Redmond
Campus, Redmond, Washington, United States) and the program SPSS (Statistical package for social science) version 21.0, IBM.
Class intervals of age groups have been divided in <24 years, 25-34 years, >34 years. The data were analyzed by descriptive
statistics like frequency, mean and standard deviation, and inferential statistics like chi-squared tests, independent t-tests, and
analysis of variance.
For all the statistical tests, p<0.05 was considered to be statistically significant, keeping α error at 5% and β error at 20%, thus
giving power to the study as 80%.
* = statistically significant difference (p<0.05)
** = statistically highly significant difference (p<0.01)
# = non-significant difference (p>0.05) for all tables
III. RESULTS
The questionnaire was circulated in over 500 people and about 80% of them completed the questionnaire. Mobile, tablets, and
computers were the devices by which users completed the questionnaire. A total of 404 responses were observed amongst the
population in Mumbai (Metropolitan) and Navi Mumbai (Suburbs) are of Maharashtra, India. Finally, 404 people from Mumbai and
Navi Mumbai areas participated in this research survey. The mean age of the respondents was 27.96 + 7.99. About 36 % were from
the age group under 24 years, 50% between 25-34 years, and over 12% over 34 years of age. Table I.
TABLE I
Frequency distribution of people according to age as the demographic variable
Variable Item Frequency (Percentage) Mean
27.96 + 7.99

Age 24 and under 147 (36.3)

25 – 34 206 (50.9)
Over 34 51 (12.6)

According to the survey, knowledge of telemedicine is not significantly related to the age of the sample population.
The findings show that more than 52% population believe they do not know Telemedicine and over 73% wanted to know more of
Telemedicine through promotions for them to be comfortable using it. Based on their knowledge, around 37% believed they have
poor accessibility to telemedicine while 52% of responses were unsure. Besides, while over 54% of the sample population has used
e-commerce services for medical purposes like ordering medicines, only 15% of people have used Telemedicine services. This
points to the fact that more promotion of Telemedicine services is needed for the population awareness and is not related to
inhibition regarding the use of all online services. Table II. Table III.

TABLE II
Distribution of individual responses to knowledge-based variables
Variable Item Frequency (Percentage)

Knowledge about ‘Telemedicine’ Yes 192 (47.5)

No 212 (52.5)

Need for Promotions Yes 298 (73.7)

No 106 (26.2)

Enough Accessibility of Telemedicine Yes 45 (11.1)

No 149 (36.8)
Maybe 210 (51.9)

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 International Journal for Research in Applied Science & Engineering Technology (IJRASET)
ISSN: 2321-9653; IC Value: 45.98; SJ Impact Factor: 7.429
Volume 8 Issue IX Sep 2020- Available at www.ijraset.com

Table III
Distribution of individual responses to attitude-based variables.
Variable Item Frequency (Percentage)

Preference of service in pandemic Telemedicine 321 (79.4)

In-person 83 (20.5)

General preference for service Telemedicine 75 (18.5)

In-person 329 (81.4)

Perceived shortcomings of Accuracy 112 (27.7)

Telemedicine Trust factor 33 (8)
Miscommunicatio 48 (11.7)
n

The beneficiary of Telemedicine in the Yes 275 (68.1)

future
No 129 (31.9)

More efficient service as perceived Telemedicine 150 (37.1)

In-person 254 (62.9)

The positive attitude about consultations seemed to be tilting more towards in-person consultations with over 81% of people
preferring in-person consultation over Telemedicine based on their current subject knowledge. Ironically though, over 79% would
prefer running to Telemedicine services in current times given the COVID-19 outbreak. The inclination towards in-person
consultations can be related to the fact that over 69% of people held back on trusting Telemedicine services with over 26%
questioning its efficiency and chances of communication gap on the open-ended question. Table III.
Comparison of frequencies of responses to each question was done with age groups <24, 25 to 34 & >35 and was found that for the
question on accessibility, there was a statistically significant difference seen for the frequencies between the groups (p<0.05) with
higher frequencies for the response maybe with age group 25 to 34 years.

TABLE IV.
Distribution of individual responses to practice-based variables.

Variable Item Frequency (Percentage)

Use of other online services Yes 221 (54.7)

No 183 (45.3)

Use of Telemedicine Services Yes 64 (15.8)

No 340 (84.2)

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 International Journal for Research in Applied Science & Engineering Technology (IJRASET)
ISSN: 2321-9653; IC Value: 45.98; SJ Impact Factor: 7.429
Volume 8 Issue IX Sep 2020- Available at www.ijraset.com

IV. DISCUSSION
The objective of this study was to assess the knowledge, attitude, and practice of Telemedicine amongst the Indian population. The
findings of this study suggest that approximately less than half of the sample population know what "Telemedicine" is but the use of
Telemedicine stands at 15.8%. The highest responses for the reasons were questions about the accuracy of this service about
chances of communication errors and psychological factors like lack of physical examination and trust issues related to
technology. According to the 2020 census, the Indian population stands at 121 crores which contributes to 17.7% of the world
population.8 causing the risk of a further increase in COVID-19 cases.
Since the nationwide lockdown, the use of telehealth has seen a solid surge, the reason being the long-pending Telemedicine
guidelines which were finally issued by the Indian Government.9 The findings of this study addressed the necessity of such a
provision and more promotion of such services.
In "Awareness, Knowledge, Attitude, and Skills of Telemedicine among Health Professional Faculty Working in Teaching
Hospitals –
Zayabalaradjane Zayapragassarazan1 and Santosh Kumar”10 41% of respondents had a high-level knowledge about Telemedicine
which complies with the finding of this study. Regarding the attitude of the population, 39% of participants had a positive attitude
towards Telehealth, which again complies with the results of the present study. This study was specifically directed towards the
assessment of knowledge and attitude of Telehealth among healthcare workers.
The Indian Space Research Organisation has taken certain initiatives beginning in 2001, with the Telemedicine Pilot Project.
ISRO’s Telemedicine Centre stretches to around 100 Hospitals all over the country with 78 Remote/Rural/District Hospitals/Health
Centres connected to 22 Specialty Hospitals located in the major cities as of 2005.11
Unfortunately, with a population of over 121 crores, the doctor-patient ratio in India is significantly low. To make up for such a
situation, aggressive take over by Telemedicine is required. This scenario interlinks with the COVID-19 pandemic. In a country that
ranks 2 in the total world population, and at Rank 1 in highest coronavirus cases in the world as of September 202012. With a poor
doctor-patient ratio, virtual medical services are a necessity to avoid the risk of disease transmission and to maintain the sanctity of
frontline workers. Besides, the accessibility to virtual services in rural population is improving. As per the reports of a leading
newspaper portal, for the first time in November 2019, India has more internet users in rural areas than the urban areas in Bangalore
province of India.13 This can be an apt time to launch and promote telemedicine services highly, for the betterment of rural Indian
healthcare.
V. CONCLUSION
Promote and optimize the use of telemedicine services for the safety of HCP and patients while using the Framework for Healthcare
Systems Providing Non-COVID-19 Clinical Care to determine when in-person care is appropriate. Include options for language
interpretation, as needed. Communicate with insurers/payers to understand the availability of covered telemedicine, telemedicine, or
nurse advice line services Use tele-triage methods for assessing and caring for all patients to decrease the volume of persons seeking
care in facilities, especially during times of high transmission of contagious diseases such as COVID-19
Provide outreach to patients with limited technology and connectivity and offer flexibility in platforms that can be used for video
consultation, or non-video options, when possible.1
Our findings suggest there are limited knowledge and certain myths about the use of Telehealth in the population. To increase its
usage, we can take up certain directed measure like:

1) Promotion of Telemedicine in the population so that people are more comfortable using Telemedicine
2) Advancing mHealth so that Telemedicine reaches the rural population
3) Making Telemedicine comfortably accessible for the geriatric population
4) Promoting clear guidelines for people to understand when to visit the doctor’s office and when to use Telemedicine

8
https://censusindia.gov.in/2011-prov-results/paper2/data_files/india/Rural_Urban_2011.pdf
9
https://www.mohfw.gov.in/pdf/Telemedicine.pdf
10
https://pubmed.ncbi.nlm.nih.gov/27134899/
11
http://www.televital.com/downloads/ISRO-Telemedicine-Initiative.pdf
12
https://covid19.who.int/
13
https://timesofindia.indiatimes.com/business/india-business/for-the-first-time-india-has-more-rural-net-users-than-
urban/articleshow/75566025.cms#:~:text=BENGALURU%3A%20For%20the%20first%20time,million%2C%20as%20of%20Nove
mber%202019.

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ISSN: 2321-9653; IC Value: 45.98; SJ Impact Factor: 7.429
Volume 8 Issue IX Sep 2020- Available at www.ijraset.com

VI. ACKNOWLEDGMENT
We would like to extend my special thanks to all the respondents who participated in the research

REFERENCES
[1] https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/
[2] https://www.who.int/goe/publications/goe_telemedicine_2010.pdf
[3] https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/telemedicine/art-20044878
[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4587917/
[5] https://www.cdc.gov/coronavirus/2019-ncov/hcp/telemedicine.html

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