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Evaluation of Internet access and utilization by medical students in Lahore,

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Evaluation of internet access and utilization by
medical students in Lahore, Pakistan
Jadoon et al.
Jadoon et al. BMC Medical Informatics and Decision Making 2011, 11:37
http://www.biomedcentral.com/1472-6947/11/37 (30 May 2011)
Jadoon et al. BMC Medical Informatics and Decision Making 2011, 11:37
http://www.biomedcentral.com/1472-6947/11/37

RESEARCH ARTICLE Open Access

Evaluation of internet access and utilization by

medical students in Lahore, Pakistan
Nauman A Jadoon1,2*, Muhammad F Zahid3, Hafiz Mansoorulhaq4, Sami Ullah5, Bilal A Jadoon6, Ali Raza2,7,
Mansoor Hussain1,2, Rehan Yaqoob1 and Mohammad A Shahzad1,2

Abstract
Background: The internet is increasingly being used worldwide in imparting medical education and improving its
delivery. It has become an important tool for healthcare professionals training but the data on its use by medical
students in developing countries is lacking with no study on the subject from Pakistan. This study was, therefore,
carried out with an aim to evaluate the pattern of internet access and utilization by medical students in Pakistan.
Methods: A structured pre-tested questionnaire was administered to a group of 750 medical students in clinical years
studying at various public and private medical colleges in Lahore. The questions were related to patterns of internet
access, purpose of use and self reported confidence in performing various internet related tasks, use of health related
websites to supplement learning and the problems faced by students in using internet at the institution.
Results: A total of 532 medical students (70.9%) returned the questionnaire. The mean age of study participants
was 21.04 years (SD 1.96 years). Majority of the respondents (84.0%) reported experience with internet use. About
half of the students (42.1%) were using internet occasionally with 23.1%, 20.9% and 13.9% doing so frequently,
regularly and rarely respectively. About two third of the students (61.0%) stated that they use internet for both
academic and professional activities. Most of the participants preferred to use internet at home (70.5%). Self
reported ability to search for required article from PubMed and PakMedinet was reported by only 34.0% of the
entire sample. Students were moderately confident in performing various internet related tasks including
downloading medical books from internet, searching internet for classification of diseases and downloading full
text article. Health related websites were being accessed by 55.1% students to supplement their learning process.
Lack of time, inadequate number of available computers and lack of support from staff were cited as the most
common problems faced by students while accessing internet in the institution premises. There were significant
differences among male and female students with respect to the place of internet use (p = 0.001) and the ability
to search online databases for required articles (p = 0.014).
Conclusions: Majority of the medical students in this study had access to internet and were using it for both
academic and personal reasons. Nevertheless, it was seen that there is under utilization of the potential of internet
resources to augment learning. Increase in awareness, availability of requisite facilities and training in computing
skills are required to enable better utilization of digital resources of digital resources by medical students.

Background practices of health care professionals. According to an

The development and evolution of internet has brought estimate, 30% of a physician time will be spent in the use
profound changes in the health care delivery systems of various information and communication technology
across the globe ranging from education and training to tools in 2010 [2]. Internet is a cost effective medium of
diagnosis and patient management [1]. Internet has fun- communication which can help in meeting the complex
damentally transformed the patient management information needs of healthcare professionals and has
important implications in medical education. It can serve
as an important learning tool in medical education by
* Correspondence: dr.naumanjadoon@gmail.com
1
Department of Medicine, Nishtar Medical College Hospital, Multan, Pakistan
providing access to latest evidence anytime and any-
Full list of author information is available at the end of the article where. It is especially useful for students from developing
© 2011 Jadoon et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Jadoon et al. BMC Medical Informatics and Decision Making 2011, 11:37 Page 2 of 6
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countries helping them to keep abreast of ever expanding and adequately trained in basic computing skills. Such
knowledge bridging the gap resulting from scarcity of training requires a survey to access the baseline profi-
resources. ciency and utilization pattern to identify the areas need-
Internet has a number of applications in the field of ing attention which is main aim of this survey. Although
medicine and health. It provides instant access to rele- the students are provided basic training on use of inter-
vant up to date information at the point of care making net and searching medical databases and have a research
it easy for the health care providers to practice evidence project as compulsory part of coursework involving
based medicine. It offers clinician the ability to manage writing a scientific article, it is not known how this
patients in remote areas while being away from them training helps them in acquiring the skills necessary to
and makes it possible to interact with colleagues on undertake independent online learning. In addition,
clinical issue via videoconferencing. It also promotes there is limited data available on the use of internet by
research and learning by providing access to medical health care professionals in developing countries.
and other online databases [3-5]. It is highly imperative Furthermore, there is no study on the access and utiliza-
that health care professionals are able to fully utilize the tion pattern of medical students in Pakistan to the best
available resources on internet so that they can evaluate of our knowledge. The study is also needed to aid in
the large quantity of medical literature available and developing evidence base for improving usage of online
find the requisite information quickly. resources and their integration into education and train-
The internet is increasingly being used worldwide in ing to bridge the information gap resulting from scarcity
imparting medical education and improving its delivery. of resources. This study was, therefore, conducted with
Internet finds many uses in the medical domain includ- an aim to determine the patterns of internet access and
ing but not limited to rapid seamless delivery of educa- utilization among medical students undergoing clinical
tional material, access to online databases, exploring the training. The study also assessed the self rated ability of
application of theoretical ideas and use of various inter- students to search online databases, self reported confi-
active tools to enhance understanding of complex ideas dence in performing various internet related tasks, use
[6-8]. In addition the beauty of internet lies in the fact of health related websites to supplement learning and
that it allows learners the convenience of studying at distribution of problems faced by students in assessing
their own pace without the hassle of attending classes at the information at their institution.
a fixed schedule and at a defined place. However, inter-
net mediated learning is not without its share of disad- Methods
vantages and limitations. These include the lack of The study was carried out at four medical colleges in
infrastructure and limited access in developing coun- Lahore which were randomly selected after dividing the
tries. Moreover, it is difficult for a busy clinician to find city into two parts. Two public and two private medical
time to keep up to date on latest breakthroughs in med- colleges were selected, one public and private college
icine. In addition the reluctance of health care profes- being from each part of the city. The public medical col-
sionals to use internet instead of traditional information leges included Allama Iqbal medical College (AIMC)
sources also hinders their ability to fully utilize this and Services Institute of Medical Sciences (SIMS). Sharif
information source [9]. Medical and Dental College (SMDC) and Fatima Mem-
Pakistan is the most populous country in the Eastern orial Hospital College of Medicine and Dentistry (FMH)
Mediterranean Region (EMR) of the World Health were the private medical colleges included in the study.
Organization (WHO). The number of internet users in All the medical schools in Lahore are affiliated with the
the country have increased from 133,900 in the year University of Health Sciences, Lahore (UHS) as are most
2000 to 18.5 million in 2010 registering a record growth other public and private medical institutions in the Pun-
of 13,716.3% from 2000 to 2010 [10]. Pakistan is jab province, the most populous province of the coun-
included in the list of low internet penetration countries try. Computer resource labs were established at all the
having internet penetration lower than the world aver- medical colleges affiliated with UHS with funding from
age of 23.8% [11]. Currently, the internet population the Higher Education Commission (HEC), Pakistan in
penetration stands at 10.4% representing 2.2% of the 2007 [13]. The labs have computers, printers and scan-
users in Asia as of June 2010 [10]. The country ranks ners providing facilities of internet, copying, scanning,
10th in the EMR, 14th in the lower middle income printing, access to various online databases through
countries and 87th globally in the 2010 network readi- HEC digital library and training to students and faculty
ness index released by the world economic forum [12]. of colleges and attached hospitals.
The various advantages of modern information tech- The study population in this study consisted of 750 ran-
nology tools can only be materialized in the developing domly selected medical students in the clinical years of
countries if the health care professionals are well versed training (3rd, 4th and Final year of M.B.B.S.). A structured
Jadoon et al. BMC Medical Informatics and Decision Making 2011, 11:37 Page 3 of 6
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questionnaire designed by the authors was used for the Table 1 Demographic Profile of the Students
study. It was pretested on a group of students before start- Variable n(%)*
ing the study. The questionnaire elicited information Age 21.04 (1.96)
about demographic profile of students and pattern of Gender
internet access and utilization. The questionnaire also
Male 215 (40.41%)
assessed self reported confidence of students in perform-
Female 317 (59.59%)
ing various internet related tasks such as downloading
Institution
medical books from internet, searching internet for classi-
fication of diseases and retrieval of full text articles. The Allama Iqbal Medical College 178 (33.5%)
answers were scored on Likert scale ranging from 1 to 5 FMH College of Medicine & Dentistry 75 (14.1%)
with 1 denoting not confident and 5 representing very Sharif Medical & Dental College 129 (24.2%)
confident. The responses were used to generate self effi- Services Institute of Medical Sciences 150 (28.2%)
cacy scores of students in performing these tasks. Ques- Year of Study
tions about use of health related websites in learning 3rd Year MBBS 151 (28.4%)
process and the problems faced by students in using inter- 4th Year MBBS 196 (36.8%)
net at campus were also included in the questionnaire.
Final Year MBBS 185 (34.7%)
The questionnaire was anonymous to increase participa-
* Data are mean ± SD for Age.
tion and reduce the potential of respondent bias. The
study was approved by Ethics Review Committee of
Nishtar Medical College Hospital Multan. Approval was Analysis of students’ perceived confidence in perform-
also sought from each of the institutions before carrying ing internet related tasks is shown in Table 3. The
out the study. The forms were distributed among the results are expressed as perceived self efficacy scores
students after taking informed consent from participants. (range 1-5). The results show that students have moder-
Data analysis was carried out using SPSS version 16. ate levels of confidence in performing various internet
Descriptive analyses were performed for various vari- related tasks. Health related websites were being used
ables. Pearson chi-square test was employed to deter- by 55.1% of the participants (Table 4). Lack of time to
mine the difference in internet access and utilization use computer (64.6%) was cited as the most common
and the use of health related websites by gender. A p problem faced by students in assessing online informa-
value of < 0.05 was considered statistically significant. tion in campus (Table 5).

Results Discussion
A response rate of 70.9% was achieved with a total of The present study examined use of internet among
532 students returning filled forms out of 750. The medical students in clinical years studying in various
mean age of students was 21.04 years (SD = 1.96 years). medical institutions in Lahore. The results of our study
Majority of the students were female (59.6%) and study- show that 83.97% of the students were able to use inter-
ing in fourth year MBBS (36.8%). The response rates net. A number of studies have assessed the use of inter-
were 71.2%, 75.0%, 73.0% and 75.0% for AIMC, FMH, net by students in healthcare professions [6,7,14-25].
SMDC and SIMS respectively. The demographic profile The results of our study are comparable to other studies
of the student is presented in Table 1. conducted earlier in Algeria, Chile, Denmark, Finland,
Students’ pattern of internet access and use is described France, India, Jordan, Malaysia, New Zealand, Nigeria,
in Table 2. Overall 84.0% of the entire sample had experi- Saudi Arabia, Sudan, Tanzania, Tunisia, Turkey, United
ence with internet use. The student surveyed were using Kingdom and the United States [6,7,14-26].
internet with various frequencies. Most of the students However, the frequency of internet use and its use in
(42.1%) reported occasional use of internet. Majority of learning were low as compared to other studies
the respondents (61.0%) were using internet for both per- [7,14-16,18,20,25,26]. There may be a number of reasons
sonal and academic services. Students preferred using for this difference in use of internet. Lack of training of
internet at home. Google was the most popular search students as well as the various problems faced by them
engine and was being used by 88.9% of the participants. in utilization of internet at institution coupled with una-
Self reported ability to search online databases was docu- vailability of access to subscription based online data-
mented by only a minority of medical students. When bases such as UpToDate at home where students mainly
the data of internet access and usage was analyzed use internet may have contributed to this problem. The
according to gender, a statistically significant difference ability to search online databases including PubMed and
was observed with respect to place of internet use and PakMedinet was reported by only one third of the stu-
the ability to search online databases for articles. dents in this study. This is lower as compared to the
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Table 2 Pattern Internet Access and Use

Item Total Male Female P Value
n % n % n %
1. Experience with internet use .156
Yes 440 84.0% 173 81.2% 267 85.9%
No 84 16.0% 40 18.8% 44 14.1%
2. Frequency of internet use .192
Frequently 120 23.1% 54 25.8% 66 21.3%
Regularly 108 20.9% 50 23.9% 58 18.8%
Occasionally 218 42.1% 79 37.8% 139 45.0%
Rarely 72 13.9% 26 12.5% 46 14.9%
3. Internet services used by students .219
Personal 108 22.0% 43 21.7% 65 22.1%
Academic 84 17.0% 27 13.6% 57 19.4%
Both 300 61.0% 128 64.7% 172 58.5%
4. Place of internet use .000
Café 34 6.6% 23 11.1% 11 3.6%
Home 363 70.5% 121 58.5% 242 78.6%
Library 107 20.8% 58 28.0% 49 15.9%
Other 11 2.1% 5 2.4% 6 1.9%
5. Search engines used .526
Google 450 88.9% 187 89.9% 263 88.3%
Yahoo 45 8.9% 15 7.2% 30 10.1%
Others 11 2.2% 6 2.9% 5 1.6%
6. Ability to search Pubmed/pakmedinet for article .014
Yes 166 34.0% 82 40.2% 84 29.5%
No 323 66.0% 122 59.8% 201 70.5%

reported rates from other countries [6,7] and may be a difference in use of information technology has been
hindrance in allowing full utilization of of internet in reported previously by many studies [15,18,24,27,28].
learning to practice evidence based medicine. Students, The reason of this disparity needs to be explored since
however, had acceptable scores in their self rated ability there was no statistically significant difference in fre-
to perform various internet related tasks including quency of internet use.
downloading medical books from internet, searching for Internet provides health professionals with a cost
classification of diseases and downloading full text arti- effective medium which can be used to gain access to
cle. This may be attributable to the self reported nature
of the rating with students over rating their perceived Table 4 Use of Health Related Websites to Supplement
abilities. Learning
A statistically significant difference in the pattern of Total Male Female P value
internet access and use was seen with respect to gender
n % n % n %
and the place of internet use and ability to search var-
1. Use them now .342
ious online databases for the required article. Gender
Yes 283 55.1% 122 57.5% 161 53.3%
No 231 44.9% 90 42.5% 141 46.7%
Table 3 Confidence in Performing Internet Related Tasks
2. Use if had to pay .988
Tasks Perceived Self Efficacy
Score Yes 126 24.6% 52 24.5% 74 24.6%
Mean SD No 387 75.4% 160 75.5% 227 75.4%
1. Downloading medical books from internet 3.00 1.564 3. Use if college pays .937
2. Search internet for classification of diseases 3.60 2.907 Yes 356 69.5% 147 69.3% 209 69.7%
3. Retrieve & download full text article 3.11 1.474 No 156 30.5% 65 30.7% 91 30.3%
Jadoon et al. BMC Medical Informatics and Decision Making 2011, 11:37 Page 5 of 6
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Table 5 Distribution of Problems Faced By Students resources and the proficiencies of students in doing so.
Assessing Information at Campus The data from this study will be helpful in devising
Problems (not mutually inclusive) n % appropriate plans and strategies to rectify the problem
Lack of time to use 331 64.6 of lower levels of utilization of internet and online
Inadequate number of computers 321 62.3 resources by health science students in the country. It is
Lack of support from staff 248 48.6
recommended that there should be an increase in avail-
able facilities and training of students to maximize use
Other reasons 168 33.3
of innumerable applications of technology in medical
education and practice. The students should be trained
latest health information anytime and anywhere by any- to assess and analyze the vast amount of information
one with resources and knowledge to make effective use available online by inclusion of basic education in utili-
of this technology. Studies have shown that online zation of information and communication technology in
resources are not only as effective as paper based current curriculum. Computer assisted instruction
resources in answering clinical queries but are also time should be introduced in medical students’ training so
efficient [29]. The individuals seeking health information that they do not feel handicapped later in this era of self
can even use a general search engine like Google to gain directed learning. In this regard, strategies should be
access to scholarly publication which now in fact gener- devised to involve students in their online learning. In
ates more referrals than those directed by PubMed [30]. addition, the barriers faced by students in using internet
However, PubMed is more updated, gives more relevant and online resources should be removed.
and recent results and has online first studies in com-
parison to Google Scholar which rates results according Conclusions
to number of hits [31]. Despite all these advantages of It is concluded that the use of internet is widespread
internet, it has certain limitations which can neverthe- among medical students, however, its use with respect
less be rectified with proper training in accessing online to its potential as a learning tool is less as compared to
content. The main problem with internet is the lack of studies from other countries. Students should have skills
quality control with large amounts of data of undeter- to fully utilize online resources to improve their learning
mined quality available. The users need to have skills to and quality of patient care bridging the gap resulting
critically analyze the data and determine its accuracy, from the scarcity of resources in developing countries.
reliability and validity. This is especially important given Increase in awareness, availability of requisite facilities
the finding that health information seekers from general and training in computing skills are required to enable
public rarely check whether the information is updated optimum utilization of digital resources by students.
and source can be identified and is reliable [32]. Further studies are needed to gather data to design cost
The present study has certain strengths and limita- effective ways of integrating information technology in
tions. The study provides a preliminary evaluation of the education and training of health care professionals in
use of internet among medical students in Pakistan. It developing countries.
adds to the limited data on the topic from developing
countries. The findings of the study can be generalized Acknowledgements
to the medical student population of the country as the We thank the students for participating in the study.
study recruited participants from both public and pri-
vate medical colleges having facilities and resources
List of abbreviations
compared to medical institutions in the rest of the AIMC: Allama Iqbal Medical College, Lahore, Pakistan; FMH: Fatima Memorial
country. The study has made important points which Hospital College of Medicine and Dentistry, Lahore, Pakistan; MBBS: Bachelor
can be elaborated in future studies. The study also has of Medicine and Bachelor of Surgery; SMDC: Sharif Medical and Dental
College, Lahore, Pakistan; SIMS: Services Institute of Medical Sciences, Lahore,
certain limitations including self reported nature of the Pakistan; UHS: University of Health Sciences, Lahore, Pakistan.
data, differences in time available to students for inter-
net access and utilization at different institutions and Author details
1
Department of Medicine, Nishtar Medical College Hospital, Multan, Pakistan.
the disparities in their levels of training. In addition, 2
Center for Biomedical Research, Lahore, Pakistan. 3Department of Surgery,
analysis of technology use poses some unique challenges Fatima Memorial College of Medicine and Dentistry, Lahore, Pakistan.
4
as it is difficult to compare results of studies conducted Department of Surgery, Sharif Medical and Dental College, Lahore, Pakistan.
5
Services Institute of Medical Sciences, Lahore, Pakistan. 6Institute of
in different settings and time periods as many advanced Management Sciences, Peshawar, Pakistan. 7Postgraduate Medical Institute,
tasks become simple and trivial with the passage of Lahore, Pakistan.
time.
Authors’ contributions
Notwithstanding these limitations, the study provides NAJ conceived, designed and coordinated the study, participated in data
important baseline assessment of the use of online acquisition, carried out analysis and interpretation, drafted the manuscript
 Jadoon et al. BMC Medical Informatics and Decision Making 2011, 11:37 Page 6 of 6
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and reviewed it. MFZ and HM participated in designing the study, data 23. Samuel M, Coombes JC, Miranda JJ, Melvin R, Young EJ, Azarmina P:
collection and analysis. BAJ was involved in data input, analysis and review Assessing computer skills in Tanzanian medical students: an elective
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