Telemedicine for Musculoskeletal Care During the COVID-19 Pandemic: Evaluating Readiness of Saudi Citizens

Introduction: Since coronavirus disease 2019 (COVID-19) was announced as a global pandemic, it has become important to control the pandemic with several approaches, including limiting hospital visits. Telemedicine is a good option to help reduce in-person visits during the pandemic. Saudi Arabia has prepared for this pandemic by implementing applications, such as Tetamman and Seha. In this study, we aimed to determine the readiness of the Saudi population to use telemedicine for musculoskeletal care during the COVID-19 pandemic. Methods: A cross-sectional study was conducted from July 2020 to October 2020. The study used a predesigned, self-administered questionnaire with acceptable internal consistency (Cronbach’s α=0.79). A questionnaire with 30 questions was distributed electronically and randomly to the Saudi population. The included participants were Arabic speakers, Saudis, and men or women age 18 years or older. Results: A total of 635 respondents, of which 250 were men (39.4%) and 385 were women (60.6%), completed the questionnaire. The most common region of residence was the Central region (41.6%), followed by the Eastern region (28%). The proportions of patients who had knowledge about virtual clinics and who used a virtual clinic during the COVID-19 pandemic were 47.6% and 30.4%, respectively. The mean overall attitude score was 24.4 (standard deviation, 9.9) of 35 points; negative, neutral, and positive attitudes were reported among 9.9%, 54.3%, and 35.7% of respondents, respectively. Compared with the older population, younger-aged participants (≤25 years) had significantly more positive attitudes about virtual clinics (χ2=6.068; p=0.048). Those respondents who had never been married showed significantly more positive attitudes about virtual clinics compared with those who had been married (χ2=6.695; p=0.035). Conclusions: The studied Saudi population shows a moderate level of acceptance of the concept of using telemedicine in musculoskeletal conditions, but some issues about patient access and understanding of the technology remain unaddressed.


Introduction
On March 11, 2020, the World Health Organization announced that coronavirus disease 2019 (COVID- 19) had become a global pandemic [1]. To prevent and control the spread of the rapidly evolving virus, global health agencies considered several precautions, such as suspension of all nonurgent elective surgeries, limitation of clinical visits in hospitals, and other measures to decrease the risk of cross-infection [2,3]. Without clinical visits in the health facilities, another system to treat patients during the COVID-19 pandemic is necessary. One of the most effective ways to continue healthcare delivery in pandemic circumstances is telemedicine [4]. Telemedicine is defined as the delivery of healthcare to patients at a distance without the need to come to the healthcare facility [5]. This technology offers many benefits; it can provide care that may not be an option otherwise, improve the quality of screening programs, reduce healthcare costs, and more. Conversely, some challenges associated with telemedicine include a breakdown in the doctor-patient relationship and patient doubts about health information received virtually [6]. Telemedicine has been used in the surgical field to improve the practice of surgeons in treating their patients [6]. During the COVID-19 pandemic, orthopedic surgeons should reach patients without face-toface consultations [7]. In Saudi Arabia, the Ministry of Health provided some applications to implement telemedicine in the country. Patients affected by COVID-19 can receive medical care through these applications. One application, Rest Assured or Tetamman, provides healthcare support mainly to citizens or residents in domestic isolation or quarantine [8]. Another application is Seha which offers consultations and diagnostic services to patients [9]. Telemedicine users have reported general satisfaction with this modality in terms of effectiveness and efficiency [10]. The COVID-19 pandemic has driven providers to find alternative methods to deliver safe orthopedic healthcare to patients. Telemedicine can provide constant continuous care for orthopedic practice [11,12]. To the best of our knowledge, no study has been conducted to determine the perception about telemedicine and readiness of patients to use telemedicine for musculoskeletal conditions during the COVID-19 pandemic in Saudi Arabia. The aim of our study is to determine the readiness of the Saudi population to use telemedicine for musculoskeletal care during the COVID-19 pandemic.

Study design and participants
A cross-sectional study was conducted from July 2020 to October 2020 in Saudi Arabia. A minimum of 385 participants needed to be recruited from the general population of Saudi Arabia to achieve a 95% confidence interval and a 5% margin of error [13,14]. A self-administrated online questionnaire was distributed randomly irrespective of their musculoskeletal condition. The included participants were Arabic speakers, Saudis, and men or women who are aged 18 years or older. Ethical approval was obtained from the ethical committee of the College of Medicine at King Faisal University (2020-10-24). Informed consent was taken from all participants before their commencement of the questionnaire, and their personal information was kept confidential.

Data collection
The sampling technique of this study was the convenience random sampling method where an Arabic online questionnaire was distributed to the community using social media platforms such as WhatsApp and Twitter. The questionnaire was taken from a previous study. The research idea and participant roles were explained and the participants' consent was obtained. Before distributing the survey, we tested the validity of the questions in a pilot study of 20 participants. Internal consistency was acceptable (Cronbach's α=0.79). The questionnaire was divided into four parts: (1) sociodemographic data (11 questions), (2) questions about musculoskeletal care (4 questions), (3) questions about telemedicine readiness (7 questions), and (4) knowledge and acceptance of telemedicine during the COVID-19 pandemic (8 questions) [15].

Calculation of scores
The attitude toward the use of a virtual clinic or telemedicine was drawn from seven statements with a 5point Likert scale; categories ranged from "strongly disagree," coded as 1, to "strongly agree," coded as 5 [15]. The total score was calculated by adding points from the seven questions. The scores generated a minimum of 7 points and a maximum of 35 points; higher scores reflected more positive attitudes toward virtual clinic use. To determine the attitudes of respondents toward the use of virtual clinics, total scores were classified as follows: attitude scores of 7-17 points reflected negative attitudes; 18-26 points, neutral; 27-35 points, positive.

Data analysis
Data were reported as the frequency, percentage, or mean and standard deviation, as appropriate. Chi-square tests were applied for between-group comparisons. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) software for Windows (version 21; IBM, Armonk, NY). Pvalues of <0.05 were considered statistically significant.

Results
We recruited 635 patients across Saudi Arabia to evaluate readiness for a virtual clinic. As seen in Table 1, the most common age group was 18-25 years (55.7%); more than 60% were women, and more than two-thirds (68.7%) had a bachelor's degree or higher. The majority of participants were never married (69.3%). The most common region of residence was the Central region (41.6%), followed by the Eastern region (28%). Nearly, all participants resided in the city (88.3%), and most lived in the villa (70.4%). Nearly, one-third (32.6%) were earning less than 5,000 SAR per month, and others were earning either 5,000-10,000 SAR (16.1%) or 10,001-20,000 SAR (17%). Notably, 38.6% lived with seven to nine family members, and 36.1% lived with four to six. The proportion of patients who had diseases that required an orthopedic visit during the pandemic was 40.9%. Approximately, 20% of the patients visited the orthopedic clinic once during the pandemic, and 12.1% visited twice.

Study data N (%)
Age   Figure 1 depicts the chronic bone diseases reported by respondents. The most common conditions were chronic pain (including lower back, shoulder, knee, hand, ankle, and neck pain; 22.8%), arthritis (3.9%), and fracture (3.8%). Soft tissue injuries were the least common (0.2%).  Table 2 presents patient knowledge about the virtual clinic during the COVID-19 pandemic. The proportions of patients who knew about the virtual clinic and who used a virtual clinic during the COVID-19 pandemic were 47.6% and 30.4%, respectively. The most commonly used method to access a virtual clinic was the Seha app (21.1%). Nearly, half of the respondents (47.1%) were hesitant to go to the hospital because of the pandemic, but 28.8% were able to visit the hospital despite the pandemic situation. The proportion of respondents who believed that the virtual clinic was fully prepared to receive patients was 63%.

Statement N (%)
Knowledge about the virtual clinic  As seen in Figure 3, the most commonly reported barrier of the virtual clinic was difficulty performing a clinical examination (69.8%), followed by difficulty clarifying the problem (50.7%) and problems with connection (38.7%). A long waiting time was the least mentioned barrier (13.2%). Figure 4 shows the specialties that patients were most willing to use virtually. The psychiatric clinic was most common (54%), followed by the dermatology clinic (46.8%) and the pediatric clinic (33.2%); the ophthalmology clinic was the least common (8%). Notably, only 17.2% of respondents were willing to use a virtual orthopedic clinic.

FIGURE 4: Most common specialties that people are willing to use in a virtual setting
In the assessment of attitudes (Table 3), patients reported positive attitudes about the statements "Consultation through the virtual clinic is better than going to another city" (strongly agree, 47.7%) and "Virtual clinic can reduce the waiting time and delay" (strongly agree, 42.2%). Conversely, respondent attitudes were negative about the following statements: "I think a doctor would be able to understand me through the virtual clinic video" (strongly agree, 9.8%) and "I prefer to consult a doctor through the virtual clinic than personally in the clinic" (strongly agree, 9.8%). The money that will go to great lengths to see a doctor, such as petrol and other things, will influence my decision on my preference for using a virtual clinic.  The descriptive statistical results of the attitudes toward virtual clinics are presented in Table 4. Results showed a mean overall attitude score of 24.4 (standard deviation, 9.9) of 35 points. Negative, neutral, and positive attitudes were classified among 9.9%, 54.3%, and 35.7%, respectively.

Discussion
Telemedicine is used to deliver real-time communication from a distant place between the doctor and the patient through an electronic device (either phone or video call) [5,16]. Telemedicine was identified as an effective way to deliver medical care during the COVID-19 pandemic, and it can be very helpful for the orthopedic specialty [7][8][9][10]. Telemedicine has been considered successful for delivering care during the COVID-19 pandemic in Saudi Arabia [17]. The approach can be used in all specialties, even those that require extensive physical examination [16].
The authors have distributed a self-administrated online questionnaire to the Saudi citizens to determine the readiness of the Saudi population to use telemedicine for musculoskeletal care during the COVID-19 pandemic. A total of 635 respondents completed the questionnaire. The mean overall attitude score was 24.4 (standard deviation, 9.9) of 35 points; negative, neutral, and positive attitudes were reported among 9.9%, 54.3%, and 35.7% of respondents, respectively. In our studied sample, positive attitude towards using telemedicine was significantly more associated with those participants who are younger-aged (≤25 years) and had never been married (χ 2 =6.068; p=0.048) and (χ 2 =6.695; p=0.035), respectively.
This study demonstrates the readiness of the Saudi population to use telemedicine for musculoskeletal complaints, and results may contribute to future preparedness for any unavoidable circumstances, such as the COVID-19 pandemic. In this study, the most common musculoskeletal complaint was chronic pain (in particular, lower back pain), which is consistent with previous studies [18,19]. In this study, arthritis was the second most common musculoskeletal complaint, unlike reports from a previously published article [19]. Similar to a previous study, this study identified a lack of knowledge about telemedicine in Saudi Arabia [20]. In our study, the Seha application, followed by the Tetamman application, was the most common application used by the Saudi population. However, another study showed that Tetamman was the most common and that Seha was only the fourth most commonly used application [17].
In our study, 15.7% reported that telemedicine was difficult to use; in another study, the percentage was higher (19.2%) [21]. This study shows that 30.4% of the queried population in Saudi Arabia used the virtual clinic; another Saudi study reported use by 36.6% [21]. However, both studies reported use lower than the published results from the United States, in which 58.2% reported telemedicine use [22]. Almuayqil et al. [23] found that technical issues were the most commonly reported barrier to telemedicine use in a Saudi population, but this result contradicts our findings. In our study, the most common barrier to using telemedicine was difficulty in performing a physical examination. This barrier can be overcome by using evidence-based guidelines with clinical scoring, as reported in a prior study [24]. Some studies also suggest applying certain guidelines to virtual musculoskeletal examinations to overcome this barrier [25,26].
Many researchers have conducted surveys to measure the actual usage of telemedicine in hospital settings. For instance, a survey conducted in China states that 93.8% of tertiary hospitals implemented telemedicine services in various forms [27]. Moreover, Dorsey and Topol [28] reported that telemedicine will be increasingly implemented in different forms, such as mobile stroke units that connect an ambulance with the stroke team to provide images in the field, which saves time in the diagnosis to proceed directly with management. In a study by Gurupur et al. [15], attitudes were positive about virtual clinics, because less waiting and easier accessibility were common.
These results suggest that patients are afraid that the doctor will not be able to understand them or they will not be able to deliver the information to the doctor. When sociodemographic data were reviewed, younger adults were found to be more accepting of telemedicine than older adults; this result is supported by a study conducted in a community in Bangladesh [29]. However, that study suggested that being a woman and having a low economic status increased the difficulties of technology use [29].
However, there are some limitations of this study including recall bias regarding the participants' use of virtual clinic during the COVID-19 pandemic. Also, we did not combine the questionnaire with structured interviews which could have enhanced the quality of data.

Conclusions
Our study findings suggest that nearly half of our participants have previous knowledge about the existence of virtual clinics in Saudi Arabia. The most commonly used application for the virtual clinic was Seha. The studied participants showed a moderate level of acceptance to use virtual clinics in Saudi Arabia for musculoskeletal care during the COVID-19 pandemic, but some issues about patient access and understanding of the technology remain unaddressed. Therefore, the authors recommend prospective studies with larger sample sizes and eliminating the possible confounding factors to assure more reliability.