A cross-sectional evaluation of computer literacy among medical students at a tertiary care teaching hospital in Mumbai (Bombay)TS Panchabhai1, NS Dangayach2, VS Mehta3, CV Patankar4, NN Rege5
1 Department of Medicine, University of Louisville, School of Medicine, Louisville, KY, USA
2 Department of Neurology, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
3 Department of Psychiatry, Central Institute of Psychiatry, Ranchi, India
4 Medical Education Unit, Seth GS Medical College and KEM Hospital, Mumbai, India
5 Medical Education Unit and Department of Pharmacology and Therapeutics, Seth GS Medical College and KEM Hospital, Mumbai, India
Background: Computer usage capabilities of medical students for introduction of computer-aided learning have not been adequately assessed. Aim: Cross-sectional study to evaluate computer literacy among medical students. Settings and Design: Tertiary care teaching hospital in Mumbai, India. Materials and Methods: Participants were administered a 52-question questionnaire, designed to study their background, computer resources, computer usage, activities enhancing computer skills, and attitudes toward computer-aided learning (CAL). The data was classified on the basis of sex, native place, and year of medical school, and the computer resources were compared. The computer usage and attitudes toward computer-based learning were assessed on a five-point Likert scale, to calculate Computer usage score (CUS - maximum 55, minimum 11) and Attitude score (AS - maximum 60, minimum 12). The quartile distribution among the groups with respect to the CUS and AS was compared by chi-squared tests. The correlation between CUS and AS was then tested. Results: Eight hundred and seventy-five students agreed to participate in the study and 832 completed the questionnaire. One hundred and twenty eight questionnaires were excluded and 704 were analyzed. Outstation students had significantly lesser computer resources as compared to local students (P<0.0001). The mean CUS for local students (27.0±9.2, Mean±SD) was significantly higher than outstation students (23.2±9.05). No such difference was observed for the AS. The means of CUS and AS did not differ between males and females. The CUS and AS had positive, but weak correlations for all subgroups. Conclusion: The weak correlation between AS and CUS for all students could be explained by the lack of computer resources or inadequate training to use computers for learning. Providing additional resources would benefit the subset of outstation students with lesser computer resources. This weak correlation between the attitudes and practices of all students needs to be investigated. We believe that this gap can be bridged with a structured computer learning program.
Keywords: Computer-aided learning, computer resources, India, medical education, preparedness
The use of computers in medicine has been increasing in the recent years; from accessing the latest treatment guidelines and computerization of patient records to protocol-driven decision-making, teaching, and learning. The internet is a great resource, which provides easy access to an ever increasing volume of information in the field of medicine. However, the introduction of computer-aided learning (CAL) has not attracted significant attention in developing countries like India. Previous studies have shown the benefit that computer-aided learning can have on the learning outcome,  through clinical simulation.  Computer-related skills form an important component of this approach to stimulate self-directed learning. The World Federation on Medical Education has previously emphasized the need for integration of computers into the medical curriculum. 
The medical education curriculum at our institute, an 1800-bed teaching hospital in India, includes the first two-and-a-half-years of basic science (pre-clinical) courses, the next two years of clinical teaching followed by a year of pre-graduate internship. Thus, at any point of time, we have students studying in six batches, that is, years I, II (Term I), II (Term III), III (Part I), III (Part II), and Interns. The student population shows geographic diversity; the local students are from Mumbai, a large metropolitan city and out-station students usually come from other smaller cities, smaller towns, and villages across the country. Diverse geographic backgrounds, among other factors, have been shown to affect computer literacy in previous studies testing computer literacy among medical students. ,, A study from southern India has concluded that although medical students use computers frequently, it is predominantly for simple tasks, which may not contribute to knowledge and data gathering skills.  Due to diverse backgrounds and different levels of exposure, an initiative to introduce CAL would require prior assessment of computer-related capabilities and attitudes toward computer-based learning.
The present study was conducted with the primary objective of generating background data about computer resources, practices, and attitudes toward CAL among medical students and interns, at a tertiary care institute in Mumbai (Bombay). We hypothesized that the place of origin (Mumbai (local) vs. outstation), sex, and year of medical school would have an effect on the computer literacy of medical students. Hence, it was decided to divide the population into the aforementioned groups. Our secondary objectives were: (1) To test whether the advance in years spent in medical school had an effect on the computer literacy of the study subjects. (2) To test the opinions of the study subjects with regards to the place of computer-aided learning in the current medical education system, through open-ended questions.
A questionnaire composed of seven sections (52 questions) was administered in paper format to collect data on the background information, available resources, frequency of use of various computer applications, activities enhancing computer skills, and attitudes toward computer-based learning. The participants were also allowed to voluntarily enlist their suggestions about changes in the existing medical education system and the integration of computers. The questionnaire was validated by three Faculty members of the Medical Education Unit, Seth GS Medical College and tested on 10 students to check for clarity and comprehension.
Approval from the Institutional Ethics Committee was obtained prior to the study initiation. Informed consent was implied on agreeing to participate in the study per informed consent waiver provided by the Institutional Ethics Committee.
Participants, inclusion, and exclusion
A total of 1080 students were eligible for inclusion in the study. Per protocol approved by the Institutional Ethics Committee, all medical students from first year to the interns who were willing to participate in the study were administered the questionnaire (in paper) to be completed in 30 minutes. The participants were informed about the nature and purpose of the study, and a general idea of the contents of the questionnaire. We excluded students of Physiotherapy, Occupational therapy, and visiting students or interns. Participants who were unable to complete the questionnaire in the allotted time of 30 minutes, for any reason, were excluded. They were not permitted to carry the questionnaire along with them. Participants who left one or more sections (excluding section G) entirely incomplete or 10 or more questions unanswered in the entire questionnaire were excluded from the analysis [Annexure I]-[Additional file 1].
The participants were classified into subgroups on the basis of sex, native place from Mumbai (local) or out of Mumbai (outstation), and year of medical school [Years I, II (term I), II (term III), III (term I), III (term II) and Interns] using descriptive statistics. The computer resources as well as activities enhancing computer skills were then compared between these three subgroups using the two-tailed Chi-squared tests. The computer usage and attitudes toward computer-based learning were assessed on a five-point Likert scale to calculate two scores: Computer usage score (CUS) and Attitude score (AS). The mean scores for each subgroup were calculated and compared using the t test and ANOVA. Two-tailed chi-squared tests were used to compare the quartile distribution among the subgroups with respect to AS and CUS. Pearson's correlation was used to test the correlation between the CUS and AS in each subgroup. Group means and SDs, frequency distributions, and chi-square and correlation analyses were obtained using SPSS software (version 12; SPSS Inc, Chicago, IL).
Of a total of 875 students who agreed to participate in the study over the four-month study period, 832 completed the questionnaire. Of these, 128 questionnaires were incomplete [one or more sections (excluding section G) entirely incomplete or 10 or more questions unanswered in the entire questionnaire] and were excluded; 704 questionnaires were then analyzed.
The per protocol set consisted of 425 males and 274 females; 298 participants were native to the city of Mumbai (Local), the remaining 388 were from outside the city (Outstation). Five hundred and seventy-nine students had undergone computer training in school, more among the local students (259 of 298 local vs. 320 of 388 outstation; P = 0.005). Two hundred and fifty students reported having undertaken computer training and courses before admission into medical school, of these, the percentage of males and local students was significantly higher (170 males vs. 80 females; P = 0.004, 162 local students vs. 88 outstation students; P = 0.003, respectively).
Computer resource assessment
As depicted in [Table 1], 442 students (62.8%) owned personal computers, predominantly desktops. Of these, a significantly higher proportion were female students (P = 0.001 vs. male) and local students (P < 0.0001 vs. outstation students). Among students who did not have their own computer, the cyber cafι or friends' computers were the most common access to these facilities. A significantly high number of outstation students accessed computers at the cyber cafι or their friends' place (P < 0.0001 vs. local students). The specific data about computer operating system, RAM, use of internet, printers, pen drives, and Wi-Fi technology is as depicted in [Table 1]. The students, when classified according to different years of medical school, differed statistically in the availability of resources like internet, printer and its type, use of pen drives, and synchronization devices. However, no specific trend was observed (data not shown).
Activities enhancing computer skills
Section E [Annexure 1]-[Additional file 1] of the questionnaire assessed the students' views on their contribution to extracurricular and co-curricular activities in their computer skills [Table 2]. A higher percentage of female students felt that such participation does help in enhancing computer skills (P = 0.003 vs. male students). While 34.2% participants felt that research projects and studentship opportunities helped in enhancing their computer skills; no difference was detected in responses from various subgroups. Forty-one percent students thought that working for the college magazine improved their computer skills considerably. Self-interest was rated as a major factor affecting computer skills by about 85% of the students in all the subgroups. Although gathering information for study purposes was considered important for improving their skills by a majority, the proportion of female students was higher (P = 0.01 vs. male students). All the participants uniformly agreed that entertainment and chatting with friends were important factors in enhancing their computer skills. When the above data was analyzed for the six batches of students (data not shown); the II (I) year had a higher number of students who felt that participation in medical symposia enhanced their computer skills (P = 0.002). Similarly, the proportion of students from III (I) and III (II) years who opined that research projects (ICMR / KVPY) helped increase their computer skills was significantly higher (P < 0.0001).
Computer usage and computer usage score
Section C [Annexure 1]-[Additional file 1] assessed the frequency of use of various computer applications, which was scored using a five-point Likert scale. The CUS was then derived for each student by summing the scores on each application. The maximal and minimal scores that could be achieved by one student were 55 and 11, respectively. The CUS for all participants was 24.9 ± 9.3 (Mean ± SD); while that for male and female students was 25.34 ± 9.8 and 24.3 ± 8.4, respectively (P = 0.162). The CUS for local students (27.0 ± 9.2) was significantly higher when compared to that of the outstation students (23.2 ± 9.05; P < 0.0001). When the quartile distribution of the students in various subgroups was analyzed [Table 3], the distribution was significantly different among local and outstation students; a majority of the latter group having CUS in the first quartile (P < 0.0001 vs. local students).
Attitudes toward computer-based learning and attitude score
Section F was designed to evaluate the attitude of the students toward the existing use of computers and a possible integration of computer-aided learning with traditional teaching. These responses were then scored on a five-point Likert scale, from strongly agree (five points) to strongly disagree (one point). The individual AS for each participant was calculated by summing the scores for each response. The maximal and minimal scores that could be achieved by one student were 60 and 12, respectively. The mean AS for the study population was 41.8 ± 5.7. The mean AS for males (42.6 ± 5.8) or females (43.1 ± 5.4) and local (42.6 ± 5.3) or outstation (42.9 ± 5.9) students did not differ significantly.
Correlation between AS and CUS
Correlation between AS and CUS was then analyzed. All the subgroups of students had a positive correlation between their AS and CUS [Table 4]. However, although positive, this correlation was extremely weak (Pearson's correlation coefficient < 2.0 for all subgroups).
Students' suggestions about computer-aided learning in context to traditional teaching
Section G [Annexure 1]-[Additional file 1] of the survey questionnaire was kept open-ended to allow the students to express their opinions about the place of computer-aided learning in the traditional medical teaching system in India. Three hundred and thirty-six students had suggestions as depicted in [Figure 1]. This qualitative data was analyzed by two independent reviewers from the medical faculty who were blinded to the study hypotheses, outcomes, and results. Although provision of Laptops, Wi-Fi facilities, and basic computer training were the major suggestions, improvement of the computer facilities for outstation students and faculty training for adequate and appropriate utilization of computer-aided learning facilities were also mentioned.
The application of computers in the current practice of medicine as well as medical education has been well-recognized by the international community.  The recognition of the role of CAL in the training of 'Next Generation Physicians' has seen many studies evaluating the need and attitudes toward such an initiative among medical students. ,,,, Very few similar studies have been reported from India,  even though India falls in the high density zone for the number of medical schools and training sites (150+) for future physicians.  Even as the need for the introduction of CAL is under serious consideration in many medical schools and universities across India, the level of preparedness and computer literacy of students for such an initiative has hitherto not been explored. The medical students from our institute form a diverse set, representing various parts of India, both urban and rural. This also implies that the cultural background, schooling, and level of exposure vary, depending on the native place. Hence, we decided to survey factors like native place, sex, background knowledge, and training of computer applications as a part of this study, as previous studies have demonstrated their effect on computer literacy and attitudes toward CAL.  We postulated that within a medical school, the factors that can primarily affect the level of computer literacy would be availability of resources, level of exposure in terms of years spent in medical school, as well as other co-curricular activities. We therefore decided to study the availability of computer resources as well as activities that students perceived would increase their computer skills. Finally, the survey questionnaire attempted to get an insight into the attitudes of students toward a possible introduction of computer-based learning through both open- and closed-ended questions.
Our study results show that the local students from the city of Mumbai seem to have increased opportunities for receiving training in computers in school as well as formal courses. Disparity is also seen in the form of statistically significant differences in computer resources possessed by the two groups [Table 1].
In the present study, computer usage was evaluated with 11 questions (Annexure I-Section C), which were graded using a 5-point Likert scale to calculate the computer usage score (CUS). Similarly, attitudes toward computer-based education were assessed with 12 questions (Annexure I-Section F) to calculate the Attitude score (AS). The mean CUS in the present study was 24.9 ± 9.3 (Mean ± SD) when the maximum achievable score was 55. This suggests a lower use of computers for the tasks studied. The CUS for local students (27.0 ± 9.2) was significantly higher than that of outstation students (23.2 ± 9.05; p < 0.0001) implying that the local students used computers to a greater extent than outstation students. No such difference was observed between male and female students. The mean AS for the study population was 41.8 ± 5.7 (Mean ± SD), when the maximum achievable score was 60. No statistically significant differences were observed between males and females or local and outstation students. We believe that the AS used in this study is a tool for assessing the willingness of students for using computers to enhance their learning. Hence, a high mean AS suggests that a majority of the study subjects were willing to use computers for enhancing their learning. However, this was not reflected in their practices of using computers for learning related tasks, as tested with the CUS. With a strong attitude toward using computers, one would expect it to be translated into practice by increased usage. On the contrary, this was not observed in our study, as AS weakly correlated with CUS for all subgroups. This finding can be explained by the lack of resources required to use computers or lack of training to use computers. As mentioned earlier, outstation students had significantly lower computer resources compared to local students. Hence, we propose that additional resources would benefit this subset of students. However, the weak correlation between AS and CUS for all students points to a possible inability to appropriately use computers despite having a strong urge to use them. This issue needs to be studied further, but one of the solutions can be a standardized computer learning program.
This study also aimed to determine the effect of the year of medical school on the level of computer literacy and attitudes toward CAL, with a hypothesis that advancing school years would reflect advanced computer skills. Although the students belonging to the six years of medical school differed in computer resources, no specific trend was observed. The AS and CUs of the six batches did not differ significantly; and both scores were weakly correlated for all batches. Hence, the advancing year of medical school did not have a significant effect on computer usage in the present study.
In an attempt to study the other factors like extracurricular activities that have an effect on computer learning skills, a series of seven questions [Annexure 1-[Additional file 1]; Section E] were designed. The II (I) and III (I and II) students felt that activities like medical symposia and research projects enhanced their computer skills (P = 0.002; < 0.0001 respectively, compared to medical students in other medical school years); 79.3% students also felt that self-interest was a strong motivation for using computers. The second and third years of medical school were the transitional years from pre-clinical to clinical rotations. Most of the students engaged themselves in co-curricular and research activities during this time frame, which justified the above-mentioned findings. Hence, encouraging co-curricular activities such as medical symposia, debates, and research projects could in turn help students enhance their computer skills.
Our study has its limitations. The inclusion of the use of specific software like MS Word, MS Office or statistical software would have thrown light on the exact needs and weaknesses of the students. Other factors that could have been studied were the specifics of schooling (as boarding schools of good repute are sometimes located away from the Metro cities), language of initial schooling (English or regional), and computer literacy and use of computers among parents and siblings. Similarly, whether it was economic constraint or a mere lack of interest in computers that precluded buying / owning a computer at home; whether it was the poor availability of internet service, the expense or the internet speed that prevented them from obtaining internet access at home was not determined. However, the length of the survey instrument was a limitation to include these factors. Another limitation was that the present study was conducted at a single large tertiary care teaching hospital. However, the medical education curriculum and structure is uniform across most public universities and medical schools across India. Hence, the findings of this study can be extrapolated to the public teaching hospitals and medical schools in India. However, educational resources and environment may be different in private medical schools. The large sample size covered in this study, which is uniformly spread over either sex or native place of stay, however, is a major strength. In addition, this study is one of the first of its kinds in the Indian setting, which has thrown light on the opinion of medical students about the possible introduction of computer-aided learning. The diverse study population and the tertiary care setting can permit an extrapolation of these findings to other major teaching hospitals in India. A previous study in southern India showed that although the use of computers among medical students was fairly common, most of these skills were acquired by themselves and were limited to simple tasks. The authors have also recommended formal computer training programs for undergraduate medical students.  The findings of the present study point in a similar direction.
The present study thus shows that medical students have a strong attitude toward using computers for their education, but this is not translated into practice. We believe that this gap can be bridged with a comprehensive computer learning program in medical schools. In the subset of outstation students, however, providing additional computer resources is equally important. In addition, extracurricular activities such as participation in medical research, symposia, and entertainment seem to enhance computer skills. Such activities need to be encouraged at the institutional, state, and national levels.
We thank all the study participants. We also wish to thank Drs. BM Kandalkar, AS Joshi, PS Bhuiyan and KP Bhate for their help in recruiting participants and Dr AN Supe for critical review of the manuscript.
[Table 1], [Table 2], [Table 3], [Table 4]