Smartphone Medical Application Use and Associated Factors Among Physician at Referral hospitals in Amhara region north Ethiopia, 2019

Background : Information in healthcare is rapidly expanding and updating. Due to this healthcare providers have to access latest scientific evidence timely in anywhere. Smartphone medical applications are tools to access the latest and reputable scientific evidence in the discipline. This study was aimed to assess smartphone medical application utilization and associated factors among physicians working at referral hospitals of Amhara region, Ethiopia. An institutional based cross-sectional study design was conducted among physicians working at referral hospitals in Amhara region, Ethiopia from February 5 to May 27, 2019. Simple random sampling was used to select 423 physicians. Self-administered questionnaire was used to collect the data and analyzed by using SPSS version 21. Binary and multivariable logistic regression analysis was performed to assess factors associated with smartphone medical application use among physicians. P < 0.05 at 95% confidence interval was considered statistically significant. The validity of the questionnaire was determined based on the view of experts and the reliability of it obtained by calculating the value of Cronbach’s alpha (α = 0.78) of application, IT support staff, and technical skill are the most notable factors that are associated with smartphone medical application use by physicians.


Background
The main source of information for healthcare professionals at the point of care was text books (1). Health care professional increasingly use electronic tools like Smartphone medical applications for patient care, clinical reference, and education(2). Smartphone applications (apps) are tools that can be downloaded onto smartphones and enhance patient care, increase efficiency, or provide individualized learning for clinicians (3). In 2011 Apple created the Apps for Healthcare Professionals section within the medical category of the iTunes App store, a unique feature among mobile app market place (4).
Smartphones have wide range of use from internet to email, they offer on the go access to information never before possible (5).

Study conducted in United kingdom (UK) shows that smartphone medical apps like
British National Formulary (BNF) , eLogbook and medical calculator(MedCalc) has been commonly used by physician (7). Technology can lead to improved decision-making and reduced numbers of medical errors and improved communication between hospital medical staff (9)(10)(11).
According to the study conducted in UK due to easiness of smartphone medical apps (18.5%) doctors made suggestions to their colleagues to be used as quick reference during clinical practice (7). However lack of support and update of applications by their developers, lack of adequate skill to use applications, lack of creating motivation in using applications, problems related to security and confidentiality of patient information has undermined the utilization of smartphone medical apps at the point of care (8,11,12).
Study conducted in Korea shows that the use of smartphone medical apps by physicians is low (6).
Evidence shown that medical app usage is high in developed countries, according to the study conducted in UK medical app usage is higher (72.4%) among doctor group (16).
The other study in united states of America reported that 56% of physician use apps in their clinical practice and there was a decreasing trend towards app use with increased training level and the most useful app types included textbook/reference materials (average response: 55%), classification/treatment algorithms (46%) and general medical knowledge (43%); there was a greater desire for apps among residents relative to fellows and attending physicians, respectively (17).
A study conducted in Korea shows that the usage pattern of smartphone medical applications among residents at clinical practice for counseling and clinical communication (50%), among interns for drug reference (56%) and among extern's resources and e-books (65%) (18).
On the other hand study done in Iran reported that the most popular medical apps were Medscape and Up-to-date, respectively and 61.3% of the physician were using their apps more than once a day and mostly for drug information (19).
According to cross sectional study done in Ghana, Over 43.1% of physicians used medical apps on their smart phone for clinical decision making frequently which shows relatively low use of medical apps than developed countries (13).
Due to different factors physicians remain reluctant to adopt these technologies in clinical practice (2), the most common factors which affect the use of smartphone medical apps are behavioral factors (IT related experience, attitude, computer related skill) (20), factors related to medical app characteristics (perceived usefulness, perceived easiness, privacy and security concerns), organizational factors(infrastructure, IT support , and computer related training) (21). Evidences revealed that underutilization of apps in the point of by healthcare professionals is due to lack of technical skill (6,22). According to the finding of cross sectional study conducted in united kingdom (UK) appear to be looking at phone during clinical practice misinterpreted as checking emails or using social network by colleagues and patients (7,(23)(24)(25)(26) Security and privacy are the key factors of the functionality of any m-health system (27), unfortunately, little emphasis was given for security , this will affect the utilization of this apps significantly (22,(28)(29)(30). Perceived ease of use is another factor which determine the utilization of smartphone medical applications. Apps with user friendly interface are more likely to be used (25,31). The aim of this study was to assess smartphone medical application use and associated factors among physicians in referral hospitals of Amhara region, Ethiopia.

Study design and setting
Institutional based cross-sectional study was conducted to assess smartphone medical application use and associated factors among physicians in referral hospitals of Amhara region, Ethiopia. The State of Amhara consists of 10 administrative zones, one special zone, 181 woredas, and 78 urban centers. Amharic is the working language of the state.

Study participant, sample size and sampling procedure
Study participants were selected using simple random sampling method, sample size was calculated using single population proportion formula using the following assumptions; proportion of smart phone medical application use (P) = 50%, margin of error (d) = 5 and 10% for non-response rate; finally, the minimum sample size of 423 was obtained.

Data collection tool and procedure
Data were collected using self-administered questionnaire and comprised of sociodemographic, behavioral, medical app related, and organizational variables.
Questionnaire was prepared in English. Before the actual data collection, pretesting of the questionnaire was conducted among 20 physicians at Debre tabor hospital. Then necessary correction was done based on the pretest finding. The validity of the questioner was determined based on the view of experts and the reliability of it obtained by calculating the value of Cronbach's alpha (α = 0.78).
Five health information technology professionals who took training and prior data collection experience were assigned for data collection. Three health professionals who had experience in health information system monitoring supervised the task. The supervisors and investigators checked data completeness and consistency.

Dependent variable
Physician's smartphone medical application use (yes, no)

Operational definitions
Physician: Physician in this study includes general practitioners, residents, dentist, specialists, and sub-specialists.
Smartphone: class of mobile phone with multipurpose mobile computing capability with features like high definition camera, third-party app installation, Global positioning system(GPS) (15).
Medical application: is a computer program or software application designed to run on a mobile device such as smartphone, tablet which is meant to be used for clinical purpose.
Smartphone Medical application: Medical application designed to run specifically on smartphone (14).
Smartphone Medical application use: Study participants who score the median=5 and above the median out of the 9 category of application were categorized as they have used smartphone medical application (13).
Attitude: Study participants who score median and more in five point Likert scale of attitude question were categorized they have good attitude and those who score below the median were categorized as they have poor attitude (34) Perceived usefulness: Study participants who score median and above the median in five point Likert scale of Perceived usefulness question were categorized they thought Smartphone Medical application as useful for their job and those who score below the median were categorized they thought Smartphone Medical application as not useful for their job (35).
Perceived easiness: Study participants who score median and above the median in five point Likert scale of Perceived easiness question were categorized they thought Smartphone Medical application as easy to use and those who score below the median were categorized they thought Smartphone Medical application as not easy to use.

Sociodemographic characteristics
A total of 417 physicians were included in this study with response rate of 98.6%. Two third of (65.9%) of the respondents were male. The mean age was 33+_8SD years with the majority of age group were 25-34. More than three fourth (89.9%) of the physicians had medical application installed on their smartphones.

Factors Associated with smartphone medical application use among physicians
The multi variable analysis of logistic regression pointed out attitude, internet access, Computer training, perceived usefulness of application, technical skill of physicians, and availability of IT support staff were significantly associated with smartphone medical application use.
In   (34). This implies that attitude of physicians is a key in implementation of such applications in the clinical practice.

Conclusion
The findings of this study showed that smartphone medical application use was 63.3%.
Favorable attitude, internet access, computer training, perceived usefulness of application, technical skill of physicians, and availability of IT support staff were the most notable factors that were associated with smartphone medical application use.

Abbreviation and Acronyms
Apps Applications.

Acknowledgment
We would like to thank University of Gondar institute of public health for the approval of the ethical clearance, Respective referral hospitals and directors for giving us permission to collect data. We also forward gratitude to data collectors, supervisors and study participants.

Funding
No funding was obtained for this study.

Availability of data and materials
Data will be available upon request from the corresponding author.

Authors' contributions
GH, conceived of the study, coordinate data collection. GH, BT, AT, AND HA performed statistical analysis and drafted the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate
Ethical clearance was obtained from the Ethical Review Board of the University of Gondar. Moreover, privacy and confidentiality of information was strictly guaranteed by all data collectors and investigators. The information retrieved was used only for the study.

Consent for publication
Not applicable.