Towards implementing telemedicine in Tunisia: A knowledge, attitude and practice study among medical doctors

Mariem Nouira; Nesrine Souayeh

doi:10.12688/f1000research.138320.2

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Research Article

Revised

Towards implementing telemedicine in Tunisia: A knowledge, attitude and practice study among medical doctors

[version 2; peer review: 2 approved, 1 approved with reservations]

Previous Title 'Towards implementing telemedicine in Tunisia: Results of a knowledge, attitude and practice study among medical doctors'

Mariem Nouira ¹, Nesrine Souayeh²

PUBLISHED 20 Aug 2024

Author details Author details

¹ Epidemiology Department, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, 1006, Tunisia
² Gynaecology and Obstetrics Department, Regional Hospital of Ben Arous, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, 1006, Tunisia

Mariem Nouira
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Resources, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Nesrine Souayeh
Roles: Conceptualization, Data Curation, Methodology, Project Administration, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background: The use of information and communication technology such as telemedicine occupies nowadays a huge place in modern medicine practice all over the world, mainly after the COVID-19 pandemic. However, its implementation in Tunisia and other developing countries has achieved little success with low utilization and can be challenging for several reasons. In this study, our aim was to assess the knowledge, attitudes and practice of Tunisian medical doctors regarding telemedicine.

Methods: This was a cross-sectional web survey, administered to medical doctors in Tunisia in October 2022. Respondents’ level of knowledge of telemedicine was assessed by calculating a knowledge score (0 to 12). Attitude subsections were about perceived telemedicine attributes of relative advantage, compatibility, trial ability and complexity.

Results: A total of 243 participants were included. The mean age was 45 ± 9.6 years old, and 57.2% were female, with a mean of 14.3 ± 10.3 years of professional experience. The majority (95.9%) had an average or high level of computer skills. More than half (59.3%) had a poor level of telemedicine knowledge. A good level of knowledge was significantly associated with age category over 50 years (p = 0.02) and with years of experience over 10 (p = 0.03). The majority (89.3%) had a moderate or high score about perceived advantages. The majority (88.5%) accepted use of telemedicine in their future practice. Almost half (46.9%) had practiced telemedicine activities before using a mobile phone (91%) or social media (64%). The principal limitations of applying telemedicine were challenges of organization and implementation, and incomplete patient examination.

Conclusions: Although Tunisian doctors’ knowledge and practice of telemedicine were unsatisfactory, their positive attitude and willingness to try it in their future practice were encouraging. There is an urgent need for implementing telemedicine in Tunisia to improve health care coverage in some unprivileged areas.

Keywords

telemedicine, knowledge, attitude, medical informatics, Tunisia

Corresponding author: Mariem Nouira

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 Nouira M and Souayeh N. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Nouira M and Souayeh N. Towards implementing telemedicine in Tunisia: A knowledge, attitude and practice study among medical doctors [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2024, 12:1025 (https://doi.org/10.12688/f1000research.138320.2) First published: 22 Aug 2023, 12:1025 (https://doi.org/10.12688/f1000research.138320.1) Latest published: 20 Aug 2024, 12:1025 (https://doi.org/10.12688/f1000research.138320.2)

Revised Amendments from Version 1

As suggested by the reviewers: The title of the manuscript was modified. Some grammar mistakes were corrected in the current version. The introduction was modified including the current definition of telemedicine by WHO, more explanation of the Tunisian presidential decree about telemedicine and a brief description of the structure of the Tunisian health system and the doctor/patient ratio. More clarifications in the methodology about the questionnaire conception, its structure and the type of questions used. The table 2 was modified with addition of the statistics (Chi-square value), degree of freedom for each variable together with the p-value. The discussion was also modified with more comparisons of the results to other countries, more explanations of the results and more detailed recommendations.

See the authors' detailed response to the review by Benson Ncube
See the authors' detailed response to the review by Sumaiah Alrawiai

Introduction

The world is witnessing rapid advances in audiovisual and digital technologies. The availability of the Internet has enabled impressive gains in terms of time and distance. In light of all this progress, remote medicine is developing at an increasingly rapid pace.¹

Information and communication technologies (ICTs) are playing an increasingly important and dominant role in the healthcare sector. They offer a multitude of solutions to the various difficulties encountered in the practice of medicine.² Telemedicine is becoming an increasingly important part of modern medical practice, in response to the new needs and challenges in the health sector.³

Telemedicine is defined by the World Health Organisation as “the delivery of health-care services where distance is a critical factor, by all health-care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries all in the interests of advancing the health of individuals and their communities”.⁴

The health crisis caused by the COVID-19 pandemic highlighted the relevance and importance of telemedicine in the medical field. Greater use was made of the various forms of telemedicine during this pandemic. Telemedicine enabled equitable access to care for all socio-economic categories of patients, improved access to healthcare services for patients who were geographically isolated or had a loss of autonomy and facilitated coordination between different healthcare providers.⁵^,⁶

The use of ICT in the medical and health care fields is very promising in terms of improving the quality and effectiveness of medical services.² However, its implementation in Tunisia and other developing countries has achieved little success with low utilization and can be challenging for several reasons.⁵^–⁸

Tunisia is a North African country with a total area of approximately 163,610 square kilometers. The current population is 12,356,121 as of 2022.⁹ The public and private sectors coexist in the structure of the Tunisian health system. Public health is a government-funded and regulated field that offers low-cost or free services to the general public. Specialized care is provided in regional and university hospitals, while primary care is provided through a network of health centers and hospitals. The doctor-to-patient ratio in Tunisia stands at approximately 1.5 doctors per 1,000 people. This ratio is slightly below the World Health Organization (WHO) recommendation of 2.3 doctors per 1,000 people for adequate healthcare delivery.¹⁰ Mobile phone penetration in Tunisia is high, with a penetration rate of about 125% in 2021, meaning there are more mobile subscriptions than there are people. Mobile services are relatively affordable, contributing to the widespread use of mobile technology for communication, banking, and accessing various services.¹¹

Given all the above, the telemedicine implementation in Tunisia is needed to bridge the gap between patients and healthcare providers, especially in remote and underserved areas. Telemedicine can significantly enhance healthcare access and delivery in Tunisia.

Legal aspects of telemedicine use might be one of the major limitations of its generalization in our context. In Tunisia, the legal framework for the exercise of telemedicine has just been obtained following the publication of the presidential decree n°318/2022 in April 2022 which establishes the conditions and regulations for the practice of telemedicine in Tunisia.¹² This decree specifies the general conditions for conducting telemedicine activities and outlines the various fields where telemedicine can be applied. It defines the types of telemedicine services that can be provided, including remote consultations, diagnostics, and follow-up care.

In this study, our primary objective was to assess the knowledge, attitudes and practice of Tunisian doctors regarding telemedicine. Our secondary objective was to determine the obstacles to the application of telemedicine.

Methods

The study was a cross-sectional web survey. A Google Forms questionnaire was sent by email to a large sample of doctors (approximately 5,000 email addresses) during October 2022. Theses email addresses were obtained from the Union of General Practitioners and Specialists and from the email list of university doctors from the Faculty of Medicine of Tunis. Inclusion criteria were being a Tunisian graduate doctor (generalist or specialist) practicing in Tunisia in the public or private sector and agreeing to be part of the survey.

We collected baseline demographic information and characteristics (age, gender, years of experience, speciality, computer skills …) and different questions to evaluate telemedicine knowledge, attitudes, and practice. The questionnaire was developed essentially by the authors and it was partly inspired from a study conducted in Ethiopia.¹³ All used questions were closed questions like Yes/No, multiple choice or Likert scale questions.

Knowledge subsection

Respondents’ level of knowledge of telemedicine was assessed by 12 questions to be answered in either “Yes” or “No.” A score of “1” was given for “Yes” and “0” for “No.” One can score a minimum of 0 and a maximum of 12 in this section. A knowledge score less than 6 was labeled as poor knowledge of telemedicine, and equal or more than a score of 6 was labeled as good knowledge of telemedicine.

Attitude subsection

Perceived telemedicine attributes of relative advantages (7 questions), compatibility (3 questions), trial ability (7 questions) and complexity (7 questions), were rated on a four-point Likert scale that ranged from “0 = strongly disagree” to “4 = strongly agree,” except for complexity attribute questions which were reversely scored (0 = strongly agree and 4 = strongly disagree). A total mean score was calculated for each subsection of attitude questionnaire (relative advantages, compatibility, trial ability and complexity). We considered a score of each subsection of attitudes ≤49% as low, 50–70% as average, and ≥71% as high.

Statistical analysis

For descriptive statistics, frequency and percentage values were calculated for categorical variables, and means (SD) values were used to describe continuous data.

The chi-square test was used to determine potential associations between the categorical groups. Statistical analysis was performed using SPSS software (version 23.0, IBM Corp). A p value ≤0.05 was considered as significant. Please see the underlying data.¹⁴

Ethical considerations

All participants were informed about the purpose of the study and were requested to participate in the study if they consented. All the information regarding the study was mentioned in the body text of the Google form and mail invitation. They were also informed about their right to refuse participation or drop out at any moment of the study collection process. All collected information and data analysis was confidential and anonymous during and after data collection. The approval of the ethics committee of Ben Arous Regional Hospital was obtained before conducting the study on 23 September 2022 with approval number 11/2022.

Results

Socio-professional characteristics

In total, 243 participants completed the questionnaire which represents a response rate = 4.9% (243/5000).

Their mean age was 45 ± 9.6 years old, and more than half (57.2%) were female, with a mean of 14.3 ± 10.3 years of professional experience. The majority (67.5%) were working in the public sector and were specialist physicians (79%) with a predominance of medical specialties (63.5%). More than half (53.9%) were hospital-university physicians. The majority worked between 31 to 50 hours per week (69.6%).

Respondents’ sociodemographic characteristics are summarized in Table 1.

Table 1. Socio-professional characteristics of study participants.

Socio-professional characteristics	Number	Percentage (%)
*Gender*
Male	104	42.8
Female	139	57.2
*Age categories (years)*
30–39	81	33.3
40–49	89	36.6
≥50	73	30
*Years of experience*
<5	47	19.3
5–10	69	28.4
>10	127	52.3
*Practice sector*
Public	164	67.5
Private	79	32.5
*Practice zone*
Urban	233	95.9
Rural	10	4.1
*Specialisation*
General medicine	51	21
Specialist	192	79
*Type of speciality*
Medical	122	63.5
Surgical	60	31.3
Biology/fundamental	10	5.2
*Working hours/week*
<30	17	7
31–40	95	39.1
41–50	74	30.5
51–60	29	11.9
>60	28	11.5

Most participants (95.9%) had an average to high level of computer skills. More than half of respondents (53.5%) declared that they had a good Internet connection at work and a suitable place for the practice of telemedicine (58%). For the computer tools available in the workplace, most of them had access to a computer (86.8%) but didn’t have a headset (72.4%) or camera (56.8%).

Knowledge

Most of the respondents had heard about telemedicine (98.4%) but more than half (56.8%) didn’t know the different fields of its application.

The most well-known telemedicine activity definition was teleconsultation (63.8%).

Only 39.1% of respondents had heard about the Tunisian telemedicine decree and 25.5% (62/243) had a little knowledge of content regulation.

The knowledge score mean value was 5.2 ± 3.5 points. More than half (59.3%) had a poor level of telemedicine knowledge. A good level of knowledge was significantly associated with the age category over 50 years (p = 0.02) and with over 10 years of experience (p = 0.03) (see Table 2).

Table 2. Results of the association between the level of knowledge and socio-professional characteristics of the study population.

Socio-professional characteristics	Level of knowledge		p	Chi-square value (degree of freedom)
Socio-professional characteristics	Poor (%)	Good (%)
*Gender*			0.13	2.207 (1)
Male	53.8	46.2
Female	63.3	36.7
*Age categories (years)*			0.02	7.608 (2)
30–39	67.9	32.1
40–49	61.8	38.2
≥50	46.6	53.4
*Years of experience*			0.03	6.708 (2)
<5	72.3	27.7
5–10	63.8	36.2
>10	52	48
*Practice zone*			1	0.002(1)
Urban	59.2	40.8
Rural	60	40
*Practice sector*			0.4	0.616(1)
Public	61	39
Private	55.7	44.3
*Specialisation*			0.3	1.067(1)
General medicine	52.9	47.1
Specialist	60.9	39.1
*Working hours/week*			0.07	8.421(4)
<30	52.9	47.1
31–40	67.4	32.6
41–50	55.4	44.6
51–60	65.5	34.5
>60	39.3	60.7

The main information sources provided about telemedicine were media (TV, radio, social media) or colleagues (58.9%, N = 129 among 219 respondents).

Attitudes

The results of doctors’ attitudes toward telemedicine are summarized in Table 3.

Table 3. Doctor's attitudes toward telemedicine based on perceived benefits, compatibility with their practice, ability to try, and perceived threats and disadvantages to telemedicine (N=243).

Attitude	Strongly disagree N (%)	Disagree N (%)	I Do not know (Undecided) N (%)	Agree N (%)	Strongly agree N (%)	Average score (Mean ± standard deviation)
Benefits						20.1 ± 6.0
Is an interesting practice (Useful) for the patient	6 (2.5)	11 (4.5)	26 (10.7)	88 (36.2)	112 (46.1)
Is an interesting practice (Useful) for the practitioner	8 (3.3)	10 (4.1)	27 (11.1)	88 (36.2)	110 (45.3)
Is an interesting practice (Useful) for the Tunisian health system	11 (4.5)	14 (5.8)	37 (15.2)	72 (29.6)	109 (44.9)
Improves access to care	7 (2.9)	11 (4.5)	25 (10.3)	91 (37.4)	109 (44.9)
Reduces the risk of medical error	41 (16.9)	57 (23.5)	71 (29.2)	45 (18.5)	29 (11.9)
Facilitates diagnosis and management	15 (6.2)	44 (18.1)	63 (25.9)	66 (27.2)	55 (22.6)
Facilitates communication between health professionals	5 (2.1)	8 (3.3)	20 (8.2)	89 (36.6)	121 (49.8)
Compatibility						7.3 ± 2.8
Is compatible with all aspects of my clinical practice	39 (16.0)	57 (23.5)	70 (28.8)	39 (16.0)	38 (15.6)
Is compatible with my current employment situation	21 (8.6)	32 (13.2)	64 (26.3)	67 (27.6)	59 (24.3)
Telemedicine would be more useful for monitoring the elderly and for chronic diseases	7 (2.9)	12 (4.9)	42 (17.3)	100 (41.2)	82 (33.7)
Ability/willingness to try telemedicine						21.5 ± 5.0
I wish to receive a training course in this practice	4 (1.6)	6 (2.5)	22 (9.1)	79 (32.5)	132 (54.3)
It is necessary (or useful) to use telemedicine in my daily practice	7 (2.9)	15 (6.2)	31 (12.8)	82 (33.7)	108 (44.4)
Trying a telemedicine application is an opportunity	4 (1.6)	8 (3.3)	26 (10.7)	93 (38. 3)	112 (46.1)
Simply assessing a telemedicine application is enough to evaluate it	18 (7.4)	64 (26.3)	95 (39.1)	42 (17.3)	24 (9.9)
I want to try a telemedicine application (exercise) before using it	5 (2.1)	5 (2.1)	14 (5.8)	105 (43.2)	114 (46.9)
I am open (I accept) to the use of telemedicine	4 (1.6)	3 (1.2)	21 (8.6)	102 (42.0)	113 (46.5)
It is necessary and useful to create a structure dedicated to the practice of telemedicine in each hospital	4 (1.6)	9 (3.7)	30 (12.3)	76 (31.3)	124 (51.0)
Threats/Complexity/Disadvantages						14.8 ± 4.9
Requires too much mental effort	24 (9.9)	60 (24.7)	77 (31.7)	70 (28.8)	12 (4.9)
Would be hard for me to learn	4 (1.6)	17 (7.0)	50 (20.6)	106 (43.6)	66 (27.2)
Would be difficult for me to apply and use	10 (4.1)	19 (7.8)	62 (25.5)	98 (40.3)	54 (22.2)
Increases workload	19 (7.8)	56 (23.0)	91 (37.4)	52 (21.4)	25 (10.3)
Poses a threat to the practitioner's practice of medicine	14 (5.8)	36 (14.8)	87 (35.8)	75 (30.9)	31 (12.8)
Engages the medico-legal liability of the physician who is not covered by a law that protects his rights	89 (36.6)	77 (31.7)	61 (25.1)	11 (4.5)	5 (2.1)
Is a threat to patient confidentiality and privacy	29 (11.9)	54 (22.2)	81 (33.3)	54 (22.2)	25 (10.3)

Relative advantages

The mean score of perceived relative advantages of telemedicine was 20.1 ± 6 points (ranging from 0 to 28). The majority (89.3%) had a moderate to high score relating to attitude about perceived advantages.

Most participants agreed or strongly agreed that telemedicine was useful for the patient (82.3%), for the physician (81.5%) and for the health system in general (74.5%).

Most participants agreed or strongly agreed that telemedicine improves access to health care (82.3%) and facilitates communication between healthcare professionals (86.4%).

Compatibility

The mean score of perceived compatibility of telemedicine was 7.3 ± 2.8 points (ranging from 0 to 12). The majority (76.5%) had a moderate to high score relating to attitude about perceived compatibility.

Only 31.7% of respondents agreed or strongly agreed that telemedicine is compatible with their clinical practice.

Trial ability

The mean score of perceived ability and motivation to try telemedicine (ranging between 0 to 28) was 21.5 ± 5 points. The majority (93%) had a moderate to high score relating to attitude about ability to try telemedicine.

Most of the participants agreed or strongly agreed that they would like to receive training about telemedicine (86.8 %); they thought that telemedicine is useful in their practice (78.2%) and agreed to use telemedicine in their future practice (88.5%).

Complexity/disadvantages

The mean score of complexity and disadvantages of telemedicine was 14.8 ± 4.9 points (ranging between 0 to 28). The majority (64.6%) had a moderate to high score relating to attitude regarding this aspect; they did not consider telemedicine as complex or having disadvantages.

The principal perceived advantages of applying telemedicine were patient interest (34.2%), tele surveillance (22.2%) and exchange of opinions between physicians (tele expertise) (20.6%).

Most of respondents thought that telemedicine is the future of medical practice (70.8%), is a necessity (72%), is a hope (70.8%) and does not interest specialists only (84%). The majority declared that they were interested in telemedicine (83.5%).

Perceived barriers to applying telemedicine

The principal perceived barriers to applying telemedicine were challenges of organization and implementation, incomplete patient examination, economic cost and remuneration and medico-legal aspects (see Figure 1). The practice sector (public or private) was significantly associated with challenges of organization and economic cost and remuneration barriers (p <10^-3, p = 0.001, respectively). The obstacle relating to the lack of credibility with patients was found to be significantly associated with gender and age (p = 0.007, p = 0.01, respectively) (see Table 4).

Figure 1. Perceived barriers to the application of telemedicine (N=243).

Table 4. Identification of the main barriers, perceived by doctors, to the application of telemedicine and the study of their association with the socio-professional factors of the study population (N = 243).

Socio-professional factors	Obstacles to telemedicine implementation
Socio-professional factors	Yes N (%)	NO N (%)	OR [CI_95%]	p
	Challenges of organization
Gender				0.4
Male	85 (81.7)	19 (18.3)	0.75 [0.4–1.5]
Female	119 (85.6)	20 (14.4)
Age categories (years)				0.18
30–39	72 (88.9)	9 (11.1)	-
40–49	70 (78.7)	19 (21.3)
≥50	62 (84.9)	11 (15.1)
Years of experience				0.12
<5	44 (93.6)	3 (6.4)	-
5–10	57 (82.6)	12 (17.4)
>10	103 (81.1)	24 (18.9)
Practice sector				<10^-3
Public	151 (92.1)	13 (7.9)	5.7 [2.7–11.9]
Private	53 (67.1)	26 (32.9)
Practice zone				1
Urban	195 (83.7)	38 (16.3)	0.6 [0.07–4.6]
Rural	9 (90.0)	1 (10.0)
Specialisation				0.7
General medicine	42 (82.4)	9 (17.6)	1.2 [0.5–2.6]
Specialist	162 (84.4)	30 (15.6)
	Economic cost and remuneration
Gender				0.2
Male	79 (76.0)	25 (24.0)	0.6 [0.4–1.2]
Female	115 (82.7)	24 (17.3)
Age categories (years)				0.6
30–39	67 (82.7)	14 (17.3)	-
40–49	69 (77.5)	20 (22.5)
≥50	58 (79.5)	15 (20.5)
Years of experience				0.2
<5	39 (83.0)	8 (17.0)	-
5–10	59 (85.5)	10 (14.5)
>10	96 (75.6)	31 (24.4)
Practice sector				0.001
Public	141 (86.0)	23 (14.0)	3.0 [1.6–5.7]
Private	53 (67.1)	26 (32.9)
Practice zone				0.2
Urban	184 (79.0)	49 (21.0)	-
Rural	10 (100.0)	0 (0.0)
Specialisation				0.7
General medicine	40 (78.4)	11 (21.6)	1.1 [0.5–2.4]
Specialist	154 (80.2)	38 (19.8)
	Lack of motivation
Gender				0.7
Male	49 (47.1)	55 (52.9)	0.9 [0.6–1.5]
Female	69 (49.6)	70 (50.4)
Age categories (years)				0.9
30–39	39 (48.1)	42 (51.9)	-
40–49	42 (47.2)	47 (52.8)
≥50	37 (50.7)	36 (49.3)
Years of experience				0.1
<5	18 (38.3)	29 (61.7)	-
5–10	39 (56.5)	30 (43.5)
>10	61 (48.0)	66 (52.0)
Practice sector				0.6
Public	78 (47.6)	86 (52.4)	0.9 [0.5–1.5]
Private	40 (50.6)	39 (49.4)
Practice zone				0.7
Urban	114 (48.9)	119 (51.1)	1.4 [0.4–5.2]
Rural	4 (40.0)	6 (60.0)
Specialisation				0.04
General medicine	31 (60.8)	20 (39.2)	0.5 [0.3–1.0]
Specialist	87 (45.3)	105 (54.7)
	Lack of time
Gender				0.02
Male	38 (36.5)	66 (63.5)	0.6 [0.3–0.9]
Female	71 (51.1)	68 (48.9)
Age categories (years)				0.7
30–39	35 (43.2)	46 (56.8)	-
40–49	43 (48.3)	46 (51.7)
≥50	31 (42.5)	42 (57.5)
Years of experience				0.8
<5	19 (40.4)	28 (59.6)	-
5–10	32 (46.4)	37 (53.6)
>10	58 (45.7)	69 (54.3)
Practice sector				0.07
Public	67 (40.9)	97 (59.1)	0.6 [0.4–1.0]
Private	42 (53.2)	37 (46.8)
Practice zone				0.5
Urban	106 (45.5)	127 (54.5)	1.9 [0.5–7.7]
Rural	3 (30.0)	7 (70.0)
Specialisation				0.5
General medicine	21 (41.2)	30 (58.8)	1.2 [0.6–2.3]
Specialist	88 (45.8)	104 (54.2)
	Lack of credibility with patients
Gender				0.007
Male	35 (33.7)	69 (66.3)	0.5 [0.3–0.8]
Female	71 (51.1)	68 (48.9)
Age categories (years)				0.01
30–39	45 (55.6)	36 (44.4)	-
40–49	37 (41.6)	52 (58.4)
≥50	24 (32.9)	49 (67.1)
Years of experience				0.1
<5	24 (51.1)	23 (48.9)	-
5–10	34 (49.3)	35 (50.7)
>10	48 (37.8)	79 (62.2)
Practice sector				0.6
Public	73 (44.5)	91 (55.5)	1.1 [0.6–1.9]
Private	33 (41.8)	46 (58.2)
Practice zone				0.1
Urban	99 (42.5)	134 (57.5)	0.3 [0.08–1.2]
Rural	7 (70.0)	3 (30.0)
Specialisation				0.2
General medicine	26 (51.0)	25 (49.0)	0.7 [0.4–1.3]
Specialist	80 (41.7)	112 (58.3)
	Medico-legal aspect
Gender				0.1
Male	78 (75.0)	26 (25.0)	0.6 [0.3–1.1]
Female	116 (83.5)	23 (16.5)
Age categories (years)				0.8
30–39	66 (81.5)	15 (18.5)	-
40–49	71 (79.8)	18 (20.2)
≥50	57 (78.1)	16 (21.9)
Years of experience				0.5
<5	40 (85.1)	7 (14.9)	-
5–10	53 (76.8)	16 (23.2)
>10	101 (79.5)	26 (20.5)
Practice sector				0.09
Public	126 (76.8)	38 (23.2)	0.5 [0.3–1.2]
Private	68 (86.1)	11 (13.9)
Practice zone				0.7
Urban	186 (79.8)	47 (20.2)	0.9 [0.2–4.8]
Rural	8 (80.0)	2 (20.0)
Specialisation				0.8
General medicine	40 (78.4)	11 (21.6)	1.1 [0.5–2.4]
Specialist	154 (80.2)	38 (19.8)
	Incomplete patient examination
Gender				0.2
Male	80 (76.9)	24 (23.1)	0.7 [0.3–1.2]
Female	116 (83.5)	23 (16.5)
Age categories (years)				0.2
30–39	69 (85.2)	12 (14.8)	-
40–49	73 (82.0)	16 (18.0)
≥50	54 (74.0)	19 (26.0)
Years of experience				0.08
<5	42 (89.4)	5 (10.6)	-
5–10	58 (84.1)	11 (15.9)
>10	96 (75.6)	31 (24.4)
Practice sector				0.9
Public	132 (80.5)	32 (19.5)	0.9 [0.5–1.9]
Private	64 (81.0)	15 (19.0)
Practice zone				0.1
Urban	190 (81.5)	43 (18.5)	2.9 [0.8–10.9]
Rural	6 (60.0)	4 (40.0)
Specialisation				0.6
General medicine	40 (78.4)	11 (21.6)	1.2 [0.6–2.5]
Specialist	156 (81.3)	36 (18.8)

Practice

Almost half (46.9%) of interrogated physicians had practiced telemedicine activities before, using a mobile phone application (91%) or social media (64%). The majority among them (82.4%) had five years or more of professional experience; 55.3% were females; 59.6% were working in the public sector and 78.9% were specialists. There was no significant association between sociodemographic characteristics of the study population and practice of telemedicine.

A total of 63.4% declared that they intended to use telemedicine in their future activity and 32.1% were undecided.

Discussion

Telemedicine is finding an increasingly obvious place in optimizing curative, collegial, evidence-based and local medicine in societies that are experiencing a tangible digitalization in healthcare. It is integrated as a key element in the evolution towards telehealth, which is supported by health management and integrates telecommunication systems and telecommunication technologies to protect and improve health.¹⁵

The use of ICT in health care systems is likely to be influenced by many factors. The main factor appears to be the availability of an Internet connection and the necessary equipment (computer, web camera, headsets, …) as well as a suitable place for telemedicine practice. In this study, most participants declared that they had a good Internet connection (53.5%), a suitable place to perform telemedicine (58%) and access to a computer (86.8%). However, the majority did not have the required accessories. In a French study carried out in 2017 among 278 physicians, although 84% stated that they had a good Internet connection, and 99.6% had access to a computer, only 34% had appropriate premises for the practice of telemedicine, and few had accessories (36% had a camera and 25% had a headset microphone).¹⁶

As for computer skills, most participants (95.9%) had an average to high level. Our findings were comparable to those of a recent study conducted in Libya, a neighbouring country, where only 26.6% of participants had professional computer skills, while 67.2% and 6.2% participants had average and beginner computer skill levels, respectively.¹⁷ These skills are highly important for implementing the use of telemedicine services.

Among human-related factors influencing the use of telemedicine, components such as users’ knowledge and attitude towards technology are highly important.¹⁸ Several studies have shown that attitude and perception are important and key research questions to explain how telemedicine is viewed and conceived by health professionals.¹⁷^,¹⁹ Our results showed that most Tunisian physicians have heard about telemedicine and the main sources of this information were media and colleagues. These findings were corroborated by the results of a large survey conducted in European countries and in Iran.²⁰

Participants’ knowledge regarding telemedicine was unsatisfactory since only 39.1% of respondents had heard about the Tunisian telemedicine decree and 59.3% had a poor level of telemedicine knowledge. Our results were consistent with studies published in developing countries. In fact, only 37.6% of medical doctors in Ethiopia had good knowledge of telemedicine.¹⁸ An Egyptian study reported that only 53.6% had a good level of knowledge about telemedicine.²¹ Moreover, a cross-sectional study in India found similar results (41% had good knowledge).²² The level of telemedicine knowledge in developing countries remains poor due to several factors. In many developing countries, healthcare professionals have limited awareness and education about telemedicine. This is partly because telemedicine is not yet widely used and there is a lack of training and educational programs to inform healthcare professionals about its benefits and applications. Also, the lack of clear regulations and policies for telemedicine in these countries contributes to a low level of knowledge.

A good level of knowledge was significantly associated with the age category over 50 years (p = 0.02) and with years of experience over 10 (p = 0.03) in our study. These results were different from most studies. In fact, a cross-sectional Indian survey observed higher knowledge scores among MDs younger than 50-years-old.²⁰ Moreover, Barton et al. found a significant difference in self-assessed knowledge and beliefs about telemedicine between the specialist physicians who were users of telemedicine and specialist physicians who were non-users of telemedicine.²³

Most of the participants in our survey had a positive attitude towards telemedicine and its perceived advantages. Similar results were found among healthcare providers in Egypt, Saudi Arabia and Ethiopia.¹³^,²¹^,²⁴ Even with limited knowledge, healthcare providers in developing countries often perceive telemedicine positively due to its potential to improve access to healthcare, especially in remote and underserved areas. They see it as a tool that can help bridge the gap in healthcare delivery. A survey in Michigan State University, USA, and other similar studies showed that the attitude of health care workers is an important factor in understanding and accepting telemedicine technologies.¹⁸^,²²^,²⁵^–²⁷ These facts are important, especially in countries struggling with implementing telemedicine in their routine practice, because attitude represents how telemedicine is perceived by health care workers. For such acceptance, program developers need to train health care workers and make the telemedicine programs usable for them.²⁸

Furthermore, the most cited advantages of telemedicine by Tunisian physicians were improving access to health care (82.3%) and facilitating communication between healthcare professionals (86.4%). The benefits of telemedicine were widely discussed in the literature, among them we found: promoting cooperation between public and private fields, reducing the waste of time and long trips for patients, resolving medical desert issues, treating isolated patients or those who cannot travel, adapting the supply of care to demographic changes and meeting the needs related to demographic changes and finally being able to respond to the growing number of patients suffering from chronic diseases.²⁹^–³¹ Moreover, qualitative studies emphasised the importance of economic gain when using telemedicine.²⁹^,³⁰

Most of our participants expressed their ability to try telemedicine in their future practice. In a large cross-sectional conducted in India, only 60% expressed interest in adopting this new technology in their future career.²⁰ However, Ethiopian physicians were more open to trying telemedicine since 93.3% of them agreed or strongly agreed that trying telemedicine was a great opportunity and 81.9% of them would like to begin a telemedicine application.⁶

The majority of interrogated Tunisian doctors found telemedicine not complex and compatible with most of their practice aspects (64.6%). However, they expressed some serious concerns regarding the challenges of organization and implementation (84%), incomplete patient examination (80.7%), economic cost and remuneration (79.8%) and medico-legal aspects (79.8%). Moreover, only 31.7% thought that telemedicine was compatible with their clinical practice. The same concerns were expressed in other studies.⁶^,²² Furthermore, new ethical issues have emerged from this type of medical practice regarding patients’ confidentiality.²⁸ These findings indicate that much work is needed to be done to educate health care professionals about telemedicine and to lay the groundwork for successful and sustainable adoption of the technology in the country.⁶

Moreover, other limitations to the implementation of telemedicine in resource limited countries deserve to be mentioned, such as technical issues and defective health care infrastructure restricting the potential for swift and innovative reforms.³²^–³⁴

As for practicing telemedicine, 46.9% of interrogated physicians had practiced telemedicine activities before, using a mobile phone (91%) or social media (64%). This emphasises the need for creating a suitable common platform in order to properly practice telemedicine and therefore avoid some confidentiality issues relating to the use of the phone or social media.

Strengths and limitations of our study

This was the first Tunisian publication studying knowledge, attitudes, and practice of telemedicine among Tunisian practitioners. Our sample size was considerable, and we included all kinds of MD (public and private, specialist and non-specialist physicians). However, the study sample was not representative of all medical practitioners and we did not take into consideration cultural aspects relating to telemedicine, or the patient’s perspective on the issue.

Recommendations

We recommend establishing continuous professional development programs to enhance healthcare professionals' knowledge of telemedicine, including its legislation in Tunisia, and to provide training in software and computer skills. Additionally, training in ethical and medico-legal issues related to telemedicine is crucial to ensure patient confidentiality.

For future perspectives, we propose a comprehensive study of telemedicine in greater depth and gather the perspectives of different stakeholders, including policymakers, platform managers, doctors, and patients. Our study addressed the issue of telemedicine from the perspective of doctors only. Further studies should target patients and policymakers to understand their perceptions of telemedicine, aiming for a comprehensive vision that includes the opinions of all stakeholders.

Moreover, qualitative studies could be valuable to gather expert opinions on the benefits and challenges of adopting telemedicine in the medical field. Understanding different practical implementation modalities before initiating large-scale projects can help ensure their success and profitability.

Conclusions

In conclusion, although Tunisian physicians’ knowledge level and practice of telemedicine were unsatisfactory, their positive attitude and willingness to try it in their future practice was encouraging. The Tunisian government should encourage this practice by must create the enabling environment, develop strategy and policies for telemedicine, and set up regulations.

Consent

Written informed consent for publication of the participants’ details was obtained from the participants.

Data availability

Underlying data

Harvard Dataverse: Underlying data for ‘Toward implementing telemedicine in Tunisia: Results of a knowledge, attitude and practice study among medical doctors’, “Telemedicine-Tunisia”, https://doi.org/10.7910/DVN/AAMOQN.¹⁴

This project contains the following underlying data:

• Date file 1: Telemedicine-Tunisia.xlsx (anonymised underlying data collected from medical doctors)

Extended data

Harvard Dataverse: Extended data for ‘Toward implementing telemedicine in Tunisia: Results of a knowledge, attitude and practice study among medical doctors’, “Telemedicine-Tunisia”, https://doi.org/10.7910/DVN/AAMOQN.¹⁴

This project contains the following extended data:

• Questionnaire: Telemedicine – English version.pdf

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Acknowledgments

The authors want to thank the “Complementary studies in pedagogical and digital engineering Committee”, Faculty of Medicine of Tunis, for their support throughout the writing process. This study was carried out to obtain the certificate of complementary studies in pedagogical and digital engineering.

References

1. Waller M, Stotler C: Telemedicine: a Primer. Curr Allergy Asthma Rep. 2018 Aug 25; 18(10): 54. Publisher Full Text
2. Ryu S: Telemedicine: Opportunities and Developments in Member States: Report on the Second Global Survey on eHealth 2009 (Global Observatory for eHealth Series, Volume 2). Healthc Inform Res. 2012 Jun; 18(2): 153–155. Publisher Full Text
3. Baker J, Stanley A: Telemedicine Technology: a Review of Services, Equipment, and Other Aspects. Curr Allergy Asthma Rep. 2018 Sep 26; 18(11): 60. PubMed Abstract | Publisher Full Text
4. Consolidated telemedicine implementation guide: (n.d.). Retrieved 9 August 2024b. https://www.who.int/publications/i/item/9789240059184
5. Wamala DS, Augustine K: A meta-analysis of telemedicine success in Africa. J Pathol Inform. 2013 Jan 1; 4(1): 6. PubMed Abstract | Publisher Full Text | Free Full Text
6. Biruk K, Abetu E: Knowledge and Attitude of Health Professionals toward Telemedicine in Resource-Limited Settings: A Cross-Sectional Study in North West Ethiopia. J Healthc Eng. 2018 Nov 18; 2018: 1–7. Publisher Full Text
7. Alboraie M, Allam MA, Youssef N, et al.: Knowledge, Applicability, and Barriers of Telemedicine in Egypt: A National Survey. Int J Telemed Appl. 2021; 2021(1): 5565652. PubMed Abstract | Publisher Full Text | Free Full Text
8. Elhadi M, Msherghi A, Elhadi A, et al.: Utilization of Telehealth Services in Libya in Response to the COVID-19 Pandemic: Cross-sectional Analysis. JMIR Med Inform. 2023; 9(2): e23335. PubMed Abstract | Publisher Full Text | Free Full Text
9. Tunisia: (n.d.). Datadot. Retrieved 13 August 2024. https://data.who.int/countries/788
10. Tunisia: (n.d.). Datadot. Retrieved 13 August 2024. https://data.who.int/countries/788
11. Tunisia Maps & Facts: WorldAtlas. December 18, 2023. https://www.worldatlas.com/maps/tunisia
12. Décret Présidentiel n° 2022-316 du 8 avril 2022, portant création d’une unité de gestion par objectifs à la Présidence du gouvernement pour la mise en place du projet de modernisation et généralisation des maisons de services et fixant son organisation et les modalités de son fonctionnement|DCAF Tunisie.[cited 2023 Jan 28]. Reference Source
13. Biruk K, Abetu E: Knowledge and Attitude of Health Professionals toward Telemedicine in Resource-Limited Settings: A Cross-Sectional Study in North West Ethiopia. J Healthc Eng. 2018; 2018(1): 2389268. PubMed Abstract | Publisher Full Text | Free Full Text
14. Nouira MTelemedicine-Tunisia [Dataset]. Harvard Dataverse. 2023. Publisher Full Text
15. WHO Group Consultation on Health Telematics (1997: Geneva S. A health telematics policy in support of WHO’s Health-for-all strategy for global health development: report of the WHO Group Consultation on Health Telematics, 11-16 December, Geneva, 1997.1998 [cited 2023 Jan 28]. Reference Source
16. Messon T: Quelle est la place des médecins généralistes dans le développement de la télémédecine? Enquête auprès des médecins généralistes de Gironde. In 2017 [cited 2023 Jan 28].Reference Source
17. Elhadi M, Elhadi A, Bouhuwaish A, et al.: Telemedicine Awareness, Knowledge, Attitude, and Skills of Health Care Workers in a Low-Resource Country During the COVID-19 Pandemic: Cross-sectional Study. J Med Internet Res. 2021 Feb 25; 23(2): e20812. PubMed Abstract | Publisher Full Text | Free Full Text
18. Ayatollahi H, Sarabi FZP, Langarizadeh M: Clinicians’ Knowledge and Perception of Telemedicine Technology. Perspect Health Inf Manag. 2015 Nov 1; 12(Fall): 1c. PubMed Abstract
19. Mairinger T, Gabl C, Derwan P, et al.: What do physicians think of telemedicine? A survey in different European regions. J Telemed Telecare. 1996 Mar 1; 2(1): 50–56. PubMed Abstract | Publisher Full Text
20. Zayapragassarazan Z: Awareness, Knowledge, Attitude and Skills of Telemedicine among Health Professional Faculty Working in Teaching Hospitals. JCDR. 2016 [cited 2023 Jan 28]; JC04. PubMed Abstract | Publisher Full Text | Free Full Text Reference Source
21. Elareed HR, Elroby FA, Adly ES, et al.: Knowledge and moral attitude toward telemedicine among Egyptian physicians. J Public Health. 2023.Publisher Full Text
22. Barton PL, Brega AG, Devore PA, et al.: Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology. Telemed J E Health. 2007 Oct; 13(5): 487–500. PubMed Abstract | Publisher Full Text
23. Olok GT, Yagos WO, Ovuga E: Knowledge and attitudes of doctors towards e-health use in healthcare delivery in government and private hospitals in Northern Uganda: a cross-sectional study. BMC Med Inform Decis Mak. 2015 Nov; 15(15): 87. Publisher Full Text
24. Ahmed TJ, Baig M, Bashir MA, et al.Knowledge, attitudes, and perceptions related to telemedicine among young doctors and nursing staff at the King Abdul-Aziz University Hospital Jeddah, KSA.Niger J Clin Pract. 2021; 24(4): 464–469. PubMed Abstract | Publisher Full Text
25. Idowu PA, Adagunodo ER, Idowu AO, et al.: Electronic referral system for hospitals in Nigeria. IFE J Sci. 2004; 6(2): 161–166.
26. Parvin R, Shahjahan M: Knowledge, Attitude and Practice on eHealth Among Doctors Working at Selected Private Hospitals in Dhaka, Bangladesh. J Int Soc Telemed eHealth. 2016 Sep 22; 4: e15 (1-11).
27. Whitten P, Holtz B, Nguyen L: Keys to a successful and sustainable telemedicine program. Int J Technol Assess Health Care. 2010 Apr; 26(2): 211–216. PubMed Abstract | Publisher Full Text
28. Presseau J, Sniehotta FF, Francis JJ, et al.: Multiple goals and time constraints: perceived impact on physicians’ performance of evidence-based behaviours. Implement Sci. 2009 Nov 26; 4(1): 77. PubMed Abstract | Publisher Full Text | Free Full Text
29. Lombardo F: La télémédecine en médecine générale: évaluation du point de vue et du ressenti des médecins généralistes. [thèse: médecine]. Paris: Université Pierre et Marie Curie.2013.
30. Carré E: Télémédecine: représentations et expériences des médecins généralistes: Étude qualitative menée auprès de médecins généralistes du Languedoc-Roussillon.
31. Mathieu S: La téléconsultation: l’avis des médecins généralistes dans les Alpes Maritimes. [thèse: médecine]. Sophia Antipolis: Université de Nice-Sophia Antipolis.2012.
32. Xu H, Huang S, Qiu C, et al.: Monitoring and Management of Home-Quarantined Patients With COVID-19 Using a WeChat-Based Telemedicine System: Retrospective Cohort Study. J Med Internet Res. 2020 Jul 2; 22(7): e19514. PubMed Abstract | Publisher Full Text | Free Full Text
33. Lonergan PE, Iii SLW, Branagan L, et al.: Rapid Utilization of Telehealth in a Comprehensive Cancer Center as a Response to COVID-19: Cross-Sectional Analysis. J Med Internet Res. 2020 Jul 6; 22(7): e19322. PubMed Abstract | Publisher Full Text | Free Full Text
34. Angood MD, Peter B: Telemedicine, the Internet, and World Wide Web: Overview, CurrentStatus, and Relevance to Surgeons. World J Surg. 2001 Nov 1; 25(11): 1449–1457. PubMed Abstract | Publisher Full Text

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Version 2

VERSION 2 PUBLISHED 22 Aug 2023

Author details Author details

Nesrine Souayeh
Roles: Conceptualization, Data Curation, Methodology, Project Administration, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

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Published: 20 Aug 2024, 12:1025

https://doi.org/10.12688/f1000research.138320.2

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https://doi.org/10.12688/f1000research.138320.1

© 2024 Nouira M and Souayeh N. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Nouira M and Souayeh N. Towards implementing telemedicine in Tunisia: A knowledge, attitude and practice study among medical doctors [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2024, 12:1025 (https://doi.org/10.12688/f1000research.138320.2)

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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested

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Reviewer Report 30 Sep 2024

Sumaiah Alrawiai, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia

Approved

https://doi.org/10.5256/f1000research.170105.r315506

The authors have addressed my concerns. However, in the future, I suggest you refer to the exact page and ... Continue reading

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Reviewer Report 05 Sep 2024

Giulio Nittari, School of Medicinal and Health Products Sciences, University of Camerino, Camerino, Italy

Approved with Reservations

https://doi.org/10.5256/f1000research.170105.r318542

A good analysis of the topic regarding telemedicine use in Tunisia.

some modifications are required before accepting for indexing:

In the introduction section/ or discussion a thorough analysis of telemedicine and telehealth should be mentioned in regards to and especially after covid-19, since more and more health professionals tend to telemedicine for patient evaluation and follow-up during this period and most of them implement it still nowadays.
you can draw information from:

(Ricci et al., 2020)(Ref-1)
(Nittari et al.,2022)(Ref-2)

In discussion section a comparison regarding European countries should be noted to have a more overall complete discussion of the topic: Information can be drawn from:

(Ricci et al., 2020)(Ref-1)

In limitations and recommendations a mention is done regarding patients and patience compliance regarding telemedicine as well as medicolegal implications need further analysis. Information regarding these two aspects can be found in:

(Nittari et al.,2023)(Ref-3)

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

References

1. Ricci G, Pallotta G, Sirignano A, Amenta F, et al.: Consequences of COVID-19 Outbreak in Italy: Medical Responsibilities and Governmental Measures.Front Public Health. 2020; 8: 588852 PubMed Abstract | Publisher Full Text
2. Nittari G, Savva D, Tomassoni D, Tayebati SK, et al.: Telemedicine in the COVID-19 Era: A Narrative Review Based on Current Evidence.Int J Environ Res Public Health. 2022; 19 (9). PubMed Abstract | Publisher Full Text
3. Nittari G, Ricci G, Savva D, Gibelli F, et al.: Telemedicine in diabetic ulcer management: A pilot study with exploration of medico-legal aspects.Nutr Metab Cardiovasc Dis. 2023; 33 (11): 2280-2286 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Telemedicine, Telepharmacy, Neuroimmaging, Neurodegeneration, neuroinflammation, Public health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report 27 Aug 2024

Benson Ncube, University of KwaZulu-Natal, Durban, South Africa

Approved

https://doi.org/10.5256/f1000research.170105.r315507

The authors have satisfactorily addressed my concerns in their manusrcipt.
However, they ... Continue reading

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Reviewer Report 26 Jun 2024

Sumaiah Alrawiai, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia

Approved with Reservations

https://doi.org/10.5256/f1000research.151510.r281821

This is an interesting paper that aims to explore the knowledge, attitudes, and practice of telemedicine by doctors in Tunisia.
However, there are some issues that need to be addressed and they are presented here:

The introduction could benefit from additional information on the current healthcare landscape in Tunisia and how telemedicine could help. What are the possible barriers and facilitators to adopting telemedicine in Tunisia, or if not available, countries with similar healthcare system to Tunisia?
Towards the end of the introduction, the objective was stated but it was missing the practice part. Only knowledge and attitudes were mentioned.
The methods section is missing some information. How did you develop the questionnaire? Was it adopted from another study, or was it developed by the authors? If developed by authors, how did you develop it, and what were the sources used? If it was adopted from another study, then please reference the source.
Also, in the methods section, when sending the invites, did you send any reminders, and were there any differences between those who responded and those who didn’t? Was the sample size enough? How did you ensure that?
If the questionnaire was developed by the authors, how did you ensure the validity and reliability of the questionnaire?
Under the discussion, some areas would benefit from an in-depth analysis of why there was a difference or a similarity between your study and other studies.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: My research topics include patient-centered care, shared decision-making, and patient-doctor communication. I've done some studies in digital health as well.

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Author Response 20 Aug 2024

Mariem Nouira, Epidemiology Department, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, 1006, Tunisia

20 Aug 2024

Author Response

Dear Dr Sumaiah Alrawiai,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the ... Continue reading Dear Dr Sumaiah Alrawiai,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the responses to your comments:

Reviewer comment: The introduction could benefit from additional information on the current healthcare landscape in Tunisia and how telemedicine could help. What are the possible barriers and facilitators to adopting telemedicine in Tunisia, or if not available, countries with similar healthcare system to Tunisia?
Author response: The introduction was modified. For the barriers to adopting telemedicine in Tunisia, it was the secondary objective of our study, and it was responded in the result section. It was also discussed in the discussion. Thank you.

Reviewer comment: Towards the end of the introduction, the objective was stated but it was missing the practice part. Only knowledge and attitudes were mentioned.
Author response: It was corrected. Thank you

Reviewer comment: The methods section is missing some information. How did you develop the questionnaire? Was it adopted from another study, or was it developed by the authors? If developed by authors, how did you develop it, and what were the sources used? If it was adopted from another study, then please reference the source.
Author response: The questionnaire was developed essentially by the authors, and it was partly inspired from a study conducted in Ethiopia that was cited. Thank you.

Reviewer comment: Also, in the methods section, when sending the invites, did you send any reminders, and were there any differences between those who responded and those who didn’t? Was the sample size enough? How did you ensure that?
Author response: We did not send reminders. And we didn’t have information about the non responders so we can’t compare them with the responders. We didn’t calculate the sample size because we didn’t have the results of a Tunisian study that was conducted previously using the same questionnaire to use the parameters to calculate the sample size. Also, we didn’t find in the literature a specific formula to calculate sample size of Knowledge Attitude and Practice studies.

Reviewer comment: If the questionnaire was developed by the authors, how did you ensure the validity and reliability of the questionnaire?
Author response: The reliability and validity of the questionnaire was not studied in our manuscript. It could constitute the aim of another manuscript. Thank you.

Reviewer comment: Under the discussion, some areas would benefit from an in-depth analysis of why there was a difference or a similarity between your study and other studies.
Author response: The discussion was enhanced and modified. Thank you very much.
Dear Dr Sumaiah Alrawiai,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the responses to your comments:

Reviewer comment: The introduction could benefit from additional information on the current healthcare landscape in Tunisia and how telemedicine could help. What are the possible barriers and facilitators to adopting telemedicine in Tunisia, or if not available, countries with similar healthcare system to Tunisia?
Author response: The introduction was modified. For the barriers to adopting telemedicine in Tunisia, it was the secondary objective of our study, and it was responded in the result section. It was also discussed in the discussion. Thank you.

Reviewer comment: Towards the end of the introduction, the objective was stated but it was missing the practice part. Only knowledge and attitudes were mentioned.
Author response: It was corrected. Thank you

Reviewer comment: The methods section is missing some information. How did you develop the questionnaire? Was it adopted from another study, or was it developed by the authors? If developed by authors, how did you develop it, and what were the sources used? If it was adopted from another study, then please reference the source.
Author response: The questionnaire was developed essentially by the authors, and it was partly inspired from a study conducted in Ethiopia that was cited. Thank you.

Reviewer comment: Also, in the methods section, when sending the invites, did you send any reminders, and were there any differences between those who responded and those who didn’t? Was the sample size enough? How did you ensure that?
Author response: We did not send reminders. And we didn’t have information about the non responders so we can’t compare them with the responders. We didn’t calculate the sample size because we didn’t have the results of a Tunisian study that was conducted previously using the same questionnaire to use the parameters to calculate the sample size. Also, we didn’t find in the literature a specific formula to calculate sample size of Knowledge Attitude and Practice studies.

Reviewer comment: If the questionnaire was developed by the authors, how did you ensure the validity and reliability of the questionnaire?
Author response: The reliability and validity of the questionnaire was not studied in our manuscript. It could constitute the aim of another manuscript. Thank you.

Reviewer comment: Under the discussion, some areas would benefit from an in-depth analysis of why there was a difference or a similarity between your study and other studies.
Author response: The discussion was enhanced and modified. Thank you very much.
Competing Interests: No competing interests were disclosed. Close
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Author Response 20 Aug 2024

Mariem Nouira, Epidemiology Department, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, 1006, Tunisia

20 Aug 2024

Author Response

Dear Dr Sumaiah Alrawiai,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the ... Continue reading Dear Dr Sumaiah Alrawiai,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the responses to your comments:

Reviewer comment: The introduction could benefit from additional information on the current healthcare landscape in Tunisia and how telemedicine could help. What are the possible barriers and facilitators to adopting telemedicine in Tunisia, or if not available, countries with similar healthcare system to Tunisia?
Author response: The introduction was modified. For the barriers to adopting telemedicine in Tunisia, it was the secondary objective of our study, and it was responded in the result section. It was also discussed in the discussion. Thank you.

Reviewer comment: Towards the end of the introduction, the objective was stated but it was missing the practice part. Only knowledge and attitudes were mentioned.
Author response: It was corrected. Thank you

Reviewer comment: The methods section is missing some information. How did you develop the questionnaire? Was it adopted from another study, or was it developed by the authors? If developed by authors, how did you develop it, and what were the sources used? If it was adopted from another study, then please reference the source.
Author response: The questionnaire was developed essentially by the authors, and it was partly inspired from a study conducted in Ethiopia that was cited. Thank you.

Reviewer comment: Also, in the methods section, when sending the invites, did you send any reminders, and were there any differences between those who responded and those who didn’t? Was the sample size enough? How did you ensure that?
Author response: We did not send reminders. And we didn’t have information about the non responders so we can’t compare them with the responders. We didn’t calculate the sample size because we didn’t have the results of a Tunisian study that was conducted previously using the same questionnaire to use the parameters to calculate the sample size. Also, we didn’t find in the literature a specific formula to calculate sample size of Knowledge Attitude and Practice studies.

Reviewer comment: If the questionnaire was developed by the authors, how did you ensure the validity and reliability of the questionnaire?
Author response: The reliability and validity of the questionnaire was not studied in our manuscript. It could constitute the aim of another manuscript. Thank you.

Reviewer comment: Under the discussion, some areas would benefit from an in-depth analysis of why there was a difference or a similarity between your study and other studies.
Author response: The discussion was enhanced and modified. Thank you very much.
Dear Dr Sumaiah Alrawiai,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the responses to your comments:

Reviewer comment: The introduction could benefit from additional information on the current healthcare landscape in Tunisia and how telemedicine could help. What are the possible barriers and facilitators to adopting telemedicine in Tunisia, or if not available, countries with similar healthcare system to Tunisia?
Author response: The introduction was modified. For the barriers to adopting telemedicine in Tunisia, it was the secondary objective of our study, and it was responded in the result section. It was also discussed in the discussion. Thank you.

Reviewer comment: Towards the end of the introduction, the objective was stated but it was missing the practice part. Only knowledge and attitudes were mentioned.
Author response: It was corrected. Thank you

Reviewer comment: The methods section is missing some information. How did you develop the questionnaire? Was it adopted from another study, or was it developed by the authors? If developed by authors, how did you develop it, and what were the sources used? If it was adopted from another study, then please reference the source.
Author response: The questionnaire was developed essentially by the authors, and it was partly inspired from a study conducted in Ethiopia that was cited. Thank you.

Reviewer comment: Also, in the methods section, when sending the invites, did you send any reminders, and were there any differences between those who responded and those who didn’t? Was the sample size enough? How did you ensure that?
Author response: We did not send reminders. And we didn’t have information about the non responders so we can’t compare them with the responders. We didn’t calculate the sample size because we didn’t have the results of a Tunisian study that was conducted previously using the same questionnaire to use the parameters to calculate the sample size. Also, we didn’t find in the literature a specific formula to calculate sample size of Knowledge Attitude and Practice studies.

Reviewer comment: If the questionnaire was developed by the authors, how did you ensure the validity and reliability of the questionnaire?
Author response: The reliability and validity of the questionnaire was not studied in our manuscript. It could constitute the aim of another manuscript. Thank you.

Reviewer comment: Under the discussion, some areas would benefit from an in-depth analysis of why there was a difference or a similarity between your study and other studies.
Author response: The discussion was enhanced and modified. Thank you very much.
Competing Interests: No competing interests were disclosed. Close
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Reviewer Report 07 May 2024

Benson Ncube, University of KwaZulu-Natal, Durban, South Africa

Approved with Reservations

https://doi.org/10.5256/f1000research.151510.r257775

1. General,
The authors are discussing an important aspect in the field of telemedicine. This is a quite relevant topic and they are commended for their work. Albeit some comments are presented to redeem this manuscript.

2. In the topic, I suggest the authors consider deleting the words "Results of a", because we know they are presenting the results.

3. Abstract. The sample size must be stated in this section.

4. Introduction. What about "cloud and mobile computing?"In para 2, The use of ICTs is not only dominant in the health sector. "Telemedicine, one of the most promising forms of ICT," This is not a true statement. Rephrase.
In para 3, I suggest you use the current definition of telemedicine by WHO. In para 5, please cite more African cases, eg. Botswana, South Africa, Egypt, Lybia, etc. There are plenty of such cases. A little bit of explanation of the presidential decree will give a better understanding to the reader.
Authors are requested to provide a more detailed context on where the study took place. What is the land size of Tunisia? population of the general public? how is the health system structured in Tunisia? What is the doctor/patient ratio? Compare this ratio with the recommended WHO ratio for Tunisia. How is the mobile phone penetraition rate, and the affordability of mobile phone services?

5. Methods. I suggest authors give a detailed description of the Questionnaire, in terms of types and number of questions, e.g. Likert, dichotomous, open-ended, closed questions. What is the sample size? Authors should be very clear on this, as they know exactly how many participants they sampled. Determine and present the response rate of participants. Your design of the study needs to be clearly articulated, to cover the sample size, sampling strategy, inclusion/exclusion criteria, and data analysis methods used. Discuss the use of statistics in the design. The results of the analysis should be presented in the Results section.

There is a need to present your Chi-square Test results, in order to help the reader to understand your presented results.

6. Results. In Table 2, why is it that some p-values are not presented? Inclusion of all p-values will make your table more complete. On page 5, where authors report statistically significant results, they should provide the statistics (Chi-square value), degree of freedom for the contigence table together with the p-value. This is the proper way of reporting this kind of result.

In Fig 1, you use the word "Main", which are the minor barriers then?
When reporting under the sub-heading "Perceived barriers ...." you used percentages which is a repetition of results since they are already reported in Fig. 1.

In sub-topic "Practice" you need to use items in the same class" So in the first sentence, you cannot use "mobile phone" but "mobile phone application"

7. Discussion. In the first paragraph, I suggest you add "in healthcare" at the end of the first sentence. Replace "our" with "this" as we know it is your study. It would appear there is an over use of the word "declared" throughout the paper. Please find alternatives. In the third paragraph replace were with where. In this paragraph, it will be interesting to compare your results with those of other countries like Botswana, Egypt, Nigeria, Pakistan, Ethiopia. (Ref-1). Do the same in paragraphs 4 & 5. In the subsequent paragraphs, I suggest you extract all your recommendations and put them under a sub-topic "Recommendations".
In paragraph 3, what about referrals, access to special services, and seeking or giving second opinion? You did not consider COVID-19 aspects? In paragraph 6, is the term "limited resources countries" or "resource limited countries"? In paragraph 7, an ambiguous clause is noted - using a mobile phone (91%) or social media (64%).

In the section, limitations of the study, what about the following? You did not consider the diversity of healthcare workers, those without access to the Internet.

8. Conclusion. Should the government provide equipment and telemedicine platforms? Or must create the enabling environment, develop strategy and policies for telemedicine, and set up regulations?

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

References

1. Ncube B, Mars M, Scott RE: Perceptions and attitudes of patients and healthcare workers towards the use of telemedicine in Botswana: An exploratory study.PLoS One. 2023; 18 (2): e0281754 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Digital health strategy and initiatives

CITE

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Author Response 01 Oct 2024

Mariem Nouira, Epidemiology Department, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, 1006, Tunisia

01 Oct 2024

Author Response

Dear Dr Benson Ncube,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the ... Continue reading Dear Dr Benson Ncube,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the responses to your comments:

Reviewer comment: In the topic, I suggest the authors consider deleting the words "Results of a", because we know they are presenting the results.
Author response: It was corrected. Thank you
“Towards implementing telemedicine in Tunisia: A knowledge, attitude and practice study among medical doctors”

Reviewer comment: Abstract. The sample size must be stated in this section.
Author response: We didn’t calculate the sample size because we didn’t have the results of a Tunisian study that was conducted previously using the same questionnaire to use the parameters to calculate the sample size. Also, we didn’t find in the literature a specific formula to calculate sample size of Knowledge Attitude and Practice studies.

Reviewer comment: Introduction. What about "cloud and mobile computing?"In para 2, The use of ICTs is not only dominant in the health sector. "Telemedicine, one of the most promising forms of ICT," This is not a true statement. Rephrase. In para 3, I suggest you use the current definition of telemedicine by WHO. In para 5, please cite more African cases, eg. Botswana, South Africa, Egypt, Lybia, etc. There are plenty of such cases. A little bit of explanation of the presidential decree will give a better understanding to the reader.Authors are requested to provide a more detailed context on where the study took place. What is the land size of Tunisia? population of the general public? how is the health system structured in Tunisia? What is the doctor/patient ratio? Compare this ratio with the recommended WHO ratio for Tunisia. How is the mobile phone penetraition rate, and the affordability of mobile phone services?
Author response: All suggested modifications were done thank you.

Reviewer comment: Methods. I suggest authors give a detailed description of the Questionnaire, in terms of types and number of questions, e.g. Likert, dichotomous, open-ended, closed questions.
Author response: All suggested modifications were done thank you.

Reviewer comment: Results. In Table 2, why is it that some p-values are not presented? Inclusion of all p-values will make your table more complete. On page 5, where authors report statistically significant results, they should provide the statistics (Chi-square value), degree of freedom for the contigence table together with the p-value. This is the proper way of reporting this kind of result.
Author response: The p-values of all variables (one p for each variable) were presented in the table 2. All other suggested modifications were done. Thank you.

Reviewer comment: In Fig 1, you use the word "Main", which are the minor barriers then?When reporting under the sub-heading "Perceived barriers ...." you used percentages which is a repetition of results since they are already reported in Fig. 1. In sub-topic "Practice" you need to use items in the same class" So in the first sentence, you cannot use "mobile phone" but "mobile phone application"
Author response: All suggested modifications were done thank you.

Reviewer comment: Discussion. In the first paragraph, I suggest you add "in healthcare" at the end of the first sentence. Replace "our" with "this" as we know it is your study. It would appear there is an over use of the word "declared" throughout the paper. Please find alternatives. In the third paragraph replace were with where. In this paragraph, it will be interesting to compare your results with those of other countries like Botswana, Egypt, Nigeria, Pakistan, Ethiopia. (Ref-1). Do the same in paragraphs 4 & 5. In the subsequent paragraphs, I suggest you extract all your recommendations and put them under a sub-topic "Recommendations".
Author response: All suggested modifications were done thank you.

Reviewer comment: In the section, limitations of the study, what about the following? You did not consider the diversity of healthcare workers, those without access to the Internet.
Author response: All suggested modifications were done thank you.

Reviewer comment: Conclusion. Should the government provide equipment and telemedicine platforms? Or must create the enabling environment, develop strategy and policies for telemedicine, and set up regulations?
Author response: All suggested modifications were done thank you very much.
Dear Dr Benson Ncube,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the responses to your comments:

Reviewer comment: In the topic, I suggest the authors consider deleting the words "Results of a", because we know they are presenting the results.
Author response: It was corrected. Thank you
“Towards implementing telemedicine in Tunisia: A knowledge, attitude and practice study among medical doctors”

Reviewer comment: Abstract. The sample size must be stated in this section.
Author response: We didn’t calculate the sample size because we didn’t have the results of a Tunisian study that was conducted previously using the same questionnaire to use the parameters to calculate the sample size. Also, we didn’t find in the literature a specific formula to calculate sample size of Knowledge Attitude and Practice studies.

Reviewer comment: Introduction. What about "cloud and mobile computing?"In para 2, The use of ICTs is not only dominant in the health sector. "Telemedicine, one of the most promising forms of ICT," This is not a true statement. Rephrase. In para 3, I suggest you use the current definition of telemedicine by WHO. In para 5, please cite more African cases, eg. Botswana, South Africa, Egypt, Lybia, etc. There are plenty of such cases. A little bit of explanation of the presidential decree will give a better understanding to the reader.Authors are requested to provide a more detailed context on where the study took place. What is the land size of Tunisia? population of the general public? how is the health system structured in Tunisia? What is the doctor/patient ratio? Compare this ratio with the recommended WHO ratio for Tunisia. How is the mobile phone penetraition rate, and the affordability of mobile phone services?
Author response: All suggested modifications were done thank you.

Reviewer comment: Methods. I suggest authors give a detailed description of the Questionnaire, in terms of types and number of questions, e.g. Likert, dichotomous, open-ended, closed questions.
Author response: All suggested modifications were done thank you.

Reviewer comment: Results. In Table 2, why is it that some p-values are not presented? Inclusion of all p-values will make your table more complete. On page 5, where authors report statistically significant results, they should provide the statistics (Chi-square value), degree of freedom for the contigence table together with the p-value. This is the proper way of reporting this kind of result.
Author response: The p-values of all variables (one p for each variable) were presented in the table 2. All other suggested modifications were done. Thank you.

Reviewer comment: In Fig 1, you use the word "Main", which are the minor barriers then?When reporting under the sub-heading "Perceived barriers ...." you used percentages which is a repetition of results since they are already reported in Fig. 1. In sub-topic "Practice" you need to use items in the same class" So in the first sentence, you cannot use "mobile phone" but "mobile phone application"
Author response: All suggested modifications were done thank you.

Reviewer comment: Discussion. In the first paragraph, I suggest you add "in healthcare" at the end of the first sentence. Replace "our" with "this" as we know it is your study. It would appear there is an over use of the word "declared" throughout the paper. Please find alternatives. In the third paragraph replace were with where. In this paragraph, it will be interesting to compare your results with those of other countries like Botswana, Egypt, Nigeria, Pakistan, Ethiopia. (Ref-1). Do the same in paragraphs 4 & 5. In the subsequent paragraphs, I suggest you extract all your recommendations and put them under a sub-topic "Recommendations".
Author response: All suggested modifications were done thank you.

Reviewer comment: In the section, limitations of the study, what about the following? You did not consider the diversity of healthcare workers, those without access to the Internet.
Author response: All suggested modifications were done thank you.

Reviewer comment: Conclusion. Should the government provide equipment and telemedicine platforms? Or must create the enabling environment, develop strategy and policies for telemedicine, and set up regulations?
Author response: All suggested modifications were done thank you very much.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 01 Oct 2024

Mariem Nouira, Epidemiology Department, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, 1006, Tunisia

01 Oct 2024

Author Response

Dear Dr Benson Ncube,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the ... Continue reading Dear Dr Benson Ncube,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the responses to your comments:

Reviewer comment: In the topic, I suggest the authors consider deleting the words "Results of a", because we know they are presenting the results.
Author response: It was corrected. Thank you
“Towards implementing telemedicine in Tunisia: A knowledge, attitude and practice study among medical doctors”

Reviewer comment: Abstract. The sample size must be stated in this section.
Author response: We didn’t calculate the sample size because we didn’t have the results of a Tunisian study that was conducted previously using the same questionnaire to use the parameters to calculate the sample size. Also, we didn’t find in the literature a specific formula to calculate sample size of Knowledge Attitude and Practice studies.

Reviewer comment: Introduction. What about "cloud and mobile computing?"In para 2, The use of ICTs is not only dominant in the health sector. "Telemedicine, one of the most promising forms of ICT," This is not a true statement. Rephrase. In para 3, I suggest you use the current definition of telemedicine by WHO. In para 5, please cite more African cases, eg. Botswana, South Africa, Egypt, Lybia, etc. There are plenty of such cases. A little bit of explanation of the presidential decree will give a better understanding to the reader.Authors are requested to provide a more detailed context on where the study took place. What is the land size of Tunisia? population of the general public? how is the health system structured in Tunisia? What is the doctor/patient ratio? Compare this ratio with the recommended WHO ratio for Tunisia. How is the mobile phone penetraition rate, and the affordability of mobile phone services?
Author response: All suggested modifications were done thank you.

Reviewer comment: Methods. I suggest authors give a detailed description of the Questionnaire, in terms of types and number of questions, e.g. Likert, dichotomous, open-ended, closed questions.
Author response: All suggested modifications were done thank you.

Reviewer comment: Results. In Table 2, why is it that some p-values are not presented? Inclusion of all p-values will make your table more complete. On page 5, where authors report statistically significant results, they should provide the statistics (Chi-square value), degree of freedom for the contigence table together with the p-value. This is the proper way of reporting this kind of result.
Author response: The p-values of all variables (one p for each variable) were presented in the table 2. All other suggested modifications were done. Thank you.

Reviewer comment: In Fig 1, you use the word "Main", which are the minor barriers then?When reporting under the sub-heading "Perceived barriers ...." you used percentages which is a repetition of results since they are already reported in Fig. 1. In sub-topic "Practice" you need to use items in the same class" So in the first sentence, you cannot use "mobile phone" but "mobile phone application"
Author response: All suggested modifications were done thank you.

Reviewer comment: Discussion. In the first paragraph, I suggest you add "in healthcare" at the end of the first sentence. Replace "our" with "this" as we know it is your study. It would appear there is an over use of the word "declared" throughout the paper. Please find alternatives. In the third paragraph replace were with where. In this paragraph, it will be interesting to compare your results with those of other countries like Botswana, Egypt, Nigeria, Pakistan, Ethiopia. (Ref-1). Do the same in paragraphs 4 & 5. In the subsequent paragraphs, I suggest you extract all your recommendations and put them under a sub-topic "Recommendations".
Author response: All suggested modifications were done thank you.

Reviewer comment: In the section, limitations of the study, what about the following? You did not consider the diversity of healthcare workers, those without access to the Internet.
Author response: All suggested modifications were done thank you.

Reviewer comment: Conclusion. Should the government provide equipment and telemedicine platforms? Or must create the enabling environment, develop strategy and policies for telemedicine, and set up regulations?
Author response: All suggested modifications were done thank you very much.
Dear Dr Benson Ncube,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the responses to your comments:

Reviewer comment: In the topic, I suggest the authors consider deleting the words "Results of a", because we know they are presenting the results.
Author response: It was corrected. Thank you
“Towards implementing telemedicine in Tunisia: A knowledge, attitude and practice study among medical doctors”

Reviewer comment: Abstract. The sample size must be stated in this section.
Author response: We didn’t calculate the sample size because we didn’t have the results of a Tunisian study that was conducted previously using the same questionnaire to use the parameters to calculate the sample size. Also, we didn’t find in the literature a specific formula to calculate sample size of Knowledge Attitude and Practice studies.

Reviewer comment: Introduction. What about "cloud and mobile computing?"In para 2, The use of ICTs is not only dominant in the health sector. "Telemedicine, one of the most promising forms of ICT," This is not a true statement. Rephrase. In para 3, I suggest you use the current definition of telemedicine by WHO. In para 5, please cite more African cases, eg. Botswana, South Africa, Egypt, Lybia, etc. There are plenty of such cases. A little bit of explanation of the presidential decree will give a better understanding to the reader.Authors are requested to provide a more detailed context on where the study took place. What is the land size of Tunisia? population of the general public? how is the health system structured in Tunisia? What is the doctor/patient ratio? Compare this ratio with the recommended WHO ratio for Tunisia. How is the mobile phone penetraition rate, and the affordability of mobile phone services?
Author response: All suggested modifications were done thank you.

Reviewer comment: Methods. I suggest authors give a detailed description of the Questionnaire, in terms of types and number of questions, e.g. Likert, dichotomous, open-ended, closed questions.
Author response: All suggested modifications were done thank you.

Reviewer comment: Results. In Table 2, why is it that some p-values are not presented? Inclusion of all p-values will make your table more complete. On page 5, where authors report statistically significant results, they should provide the statistics (Chi-square value), degree of freedom for the contigence table together with the p-value. This is the proper way of reporting this kind of result.
Author response: The p-values of all variables (one p for each variable) were presented in the table 2. All other suggested modifications were done. Thank you.

Reviewer comment: In Fig 1, you use the word "Main", which are the minor barriers then?When reporting under the sub-heading "Perceived barriers ...." you used percentages which is a repetition of results since they are already reported in Fig. 1. In sub-topic "Practice" you need to use items in the same class" So in the first sentence, you cannot use "mobile phone" but "mobile phone application"
Author response: All suggested modifications were done thank you.

Reviewer comment: Discussion. In the first paragraph, I suggest you add "in healthcare" at the end of the first sentence. Replace "our" with "this" as we know it is your study. It would appear there is an over use of the word "declared" throughout the paper. Please find alternatives. In the third paragraph replace were with where. In this paragraph, it will be interesting to compare your results with those of other countries like Botswana, Egypt, Nigeria, Pakistan, Ethiopia. (Ref-1). Do the same in paragraphs 4 & 5. In the subsequent paragraphs, I suggest you extract all your recommendations and put them under a sub-topic "Recommendations".
Author response: All suggested modifications were done thank you.

Reviewer comment: In the section, limitations of the study, what about the following? You did not consider the diversity of healthcare workers, those without access to the Internet.
Author response: All suggested modifications were done thank you.

Reviewer comment: Conclusion. Should the government provide equipment and telemedicine platforms? Or must create the enabling environment, develop strategy and policies for telemedicine, and set up regulations?
Author response: All suggested modifications were done thank you very much.
Competing Interests: No competing interests were disclosed. Close
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VERSION 2 PUBLISHED 22 Aug 2023

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Benson Ncube, University of KwaZulu-Natal, Durban, South Africa
Sumaiah Alrawiai, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
Giulio Nittari, University of Camerino, Camerino, Italy

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30 Sep 2024 | for Version 2

Sumaiah Alrawiai, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia

4 Views Cite this report Responses(0)

Approved

The authors have addressed my concerns. However, in the future, I suggest you refer to the exact page and line where you made the requested modification, to make it easier for the reviewer to view the changes made.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

My research topics include patient-centered care, shared decision-making, and patient-doctor communication. I've done some studies in digital health as well.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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05 Sep 2024 | for Version 2

Giulio Nittari, School of Medicinal and Health Products Sciences, University of Camerino, Camerino, Italy

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Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Telemedicine, Telepharmacy, Neuroimmaging, Neurodegeneration, neuroinflammation, Public health

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8 Views

27 Aug 2024 | for Version 2

Benson Ncube, University of KwaZulu-Natal, Durban, South Africa

8 Views Cite this report Responses(0)

Approved

The authors have satisfactorily addressed my concerns in their manusrcipt.
However, they need to replace "by" with "but" in their last sentence in the conclusion section.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Digital health strategy and initiatives

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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6 Views

26 Jun 2024 | for Version 1

Sumaiah Alrawiai, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia

6 Views Cite this report Responses(1)

Approved With Reservations

The introduction could benefit from additional information on the current healthcare landscape in Tunisia and how telemedicine could help. What are the possible barriers and facilitators to adopting telemedicine in Tunisia, or if not available, countries with similar healthcare system to Tunisia?
Towards the end of the introduction, the objective was stated but it was missing the practice part. Only knowledge and attitudes were mentioned.
The methods section is missing some information. How did you develop the questionnaire? Was it adopted from another study, or was it developed by the authors? If developed by authors, how did you develop it, and what were the sources used? If it was adopted from another study, then please reference the source.
Also, in the methods section, when sending the invites, did you send any reminders, and were there any differences between those who responded and those who didn’t? Was the sample size enough? How did you ensure that?
If the questionnaire was developed by the authors, how did you ensure the validity and reliability of the questionnaire?
Under the discussion, some areas would benefit from an in-depth analysis of why there was a difference or a similarity between your study and other studies.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

My research topics include patient-centered care, shared decision-making, and patient-doctor communication. I've done some studies in digital health as well.

Respond to this report

Responses (1)

Author Response

20 Aug 2024

Mariem Nouira, Epidemiology Department, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, 1006, Tunisia

Dear Dr Sumaiah Alrawiai,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the responses to your comments:

Reviewer comment: The introduction could benefit from additional information on the current healthcare landscape in Tunisia and how telemedicine could help. What are the possible barriers and facilitators to adopting telemedicine in Tunisia, or if not available, countries with similar healthcare system to Tunisia?
Author response: The introduction was modified. For the barriers to adopting telemedicine in Tunisia, it was the secondary objective of our study, and it was responded in the result section. It was also discussed in the discussion. Thank you.

Reviewer comment: Towards the end of the introduction, the objective was stated but it was missing the practice part. Only knowledge and attitudes were mentioned.
Author response: It was corrected. Thank you

Reviewer comment: The methods section is missing some information. How did you develop the questionnaire? Was it adopted from another study, or was it developed by the authors? If developed by authors, how did you develop it, and what were the sources used? If it was adopted from another study, then please reference the source.
Author response: The questionnaire was developed essentially by the authors, and it was partly inspired from a study conducted in Ethiopia that was cited. Thank you.

Reviewer comment: Also, in the methods section, when sending the invites, did you send any reminders, and were there any differences between those who responded and those who didn’t? Was the sample size enough? How did you ensure that?
Author response: We did not send reminders. And we didn’t have information about the non responders so we can’t compare them with the responders. We didn’t calculate the sample size because we didn’t have the results of a Tunisian study that was conducted previously using the same questionnaire to use the parameters to calculate the sample size. Also, we didn’t find in the literature a specific formula to calculate sample size of Knowledge Attitude and Practice studies.

Reviewer comment: If the questionnaire was developed by the authors, how did you ensure the validity and reliability of the questionnaire?
Author response: The reliability and validity of the questionnaire was not studied in our manuscript. It could constitute the aim of another manuscript. Thank you.

Reviewer comment: Under the discussion, some areas would benefit from an in-depth analysis of why there was a difference or a similarity between your study and other studies.
Author response: The discussion was enhanced and modified. Thank you very much.

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

21 Views

07 May 2024 | for Version 1

Benson Ncube, University of KwaZulu-Natal, Durban, South Africa

21 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Digital health strategy and initiatives

Respond to this report

Responses (1)

Author Response

01 Oct 2024

Mariem Nouira, Epidemiology Department, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, 1006, Tunisia

Dear Dr Benson Ncube,

Thank you very much for your review. We really appreciate your response and time. We have revised our manuscript as you suggested. Here are the responses to your comments:

Reviewer comment: In the topic, I suggest the authors consider deleting the words "Results of a", because we know they are presenting the results.
Author response: It was corrected. Thank you
“Towards implementing telemedicine in Tunisia: A knowledge, attitude and practice study among medical doctors”

Reviewer comment: Abstract. The sample size must be stated in this section.
Author response: We didn’t calculate the sample size because we didn’t have the results of a Tunisian study that was conducted previously using the same questionnaire to use the parameters to calculate the sample size. Also, we didn’t find in the literature a specific formula to calculate sample size of Knowledge Attitude and Practice studies.

Reviewer comment: Introduction. What about "cloud and mobile computing?"In para 2, The use of ICTs is not only dominant in the health sector. "Telemedicine, one of the most promising forms of ICT," This is not a true statement. Rephrase. In para 3, I suggest you use the current definition of telemedicine by WHO. In para 5, please cite more African cases, eg. Botswana, South Africa, Egypt, Lybia, etc. There are plenty of such cases. A little bit of explanation of the presidential decree will give a better understanding to the reader.Authors are requested to provide a more detailed context on where the study took place. What is the land size of Tunisia? population of the general public? how is the health system structured in Tunisia? What is the doctor/patient ratio? Compare this ratio with the recommended WHO ratio for Tunisia. How is the mobile phone penetraition rate, and the affordability of mobile phone services?
Author response: All suggested modifications were done thank you.

Reviewer comment: Methods. I suggest authors give a detailed description of the Questionnaire, in terms of types and number of questions, e.g. Likert, dichotomous, open-ended, closed questions.
Author response: All suggested modifications were done thank you.

Reviewer comment: Results. In Table 2, why is it that some p-values are not presented? Inclusion of all p-values will make your table more complete. On page 5, where authors report statistically significant results, they should provide the statistics (Chi-square value), degree of freedom for the contigence table together with the p-value. This is the proper way of reporting this kind of result.
Author response: The p-values of all variables (one p for each variable) were presented in the table 2. All other suggested modifications were done. Thank you.

Reviewer comment: In Fig 1, you use the word "Main", which are the minor barriers then?When reporting under the sub-heading "Perceived barriers ...." you used percentages which is a repetition of results since they are already reported in Fig. 1. In sub-topic "Practice" you need to use items in the same class" So in the first sentence, you cannot use "mobile phone" but "mobile phone application"
Author response: All suggested modifications were done thank you.

Reviewer comment: Discussion. In the first paragraph, I suggest you add "in healthcare" at the end of the first sentence. Replace "our" with "this" as we know it is your study. It would appear there is an over use of the word "declared" throughout the paper. Please find alternatives. In the third paragraph replace were with where. In this paragraph, it will be interesting to compare your results with those of other countries like Botswana, Egypt, Nigeria, Pakistan, Ethiopia. (Ref-1). Do the same in paragraphs 4 & 5. In the subsequent paragraphs, I suggest you extract all your recommendations and put them under a sub-topic "Recommendations".
Author response: All suggested modifications were done thank you.

Reviewer comment: In the section, limitations of the study, what about the following? You did not consider the diversity of healthcare workers, those without access to the Internet.
Author response: All suggested modifications were done thank you.

Reviewer comment: Conclusion. Should the government provide equipment and telemedicine platforms? Or must create the enabling environment, develop strategy and policies for telemedicine, and set up regulations?
Author response: All suggested modifications were done thank you very much.

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Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

[1] 1. Waller M, Stotler C: Telemedicine: a Primer. Curr Allergy Asthma Rep. 2018 Aug 25; 18(10): 54. Publisher Full Text

[2] 2. Ryu S: Telemedicine: Opportunities and Developments in Member States: Report on the Second Global Survey on eHealth 2009 (Global Observatory for eHealth Series, Volume 2). Healthc Inform Res. 2012 Jun; 18(2): 153–155. Publisher Full Text

[3] 3. Baker J, Stanley A: Telemedicine Technology: a Review of Services, Equipment, and Other Aspects. Curr Allergy Asthma Rep. 2018 Sep 26; 18(11): 60. PubMed Abstract | Publisher Full Text

[4] 4. Consolidated telemedicine implementation guide: (n.d.). Retrieved 9 August 2024b. https://www.who.int/publications/i/item/9789240059184

[5] 5. Wamala DS, Augustine K: A meta-analysis of telemedicine success in Africa. J Pathol Inform. 2013 Jan 1; 4(1): 6. PubMed Abstract | Publisher Full Text | Free Full Text

[6] 6. Biruk K, Abetu E: Knowledge and Attitude of Health Professionals toward Telemedicine in Resource-Limited Settings: A Cross-Sectional Study in North West Ethiopia. J Healthc Eng. 2018 Nov 18; 2018: 1–7. Publisher Full Text

[7] 7. Alboraie M, Allam MA, Youssef N, et al.: Knowledge, Applicability, and Barriers of Telemedicine in Egypt: A National Survey. Int J Telemed Appl. 2021; 2021(1): 5565652. PubMed Abstract | Publisher Full Text | Free Full Text

[8] 8. Elhadi M, Msherghi A, Elhadi A, et al.: Utilization of Telehealth Services in Libya in Response to the COVID-19 Pandemic: Cross-sectional Analysis. JMIR Med Inform. 2023; 9(2): e23335. PubMed Abstract | Publisher Full Text | Free Full Text

[9] 9. Tunisia: (n.d.). Datadot. Retrieved 13 August 2024. https://data.who.int/countries/788

[10] 10. Tunisia: (n.d.). Datadot. Retrieved 13 August 2024. https://data.who.int/countries/788

[11] 11. Tunisia Maps & Facts: WorldAtlas. December 18, 2023. https://www.worldatlas.com/maps/tunisia

[12] 12. Décret Présidentiel n° 2022-316 du 8 avril 2022, portant création d’une unité de gestion par objectifs à la Présidence du gouvernement pour la mise en place du projet de modernisation et généralisation des maisons de services et fixant son organisation et les modalités de son fonctionnement|DCAF Tunisie.[cited 2023 Jan 28]. Reference Source

[13] 13. Biruk K, Abetu E: Knowledge and Attitude of Health Professionals toward Telemedicine in Resource-Limited Settings: A Cross-Sectional Study in North West Ethiopia. J Healthc Eng. 2018; 2018(1): 2389268. PubMed Abstract | Publisher Full Text | Free Full Text

[14] 14. Nouira MTelemedicine-Tunisia [Dataset]. Harvard Dataverse. 2023. Publisher Full Text

[15] 15. WHO Group Consultation on Health Telematics (1997: Geneva S. A health telematics policy in support of WHO’s Health-for-all strategy for global health development: report of the WHO Group Consultation on Health Telematics, 11-16 December, Geneva, 1997.1998 [cited 2023 Jan 28]. Reference Source

[16] 16. Messon T: Quelle est la place des médecins généralistes dans le développement de la télémédecine? Enquête auprès des médecins généralistes de Gironde. In 2017 [cited 2023 Jan 28].Reference Source

[17] 17. Elhadi M, Elhadi A, Bouhuwaish A, et al.: Telemedicine Awareness, Knowledge, Attitude, and Skills of Health Care Workers in a Low-Resource Country During the COVID-19 Pandemic: Cross-sectional Study. J Med Internet Res. 2021 Feb 25; 23(2): e20812. PubMed Abstract | Publisher Full Text | Free Full Text

[18] 18. Ayatollahi H, Sarabi FZP, Langarizadeh M: Clinicians’ Knowledge and Perception of Telemedicine Technology. Perspect Health Inf Manag. 2015 Nov 1; 12(Fall): 1c. PubMed Abstract

[19] 19. Mairinger T, Gabl C, Derwan P, et al.: What do physicians think of telemedicine? A survey in different European regions. J Telemed Telecare. 1996 Mar 1; 2(1): 50–56. PubMed Abstract | Publisher Full Text

[20] 20. Zayapragassarazan Z: Awareness, Knowledge, Attitude and Skills of Telemedicine among Health Professional Faculty Working in Teaching Hospitals. JCDR. 2016 [cited 2023 Jan 28]; JC04. PubMed Abstract | Publisher Full Text | Free Full Text Reference Source

[21] 21. Elareed HR, Elroby FA, Adly ES, et al.: Knowledge and moral attitude toward telemedicine among Egyptian physicians. J Public Health. 2023.Publisher Full Text

[22] 22. Barton PL, Brega AG, Devore PA, et al.: Specialist physicians’ knowledge and beliefs about telemedicine: a comparison of users and nonusers of the technology. Telemed J E Health. 2007 Oct; 13(5): 487–500. PubMed Abstract | Publisher Full Text

[23] 23. Olok GT, Yagos WO, Ovuga E: Knowledge and attitudes of doctors towards e-health use in healthcare delivery in government and private hospitals in Northern Uganda: a cross-sectional study. BMC Med Inform Decis Mak. 2015 Nov; 15(15): 87. Publisher Full Text

[24] 24. Ahmed TJ, Baig M, Bashir MA, et al.Knowledge, attitudes, and perceptions related to telemedicine among young doctors and nursing staff at the King Abdul-Aziz University Hospital Jeddah, KSA.Niger J Clin Pract. 2021; 24(4): 464–469. PubMed Abstract | Publisher Full Text

[25] 25. Idowu PA, Adagunodo ER, Idowu AO, et al.: Electronic referral system for hospitals in Nigeria. IFE J Sci. 2004; 6(2): 161–166.

[26] 26. Parvin R, Shahjahan M: Knowledge, Attitude and Practice on eHealth Among Doctors Working at Selected Private Hospitals in Dhaka, Bangladesh. J Int Soc Telemed eHealth. 2016 Sep 22; 4: e15 (1-11).

[27] 27. Whitten P, Holtz B, Nguyen L: Keys to a successful and sustainable telemedicine program. Int J Technol Assess Health Care. 2010 Apr; 26(2): 211–216. PubMed Abstract | Publisher Full Text

[28] 28. Presseau J, Sniehotta FF, Francis JJ, et al.: Multiple goals and time constraints: perceived impact on physicians’ performance of evidence-based behaviours. Implement Sci. 2009 Nov 26; 4(1): 77. PubMed Abstract | Publisher Full Text | Free Full Text

[29] 29. Lombardo F: La télémédecine en médecine générale: évaluation du point de vue et du ressenti des médecins généralistes. [thèse: médecine]. Paris: Université Pierre et Marie Curie.2013.

[30] 30. Carré E: Télémédecine: représentations et expériences des médecins généralistes: Étude qualitative menée auprès de médecins généralistes du Languedoc-Roussillon.

[31] 31. Mathieu S: La téléconsultation: l’avis des médecins généralistes dans les Alpes Maritimes. [thèse: médecine]. Sophia Antipolis: Université de Nice-Sophia Antipolis.2012.

[32] 32. Xu H, Huang S, Qiu C, et al.: Monitoring and Management of Home-Quarantined Patients With COVID-19 Using a WeChat-Based Telemedicine System: Retrospective Cohort Study. J Med Internet Res. 2020 Jul 2; 22(7): e19514. PubMed Abstract | Publisher Full Text | Free Full Text

[33] 33. Lonergan PE, Iii SLW, Branagan L, et al.: Rapid Utilization of Telehealth in a Comprehensive Cancer Center as a Response to COVID-19: Cross-Sectional Analysis. J Med Internet Res. 2020 Jul 6; 22(7): e19322. PubMed Abstract | Publisher Full Text | Free Full Text

[34] 34. Angood MD, Peter B: Telemedicine, the Internet, and World Wide Web: Overview, CurrentStatus, and Relevance to Surgeons. World J Surg. 2001 Nov 1; 25(11): 1449–1457. PubMed Abstract | Publisher Full Text

Towards implementing telemedicine in Tunisia: A knowledge, attitude and practice study among medical doctors

Abstract

Keywords

Revised Amendments from Version 1

Introduction

Methods

Knowledge subsection

Attitude subsection

Statistical analysis

Ethical considerations

Results

Socio-professional characteristics

Table 1. Socio-professional characteristics of study participants.

Knowledge

Table 2. Results of the association between the level of knowledge and socio-professional characteristics of the study population.

Attitudes

Table 3. Doctor's attitudes toward telemedicine based on perceived benefits, compatibility with their practice, ability to try, and perceived threats and disadvantages to telemedicine (N=243).

Figure 1. Perceived barriers to the application of telemedicine (N=243).

Table 4. Identification of the main barriers, perceived by doctors, to the application of telemedicine and the study of their association with the socio-professional factors of the study population (N = 243).

Practice

Discussion

Strengths and limitations of our study

Recommendations

Conclusions

Consent

Data availability

Underlying data

Extended data

Acknowledgments

References

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