Use of smartphones among medical students in the clinical years at a medical school in Sub-Sahara Africa: A pilot study

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Nasiru A Ibrahim, MBBS, FWACS¹, Mohammad Salisu, MBBS, FWACPaed², Abiodun A Popoola, MBBS, FWACS³, Taofeeq I Ibrahim, MBBS⁴

¹Department of Surgery, Lagos State University College of Medicine, Ikeja, Lagos State, Nigeria; ²Department of Paediatrics, Lagos State University College of Medicine, Ikeja, Lagos State, Nigeria; ³Department of Radiology, Lagos State University College of Medicine, Ikeja, Lagos State, Nigeria; ⁴Federal Medical Centre, Ebute Metta, Lagos State, Nigeria

Corresponding author: Nasiru A Ibrahim, Department of Surgery, Lagos State University College of Medicine, 1–4 Oba Akinjobi Street, Ikeja, Lagos State, Nigeria. Tel: +2348023044971, E-mail: ibrahimakanmu@yahoo.com

Journal MTM 3:2:28–34, 2014

doi:10.7309/jmtm.3.2.5

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Background

Use of smartphones has become an important and useful component of medical education. With increasing amount of information available in medicine today, use of these portable devices help in quick access to medical information and improves clinical management of patients¹. These devices, also referred to as personal digital assistants (PDAs), have various applications in medical learning and care of patients. They include the iPhone, Blackberry and iPad. Common learning activities are formal instruction, conducting real-time surveys via wireless units, feedback to students, course administration, students gathering data to post to the course or to other students, question and answer sessions, and assessment^2,3. Bedside use include calculation of clinical prediction rules, checking for drug interactions, expanding differential diagnoses by consulting references, electronic order entry and patient tracking^4,5. These functions are found to enhance student learning in the clinical environment and increase their knowledge scores⁶. Studies have shown that 60% to 70% of medical students in the clinical years and residents use PDAs for educational purposes or patient care. In addition, high level of satisfaction was observed and this correlated with the level of handheld computer experience⁷.

Several factors influence adoption of mobile learning in medical education. These include building specialized network for smartphones, provision or subsidizing cost of the device to students, adapting materials specifically for the phones, providing training and technical support to students and staff^7,8. On the other hand, insufficient security, requirement for change, costs, poorly designed packages, inadequate technology, lack of skills, need for a component of face to face teaching, time intensive nature of e-learning, computer anxiety and lack of institutional support are some of the identified barriers^9–11.

Functions of smartphones have been increasing in scope since the release of the Apple Newton and Palm Pilot smartphones in 1993 and 1996 respectively. Apple’s iPhone released in June 2007 blended the features of the PDA with those of the mobile phone. Current devices are smaller, lighter in weight and have sufficient memory to store large amounts of data and reference material. They also have larger number of applications including those designed for specific medical fields.^12,13. Access to mobile phones is rapidly growing in Africa while internet facilities are also increasing with installation of multiple undersea fibre-optic cables¹⁴. Mobile telephony employing the Global System for Mobile Communication (GSM) was introduced into Nigeria in the year 2001. Presently, vast majority among the population own mobile phones with many having the latest versions of smartphones.

Mobile learning has not been fully incorporated into the medical education methods in majority of sub-sahara African medical schools. This is largely due to poor communication infrastructure and limited financial resources. A survey among health care students and tutors in Uganda revealed that 98% owned mobile phones but access to the internet was poor¹⁵. Nigeria has 25 medical schools; 21 were established by Government and students pay subsidized fees while the remaining 4 were privately owned. Lagos State University College of Medicine (LASUCOM) established less than two decades ago by the Lagos State Government is reputed to be one of the fastest growing medical schools in Nigeria in terms of infrastructure and manpower. Improving quality of teaching and learning in the school by wider and institutionalized use of modern information and communication technology in the educational process is desirable. We, therefore, conducted a single institution survey of medical students in the clinical years to assess their current utilization of smartphones, the perceived advantages as well as barriers to the use of the device. Results from this pilot study may assist in identifying areas of needed support to the students and inform the need for a wider study that may help in producing well trained Doctors that would contribute meaningfully to health care delivery especially in resource-poor settings.

Methods

Participants

One hundred and twenty five medical students in the 5^th and 6^th (final) clinical years at the Lagos State University College of Medicine were the target study population. They had completed the basic medical sciences and the laboratory medicine classes and had commenced direct interaction with patients in the course of their learning in the medical school. They are expected to be in greater need for the various clinical applications developed for smartphones that aid learning and patient care. The final year students have, at least, one year extra clinical exposure over their 5^th year colleagues. The survey was conducted in November 2012. The National Health Research Ethics Committee deemed this survey exempt from health research ethics committee oversight as the study is to evaluate education instructional strategy and improve student learning experience. In addition, it poses no added risk to participants. Statement of consent to participate was incorporated into the survey form. Participants were informed about the objectives of the study and were assured that their responses shall be anonymous and confidential. It was also stated that participation in the study shall be voluntary.

Measures

The survey questionnaire used in the study was adapted from the one used in a previous study¹¹. The questionnaire was in four parts. The first section described the gender, level of study and information regarding the type of mobile device owned by the students. In the second part, various activities that mobile phones could be used for were listed and participants were asked to tick the ones they use their device for. They were also required to state the frequency of such usage in the past one year. Participants were asked to tick five greatest barriers to using mobile phones for clinical and learning activities among nineteen identified options in the third part while the fourth section required respondents to tick five greatest advantages to the use of the device among fourteen listed options. They were also allowed to make other comments if they so desired in this section.

Procedure

Pre-test of the questionnaire was conducted among ten fourth year medical students who have had some exposure to clinical medicine. Areas of ambiguities that were identified were modified to achieve clarity. Printed survey forms were then distributed to the eligible students through their respective heads of class who were also mandated to collect the filled forms and submit to the first author.

Data analysis

Variables were coded and data entered electronically into SPSS version 15 spread sheet. Frequency distribution and percentages were produced for categorical variables while statistical comparison was conducted using chi-square test. Level of statistical significance was set at p < 0.05.

Results

Completed survey questionnaires were returned by 123 out of 125 eligible students giving a response rate of 98.4%. Among 110 respondents who indicated their sex, 64 (58%) were males while 46 (42%) were females. Sixty three (51.2%) were 5^th year medical students while the remaining 60 (48.8%) were in the 6^th year. All the participants owned smartphones with majority (58.5%) having the Blackberry brand. Other brands owned by respondents are as shown in Table 1. The phones were less than 2 years old in 101(82%) respondents. Gender and year of study did not significantly influence the brand of phone owned by the respondents (p > 0.05).

Table 1: Brand of phones owned by the students

Activities smartphones were used for are as shown in Table 2. Greatest use among majority (>63%) was for routine functions such as receiving or making calls, sending or receiving SMS and e-mails, as schedule/calendar/planner and as dictionary. Other frequent usage (41% to 59%) were to access and take lecture notes, access medical videos, electronic textbook and for medical research. Usage as clinical tools in patient management, course evaluation and as log book were the least frequent (<32%). Activities were not influenced by gender of participants (p > 0.05). Activities influenced significantly by year of study were making and receiving calls which was more frequent among 5^th year students (p = 0.043) while 6^th year students were using their phones more frequently in taking notes (p = 0.014), accessing journal articles (p = 0.022) and as planner/scheduling/calendar (p = 0.021).

Table 2: Activities smartphones were used for by the respondents

Table 3 shows barriers and advantages of smartphones in mobile learning as perceived by the students. Battery life, small size screen, slow speed, limited memory and cost were the major barriers to mobile learning while the greatest advantages were mobility of the device, ease of use, access to current information anywhere anytime and ease of access to resources. There is no significant difference among the respondents regarding perception of barriers and advantages to use of smartphones in mobile learning in terms of their gender or year of study (p > 0.05). Extra comments were not made by the respondents.

Table 3: Barriers and advantages of smartphones in mobile learning as perceived by students

Discussion

Although, smartphones could be used for different activities such as routine personal applications, searching academic resources, clinical references and electronic medical records, pattern of usage vary among medical students. Most frequent usage of mobile phones in this study were for personal applications, accessing lecture notes and searching academic resources. This pattern of usage is similar to what was found among final year medical students in Oman¹¹. In contrast, clinical students in two medical schools in the United States of America (USA) used handheld devices more frequently as drug references and clinical calculator. However, pre-clinical students in the two schools used their mobile phones mainly for personal scheduling and task lists¹⁶, similar to usage pattern in this study. Other studies conducted in developed countries also reported greater use of mobile devices by students for medical care purposes^17,18. Poor usage of smartphones by our students for activities relating to patient care could be because support medical services in the hospital are not fully computerized and are not accessible electronically. In addition, our students have only limited responsibility in patient care and this may also be factor. Masters et al¹¹ suggested similar reason for poor point of care usage of mobile phones by final year students in his institution.

Participants usage of smartphones for educational purposes was mainly in self-directed learning in form of electronic textbook and to access lecture notes, academic resources and medical videos. Similar trend was observed among health care students in Uganda¹⁵. Formal teaching and evaluation of students using mobile technology have not been incorporated into our medical education system. Many schools especially in developed nations have adopted this valuable tool in the classroom setting for the students and their teachers. Advantages include downloading lecture materials before-hand thereby allowing students concentrate during lectures, real-time assessment of students knowledge, documentation of clinical and procedural experiences instead of using traditional logbooks and teaching evaluation^1–3,7,19

Majority among the students found mobility, ease of use, quick access to current information and resources as the main advantages in the use of smartphones in medical learning. These factors were cited by medical students in other studies as facilitating use of these devices^11,18. Although, improvement in the quality of care, efficiency and clinical knowledge were considered by medical students as the main advantages of mobile devices in a study conducted by Stephens et al¹⁷ in an institution that supports medical computing, these were less important to students in this study. Since majority among the students rarely use their phones for clinical purposes, it could explain why these important point of care attributes of smartphones were not appreciated by our students. Similar observations were made by Masters et al¹¹ among medical students in Oman, a similar developing nation. Provision of smartphones uploaded with clinical decision support software (CDSS) to medical students was associated with increased use in clinical settings and improved knowledge of evidence-based medicine²⁰. Resident Doctors who shoulder greater responsibility in patient care consider smartphones an important tool in enhancing productivity, quality of patient care and services²¹.

More than half among participants cited battery life and small size screen as the greatest barriers to using smartphones. These physical features of the phones were also reported to be major barriers in other studies^11,21,22. Increasing the screen size may negates the pocket size feature of mobile phones which is considered an advantage²³. Cost of smartphones was a limitation among 40% in this study. Concerns regarding cost were also reported in other studies^11,18,24. Type, level of sophistication of device and the number of medical application software incorporated into the phones owned by students determine the cost and may influence the way they perceive this as a barrier. Other important limitations reported were lack of technical support as well as training on the use of the device^16,17. These were mentioned mainly by students in institutions that support and encouraged mobile learning either by providing PDAs to their students or having computer-based hospital information system. Less than a third among our students considered these as barriers. Possible reason could be because they use their smartphones mainly for routine functions and to search academic resources and not for sophisticated medical applications.

Use of smartphones in medical learning, teaching and patient care is rapidly expanding and may eventually become universal. With the potential of improving learning, patient safety and care, medical institutions have commenced incorporating use of these devices in the curriculum as an educational tool^17,19,25. Institutional support to encourage adoption of the new technology included training for students and staff and creation of specific and customized teaching applications for the device^7,19. However, concerns were equally raised regarding some perceived drawbacks of the new technology. Encouraging superficial learning as against internalization of knowledge which is a traditional part of medical education¹⁸, over-reliance on the device²¹ and security of patients information¹⁸ were some of the challenges. Our medical students are being trained to become Doctors, well-equipped to meet the ever increasing challenges of modern medical practice. They should keep pace with ever increasing body of knowledge, evidence based practice and changing protocols and guidelines in the management of diseases that are specific and relevant to our environment e.g. HIV, Tuberculosis and Malaria. Therefore, they should not be left behind in current trends in medical learning. Achieving this poses a greater challenge in our setting with inadequate resources to fund education.

Conclusions

Our medical students were able to own smartphones and appeared comfortable with the use of the device for routine personal applications, searching academic resources like medical videos and electronic textbook as well as accessing and taking lecture notes without institutional support. They could be encouraged to use their smartphones for more educational activities with minimal support. Such activities include allowing students download lecture notes before time. This allows the students listen and concentrate during lecture time. Also, assessment of students can be conducted by posting questions on-line while they respond at the same time allowing real-time assessment and interactivity. In addition, they could be assisted and guided in assessing clinical materials such as clinical decision software, practice guidelines, medication reference tools and electronic textbooks available on the web. Our hospitals should be encouraged to move towards electronic data base and information system which will allow students greater use of their mobile devices for point of care activities. Furthermore, there is need for a multi-centre study involving public and private medical schools to give the findings a nationally representative perspective.

Conflict of interest

All the authors declare no conflict of interest

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