CHAPTER ONE: INTRODUCTION

1.1 BACKGROUND

Telemedicine, the use of technology to provide remote medical services, has

gained prominence worldwide, revolutionizing healthcare delivery. Nigeria,
with a high burden of HIV/AIDS 1, faces significant challenges in providing
accessible and quality care to patients living with HIV, particularly in remote
areas. Telemedicine presents an opportunity to bridge the gap and enhance
healthcare services for these patients. This chapter aims to conceptualize the
awareness of telemedicine and the acceptability of tele-consultation among
patients living with HIV attending a tertiary center in Nigeria.

The advent of telemedicine has revolutionized the landscape of healthcare

delivery, transcending geographical barriers and bridging the gap between
patients and healthcare providers. Telemedicine encompasses a wide array of
technologies and services that enable remote medical consultations,
diagnosis, treatment, and monitoring. In the context of HIV/AIDS care, where
access to specialized healthcare services is crucial for improved patient
outcomes, telemedicine has the potential to play a pivotal role in transforming
healthcare delivery for patients living with HIV. Nigeria, being one of the
countries most impacted by the HIV/AIDS epidemic, presents a critical and
compelling context to explore the awareness and acceptability of telemedicine
and tele-consultation services.

1.1.1 HIV/AIDS IN NIGERIA

HIV infection has spread over the last 30 years and has a great impact on
health, welfare, employment and criminal justice sectors; affecting all social
and ethnic groups throughout the world. Recent epidemiological data indicate
that HIV remains a public health issue that persistently drains our economic
sector having claimed more than 25 million lives over the last three decades 2.

Despite significant progress in combating the HIV pandemic, the global

burden remains substantial. In 2022, there were 39 million people living with
HIV, with 16.9 million being men, who play a critical role in sustaining the
epidemic 3. Sub-Saharan Africa bears a significant share of this burden
hosting 25.6 million people living with HIV and accounting for over half
(50.8%) of new global HIV infections 3. Nigeria, with a HIV prevalence of 1.4%

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and an estimated 1.9 million people living with HIV, is one of the high burden
countries 4.

The country already burdened by political instability and endemic political

corruption as a result of almost 33 years of military rule now seems prepared
to ‘wipe out’ the virus within a few decades 5. Notwithstanding the progress in
institutional reforms and political commitment to tackle the disease, the
country has seen more citizens placed on life saving medication of active
antiretroviral therapy (AART) to increase the survival of such HIV seropositive
individuals 5.

1.1.2 HEALTH INFRASTRUCTURE IN NIGERIA

Health infrastructure is an intricate support for public health delivery and the
nerve centre of public health system essential in encouraging good health
services and well-being 6. It offers the basis for planning, evaluating,
delivering, and enhancing development in public health 6. As such, the
delivery of public health service in every country is hinged on its health
infrastructure 7. In Nigeria, health infrastructure is at its low ebb, as there is
huge infrastructural deficit which constitute a major challenge to public health
in Nigeria 8. In Nigeria, the Federal, State and Local government is
empowered to legislate on matters on health, considering that it is contained
in the concurrent legislative list [Second Schedule and Fourth Schedule of the
Constitution of the Federal Republic of Nigeria, 1999 (Third Alteration).]. As
such, diverse challenges facing health care sector can be analyzed from
different levels of health care thus: Tertiary health care (managed by the
Federal Government), secondary health care (managed by the State
Government) and primary health care (administered by Local Government) 9.
Interestingly, a common challenge of these three triers of health care is the
deficiency in healthcare infrastructure. Most health institutions battle with age
long problem of weak, defective, insufficient and obsolete infrastructure 10.

1.1.3 TELMEDICINE IN NIGERIA

Telemedicine has been defined as the delivery of healthcare and the

exchange of health information across distances, including all medical
activities: making diagnosis, treatment, prevention, education and research 11.
It may be as simple as two health professionals discussing a patient's case
over the telephone, or as sophisticated as using satellite technology to
broadcast a consultation between healthcare centres in two countries using
videoconferencing equipment. The American Telemedicine Association
defines telemedicine as the use of medical information exchanged from one
site to another via electronic communication for health and education of the

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patient or healthcare providers and for the purpose of improving patient care
12
.

Telemedicine, the provision of healthcare services, clinical information, and

education over a distance using telecommunication technology existed long
before the Internet. Some authors noted that telemedicine was broadly
conceived even when the term was used almost three decades ago 13.

Currently, Nigeria has an estimated population of more than 200 million

people (UN) 14, a major percentage of which live in the remote rural and
poorer areas with most of the best equipped hospitals including teaching
hospitals and medical experts located in the urban cities. This situation
prevented the majority of people living in remote rural areas from reaching
healthcare practitioners to meet their medical service needs. Consequent
upon this, governments at federal, state and local levels have been making
healthcare in these remote areas their focal point over the years so as to
enhance the citizen's equality in the availability of various medical services
and clinical healthcare despite geographic isolation; but this has not yielded
any serious results.

According the Chief Executive Officer of Telemedicine Africa, telemedicine

guarantees reduced patient waiting times in an efficient and cost effective
manner 15 . Telemedicine is still an experimental tool by health practitioners in
Sub-Saharan Afrcia. As far back as 2010, some Nigerian higher institutions
such as UNILAG announced the development of their own telemedicine
solutions 16. Former Chief Medical Director, Professor Akin Osibogun,
attributed the success of the telemedicine solutions to government. Medical
consultations in Nigeria are carried out in hospitals and other medical
facilities, leads to increase in the number of deaths due to delay in reaching
health facilities. Experts profound a solution to this via telemedicine. Lack of
adequate medical doctors have led to increase in mortality. The World Health
Organization requires that a country maintains a standard doctor-patient ratio
of 1:600. Nigeria’s currently doctor-patient ratio is at 1:3500 17.On November
11, 2007, the National Space Research and Development Agency (NASRDA),
a Nigerian Federal Government establishment, along with the Nigerian
Ministry of Health began an initiative to embark on a pilot project using
telemedicine to improve care to Nigerians living in rural areas, far from the
country's professional health facilities 18. The initiative relied on NigComSat-1
and began with eight remote terminals that would serve as stationary nodes at
which patients could access care from medical professionals living in Abuja or
Lagos, and a single mobile unit that would travel into more remote areas of
Nigeria.

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1.1.4 TELECONSULTATION AND HIV CARE

In 2020, an estimated 87% of people living in LMICs (Low and Middle Income
Countries) had access to a mobile phone, and over half of those in LMICs
used the Internet 12. Although Telemedicine has long been technologically
feasible, it was not widely adopted until the coronavirus disease 2019
(COVID-19) pandemic necessitated remote health care delivery options that
supported physical-distancing precautions, Implementing telemedicine
services during COVID-19: guiding principles and considerations for a
stepwise approach 19. After widespread uptake during the pandemic,
Telemedicine has the potential to address existing and growing inequities in
the global HIV response by improving both provider-patient and provider-
provider communication 20.

While Telemedicine holds promise for the prevention and management of HIV
and other chronic diseases in LMICs, there are several challenges to consider
before widespread implementation can be realised 21. At the national level,
countries may lack sufficient legal and regulatory frameworks to guide
telemedicine implementation 22. Regulations such as those governing
licensure, online prescribing, and financial reimbursement mechanisms may
need to be developed or modified 23. A 2015 WHO evaluation found that only
22% of the 125 countries surveyed had a national policy for Telemedicine 24. A
lack of national strategy for Telemedicine can lead to gaps in coordination
among stakeholders, particularly between the private and public sectors.
Many pilot programs in LMICs have been funded by private donors and run
without the involvement of local governments 25.

At the implementation level, issues of privacy, confidentiality, and data security

are of paramount importance for patients, particularly for PLHIV seeking HIV-
related care 26. Telemedicine can pose greater privacy risks than in-person
visits. Housemates or family members may be nearby or may interrupt
Telemedicine conversations, cell phones or computers could inadvertently
reveal patient information to others, and home-based lab kits or medication
delivery could inadvertently disclose patient health information. Health care
providers should select telemedicine technology platforms with appropriate
safeguards and data security. Workflows may need to be restructured to
facilitate virtual delivery of health services and health care providers need
training on how to best deliver patient care and HIV services via Telemedicine
26

In December 2020, Abia State Government in partnership with SandsClinic

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has introduced telehealth specific services to people living with HIV (PLHIV) in
the state.
SandsClinic is a fast growing telemedicine company with the aim of providing
convenient and affordable healthcare that saves customers time so that they
can face family and other things.27

1.2 STATEMENT OF THE PROBLEM

HIV/AIDS remains a significant public health challenge in Nigeria, with a high

burden of cases and limited access to specialized healthcare services,
especially for patients attending tertiary centers. Despite the potential of
telemedicine to address healthcare disparities and improve patient outcomes,
its awareness, acceptability, and readiness for implementation among
patients living with HIV and healthcare workers in such settings have not been
extensively explored.

Limited access to healthcare facilities, exacerbated by factors such as long

distances, inadequate resources, and social stigma, hinder patients' ability to
receive timely and appropriate care. Additionally, healthcare workers and
program managers may face challenges in effectively implementing
telemedicine and tele-consultation services due to factors like technological
preparedness, training, and program support.

The lack of comprehensive research on the awareness and acceptability of

telemedicine among patients living with HIV and the readiness of healthcare
workers and program managers in tertiary centers poses a significant barrier
to harnessing the full potential of telemedicine in HIV/AIDS care.
Understanding these crucial aspects is essential to develop patient-centered
interventions, bridge healthcare disparities, and optimize the integration of
telemedicine in resource-limited settings like Nigeria.

Therefore, this research aims to address these gaps in knowledge by

investigating the awareness and acceptability of telemedicine and tele-
consultation services among patients living with HIV attending a tertiary center
in Nigeria. It also seeks to explore the readiness of HIV/AIDS healthcare
workers and program managers to implement telemedicine, with the ultimate
goal of informing evidence-based strategies that enhance HIV/AIDS care and
expand access to specialized healthcare services in Nigeria.

Despite the potential benefits of telemedicine and tele-consultation in

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improving healthcare access and delivery, there is a lack of comprehensive
research on the awareness and acceptability of these technologies
specifically among patients living with HIV attending a tertiary center in
Nigeria. This research aims to address this gap by examining the following
key aspects:

1. Limited Awareness of Telemedicine among Patients Living with HIV

The level of awareness of telemedicine and its applications for healthcare

remains relatively low in Nigeria (Ifeyinwa Arize et al. Digit Health. 2017)
particularly among patients living with HIV. Many individuals may not be
familiar with tele-consultation services, how they work, or the potential
benefits they offer. As a result, patients may not consider tele-consultation as
a viable option for their HIV care and may not be actively seeking information
about its availability.

2. Factors Influencing Acceptability of Tele-Consultation

The acceptance of tele-consultation among patients living with HIV attending

tertiary centers in Nigeria depends on various factors. Some patients may be
hesitant to use telemedicine due to concerns about the quality of care
provided remotely, privacy and security of personal health information, and
potential technical challenges in accessing tele-consultation platforms.

Moreover, socio-cultural factors, such as stigma and discrimination associated

with HIV, may influence patients' willingness to engage in tele-consultation.
Patients' perceptions of telemedicine and their trust in healthcare providers'
ability to deliver effective care through tele-consultation may also play a
significant role in determining its acceptability.

3. Potential Benefits and Challenges of Implementing Telemedicine for HIV

Care, Implementing telemedicine for HIV care in Nigeria brings forth both
opportunities and challenges. The potential benefits of tele-consultation
include improved healthcare access for patients in remote areas, reduced
travel time and costs, enhanced communication between healthcare providers
and patients, and potentially better treatment adherence through regular
remote consultations.

1.3 JUSTIFICATION/RATIONALE FOR THE STUDY

 Public Health Relevance

HIV/AIDS continues to be a significant public health challenge globally, with

Nigeria accounting for a substantial proportion of new infections and existing

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cases. Tertiary centers serve as important hubs for HIV/AIDS care, providing
specialized treatment and management. However, challenges such as long
distances to healthcare facilities, limited healthcare resources, and stigma
associated with the disease can impede patient access to quality care. By
investigating the awareness and acceptability of telemedicine and tele-
consultation among patients living with HIV in a tertiary center, this study aims
to identify the potential benefits and barriers that telemedicine can offer to
improve healthcare access and outcomes for this vulnerable population.

 Advancing Telemedicine in Resource-Limited Settings

While telemedicine has shown great promise in high-income countries, its

implementation and impact in resource-limited settings like Nigeria remain
understudied. By examining the awareness and acceptability of telemedicine
among patients living with HIV attending a tertiary center, this study can
provide insights into tailoring telemedicine solutions to suit the unique needs
and challenges of such settings. The findings can contribute to the
development of telemedicine strategies that are culturally appropriate, cost-
effective, and sustainable.

 Enhancing Patient-Centered Care

Understanding patient perspectives and attitudes towards telemedicine and

tele-consultation services is crucial to ensure patient-centered care. By
evaluating the acceptability of these technologies among patients living with
HIV, this study seeks to identify factors that can influence patient
engagement, satisfaction, and adherence to treatment. The results can inform
the design of patient-centric telemedicine interventions that foster trust,
privacy, and confidentiality, leading to better health outcomes and improved
overall quality of life.

 Informing Policy and Practice

The insights gained from this study can inform policymakers, healthcare
providers, and stakeholders in Nigeria's healthcare system. Understanding the
barriers and facilitators to the adoption of telemedicine can help shape
healthcare policies that promote the integration of telemedicine services into
existing HIV/AIDS care programs. Additionally, healthcare providers can use
the findings to develop targeted interventions and educational programs to
raise awareness and promote the acceptability of telemedicine among
patients living with HIV.

1.4 RESEARCH QUESTIONS

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To achieve the stated objectives, this research will seek answers to the
following questions:

1. What is the current level of awareness of telemedicine among patients

living with HIV attending AKTH?
2. How acceptable is tele-consultation among patients living with HIV
attending AKTH
3. What factors influence patients' acceptance and willingness to engage
in tele-consultation services?
4. What are the perspectives of HCWs and patients on potential benefits
and challenges of implementing telemedicine for HIV care in AKTH?

1.5 AIM/OBJECTIVES

Aim/General Objective:

To assess the awareness, and determinants of acceptability of tele-

consultation among patients living with HIV attending Aminu Kano Teaching
Hospital, Kano.

Specific Objectives:

1. To assess the level of awareness of telemedicine among patients living with

HIV attending AKTH
2. To determine the acceptability and willingness to use tele-consultation
among patients living with HIV
3. To identify factors associated with patients' acceptance and willingness to
use tele-consultation services for HIV care.
4. To explore HCW and patients’ perspectives about the potential benefits and
challenges of implementing tele-consultation services for HIV care in AKTH.

1.6 SIGNIFICANCE OF THE STUDY

This research is significant for several reasons:

- It will contribute to the existing body of knowledge on telemedicine adoption
and acceptance among patients living with HIV in Nigeria.
- Findings will guide policymakers and healthcare providers in tailoring
telemedicine interventions to address the specific needs of this population.
- Improved awareness and acceptance of tele-consultation could enhance
healthcare access and outcomes for patients living with HIV.

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 CHAPTER 2

Literature Review

2.1 Introduction

This chapter presents a comprehensive literature review focused on the

specific objectives of this study: Assessing the awareness of telemedicine and
the acceptability of tele-consultation among patients living with HIV attending
Aminu Kano Teaching Hospital (AKTH) in Kano, Nigeria. The review aims to
provide insights into the current state of telemedicine adoption in HIV care
and its potential impact on healthcare delivery for patients with HIV in the
world and Nigerian context.

Introduction To Telemedicine And Hiv Care

Telemedicine, a term encompassing the utilization of telecommunication

technologies to facilitate remote delivery of healthcare services, includes tele-
consultation, a specific facet involving virtual interactions between healthcare
providers and patients.

The advent of advanced computer and internet technologies since the early
1990s has opened novel avenues for doctors and patients. In developed
nations, doctors employ computers to transmit real-time video, audio, and
high-resolution images across vast distances, even conducting patient
assessments in clinics thousands of miles away 28. Moreover, the rapid
proliferation of mobile phones, promising universal connectivity, strengthens
the belief that the latest generation of information and communication
technologies (ICTs) will drive significant beneficial transformations in the
healthcare sector's organization 29.

Global concerns about health issues have escalated due to a surge in life-
threatening ailments, some of which remain incurable. The complex nature of
health challenges in Nigeria has necessitated multifaceted study approaches
30
.

The far-reaching impact of HIV infection over the past three decades has
reverberated across health, social, economic, and legal domains, affecting
diverse global demographics. Recent epidemiological data underscore the
ongoing public health challenge posed by HIV, which has claimed over 25
million lives. This continuing burden exerts strain on economies 31.

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Despite substantial strides in combatting the HIV pandemic, a significant
global burden persists. In 2022 alone, 16.9 million males were living with HIV,
contributing substantially to the total of 39 million survivors of the epidemic 32.
Sub-Saharan Africa shoulders a considerable portion of this burden, housing
25.6 million people with HIV and accounting for more than half (50.8%) of all
new HIV cases worldwide. Nigeria, with an HIV prevalence of 1.4%, is among
the high burden countries, with an estimated 1.9 million individuals living with
HIV 33.

In a prospective randomized study conducted over a span of two years by A

Leon et al., a comparison was made between standard care and Virtual
Hospital care for HIV-infected patients. Those with access to a computer and
broadband were randomized to receive monitoring either through Virtual
Hospital (Arm I) or standard care at the day hospital (Arm II). The study
concluded that Virtual Hospital is a feasible and secure tool for the
multidisciplinary home care of chronic HIV patients. Telemedicine emerges as
a viable support service for managing chronic HIV infection 34.

2.2 Telemedicine Awareness and HIV/AIDS patients

2.2.1 Knowledge of Telemedicine Among Patients with chronic conditions

In 2015, a group of Korean researchers conducted a randomized clinical trial

with the aim of evaluating the effectiveness of remote patient monitoring and
physician care in reducing office blood pressure (BP). They randomized 374
hypertensive patients into three groups: the first group received usual clinical
care with home BP monitoring (HBPM), the second group underwent remote
monitoring and received office follow-up, and the third group received remote
monitoring alone without physician office care, using the remote monitoring
device. In each group, in-office follow-up care was scheduled every 8 weeks
for a span of 24 weeks. The primary endpoint was the difference in sitting
systolic BP at the 24-week follow-up. No significant differences were observed
among the three groups. The study concluded that remote monitoring alone or
coupled with remote physician care demonstrated efficacy comparable to
usual office care in reducing BP, with similar safety and effectiveness for
hypertensive patients 35.

In a recent meta-analysis, Omboni and colleagues compiled data from 7037

hypertensive patients enrolled in 23 high-quality randomized controlled
studies. The analysis revealed that regular BP tele-monitoring at home led to
a significantly greater reduction in both office and ambulatory BP compared to
usual care. Specifically, the mean reductions in office systolic and diastolic BP

10
were 4.7 and 2.5 mmHg larger, respectively, in the BP tele-monitoring group.
Furthermore, a significantly higher proportion of patients in the intervention
group achieved office BP normalization (< 140/90 mmHg for non-diabetic and
< 130/80 mmHg for diabetic patients), demonstrating the effectiveness of the
intervention 36.

2.2.2 Knowledge of Telemedicine Among Patients with HIV

In a study comparing telemedicine with in-person subspecialty clinic visits for

HIV and hepatitis C, telemedicine demonstrated several advantages,
including higher clinic completion rates, improved access, high patient
satisfaction, and reduced health visit-related time 37. This pre- and post-
intervention study focused on HIV and hepatitis C patients residing in two
rural catchment areas. The primary binary outcome assessed was clinic
completion. The researchers employed a logistic regression model with
patient-level fixed effects, which controlled for visit clustering by patient and
utilized each patient's in-person clinic experience as an internal control group.
This approach effectively eliminated confounding factors at the person-level.
Additionally, patient surveys were conducted to evaluate satisfaction levels
and perceived reductions in health visit-related time.

A study conducted in Nigeria by I. Arize and O. Onwujekwe in 2017 revealed

a low level of awareness regarding telemedicine services in Enugu State,
located in the South East of Nigeria. The study utilized primary data collected
through an interviewer-administered questionnaire, targeting 370 individuals
aged 25 and over, including both males and females. The questionnaire
employed a bidding game question format to gather data on respondents'
awareness and acceptability of telemedicine services 38.

2.3 Acceptability Of Teleconsultation

2.3.1 Awareness of Tele-Consultation Among Patients

In a study conducted in India by R. Sujitra et al., it was found that 45% of

patients became aware of teleconsultation only after physically visiting the
hospital, while 30% learned about it through word of mouth. This study
focused on 355 pregnant women who were contacted via telephone by the
principal investigator or co-investigator. Verbal telephonic consent was
obtained, after which the investigator administered a questionnaire to collect
data. The questionnaire was designed to assess awareness of

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teleconsultation, its outcomes, patient satisfaction, and factors influencing
teleconsultation services 39.

In another study carried out by Mansoor et al. in Canada in 2020, it was

demonstrated that the teleconsultation program could sustain 10.89% of the
weekly pre-lockdown eye care services. While the post-lockdown consultation
load did not match pre-lockdown levels, teleconsultation still enabled the
maintenance of eye care services to a certain extent during the COVID-19
pandemic 40.

2.3.2 Awareness of Tele-Consultation Among Patients Living with HIV

In a study conducted by K. Galaviz et al. in Atlanta, Georgia, it was observed

that patients with HIV displayed a general awareness of and satisfaction with
telephone-based telemedicine during the COVID-19 pandemic. The study
invited a convenience sample of adults (>18 years) receiving care in an urban
clinic in Atlanta to participate. Patients completed a structured survey
assessing the usefulness, quality, satisfaction, and concerns related to
telemedicine services (telephone calls) received during the initial wave of the
COVID-19 pandemic (March-May 2020). Differences in patient experiences
based on age, sex, and race were examined using bootstrapped t-tests and
Chi-square tests. Out of 406 people living with HIV (PWH) contacted, 101
completed the survey (median age 55 years, 84% male, 77% Black, 98%
virally-suppressed, median CD4 count 572 cells/µL). Primary disruptions in
HIV care included delayed follow-up visits (40%), challenges in obtaining viral
load measurements (35%), and difficulties accessing antiretroviral therapy
(21%). Participants gave high ratings for quality (median score 6.5/7),
usefulness (median score 6.0/7), and satisfaction (median score 6.3/7) with
telemedicine 41.

In a 2019 study by L. Margusino-Framiñán et al. in the US, a teleconsultation

protocol associated with home antiretroviral delivery or medication
observation point (MOP) was found to achieve a high level of awareness and
satisfaction among HIV hospital outpatients receiving treatment. This
approach did not impact therapeutic objectives and resulted in substantial
cost savings for both patients and indirect labor productivity 42.

In another observational retrospective study conducted by Kadam et al. in

India in 2023, it was demonstrated that in a resource-limited setting, CD4-
based assessment via telemedicine remains valuable when a consistent
record is maintained. The study evaluated 430 cases in terms of

12
demographics, CD4 trends, and adverse effects. This telemedicine platform
also facilitated the tracking and monitoring of cases lost to follow-up 43.

2.4 Factors influencing Acceptability and willingness of Tele-

Consultation Among Patients Living with HIV

In a 2020 study conducted by Patricia Baudier and G. Kondrateva, the

acceptance of teleconsultation solutions by patients during the COVID-19
pandemic was investigated. The results revealed that age, gender, and
country play a moderating role in the adoption of teleconsultation solutions,
with performance expectancy emerging as a significant factor. The study
utilized constructs from the Unified Theory of Acceptance and Use of
Technology 2 (UTAUT2) model, specifically Personal Traits, Availability, and
Perceived Risks. Additionally, the authors introduced a new scale called
Contamination Avoidance. The questionnaire was distributed across multiple
countries in Europe and Asia, yielding a total sample of 386 respondents. The
findings underscored the substantial influence of Performance Expectancy,
the adverse impact of Perceived Risk, and the positive effect of
Contamination Avoidance on the adoption of teleconsultation solutions. The
study also highlighted the moderating effects of Age, Gender, and Country 44.

In a study conducted by Germano Vera Cruz et al. in Mozambique, it was

observed that a majority of participants expressed a high willingness to use
tele-consultation public health services for mild illnesses, affordable prices,
and follow-up consultations. The study engaged 403 adults and presented 32
vignettes describing various health problem scenarios where individuals were
asked to rate their willingness to use tele-consultation services on an 11-point
scale. The research employed cluster analysis and statistical tests to examine
the effects of health problem situations and sociodemographic characteristics
on participant ratings. The study revealed that participants, especially those
who were younger, more educated, wealthier, urban, and reported lower
levels of perceived stress, were significantly inclined to use tele-consultation
services, particularly for mild health issues, follow-up consultations, and cost-
effective options 45.

In another study by Ita Daryanti Saragih et al., telehealth-assisted

interventions were found to significantly enhance treatment adherence,
improve quality of life, and reduce depressive symptoms among people living
with HIV/AIDS. The study suggested that delivering health management
interventions remotely through telehealth-assisted modalities is feasible and
effective in yielding health benefits for individuals living with HIV/AIDS.

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Integrating telehealth-assisted interventions into HIV/AIDS care could
contribute to continuous care and sustained well-being 46.

Patricia Baudier et al. conducted a cross-national study on Patients’

perceptions of teleconsultation during COVID-19, revealing that age, gender,
and country play a moderating role in the adoption of teleconsultation
solutions, with performance expectancy being a significant factor 47.

2.5 Perception of healthcare workers on telemedicine and HIV care

In a Canadian study conducted by K. Anderson et al., the aim was to

investigate physician perceptions regarding the use of telemedicine in human
immunodeficiency virus (HIV) patient care. A cross-sectional web-based
survey was employed, and out of the 51 invited participants, 48 (94%)
completed the survey. Among respondents, 62% (29/47) reported using some
form of telemedicine for caring for HIV patients in their practice. The
modalities frequently used included telephone (86%, 25/29), email (69%,
20/29), and teleconsultation (24%, 7/29). A significant number of physicians
(83%, 38/46) indicated that a hurdle to adopting telemedicine is the perception
that it does not allow for a comprehensive patient health assessment.
Moreover, 65% (28/43) of physicians concurred that patients might not feel
adequately connected to them as providers if telemedicine were used.
However, 85% (39/46) of respondents believed that telemedicine could
enhance access, timeliness of care, and the frequency of physician-patient
interactions, ultimately leading to improved patient care 48.

In a US study by Waldura et al., an electronic survey was utilized to explore

primary care clinicians' self-perceived confidence and self-reported clinical
practices after utilizing the University of San Francisco-based National Human
Immunodeficiency Virus (HIV) Telephone Consultative Service (HIV
Warmline). The HIV Warmline offers clinicians real-time telephone
consultations with experts in HIV medicine. Over a two-year period, the study
found that the majority of primary care clinicians (physicians and mid-level
practitioners) perceived the HIV Warmline as quicker, more applicable to their
clinical management concerns, and more reliable than other HIV information
sources. Additionally, most participants reported that using the
teleconsultation service increased their confidence in managing HIV patients,
led to changes in their HIV management approach, and reduced the likelihood
of referring patients to an HIV specialist 49.

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2.6 Telemedicine Implementation and readiness in resource limited
settings

In a study conducted by J. Waldura et al. in 2013, it was found that

teleconsultation could serve as a potent tool to streamline HIV care in primary
care settings and could potentially be adapted for various other medical
conditions. Primary care clinicians who engaged with the HIV Warmline
reported heightened confidence in their HIV care and reduced necessity for
specialist referrals. While teleconsultation holds promise, its direct impact on
referral rates, care quality, and clinical outcomes necessitates further
investigation 49.

A study by J. Waldura and Sarah Neff et al. in 2011 demonstrated the

potential of HIV teleconsultation in enhancing HIV care, particularly in regions
with limited access to HIV expertise. The objective of the study was to
examine the infrastructure, successes, and challenges of a teleconsultation
service for HIV clinicians. The HIV Warmline, a telephone consultation
service, has provided over 37,000 consultations since its inception in 1992,
catering to clinicians across all 50 states and diverse professional
backgrounds. While the majority of call topics revolved around antiretroviral
therapy, callers expressed satisfaction with the service, as evidenced by a
mean Likert scale rating of 4.7 on satisfaction survey questions 50.

A study conducted by Cesar Caceres et al. in Spain presented a success

story in the realm of telemedicine care for HIV patients. This study introduced
an innovative home telecare model, known as the "VIHrtual Hospital," at the
Clinic Hospital in Barcelona. The web-based system's architecture met
stringent security and integration requirements, and a user-friendly interface
was developed for patients and professionals alike. The system's cost-
effectiveness enabled broad patient coverage, with promising outcomes for
enhancing follow-up care and establishing a new care model for chronic
HIV/AIDS patients 51.

In another study carried out by Babatunde et al. in 2021 in Nigeria, the

potential of telemedicine in revitalizing healthcare systems in low and middle-
income countries (LMICs) was acknowledged. However, challenges were
noted that could potentially exacerbate health inequalities, particularly based
on income. This study delves into the discourse surrounding the role of
telemedicine in LMICs and underscores the need for strategies to prevent the
widening of health inequalities stemming from telemedicine use. The study
also presents recommendations to promote universal health coverage through
telemedicine in LMICs.52

15
2.7 Best practices and guidelines for teleconsultation in HIV care

According to Richard Wootton et al., understanding the effectiveness and

impact of a telemedicine network is crucial, serving as a yardstick for gauging
its intended functionality. Drawing from extensive field experience, the
proposed framework stands as a practical instrument, enabling organizations
to evaluate their network's performance and enhance it through comparative
analysis. A fundamental aspect of all telemedicine systems is the provision of
information about setup and operational expenses, as cost-effectiveness
remains pivotal for long-term viability.53

Telemedicine projects often encounter challenges in progressing beyond their

initial pilot phases. In addition to the conventional obstacles such as
reimbursement and legal aspects, user acceptance of telemedicine
technologies holds paramount significance. A study conducted by Priscilla E
Essar et al. underscores the crucial role of instrumental and affective
communication behaviors among teleconsultation participants. Similarly, the
participants' perceptions regarding the effectiveness, efficiency, and
'affectiveness' of the telemedicine system are of equal importance. This
framework has the potential to enrich design methodology by offering a
practical tool for design professionals to consider users throughout every
phase of the design process, even in intricate and unfamiliar contexts.54

2.8 Gaps in literature and research need

People living with HIV (PWH) face an elevated risk of episodic or permanent
disability due to their condition.55 Additionally, individuals with disabilities are
more susceptible to HIV infection due to limited testing access or resources. 56
Regrettably, there is scant knowledge about telehealth utilization among
individuals with disabilities and chronic diseases, including HIV, amid the
pandemic. A US study suggests that approximately 40% of people with
disabilities may have availed themselves of telehealth during the pandemic. 57
However, utilization patterns differed based on the type of disability and
socioeconomic status. For instance, those with mobility or cognitive
disabilities were more inclined to use telehealth compared to those with
hearing or visual impairments. Moreover, individuals with disabilities
possessing graduate degrees and insurance displayed a higher likelihood of
using telehealth in comparison to other groups. 58 The findings from this US
study further underscore disparities in telehealth utilization. Consequently, it
becomes imperative to delve into the role of telehealth in managing chronic

16
diseases within this demographic, while assessing its implications on their
quality of life, healthcare access, and overall outcomes.

The availability of effective antiretroviral therapy has transformed HIV from an

acute disease into a manageable chronic condition for many people living with
HIV (PLWH). In this context, mobile phones equipped with short message
service (SMS) present a unique opportunity to enhance treatment and
prevention efforts for individuals managing HIV.

A study identified that an SMS-based intervention, incorporating interactivity,

frequency, timing, and tailored messages, holds promise for improving
medication adherence and impacting other interconnected behaviors and
factors. These include heightened patient involvement, increased social
support, reduced risk behaviors, and enhanced overall health and well-being.
This intervention has the potential to contribute to improved healthcare quality
and clinical outcomes for PLWH.

To further enhance our understanding, we recommend that future studies

delve into the potential relationships between variations in SMS
characteristics and these mediating factors. This exploration can shed light on
whether and how these factors influence broader outcomes.59

2.9 Conceptual framework

Conceptual Framework: Telehealth Utilization for Chronic Disease

Management (HIV)

1.
Input Factors:
1.
Demographic Characteristics: Age, gender, education,
socioeconomic status, insurance coverage, type of disability.
2.
Healthcare Infrastructure: Availability of telehealth services,
institutional support, healthcare access.
2.
Process Factors:

17
 1.
Telehealth Modalities: Video visits, telephone calls, text messaging,
web-based content, applications.
2.
Telehealth Utilization: Frequency, purpose, duration of telehealth
interactions.
3.
Patient-Provider Communication: Communication quality,
information exchange, rapport building.
3.
Mediating Factors:
1.
Disability Impact: Level of disability, episodic/permanent disability,
impact on mobility/cognition.
2.
Healthcare Access: Geographical barriers, transportation limitations,
in-person visit challenges.
3.
Health Literacy: Understanding of telehealth platforms,
communication preferences, technological proficiency.
4.
Outcome Factors:
1.
Quality of Care: Patient satisfaction, perceived effectiveness of
telehealth for chronic disease management.
2.
Healthcare Outcomes: Viral load control, CD4 count stability,
medication adherence, disease progression.
3.
Quality of Life: Emotional well-being, social connectedness,
psychological impact of disability and disease management.
4.
Health Disparities: Differential telehealth utilization, disparities in
health outcomes among subgroups.
5.
External Factors:
1.
Healthcare Policies: Telehealth regulations, reimbursement policies,
incentives for telehealth utilization.
2.
Technological Advancements: Accessibility of devices, user-friendly
platforms, continuous tech improvements.

18
 3.
Sociocultural Context: Stigma, societal attitudes towards disabilities,
community support systems.
6.
Feedback Loop:
1.
Patient Preferences: Preferred telehealth modalities, communication
style, satisfaction with services.
2.
Provider Practices: Adaptation of telehealth to patient needs,
challenges faced in delivering telehealth care.

This conceptual framework encompasses various dimensions of telehealth

utilization for chronic disease management among individuals with disabilities,
particularly focusing on HIV care. It considers input factors, the process of
telehealth utilization, mediating influences, expected outcomes, external
contextual factors, and a feedback loop to capture patient preferences and
provider practices. This framework aims to comprehensively guide your
research by examining how different factors interact and contribute to the
overall effectiveness and equity of telehealth services for this vulnerable
population.

19
Summary

This chapter provides a concise summary of the literature review, highlighting

key findings relevant to the specific objectives of the study. The literature
review serves as a foundation for understanding the current state of
telemedicine awareness and acceptability among patients living with HIV in
global and local literatures. The insights gained from this review will guide the
research methodology and data analysis in subsequent chapters, leading to a
comprehensive understanding of the awareness and acceptability of tele-
consultation among patients living with HIV in the Nigerian context.

CHAPTER THREE

20
 METHODOLOGY

3.1 Study area

Kano state is situated in North-Western Nigeria and was established on May

27, 1967, following the division of the Northern region. It shares borders with
Katsina state to the North-West, Jigawa state to the North-East, Bauchi state
to the South-East, and Kaduna state to the South-West. The state's capital is
Kano. As of the 2006 census, the state had a population of 9,401,288, and it
is projected to have reached 15,462,200 by 2022, and it will be about
15,926,066 in 2023 assuming a growth rate of 3% per annum. With an
average density of 442 people per square kilometer, it stands as the most
densely populated state in the North. Kano comprises 44 local government
areas, with the Metropolis encompassing 8 local government areas situated
within the city. These areas include Kano municipal, Dala, Gwale, Fagge,
Nassarawa, Tarauni, Ungoggo, and Kumbotso. They collectively form the
primary hub of trade and commerce.

The state has several tertiary hospitals, including Aminu Kano Teaching
Hospital, National Orthopaedic Hospital Dala, Murtala Muhammad Specialist
Hospital, and Muhammad Abdullahi Wase Specialist Hospital. Additionally,
secondary care hospitals and primary level care centers, such as
Comprehensive and Primary Health care Centers, are strategically dispersed
across the state.

3.2 Study site

The study will be conducted at Aminu Kano Teaching Hospital, one of the two
tertiary referral centers [Dala Orthopaedic hospital is the other one] under the
Federal Ministry of Health for over 13 million people located in Kano, in
northern Nigeria.60 The hospital operated at a temporary site at Murtala
Muhammad Specialist Hospital, Kano before moving to the permanent site
along Zaria Road in Tarauni local government in January 1996. Presently, the
hospital is easily accessible via the various tarred roads and several transport

21
systems operating in the area.

Study site and population

The study will be conducted at the S.S. Wali HIV Center at Aminu Kano
Teaching Hospital (AKTH), Kano, Nigeria. AKTH is a 750-bed tertiary hospital
and operates a multidisciplinary, specialist HIV clinic 5 days a week. Clinical
examinations, laboratory investigations, and antiretroviral drugs are provided
at no charge. Patient support groups, counseling, testing, and home-based
care are also offered.

3.3 Study design and sampling

This will be a clinic-based sequential, explanatory, mixed-methods study

deploying a pragmatic paradigm. First, a cross-section of PLHIV (persons
living with HIV) receiving antiretroviral treatment will be interviewed by the
researcher and trained research assistants fluent in the local Hausa language
using structured survey questionnaires. This will be complemented with in-
depth interviews with a sub-sample of 20 survey respondents to capture
nuanced explanations of survey responses. The research team will include
quantitative, qualitative and mixed-methods expertise, with four trained
research assistants. None of the research staff will have direct clinical
responsibility at the HIV treatment center. Research staff will be trained
intensively on interview techniques, sampling methods, confidentiality,
consent and administration of structured questionnaires, as well as ethics and
human participant protection.

Study population

The study participants will be adults (≥18 years old) of both sexes, living with
HIV, and enrolled in the antiretroviral treatment (ART) program at AKTH. As
patients arrive for their appointments, they will be registered sequentially and
allocated to a consultation room. While waiting for their turn, a trained health
worker will inform them of the purpose of the study and request their
participation. The research assistants will check for eligibility. Only patients
who provide informed consent will be interviewed. We will exclude individuals
who are too ill to be interviewed and those with cognitive impairment.

3.4 Sample size determination

Sample size was determined using Fisher’s formula for sampling a proportion

22
from an infinite population.
n = (z2pq) /d2
Where n=the minimum sample size,
z = the percentage point of the standard normal distribution curve, which the
curve defines 95% confidence interval (the value obtained from a normal
distribution table is 1.96).
p = prevalence of acceptability of telemedicine consultation from a previous
study (41.1%) equivalent to p=0.411) Arize Ifeanyi et al.61
q = complementary probability of p i.e. (1-p = 1-0.411 = 0.589)
d = maximum sampling error tolerable (i.e. precision)=5%, equivalent to 0.05
n= [(1.96)2(0.411) (0.589)]/0.052 = 371.9=372
Based on the above, the minimum sample size was 372 but 10% of the
calculated minimum sample size was added to cater for anticipated non-
response (372/0.90) giving 414.

Participant recruitment and sampling

A systematic sample of PLHIV will be selected starting with a simple ballot

between the first eligible attendee and the attendee whose serial number
tallied with the sampling interval. Subsequent respondents will be identified by
adding the sampling interval to the previous respondent’s serial number until
the desired sample size is met. For the qualitative component, to achieve
maximum variation, a stratified purposive sub-sample of PLHIV (n=20) who
responded to the survey will be interviewed to further explore the responses
to questions regarding acceptability of telemedicine and tele consultation.
Stratification will be based on socio-demographics (sex, age, education,
income, residence), and clinical characteristics including self-assessed health
status.

Measures and data collection

For the survey, we will adapt validated questionnaires used in previous

studies . Our adaptation had the following sections: Section A include socio-
demographic and HIV-related clinical data, and section B with information on

23
awareness and knowledge of telemedicine and tele consultations and Section
C will assess the acceptability and experiences with telemedicine and tele
consultation. Examples of questions assessing acceptability of tele-
consultation include:

Would you be willing to use tele-consultation services for your HIV care?

With response options as follows;

( ) Yes

( ) No

( ) Not Sure

To elucidate survey findings, the qualitative interview guide will have open-
ended questions with probes for detailed descriptions. The guide will explore
PLHIV’s perceptions of telemedicine, acceptability and experiences. All
participants will provide written or thumb-printed informed consent.
Confidentiality in reporting qualitative findings will be ensured by removing
identifiers.

The study protocol will be reviewed and approved by the Aminu Kano
Teaching Hospital/Bayero University Research Ethics Committees. Potential
participants will be individually contacted by trained research assistants and
provided detailed information on the study objectives and what participation
entailed. They will be informed that participation is voluntary. Those who sign
an informed consent form will be interviewed in a private room allocated for
the purpose.

3.5 Preparation for data collection

A research proposal together with introductory letter from the Head of

department of community medicine, Bayero University Kano/Aminu Kano
Teaching Hospital seeking the permission of the hospital authority and ethical
committee review and approval will be submitted. After obtaining the approval
informed consent will be obtained from all the respondents before the

24
administration of the questionnaires.

Data Analysis

The data will be entered into a Microsoft Excel spreadsheet and subsequently
analyzed using the IBM Statistical Package for the Social Sciences (SPSS)
Version 22. Prior to analysis, a thorough process of data cleaning and
checking will be conducted to eliminate incomplete, inaccurate, and
inconsistent data entries.

Quantitative variables will be summarized and presented through the use of

mean, median, standard deviation, and range, along with grouped frequency
tables. Meanwhile, qualitative variables will be summarized and visually
represented through frequency tables, bar charts, and pie charts. The creation
of tables will be accomplished using Microsoft Word, while Microsoft Excel will
be utilized for generating charts.

For the assessment of significant associations between categorical variables,

the statistical test of significance (χ2) will be employed, with a significance
level set at P < 0.05.

Qualitative data analysis

Qualitative interviews will be recorded and transcribed verbatim. Thematic

analysis will be performed based on the ‘Framework Approach’, and will
include familiarization through repeated reading, coding, theme generation,
applying the codes to the transcripts, matrix formation, and interpretation.
Findings from the two components of the mixed-methods study will be
integrated.

CHAPTER 4: RESULTS

4.1. RESPONSE RATE

25
Out of a total of 450 questionnaires distributed, 415 were successfully
completed and retrieved, yielding a response rate of 92%.
4.2. SOCIO-DEMOGRAPHICS

The sociodemographic characteristics of the participants are summarized in

Tables below.

Table 4.1: Sociodemographic Characteristics (LGA of Residence)

S/N LOCAL GOVERNMENT N (%)

1 TARAUNI 79 (19%)
2 KUMBOTSO 62 (15%)
3 NASSARAWA 54 (13%)
4 KANO MUNICIPAL 44 (10.6%)
5 FAGGE 32 (7.7%)
6 DALA 30 (7.2%)
7 GWALE 26 (6.3%)
8 UNGOGGO 16 (3.8%)
9 TAKAI 10 (2.4%)
10 OTHERS 62 (15%)

Age Distribution Of Respondents (N=415). Table 4.2

Frequency Percent
AGE <20 2 0.5
GROUP 20-29 60 14.4
30-39 139 33.5
40-49 133 32.0
>/=50 81 19.5
Total 415 100.0

26
Table 4.2 depicts the age distribution of the participants with majority of the
patients in age category of 30-49, reprensenting about 65.5% of the
respondents.

Socio-Demographics (N=415) Table 4.3

VARIABLE FREQUENCY PERCENTAGE (%)

GENDER MALES 144 34.7
FEMALES 271 65.3

ETHNICITY HAUSA 264 63.6

FULANI 73 17.6
YORUBA 38 9.2
IGBO 21 5.1
OTHERS 19 4.6

RELIGION ISLAM 358 86.3

CHRISTIANITY 57 13.7

27
MARITAL SINGLE 66 15.9
STATUS MARRIED 257 61.9
DIVORCED 38 9.2
WIDOWED 54 13

FAMILY TYPE MONOGAMOUS 312 75.2

POLYGAMOUS 103 24.8

HIGHEST QURAN/ISLAMIC 71 17.1

LEVEL OF PRIMARY 31 7.5
EDUCATION SECONDARY 132 31.8
POST- 144 34.7
SECONDARY
OTHERS 37 8.9

OCCUPATION HOUSEWIFE 88 21.2

UNEMPLOYED 29 7.0
TRADING 73 17.6
FARMING 19 4.6
CIVIL SERVANT 58 14.0
BUSINESS 103 24.8
STUDENT 21 5.1
OTHERS 24 5.8

Table 4.3 presents additional sociodemographic characteristics, indicating that

65.3% of the participants are female, 63.6% belong to the Hausa ethnicity,
86.3% adhere to the Muslim faith, 61.9% are married, 75.18% reside in a
monogamous setting, 34.7% and 31.8% have post-secondary and secondary
education, respectively, as their highest level of education, and about 24.8%
engage in business as their primary means of livelihood.

28
29
30
3. CLINICAL CHARACTERISTICS

The clinical characteristics of the participants are summarized in Table 4.4

below.

Table 4.4: Clinical Characteristics

Frequency Percent
Co-mordity 56 13.5
present
Co-morbidity 359 86.5
absent
Total 415 100.0

31
Table 4.5 Types of co-morbidities
Frequency Percent
CARDIAC DISEASE 1 0.2
DIABETES 6 1.4
FIBROID 2 .5
HEART FAILURE 1 .2
HYPERTENSION 37 8.9
HYPERTENSION AND DIABETES 3 0.7
ULCER 2 0.5
Total 56 13.5
Table 4.5 shows the distribution of comorbidities amongst the participants,
with hypertension taking about 37%, then followed by diabetes mellitus.

Table 4.6: Clinical Characteristics

The average duration of HIV diagnosis and the average duration of
Antiretroviral treatment (ART), with minimum durations of 5 months and
maximum durations of 39 and 34 years, respectively. The mean duration is 9
years for both diagnosis and the initiation of ART, with an average of 1 year
between diagnosis and the commencement of treatment.

Overall Health Of Participants

Table 4.7: Overall health of participants

Frequency Percent
Very Good 108 26.0
Good 269 64.8
Fair 35 8.4
Poor 3 .7
Total 415 100.0

32
4.3 Level of Awareness of Telemedicine

The level of awareness of telemedicine among patients living with HIV

attending AKTH is depicted in the table below;

Table 4.8
Frequency Percent
Heard of Telemedicine NO 309 74.5
before the survey? YES 106 25.5
Total 415 100.0

Table 4.9
Frequency Percent
Familiar with any NO 400 96.4
Telemedicine services YES 15 3.6
in Nigeria? Total 415 100.0

33
Table 4.10
Frequency Percent
Interested about YES 261 62.9
learning about NO 121 29.1
Telemedicine? NOT 33 8.0
SURE
Total 415 100.0

Table 4.11

Frequency Percent
How often do you use DAILY 254 61.2
technology or internet in WEEKL 57 13.7
your daily life? Y
MONTHLY 17 4.1
RARELY 57 13.7
NEVER 30 7.2
Total 415 100.0

From these tables only 25.5% heard about telemedicine before the survey
and only 3.6% are familiar with Telemedicine services in Nigeria, However
about 62.9% are interested in knowing more about it, and a significant number
of them (61.2%) use technology and internet daily.

34
4.4 Acceptability and willingness to use Teleconsultation

The acceptability and willingness of patients living with HIV to use tele-
consultation services are outlined below;

Table 4.12
Frequency Percent
Willing to use YES 231 55.7
use NO 133 32.0
Teleconsultatio NOT 51 12.3
n services for SURE
HIV care Total 415 100.0

QUALIFIED ACCEPTABILITY SCORE

Table 4.13
Frequency Percent
QAS NO 214 51.6
YES 201 48.4
Total 415 100.0

CRUDE ACCEPTABILITY SCORE

Table 4.14
Frequency Percent
Value VERY ACCEPTABLE 46 11.1
ACCEPTABLE 180 43.4
NEUTRAL 117 28.2
UNACCEPTABLE 71 17.1
VERY UNACCEPTABLE 1 0.2
Total 415 100.0

From these tables above it was depicted that about 55.7% are willing to use
Teleconsultation services for their HIV care and a Qualified acceptability score
of 48.4%,and also a significant crude acceptability score, where 43.4%
choses ACCEPTABLE and about 11.1% VERY ACCEPTABLE.

35
4.5 Factors Associated with Acceptance and Willingness to Use Tele-
Consultation

The factors associated with patients' acceptance and willingness to use tele-
consultation services for HIV care are presented below;

FACTORS ASSOCIATED WITH ACCEPTANCE AND WILINGNESS TO USE

TELECONSULTATION
SERVICES FOR HIV CARE

Respondents’ Accepatance and willingness

Socio- to use teleconsultation and
demographic Telemedicine sevices
Total
χ2 P Value
Factors
YES NO NOT
SURE
Age(years) 9.412 0.309
<20 0 1 1 2
20-29 34 18 8 60
30-39 77 39 23 139
40-49 74 46 13 133
>=50 46 29 6 81
Gender 24.729 <0.001

36
Respondents’ Accepatance and willingness
Socio- to use teleconsultation and
demographic Telemedicine sevices
Total
χ2 P Value
Factors
YES NO NOT
SURE
Male 101 24 19 144
Female 130 109 32 271
Ethnicity 8.049 0.429
Hausa 141 88 35 264
Fulani 44 21 8 73
Yoruba 26 10 2 38
Igbo 9 7 5 21
Others 11 7 1 19
Religion 0.161 0.923
Islam 198 116 44 358
Christianity 33 17 7 57
Marital status 38.395 <0.001
Single 45 17 4 66
Married 154 68 35 257
Divorced 17 13 8 38
Widowed 15 35 4 54
Family type
Monogamous 177 91 44 312 11.366 0.023
Polygamous 54 42 07 103
Highest level
of Education
Quran/Islamic 28 31 13 72 41.442 <0.001
Primary 9 19 3 31
Secondary 70 43 19 132
Tertiary 104 26 14 144
Others 20 14 2 36
Occupation 40.833 <0.001
Housewife 44 26 18 88
Unemployed 7 15 7 29
Trading 37 33 3 73
Farming 11 7 1 19
Civil servant 40 12 6 58

37
Respondents’ Accepatance and willingness
Socio- to use teleconsultation and
demographic Telemedicine sevices
Total
χ2 P Value
Factors
YES NO NOT
SURE
Business 64 25 14 103
Student 15 4 2 21
Others 13 11 0 24

Table 4.15
FACTOR CHI-SQUARE P-VALUE ASSOCIATION
AGE 9.412 0.309 -
GENDER 24.729 <0.001 +
ETHNICITY 8.049 0.429 -
RELIGION 0.161 0.923 -
MARITAL STATUS 38.395 <0.001 +
FAMILY TYPE 11.366 0.023 +
HIGHEST LEVEL OF 41.442 <0.001 +
EDU.
OCCUPATION 40.833 <0.001 +
INCOME 107.422 0.130 -

Table 4.15 depicts the relationship between various factors and patient's
acceptance and willingness to use teleconsultation services, with P-VALUE as
<0.005 signifying statistically significant relationship. (+) means there is
statistically significant association and (-) means ther is no statistically
significant association.

FACTORS AFFECTING WILLING TO USE TELECONSULTATION

Table 4.16
FACTOR FREQUENCY/415 PERCENTAGE
(%)
LACK OF TRUST IN TECHNOLOGY 100 24.1
CONCERNS ABOUT PRIVACY & SECURITY 99 23.9
LACK OF TECHNICAL SKILLS 36 8.7
PREFER IN-PERSON CONSULTATIONS 59 14.2
FEAR OF MISDIAGNOSIS OR INACCURATE 19 4.6

38
TREATMENT
LACK OF INFORMATION ABOUT 11 2.7
TELECONSULTATION SERVICES
OTHERS 0 0

From this table (4.16) it was noted that the main factors affecting willing to use
teleconsultation seevices are Lack of trust in technology and concerns about
privacy and security.

FACTORS AFFECTING WILLING TO USE TELECONSULTATION

Table 4.17
FACTOR FREQUENCY/415 PERCENTAGE
(%)
CONVENIENCE AND TIME SAVING 194 46.7
REDUCED TRAVEL COST 132 31.8
ACCESS TO SPECIALISTS 72 17.3
AVAILABILITY OF REMOTE MONITORING 44 10.6
ASSURANCE OF CONFIDENTIALITY IN 30 7.2
TELECONSULTATIONS
POSITIVE REVIEWS OR 5 1.2
RECOMMENDATION FROM OTHERS
OTHERS 1 0.2

Also in this table (4.17) it was clearly shown that convenience and time
saving, and reduced travel cost are factors that may influence the use
teleconsultation services in HIV care.

4.6 CHALLENGES
Table 4.18
FACTOR FREQUENCY/415 PERCENTAGE
(%)
LACK OF FACE TO FACE CONSULTATION 181 43.6
TECHNICAL DIFFICULTIES 151 36.4
PRIVACY AND SECURITY CONCERNS 143 34.5
LANGUAGE BARRIERS 60 14.5
UNCERTAINTY ABOUT THE QUALITY OF 72 17.3

39
CARE
OTHERS 2 0.5

From table 4.18 it was found that the main challenges affecting the use of
teleconsultation services in HIV care are lack of face to face consultation,
technical difficulties and privacy & security concerns.

4.7 POTENTIAL BENEFITS

Table 4.19
FACTOR FREQUENCY/415 PERCENTAGE
(%)
REDUCED TRAVEL AND 276 66.5
TRANSPORTATION COST
ACCESS TO SPECIALIST CARE 118 28.4
TIMELY MEDICAL ADVICE 113 27.2
FLEXIBILITY IN APPOINTMENT 90 21.7
SCHEDULING
BETTER COMMUNICATION WITH HCW 28 6.7
OTHERS 0 0

Also in the above table (4.19) it was shown that the potential benefits for using
teleconsultation services are reduced travel and transportation cost, access to
specialist care, timely medical advice and flexibilty in appointment schedule.

4.8 QUALITATIVE PART (INDEPTH INTERVIEW)

Perspectives of HCWs and Patients:

Qualitative findings

The themes derived from the qualitative analysis provide a nuanced

understanding of the perceptions surrounding tele-consultation in HIV care.
While participants acknowledged the potential benefits, concerns about
challenges such as network issues and financial constraints were prevalent.
Diverse perspectives on the pros and cons of in-person visits and tele-
consultation for HIV care emerged, with some emphasizing the convenience
of teleconsultations and time and cost savings, while others highlighted the
importance of physical assessment during in-person visits.

Thoughts and Feelings about Tele-Consultation

40
Participants expressed positive thoughts and feelings about tele-consultation,
associating it with the current economic situation and improved access to
care. The convenience of obtaining information through a simple phone call
was highlighted, as one participant stated:

"I like it; the concept is good considering the current economic situation. If you
want to contact your healthcare provider, you simply get your recharge cards
or data, call your healthcare provider, then talk and get prescribed drugs for
your care."

Another participant emphasized the emotional aspect, stating,

"To me, I feel it is very good because it shows that I am being loved and cared
for by some people somewhere. Even though there is no physical contact, at
least someone will call, 'hello, am calling from AKTH, how are you doing.'
Seriously, I will be glad."

In contrast, a respondent expressed reservations about teleconsultation for

HIV care, preferring face-to-face consultation for the physician's ability to
assess physically:

"Well, some people think it is easier. For me, I prefer to have an in-person
consultation; it is much better than that phone call. The difference is if it is in-
person, the physician can easily assess you and see things physically, which
is not so with tele-consultation."

Potential Benefits of Tele-Consultation

Participants acknowledged numerous benefits of using tele-consultation for

managing HIV. These included resource savings from the elimination of
transport costs, avoidance of long queues, enhanced privacy, and improved
access to healthcare:

"The benefits are many; people don’t have to come here; it eliminates
transport costs, reduces contact with others, thereby enhancing privacy. For
the medical practitioners, they don’t have to interact with and encounter so
many people like it is now."

"There are benefits like when you are seriously ill and cannot make it down to
the clinic, or when you are too busy, then you can make a call so that you
have your medications sent to you."

Circumstances Encouraging Tele-Consultation Use

41
Several circumstances might encourage individuals to opt for tele-
consultation, including factors like insecurity, lockdown situations, long
queues in clinics, emergencies at night, travel-related issues, and the
convenience of accessing healthcare remotely:

"There are so many factors; insecurity, the COVID-19 lockdown, and long
queues in the clinic. When we first started attending this clinic, we were few,
but the number of patients coming to the clinic now per day is too much for
the number of healthcare providers."

"If I travel, instead of missing my clinic appointment, I can choose

teleconsultation because of the distance. Similarly, the incessant strike by
transport workers; one can temporarily use teleconsultation instead of a
physical follow-up visit."

Challenges and Drawbacks of Tele-Consultation

Participants highlighted several challenges anticipated with tele-consultation

in the context of HIV care. These include telecommunication infrastructure
and network issues, limited phone literacy, and financial constraints limiting
the procurement of recharge cards and data:

"There are challenges like network; we all know how our network signal is in
this country. Then people who cannot operate their phones very well, financial
issues of not affording the phone."

"There could be network problems or if there is no credit to make the phone

call. Another challenge is if the phone’s battery is low; you cannot make the
phone call. In this case, there is nothing you can do but to get to the clinic."

Factors Influencing Decision to Use Tele-Consultation

Participants outlined various factors that could influence their adoption of tele-
consultation services for HIV care. Prompt response to calls by healthcare
providers and perceived disturbance to healthcare providers were highlighted.
A participant emphasized,

"The only factor that will influence me is if I call, and they respond to me on
time, that will encourage me to be using tele-consultation anytime. But if they
don’t respond, then there is no need. Importantly, teleconsultation should be
optional; face-to-face should remain the norm."

Concerns and Reservations about Tele-Consultation

42
While participants generally expressed comfort with tele-consultation,
concerns about phone-related issues such as low credit, network problems,
and the need for a fixed call schedule were raised. One participant stated,

"There may be concerns if I don’t have the phone or credit and also network;
then I must come to the clinic in-person for consultation."

However, some were not as comfortable with teleconsultation:

"It is not comfortable because, to talk to your healthcare provider on the

phone about your problem is not as comfortable as when you come down in-
person for the consultation. I think it is only if the problem is not that much or
serious; then I can make the call to the doctor."

CHAPTER 5 (DISCUSSSION)

This chapter serves as a conduit for insightful analysis, offering a nuanced

comparison between the findings of this study and existing literature. Through
this comparative lens, we not only illuminate the unique contributions of our
research but also discern patterns, divergences, and convergences in the
broader scholarly landscape. It's a canvas where the brushstrokes of our
results blend with the strokes of previous studies, creating a comprehensive
tapestry of understanding. As we navigate this comparative journey, the
chapter endeavors to distill not only what distinguishes our research but also
how these distinctions contribute to the overarching discourse within the
context of telemedicine and HIV care.

The average age of 40, with a minimum of 18 and a maximum of 73, indicates
a diverse representation of age groups in the study. The predominance of
participants from different Local Government Areas (LGAs) illustrates the wide
geographic reach of the study, contributing to its external validity.

43
The gender distribution reveals a higher percentage of female participants
(65.3%), reflecting the broader epidemiological trend of a higher prevalence of
HIV among women in certain regions. The diverse representation of
ethnicities, religions, and marital statuses ensures a heterogeneous sample,
contributing to the study's generalizability.

The educational diversity, with participants ranging from Quran/Islamic

education to post-secondary levels, offers insights into the varied educational
backgrounds of the participants. The occupational distribution, including
housewives, students, and those engaged in various professions, contributes
to a comprehensive understanding of the sociodemographic landscape. The
prevalence of monogamous family settings aligns with cultural norms in the
region.

The prevalence of comorbidities, particularly hypertension and diabetes

mellitus, underscores the complexity of healthcare needs among this
population. These findings emphasize the importance of holistic healthcare
approaches that consider both HIV and associated health conditions.

The average duration of HIV diagnosis and Antiretroviral Treatment (ART)

initiation, both approximately 9 years, highlights the chronic nature of HIV and
the sustained commitment to treatment among the participants. The one-year
average gap between diagnosis and ART initiation raises questions about
potential delays or barriers in accessing treatment.

The majority of participants self-reported their overall health as either "Very

Good" or "Good," indicating a generally positive perception of their health
status. This self-assessment aligns with the longevity of HIV diagnosis and
treatment, suggesting effective management and care.

The findings of this study indicate that there is a low level of awareness of
telemedicine among patients living with HIV attending AKTH. Only 25.5% of
respondents had heard of telemedicine before the survey, and only 3.6%
were familiar with telemedicine services in Nigeria. This is consistent with
other studies that have found that telemedicine is still relatively unknown in
many parts of the world, particularly in low- and middle-income countries
(LMICs).

This is similar to a study conducted in Nigeria by I. Arize and O. Onwujekwe in

2017, which revealed a low level of awareness regarding telemedicine
services in Enugu State, located in the South East of Nigeria.38 This is in
contrast with a study by L. Margusino-Framiñán et al. in the US, which found
that telemedicine and teleconsultation achieve a high level of awareness and
satisfaction among HIV hospital outpatients receiving treatment.42 Despite

44
the low level of awareness, there was a high level of interest in learning more
about telemedicine. Approximately 62.9% of respondents were interested in
learning more about telemedicine, suggesting that there is a potential demand
for these services among patients living with HIV. This is encouraging, as
telemedicine has the potential to improve access to care for patients living
with HIV in LMICs, where there is often a shortage of healthcare providers.3

This is in contrast with another study conducted by K. Galaviz et al. in Atlanta,

Georgia; it was observed that patients with HIV displayed a general
awareness of and satisfaction with telephone-based telemedicine during the
COVID-19 pandemic.41

The study also found that there is a high level of acceptability and willingness
to use teleconsultation services among patients living with HIV. Approximately
55.7% of respondents were willing to use teleconsultation services for their
HIV care, and a further 28.2% were neutral on the issue. This is higher than
the findings of some other studies, which have found that acceptability of
teleconsultation is lower among patients living with HIV. [4, 5] This is also in
line with a study conducted by Germano Vera Cruz et al. in Mozambique; it
was observed that a majority of participants expressed a high willingness to
use tele-consultation public health services for mild illnesses, affordable
prices, and follow-up consultations.45

Also, in another study by Ita Daryanti Saragih et al., telehealth-assisted

interventions were found to significantly enhance treatment adherence,
improve quality of life, and reduce depressive symptoms among people living
with HIV/AIDS. The study suggested that delivering health management
interventions remotely through telehealth-assisted modalities is feasible and
effective in yielding health benefits for individuals living with HIV/AIDS.
Integrating telehealth-assisted interventions into HIV/AIDS care could
contribute to continuous care and sustained well-being.46

There are a number of factors that may contribute to the high level of
acceptability of teleconsultation in this study. First, a significant number of
respondents (61.2%) use technology and the internet daily, suggesting that
they are comfortable using these tools for communication. Second, many
respondents (46.7%) reported that they are interested in teleconsultation
because it would be convenient and save them time. Third, many respondents
(31.8%) reported that they are interested in teleconsultation because it would
give them access to specialist care. The study also found that a number of
factors are associated with patients' acceptance and willingness to use
teleconsultation services for HIV care. These factors include age, gender,
ethnicity, marital status, family type, highest level of education, and
occupation. Patients who were younger, female, married, had a higher level of

45
education, and were employed were more likely to be willing to use
teleconsultation services. This is consistent with the findings of other studies,
which have found that these factors are associated with increased use of
technology and telemedicine [6, 7].

This is similar to a finding in a Patricia Baudier et al. cross-national study on

Patients’ perceptions of teleconsultation during COVID-19, revealing that age,
gender, and country play a moderating role in the adoption of teleconsultation
solutions, with performance expectancy being a significant factor.47

The study also identified a number of challenges that may affect the use of
teleconsultation services in HIV care. These challenges include lack of face-
to-face consultation, technical difficulties, privacy and security concerns,
language barriers, and uncertainty about the quality of care. These challenges
are similar to those that have been identified in other studies of telemedicine
in LMICs [8, 9]. It is important to address these challenges to ensure that
teleconsultation is a viable option for patients living with HIV in these settings.

This is in line with a study carried out by Babatunde et al. in 2021 in Nigeria,
where the potential of telemedicine in revitalizing healthcare systems in low
and middle-income countries (LMICs) was noted, along with various
challenges that could potentially exacerbate health inequalities, particularly
based on income, technical difficulties, and language barriers.52

Despite the challenges, there are a number of potential benefits to using

teleconsultation services in HIV care. These benefits include reduced travel
and transportation costs, access to specialist care, timely medical advice, and
flexibility in appointment scheduling. These benefits are particularly important
for patients living with HIV in LMICs, where access to care is often limited.
Teleconsultation can help to address these limitations and improve the quality
of care for patients living with HIV in these settings. This is similar to a study
conducted by Cesar Caceres et al. in Spain, which presented a success story
in the realm of telemedicine care for HIV patients, emphasizing reduced
hospital visits, timely medical advice, and potential benefits.51

The qualitative analysis of participants' perspectives on tele-consultation in

HIV care reveals a nuanced landscape characterized by diverse sentiments.
While participants acknowledged the potential benefits, including
convenience, cost savings, and improved access, concerns about challenges
such as network issues and financial constraints were prevalent. Notably,
participants presented a spectrum of views on the efficacy of tele-consultation
compared to in-person visits, with some emphasizing the efficiency and
emotional significance of remote consultations, while others underscored the

46
importance of physical assessments during face-to-face encounters with
healthcare providers.

In exploring thoughts and feelings about tele-consultation, participants

expressed positive sentiments, associating it with economic considerations
and improved access to care. The immediacy of obtaining healthcare
information through a phone call was praised for its simplicity, and some
participants found emotional value in the remote interactions, feeling cared for
even without physical contact. However, reservations were voiced, particularly
by those who favored in-person consultations for the physician's ability to
conduct physical assessments. The findings suggest a complex interplay of
practical and emotional factors influencing the acceptability of tele-
consultation in the context of HIV care. This is in accordance with two studies
in Canada and the United States.

In a Canadian study conducted by K. Anderson et al., the aim was to

investigate physician perceptions regarding the use of telemedicine in human
immunodeficiency virus (HIV) patient care. A cross-sectional web-based
survey was employed, and out of the 51 invited participants, 48 (94%)
completed the survey. Among respondents, 62% (29/47) reported using some
form of telemedicine for caring for HIV patients in their practice. The
modalities frequently used included telephone (86%, 25/29), email (69%,
20/29), and teleconsultation (24%, 7/29). A significant number of physicians
(83%, 38/46) indicated that a hurdle to adopting telemedicine is the perception
that it does not allow for a comprehensive patient health assessment.
Moreover, 65% (28/43) of physicians concurred that patients might not feel
adequately connected to them as providers if telemedicine were used.
However, 85% (39/46) of respondents believed that telemedicine could
enhance access, timeliness of care, and the frequency of physician-patient
interactions, ultimately leading to improved patient care.48

In a US study by Waldura et al., an electronic survey was utilized to explore

primary care clinicians' self-perceived confidence and self-reported clinical
practices after utilizing the University of San Francisco-based National Human
Immunodeficiency Virus (HIV) Telephone Consultative Service (HIV
Warmline). The HIV Warmline offers clinicians real-time telephone
consultations with experts in HIV medicine. Over a two-year period, the study
found that the majority of primary care clinicians (physicians and mid-level
practitioners) perceived the HIV Warmline as quicker, more applicable to their
clinical management concerns, and more reliable than other HIV information
sources. Additionally, most participants reported that using the
teleconsultation service increased their confidence in managing HIV patients,
led to changes in their HIV management approach, and reduced the likelihood
of referring patients to an HIV specialist.49

47
This study is one of the first to examine the awareness, acceptability, and
willingness to use teleconsultation among patients living with HIV in Nigeria.
The findings suggest that there is a high level of interest in teleconsultation
among these patients, and that teleconsultation has the potential to improve
access to care for patients living with HIV in Nigeria. However, there are a
number of challenges that need to be addressed in order to ensure that
teleconsultation is a viable option for these patients.

It is important to continue to conduct research on telemedicine in LMICs to

better understand the challenges and opportunities associated with these
services. This research will help inform the development and implementation
of telemedicine programs that are effective and sustainable in these settings.

CHAPTER 6

CONCLUSIONS & RECOMMENDATIONS

6.1 Conclusions

This study underscores the transformative potential of telemedicine in

enhancing healthcare delivery, particularly in the context of HIV care at AKTH.
The recommendations outlined above, tailored to various stakeholders, aim to
create a conducive environment for the successful integration of telemedicine
services.

By collectively embracing these recommendations, the Federal Government,

State Governments, Local Governments, AKTH, communities, and individuals
can contribute to a healthcare landscape that is more accessible, inclusive,
and technologically advanced. The successful implementation of telemedicine
requires a collaborative and multifaceted effort, recognizing the unique roles
each stakeholder plays in this transformative journey.

48
In conclusion, the findings of this study not only shed light on the current
challenges and opportunities but also pave the way for a future where
telemedicine becomes an integral part of healthcare delivery, ultimately
improving the lives of individuals living with HIV in the community.

6.2 Recommendations

Enhancing Telemedicine Awareness:

Given the low level of awareness of telemedicine among patients living with
HIV at AKTH, targeted educational campaigns are imperative. The following
strategies are recommended:

1. Community Workshops: Conduct workshops in collaboration with

community leaders to disseminate information about telemedicine
benefits, dispel myths, and address concerns.
2. Digital Literacy Programs: Implement programs to enhance digital
literacy, especially among older participants, to empower them to
engage with telemedicine platforms confidently.
3. Utilize Local Media: Leverage local radio stations, community bulletin
boards, and community gatherings to share information about
telemedicine services.

Addressing Trust and Privacy Concerns:

To foster trust and address privacy concerns, the following measures are
recommended:

1. Transparent Communication: Establish transparent communication

channels to inform patients about the security measures in place during
tele-consultations.
2. Privacy Safeguards: Implement robust privacy safeguards in
telemedicine platforms, ensuring compliance with international privacy
standards.
3. Patient Education: Develop informational materials explaining the
security protocols in place during telemedicine consultations.

Technical Skills Training:

To address the lack of technical skills reported by some participants, the

following actions are recommended:

49
 1. Training Programs: Offer training programs to enhance participants'
technical skills, providing step-by-step guidance on accessing and
utilizing tele-consultation platforms.
2. User-Friendly Platforms: Advocate for or develop user-friendly
telemedicine platforms that are intuitive and require minimal technical
expertise.

Collaboration with Healthcare Workers:

Enhancing collaboration with healthcare workers is crucial for successful

telemedicine implementation. Recommendations include:

1. Healthcare Worker Training: Provide comprehensive training for

healthcare workers on tele-consultation best practices, communication
skills, and platform usage.
2. Establish Guidelines: Develop clear guidelines for healthcare workers
to navigate telemedicine consultations, emphasizing ethical
considerations, and maintaining patient confidentiality.

Infrastructure Improvement:

To address challenges related to technical difficulties and connectivity issues,

the following infrastructure improvements are recommended:

1. Investment in Technology: Advocate for increased investment in

technology infrastructure, including improved internet connectivity and
access to devices for both patients and healthcare workers.
2. Telecommunication Partnerships: Explore partnerships with
telecommunication companies to enhance network stability and data
access.

6.2.1 Federal Government

Telemedicine Policy Framework: The Federal Government should develop

a comprehensive national policy framework for telemedicine, providing
guidelines, standards, and incentives to promote its adoption across
healthcare institutions. This includes creating an enabling environment for
research, development, and implementation of telemedicine services.

Infrastructure Investment: Allocate funds for the improvement of

telecommunication infrastructure, ensuring reliable internet connectivity and
accessibility to remote areas. Collaborate with private sector entities to
establish telemedicine hubs and support telehealth initiatives.

50
Training Programs: In collaboration with educational institutions, initiate
training programs for healthcare professionals to enhance their skills in
telemedicine, focusing on ethical considerations, patient communication, and
the use of telehealth technologies.

6.2.2 State Governments

Telehealth Integration in State Healthcare Systems: State governments

should integrate telehealth into their healthcare systems, collaborating with
healthcare institutions to establish telemedicine units. Allocate resources for
the deployment of telehealth solutions in state hospitals and clinics.

Public Awareness Campaigns: Initiate public awareness campaigns to

educate citizens about the benefits of telemedicine. Leverage existing state
communication channels, such as radio and community events, to
disseminate information on telehealth services and how to access them.

Incentive Programs: Introduce incentive programs for healthcare institutions

and professionals that actively adopt and excel in telehealth services. This
could include grants, tax incentives, or recognition programs.

6.2.3 Local Governments

Community Engagement: Local governments play a pivotal role in

community engagement. Facilitate community workshops and town hall
meetings to educate residents about telemedicine. Encourage community
leaders to actively support and promote telehealth initiatives.

Local Telehealth Hubs: Collaborate with local healthcare providers to

establish telehealth hubs within communities. Ensure that these hubs are
equipped with necessary technology and staffed with trained healthcare
professionals.

Data Security Measures: Implement data security measures at the local

level to address concerns about privacy. Work with local IT experts to ensure
that telehealth platforms comply with privacy regulations.

6.2.4 Aminu Kano Teaching Hospital (AKTH)

Telemedicine Infrastructure: AKTH should invest in state-of-the-art

telemedicine infrastructure, ensuring that the hospital is equipped with the
necessary technology for efficient tele-consultations.

51
Training Programs for Staff: Conduct comprehensive training programs for
healthcare staff to enhance their proficiency in telehealth services. This
includes both clinical and administrative staff to ensure seamless integration.

Research and Development: Encourage and fund research initiatives on the

impact of telemedicine in HIV care. Explore opportunities for collaboration with
academic institutions for ongoing research in telehealth.

6.2.5 Community

Community Advocacy: Communities should advocate for the adoption of

telemedicine services by actively engaging with local healthcare providers and
government authorities. Encourage participation in workshops and information
sessions.

Support for Vulnerable Populations: Community organizations should

focus on providing support to vulnerable populations, ensuring they have
access to and are comfortable with telehealth services. This includes the
elderly, low-income individuals, and those with limited digital literacy.

Feedback Mechanism: Establish a feedback mechanism between the

community and healthcare providers to address concerns and continuously
improve telehealth services based on community needs.

6.2.6 Individuals

Digital Literacy Initiatives: Individuals should proactively engage in digital

literacy initiatives to build confidence in using telehealth platforms. This
includes attending training programs and seeking assistance from community
resources.

Regular Health Check-ups: Encourage individuals to consider regular health

check-ups through telemedicine platforms, especially for managing chronic
conditions like HIV. This proactive approach can lead to better health
outcomes.

Advocacy for Telemedicine: Individuals can contribute to the wider adoption

of telemedicine by advocating for its benefits within their social circles.
Sharing positive experiences can help reduce skepticism and increase
acceptance.

52
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DEPARTMENT OF COMMUNITY MEDICINE

FACULTY OF CLINICAL SCIENCES
COLLEGE OF HEALTH SCIENCES
BAYERO UNIVERSITY, KANO

FINAL YEAR MEDICAL STUDENT QUESTIONNAIRE

STUDY TITLE: Awareness of Telemedicine and Acceptability of Tele-

consultation among patients living with HIV attending Aminu Kano
Teaching Hospital.

60
 Dear respondent,

My name is Abdullahi Sani Abdullahi, a final year medical student at BUK,

conducting a research project under the supervision of Prof. Zubairu Iliyasu
from the Department of Community Medicine. The study aims to assess the
awareness and acceptability of telemedicine and tele-consultation among
patients living with HIV attending Aminu Kano Teaching Hospital. The
information you provide is strictly for research purposes and will be treated
confidentially. Your name is not required to maintain confidentiality. Thank you
for considering participation in this study.

Section 1: Sociodemographic Characteristics

1. Local Government Area of

Residence …………………………………………..

2.
How old are you? _______________________________years old

3. Indicate respondent’s gender 1. Male

2. Female

4. What is your ethnic group? [ 1 ] Hausa

[ 2 ] Fulani
[ 3 ] Yoruba
[ 4 ] Igbo
[ 5 ] Others (specify)…………………………

5. What is your religion? [ 1 ] Islam

[ 2 ] Christianity

6. Marital status [ 1 ] Single

[ 2 ] Married
[ 3 ] Divorced
[ 4 ] Widowed
[ 5 ] Others (specify)……………………………

7.
Total Number of children ……………………….

8 Type of family structure [ 1 ] Monogamous

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 [ 2 ] Polygamous

9 Highest education level [ 1 ] Qur’anic/Islamiyyah only

[ 2 ] Primary
[ 3 ] Secondary
[ 4 ] Post-secondary
[ 5 ] Others (specify)………………………….

10. Main Occupation [ 1 ] Housewife

[ 2 ] Unemployed
[ 3 ] Trading
[ 4 ] Farming
[ 5 ] Civil servant
[ 6 ] Business
[ 7 ] Student
[ 8 ] Others (Specify)…………………………..

11. Monthly household income

………………………………. (Naira)

12. Duration of HIV diagnosis

………………………………. (years)

13. Duration on Antiretroviral

treatment (ART) ……………………………….. (years)

General health

14. Do you have other chronic [ 1 ] Yes

medical conditions (e.g. [ 2 ] No
hypertension, diabetes, etc.) in
addition to HIV? If yes, specify………………………………….

15. How would you rate your overall [ 1 ] Very good

health status? [ 2 ] Good
[ 3 ] Fair
[ 4 ] Poor
[ 5 ] Very poor

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Section 2: Awareness of Telemedicine

16. Have you heard of telemedicine before this survey? ( ) Yes ( ) No

17. If yes, what does telemedicine refer to: (multiple choices
allowed)

a) It refers to medical consultations over the phone.

b) It involves using the internet for remote medical diagnoses.
c) It's about video calls between patients and healthcare providers.
d) It relates to receiving medical advice through mobile apps
e) others (specify)……………………………………….
18. How often do you use technology or the internet in your daily life?
( ) Daily
( ) Weekly
( ) Monthly
( ) Rarely
( ) Never
19. Are you familiar with any telemedicine services available in
Nigeria?
( ) Yes ( )No
20. If yes, please mention the telemedicine services you know:

……………………………………………………………………………………..
21. If no, would you be interested in learning more about
telemedicine services for HIV care in Nigeria?
( ) Yes
( ) No
( ) Not Sure
22. Which sources of information about telemedicine do you trust the
most?
( ) Healthcare Providers
( ) Government Health Agencies
( ) Non-Governmental Organizations (NGOs)
( ) Media (TV/Radio/Newspaper/Internet)
( ) Friends/Family
( ) Other (Specify): ……………………………………..

Section 3: Tele-consultation Acceptability

23. Would you be willing to use tele-consultation services for your HIV
care?
( ) Yes
( ) No

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 ( ) Not Sure
24. If no or not sure, what are the reasons? (Multiple responses
allowed)
( ) Lack of Trust in Technology
( ) Concerns about Privacy and Security
( ) Lack of Technical Skills
( ) Prefer In-Person Consultations
( ) Fear of Misdiagnosis or Inaccurate Treatment
( ) Lack of Information about Tele-consultation Services
( ) Other (Specify):
…………………………………………………….
25. If yes, what factors would motivate you to use tele-consultation
services for HIV care? (Multiple responses allowed)
( ) Convenience and Time-Saving
( ) Reduced Travel Costs
( ) Access to Specialists
( ) Availability of Remote Monitoring
( ) Assurance of Confidentiality in Tele-consultations
( ) Positive Reviews or Recommendations from Others
( ) Other (Specify):
…………………………………………………………….
26. Do you have any concerns or fears about using tele-consultation
services for your HIV care?
( ) Yes
( ) No
27. Are there any specific features or services you would like to see in
a tele-consultation platform for HIV care?

Section 4: Perspectives on Tele-consultation

28. What potential benefits do you see in using tele-consultation for

your HIV care?
( ) Reduced travel and transportation costs
( ) Access to specialist care
( ) Timely medical advice
( ) Flexibility in appointment scheduling
( ) Better communication with healthcare providers
( ) Other (Specify): ……………………………………………………………
29. What challenges or concerns do you have about using tele-
consultation for your HIV care?
( ) Lack of face-to-face interaction with healthcare providers
( ) Technical difficulties
( ) Privacy and security concerns

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 ( ) Language barriers
( ) Uncertainty about the quality of care
( ) Other (Specify):
………………………………………………………………..

Section 5: Qualified and Crude Acceptability Scores

Qualified Acceptability Score

30. Based on your overall perceptions and experiences, please indicate

whether you would give a positive qualified score to tele-consultation via
synchronous teleconferencing:

( ) Yes
( ) No

31. If you answered "Yes," please explain why you would give a positive
qualified score to tele-consultation. (Open-ended)
…………………………………………………………………………………………
…………………………………………………………………………………………
………………………

32. If you answered "No," please explain why you would not give a positive
qualified score to tele-consultation. (Open-ended)
…………………………………………………………………………………………
…………………………………………………………………………………………
………………………

Crude Acceptability Score

33. Please provide a crude acceptability score for tele-consultation via

synchronous teleconferencing, considering your overall experience and
perception:

( ) Very Acceptable
( ) Acceptable
( ) Neutral
( ) Unacceptable
( ) Very Unacceptable

34. If you selected "Very Acceptable" or "Unacceptable," please briefly explain

the reasons for your choice. (Open-ended)
…………………………………………………………………………………………

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…………………………………………………………………………………………
………………………

Thank you for your participation in this survey. Your valuable insights will
contribute to our understanding of the awareness and acceptability of
telemedicine and tele-consultation for patients living with HIV.

INFORMED CONSENT FORM FOR STUDY PARTICIPANTS

Research Title: Awareness of Telemedicine and Acceptability of

Teleconsultation among patients living with HIV attending Aminu Kano
Teaching Hospital

INTRODUCTION

My name is Abdullahi Sani Abdullahi, a final year medical student of Bayero

university Kano carrying out a final year project under the supervision of
Professor Zubair Iliyasu of the department of community medicine.

The aim of this study is to assess awareness, and determinants of

acceptability of tele-consultation among HIV-positive patients attending Aminu
Kano Teaching Hospital, Kano, Nigeria. You were selected to participate
because you are enrolled in S S Wali centre.

Discomfort and risks of participation

There is almost no risk of harm to you for participating in this study.

What will happen in this study?

If you agree to participate, I will read out questions in your preferred language
(Hausa or English) and I will fill your responses into the questionnaire.
Participation in this research is entirely voluntary. If you do not agree to
participate, it will in no way affect the care and treatment you receive in this
hospital.

Benefits to yourself:
By agreeing to take part in this study, you will provide information together
with other participants regarding telemedicine and tele-consultation

66
acceptability among HIV-positive patients attending Aminu Kano Teaching
Hospital, which will inform communication strategies and health education to
improve HIV care services in the facility.

Compensation: No compensation or money will be given to you for

participating in this study. We will however, be grateful for your time as you
are contributing to improving the health of Nigerians.

Benefits for the community This study will help with valuable insights that
can inform healthcare policies and strategies leading to integration of tele-
consultation into HIV care in a patient-centered manner, it will also enhanced
access, patients engagement, resource optimization, treatment adherence,
stigma reduction, provider training, health system efficiency and literature
contribution..
Confidentiality
Your name and identity will not be collected. The data and reports from this
project will not have anything to identify you. All information will be kept
confidential.

Voluntary consent
Your participation in this study is voluntary. You do not have to take part in
this study if you do not wish to do so. You may decline participation now or
later. If you refuse to participate, there will be no consequences.

Contact information
You can ask any questions about this study or the consent form now. If you
have any concerns or questions subsequently, please contact this number
07061624466, 08177720933 or contact my supervisor Prof. Zubairu Iliyasu
on +2348035868293 or chairman Ethics committee Aminu Kano Teaching
Hospital Kano, Prof Musa M. Borodo on +2348033268903.

67
CERTIFICATE OF CONSENT

- I have been invited to take part in the research on Awareness of

Telemedicine and accepatability of Teleconsultation among HIV-positive
patients attending Aminu Kano Teaching Hospital.
- I have read (or someone has read and interpreted) the foregoing
information.
- I understand the information I have received.
- I have been given an opportunity to ask any questions I may have, and all such

questions or inquiries have been answered to my satisfaction.

- I further understand that my records will be kept confidential and that I may withdraw

from this study at any time.

- I understand the benefits and risks of the study. If I have concerns, about
my participation in the study, I can contact the student, the principal
investigator or Chairman of the ethics committee at any time.
- I have been informed orally and in writing of whom to contact in case of an
emergency. I agree to participate in this study as a volunteer subject
- I consent voluntarily to be a participant in this study and understand that I
have the right to withdraw from the study at any time, without any
consequences to me.

Signature of Participant __________ ____________________________

Date ……………………………………………………….

68
“I, the undersigned, have explained to the participant in a language he/she
understands the procedures to be followed in the study and the risks and
benefits involved."

__________ ____________________________
Date Signature of Investigator

__________ _____________________________
Date Signature of Witness to the Above Signatures and Explanations

69