Attitude, awareness, and knowledge of telemedicine among medical students: A systematic review of cross‐sectional studies

Abstract

Background and Aims

The success of every new technology depends on numerous factors, including specialists' knowledge and perceptions of the concept, acquired attitude skills, and work environments. This systematic review aimed to examine medical students' knowledge, attitudes, and perceptions of telemedicine.

Methods

Studies were obtained from the PubMed, Embase, Scopus, and Web of Science databases on June 9, 2022. We followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Cross‐sectional studies that examined medical students' knowledge, attitude, and perceptions of telemedicine approaches were considered inclusion criteria. Titles and abstracts were independently screened based on eligibility criteria. Articles that did not meet the inclusion criteria were excluded from this review. After that, the complete texts were retrieved and screened by two separate researchers based on the eligibility criteria. Disputes were resolved by discussion. The same checklist was used for data extraction. To assess the quality of the studies entering this study, the Joanna Briggs Institute Critical Appraisal Checklist for analytical cross‐sectional studies was used.

Results

In total, 10 eligible articles were found through this review. The sample size of the studies ranged from 60 to 3312 participants, or 6172 participants on the whole. The medical students' attitudes toward telemedicine were evaluated in eight included studies. Many of these studies (seven cases) reported positive and promising perspectives on telemedicine. However, in one study, participants revealed moderate attitudes toward online health information and online health experience sharing (p < 0.05). Students' knowledge of the telemedicine approach was evaluated in eight included studies. Many of these studies (five cases) reported that students possessed an extensively poor knowledge of telemedicine's uses. In three other studies, two reported moderate and one disclosed desirable levels of students' knowledge. All the included studies attributed medical students' poor knowledge to the lack of, and thus failure of, educational courses in this field.

Conclusion

The evidence obtained from this review reveals that medical students possess positive and promising attitudes toward telemedicine technology for education, treatment, and care. However, their knowledge levels were extremely insufficient, and many had not passed any educational courses in this respect. Such results can foreground the health and education policymakers' obligations for planning, training, and empowering digital health and telemedicine literacy among medical students as the primary players in social health.

1. INTRODUCTION

Medical services empowered by information technology (IT), for example, telemedicine and eHealth, have been hastily developing in the near past and support telehealth services. This term often functions as a general term encompassing telehealth, electronic medical records (EMRs), eHealth, and other health IT components. ¹ Telemedicine and eHealth imply using electronic information and advanced telecommunication technologies to support remote clinical healthcare, patients and their health records, professional health‐related training, public health, and health management. ¹ , ² The World Health Organization has recently defined eHealth as a mixed application of information and communication technology (ICT) for health. ² Recent advancements in medical technology have resulted in telemedicine applications ranging from telephone triage and outpatient e‐Visits to mental health, postoperative follow‐ups, and specialized counseling. Because patients and providers become accustomed to these virtual connections during the epidemic, many will likely continue to use telemedicine in the future. ³ The health domain has experienced a slower trend than other sectors in employing ICT. ⁴ There are countless reasons why implementing eHealth systems is still challenging despite the available studies on clinical benefits, efficacy costs, and increased access to healthcare services at the macrolevel. ⁵ , ⁶ , ⁷ Regardless of the potential advantages and technical superiority of telemedicine, its admission is often known as a failed project, ⁸ and the user's nonacceptance is one of the significant reasons for its failure. ⁹ Put differently, the success of every new technology depends on numerous factors, including specialists' knowledge and perceptions of the concept, acquired attitude skills, and work environments. ¹⁰

Also, as medicine continues to incorporate telemedicine technologies into patient care, it is important for medical institutions and universities to expose students to the care methods they will use in the future and get them to analyze and understand their merits and demerits. For this, first, it is necessary to evaluate what attitude future physicians have toward telemedicine and how much they know about it or have used it.

On the other hand, despite the growing contribution of telemedicine to healthcare and the research on healthcare students' attitudes toward telemedicine, few systematic reviews integrate the best evidence and provide overviews in this domain. Furthermore, no systematic review has yet evaluated medical students' attitudes, awareness, and knowledge as key players in social health. Hence, this systematic review examined medical students' knowledge, attitudes, and perceptions of telemedicine.

2. METHODS

2.1. Study design

This study followed Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) to report the evidence obtained from studies included in this systematic review. ¹¹ , ¹² The PRISMA checklist is shown in Appendix A. We conducted a literature search on the PubMed, Embase, Scopus, and Web of Science databases on June 9, 2022. The below Medical Subject Headings and Emtree keywords and terms were used to search the databases:

• 1.“Students, Medical” OR “Medical Students” OR “Student, Medical” OR “Medical Student.”
• 2.“Attitude OR “Sentiment” OR “Sentiments” OR “Opinions” OR “Opinion “OR “Perception” OR “Knowledge” OR “awareness.”
• 3.“Telemedicine” OR “Telerehabilitation” OR “telehealth” OR “Mobile Health” OR “eHealth “ OR “mHealth.”

2.2. Eligibility criteria

The studies were entered into the review if they possessed the following inclusion criteria: (1) cross‐sectional studies investigating medical students' knowledge, attitudes, and perceptions of telemedicine approaches; and (2) examining populations of medical students. On the other hand, the exclusion criteria were: (1) other than journal articles, type of publication (e.g., books, review papers, and letters); (2) lack of availability of full text in English; and (3) scarcity of title relating to the abstract or full text of papers to the aim of the study.

2.3. Data extraction and synthesis

All articles were collected from the literature search, and duplicate articles were excluded from this review. Titles and abstracts were independently screened based on eligibility criteria. Articles that did not meet the inclusion criteria were excluded from this review. After that, the complete texts were retrieved and screened by two separate researchers based on the eligibility criteria. Disputes were resolved by discussion, and in the event of disagreement, the third author would give the final opinion. The same checklist was used for data extraction. The data items in this form include the following: reference, a country under study, publication year, participants' characteristics, the technology‐based approach that was used, study goals, the attitude toward telemedicine, the knowledge toward telemedicine, and main study findings.

2.4. Quality assessment

To assess the quality of the studies entering this study, the Joanna Briggs Institute Critical Appraisal Checklist for analytical cross‐sectional studies was used. ¹³ The study specifically obtained eight questions to evaluate the quality of these studies and categorize the questions into two categories: yes and no. If the answer to a question was yes, it was indicated as 1, and no was marked as 0. Therefore, the maximum quality score that each study could obtain was 8, and exclusion only takes effect if the study quality score was less than 5.

3. RESULTS

3.1. Study selection

The process of identifying and selecting the studies based on the PRISMA diagram is shown in Figure 1. In total, 508 documents were initially retrieved through scientific database searching. Finally, 10 eligible articles were found through this review.

Figure 1.

Flowchart of the study selection.

3.2. Quality assessment

The quality assessment results shown in Table 1 show that there was no significant bias in the studies and that all quality studies were included in our study.

Table 1.

Summary of the quality assessment of articles using the JBI Critical Appraisal Checklist.

Study/questions	1	2	3	4	5	6	7	8	Score
[14] [2020, Saudi Arabia]	Y	Y	Y	Y	N	N	Y	Y	6
[15] [2022, Iran]	Y	Y	Y	Y	N	N	Y	Y	6
[16] [2013, Iran]	Y	Y	Y	Y	N	N	Y	Y	6
[17] [2007, Sri Lanka]	Y	Y	Y	Y	N	N	Y	N	5
[18] [2022, Nepal]	Y	Y	Y	Y	N	N	Y	Y	6
[19] [2020, 39 countries of the European continent]	Y	Y	Y	Y	N	N	Y	Y	6
[20] [2003, Australia]	N	Y	Y	Y	N	N	Y	Y	5
[21] [2021, United States]	Y	Y	Y	Y	N	N	Y	Y	6
[22] [2022, France]	Y	Y	Y	Y	N	N	Y	Y	6
[23] [2022, Pakistan]	Y	Y	Y	Y	N	N	Y	Y	6

Abbreviations: JBI, Joanna Briggs Institute; N, no; Y, yes.

3.3. Study characteristics

Table 2 reports the characteristics of the included studies. Out of the 10 included studies, 2 (20%) belonged to Iran, ¹⁵ , ¹⁶ and the rest were conducted in Australia, ²⁰ Saudi Arabia, ¹⁴ Sri Lanka, ¹⁷ Nepal, ¹⁸ the United States of America, ²¹ France, ²² and Pakistan. ²³ There was also one study targeting 39 European countries. ¹⁹ The sample size of the studies ranged from 60 (Ehteshami et al. ¹⁶ ) to 3312 (Yaghobian et al. ²² ) participants, or 6172 participants on the whole. Four studies used in‐person questionnaires, ¹⁴ , ¹⁶ , ¹⁷ , ²⁰ while the other six distributed online questionnaires among participants. ¹⁵ , ¹⁸ , ¹⁹ , ²¹ , ²² , ²³

Table 2.

Summary of study characteristics.

Source (year, country)	Research instrument	No. of participants	Purpose of study	Attitude toward telemedicine	Knowledge of telemedicine	Research outcome
[14] [2020, Saudi Arabia]	Paper questionnaire	440	Determining knowledge, attitude, the field of activity, and identifying factors predicting eHealth performance among medical students	Almost three‐fourths (73.4%) of students possessed positive attitudes toward using eHealth, and only 2% reported negative attitudes (p = 0.04).	Only 43.6% of the students reported satisfactory general knowledge of eHealth (p = 0.03).	Although the students' general knowledge of eHealth was inadequate, they manifested satisfactory attitudes and proper performance. Students' eHealth performance was significantly predicted by their attitudes and knowledge of eHealth.
[15] [2022, Iran]	Online survey	387	Determining medical students' attitudes and knowledge of online oral health information and online information sharing, and determining the correlation of online oral health information in searching participants' experiences with knowledge, attitudes, and oral health approaches	Participants' attitudes toward online health information and online sharing of health experiences were moderate (p < 0.05).	–	The general attitude toward using the internet for health and the consequences of using certain health‐related internet sources was moderate among participants.
[16] [2013, Iran]	In‐person questionnaire	60	Investigating medical students' knowledge of mobile health in clinical phases, how much they use this technology, and the interrelationships of variables	–	Generally, students' average knowledge of all telemedicine fields equaled 54.4%.	No‐trained application of information technology is not efficient and desirable. This technology can help fill the gaps between required and accessible information. However, using electronic information‐and communication sources requires increased awareness and skills.
[17] [2007, Sri Lanka]	In‐person questionnaire	136	Examining medical students' knowledge and attitudes toward eHealth in Sri Lanka	Over 80% of respondents believed that eHealth played a significant role in the current and future health sector, especially in developing countries.	88% of respondents admitted to having received no training or practice in eHealth approaches.	77% of respondents admitted that systematic knowledge and skills were not presented in their syllabuses and perceived the lack of formal eHealth training as a serious deficit.
[18] [2022, Nepal]	Online questionnaire	113	Evaluating Nepalese medical students' knowledge and attitudes toward telemedicine	Despite their limited encounters with telemedicine, participants supported the spread and extensive use of telemedicine for economic, technological advancement, and topographical diversity reasons.	Participants were well aware of the significance of telemedicine. However, a few had received training about how to employ it.	Formal and structured training may enable optimistic enthusiasts to integrate telemedicine skills with healthcare provisions easily.
[19] [2020, 39 countries of the European continent]	Online questionnaire	451	Evaluating European medical students' knowledge and perceptions of digital health, the implementation state of digital health in medical education, and the essential needs of students	84.9% (451/383) of medical students strongly agreed that further digital health training should be incorporated into the medical curriculum.	Students demanded training via health information technology, such as health information systems.	The findings of this study show a gap between medical students' willingness to actively contribute to the digital healthcare transformation and the training they received in their faculties.
[20] [2003, Australia]	In‐person questionnaire	749	Investigating the effect of telemedicine courses on medical students' knowledge and interests in telemedicine	Many students (75%) thought that they benefited from distance learning.	Students were mainly familiar with telemedicine through articles published in journals and newspapers (41%). However, many (95%) reported that they were unaware of the telemedicine lecture presented by Innsbruck University.	This survey revealed that medicine faculties should present extra special lectures and telemedicine BA and MA certificates.
[21] [2021, United States]	Online questionnaire	63	Investigating medical students’ experiences, satisfaction, perceptions, and knowledge of e‐learning, distance learning, e‐health, and related methods	Many students (76%) felt that the medical training they received through distance learning and e‐learning had well prepared them for their shelfa examinations and the United States Medical Licensing Examination‐ Step 2 (USMLE Step 2 Clinical Knowledge). However, only 37% felt prepared for the internship year.	–	Telemedicine enjoys the considerable potential to handle many challenges ahead of modern medical education environments. In future years, we will witness applying telemedicine and telehealth approaches as platforms in medical education.
[22] [2022, France]	Online questionnaire	3312	Investigating French medical students' and residents' self‐perceived knowledge, attitudes, and performances, as well as telemedicine e‐training (ET)	82.8% of the students and residents confirmed the relationship between telemedicine and improved access to care.	Many respondents (84.8%) revealed their unfamiliarity with telemedicine regulations. However, 97.9% articulated their inadequate reception of training.	Despite the positive attitudes, it became clear that participants had limited ET and knowledge and knew less about telemedicine methods. However, the demand for telemedicine (ET) is increasing.
[23] [2022, Pakistan]	Online questionnaire	398	Evaluating medical students’ knowledge and perceptions of telemedicine as a method for providing health facilities in different provinces of Pakistan	Many respondents (n = 187, 47%) possessed satisfactory attitudes toward telemedicine. There were no significant relationships between independent variables (age, gender, province, academic year, and degree) and respondents' attitudes toward telemedicine (p > 0.05).	Many respondents (n = 235, 59%) were well informed about telemedicine, and the average awareness scores were significantly related to participants’ age, province, and academic year (p < 0.05).	Telemedicine education should be incorporated into curricula. It is time to integrate telemedicine into the first healthcare service in Pakistan. Medical students need to be acquainted with this system and receive sufficient training.

^a Shelf examinations: Shelf examinations are subject‐based, standardized exams meant to evaluate knowledge acquisition in the seven clerkships that have been identified as the foundation of medicine.

3.4. Students' attitudes toward telemedicine

According to Table 2, the medical students' attitudes toward telemedicine were evaluated in eight included studies. Many of these studies (seven cases) reported positive and promising perspectives on telemedicine. ¹⁴ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²² , ²³ However, in one study, participants revealed moderate attitudes toward online health information and online health experience sharing (p < 0.05). ¹⁵

Aldebasi et al. documented that less than two‐thirds of medical students agreed and strongly agreed that using computers during patient interviews saved time (64.9%), and under one‐third disagreed with employing the internet in the difficult health domain (63.2%). The average mean score of students' perspectives toward eHealth equaled 82.32% (positive attitudes), and almost three‐fourths (73.4%) of students possessed optimistic views about eHealth's uses, while 2% revealed their negative attitudes toward telemedicine. ¹⁴ Edirppulige et al. reported that >80% of respondents believed eHealth played a significant role in current and future social health, especially in developing countries. ¹⁷

In Kunwar et al.'s study, although many students had already heard about telemedicine, they had not received any formal telemedicine education and demanded its incorporation into their curricula. As a result, the telemedicine attitudes hardly differed among students studying at different education levels or universities, such that 88.5% (n = 100) were dissatisfied with telemedicine coverage and methods, while 43.4% (n = 49) were optimistic about employing telemedicine in the future. Thus, they claimed that participants supported the spread and extensive use of telemedicine for economic, technological, and topographical diversity reasons despite their limited encounters with this distant health service. ¹⁸ Furthermore, Machleid et al. reported that many European medical students viewed healthcare digitalization positively and tended to play active roles and take on the responsibility of mediating digital health literacy to patients. ¹⁹ In their study, Moser et al. asserted that numerous students (75%) thought they would benefit from teleteaching or telelearning. In the meantime, the telemedicine future was evaluated highly (79%), and telesurgery or telerobotics (71%), teleradiology (51%), telecardiology (46%), and telepathology (37%), as the potential flourishing areas of telemedicine, were considered. In addition, students' interests in telemedicine were observed not only in their extensive willingness to participate in telemedicine conferences (77%) but also in the fact that 72% of students declared they appreciated telemedicine certificates presented at BA or MA levels. ²⁰ Yaghobian et al. found that medical students possessed positive attitudes toward telemedicine technology, such that 82.8% believed telemedicine facilitated access to healthcare and educational services among students, patients, and providers. ²²  In another study, Kazmi et al. reported that many respondents (47%) revealed acceptable attitudes toward telemedicine, and 57.8% of participants believed telemedicine services could be effectively provided through voice and video calls and emails. They found that out of 398 respondents, 334 subjects (83.9%) considered that high‐quality care‐providing hospitals should possess commensurate telemedicine systems, and 360 respondents (90.5%) agreed and strongly agreed that telemedicine services should be preserved. All in all, 146 (36.7%) and 193 (48.5%) strongly agreed and agreed that telemedicine could radically contribute to improving healthcare systems, and 73.9% would employ telemedicine systems as healthcare personnel in the future. ²³

3.5. Students' knowledge of telemedicine

Students' knowledge of the telemedicine approach was evaluated in eight included studies. Many of these studies (five cases) reported that students possessed extensively poor knowledge of telemedicine uses. ¹⁴ , ¹⁷ , ¹⁸ , ¹⁹ , ²² In the meantime, one study documented that students enjoyed high knowledge concerning the significance of telemedicine but were less informed of its uses; for example, a few had received training on employing telemedicine approaches. ¹⁸ Two studies reported moderate, ¹⁵ , ¹⁶ and one disclosed desirable levels of students' knowledge. ²³

Aldebasi et al. assessed knowledge of eHealth in three domains: its essence and definition, uses, and application methods. They discovered that students possessed undesirable knowledge about eHealth (70.7%), satisfactory knowledge about its uses (76.4%), and incongruous knowledge about its application methods (65.7%). On the whole, they revealed that the average general knowledge score for eHealth was 71.6% and was satisfactory. However, only 43.6% of students possessed satisfactory general knowledge of eHealth. ¹⁴ In another study, Edirippulige et al. asserted that 43% of respondents were familiar with the term “eHealth,” 51% evaluated their knowledge of eHealth uses as low, and 88% admitted that they had received no eHealth training. ¹⁷ In Machleid et al.'s study, more than half of the respondents (239/451, 53.0%) were familiar with the eHealth term thoroughly, while two‐thirds (274/451, 60.8%) claimed that they did not employ eHealth technologies. Hence, the results of this study indicated a lack of applicable knowledge and skills and an inadequate evaluation of eHealth technologies, all of which can be attributed to the absence of respective topics in medical curricula. ¹⁹ In addition, Yaghobian et al. observed that many respondents (84.8%) expressed their unfamiliarity with telemedicine regulations, and 97.9% revealed their insufficient training. ²² In Kunwar et al.'s study, 77.4% of students declared they were familiar with the term “telemedicine,” while only 8.8% (10 students) had participated in some courses, and 6% (n = 4) of students already consulting through telemedicine evaluated their experience poorly. ¹⁸

On the contrary, Moser et al. explained that telemedicine was known to many students (41%), thanks to articles published in journals and newspapers. However, a large number of students (95%) reported that they were unaware of the telemedicine lectures presented by Innsbruck University. ²⁰ Ehteshami et al. found that medical students' awareness of mobile health technology and its potential and de facto advantages were relatively low, such that the students' highest knowledge of mobile health technology at the clinical stage equaled 45.6%, and their minimum knowledge of the infrastructural domain was 17.8%, while their average general knowledge of telemedicine was 54.4%. They also reported that the highest and lowest use of mobile health technology among medical students was 14.6% and 6.8% in the educational and care domains, respectively, and that the average use, which was undesirable, equaled 9.4%. ¹⁶

4. DISCUSSION

4.1. Principal findings

Telemedicine is a critical technology for healthcare specialists, particularly doctors and medical students, who are key players in social health. ²⁴ , ²⁵ Health specialists' attitudes, awareness, knowledge, skills, and acceptance of telemedicine are the prerequisites for merging this new tool successfully. Hence, this systematic review aimed to integrate the best research evidence about medical students' attitudes, awareness, and knowledge of telemedicine. The results show that medical students possess positive and promising attitudes toward telemedicine technology for education, treatment, and care. Nonetheless, they were not well informed of this technology and had not passed any respective academic courses. This review found 10 studies that met all of the inclusion criteria. These studies were cross‐sectional and evaluated medical students' attitudes, awareness, and knowledge of telemedicine.

According to the findings of our study, medical students' attitudes toward telemedicine were evaluated in eight included studies. Many of these studies (seven cases) revealed positive and promising perspectives on telemedicine., ¹⁴ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²² , ²³ while participants' attitudes toward online health information and online health experience sharing were moderate in one study (p < 0.05). ¹⁵ A study in Bangladesh reported that many students believed the internet was helpful for making health decisions. ²⁶ On the other hand, in a survey of Iranian students, most thought the internet was a proper channel for sharing oral health experiences and searching for similar individuals. However, they were skeptical of using the internet to share their health problems with others and believed that online searches were ineffective for better managing conditions associated with them. ¹⁵ Machleid et al.'s study in 39 European countries depicted a gap between medical students' eagerness to play active roles and change into key players in digital healthcare and educational transformation and the lack of applicable knowledge and skills and adequate evaluation of eHealth technologies, all of which were attributed to the absence of respective topics in medical syllabi. ¹⁹ Similarly, studies in Nepal, ¹⁸ Australia, ²⁰ France, ²² and Pakistan ²³ discovered that medical students favored telemedicine. Hence, it seems that regional differences with various constraints and problems do not impact students' perspectives on telemedicine approaches noticeably.

The medical students' knowledge of telemedicine was evaluated in eight studies entered into the review. Many of these studies (five cases) reported students' poor knowledge of telemedicine uses and applications. ¹⁴ , ¹⁷ , ¹⁸ , ¹⁹ , ²² However, a survey documented that students enjoyed high knowledge concerning telemedicine's significance despite their low awareness of its uses, such that only a few had received training about telemedicine approaches. ¹⁸ However, numerous students are hopeful about telemedicine as a distant learning platform. ²⁰ , ²⁷ Similarly, Mousavi Baigi et al.'s, first evaluated the teaching of how to use telemedicine and then evaluated the impact of telemedicine on improving the nutrition knowledge of students, which showed that teaching the use of telemedicine was positive and improved the nutrition knowledge of students. ²⁸ Two studies reported moderate ¹⁶ , ²⁰ and one disclosed desirable levels of students' knowledge. ²³ In Kazmi et al.'s recent study in 2022, many respondents (59%) were well knowledgeable about telemedicine, and their average awareness scores were significantly associated with age, province, and academic year (p < 0.05). ²³ Hence, it is likely that telemedicine knowledge is surging among students due to the increasing growth of the digital world. However, the results mainly indicate that students' telemedicine knowledge and skills are still inadequate despite recent advancements in this area. ¹⁴ , ¹⁷ , ¹⁸ , ¹⁹ , ²²

Despite the fact that the majority of studies were conducted in low‐ and middle‐income countries (LMICs) and students' knowledge levels were low, Moser et al. ²⁰ discovered in 2003 in a high‐income country (HIC) that students reported that telemedicine lectures were not informed. However, the majority of them were familiar with telemedicine from the previous decade. Also, in the recent study by Franklin et al. ²¹ in the United States, the results indicated that the students were well aware of telemedicine and were very eager to learn as many methods as possible using telemedicine. However, only 37% of the students felt prepared for their internship year. Therefore, in HICs, students' general awareness of telemedicine may be positive and promising to an acceptable extent. However, their practical knowledge is also weak. On the contrary, in LMICs, students' both basic and applied knowledge of telemedicine is weak.

On the other hand, Elhadi et al. conducted a study with the aim of investigating the awareness, knowledge, attitude, and skills of physicians in using telehealth services in Libya as an LMIC. They found that 377 (56%), 582 (86.5%), and 566 (82.6%) of the physicians who responded to their survey had high awareness, knowledge, and attitudes toward telemedicine, respectively. However, only 248 (36.8%) of the participants had adequate or high computer skills. This specifically shows that physicians increase their knowledge by being exposed to the work environment and gaining experience. However, in a medical student's future, the practical knowledge and skills of working with systems in physicians must be improved. ²⁹ Similarly, Kirchberg et al. reported that telemedicine is often welcomed by German physicians. However, there is clearly a severe lack of telemedicine literacy and knowledge about the safe implementation of these technologies in routine clinical practice. ³⁰

All studies included in this review attribute medical students' poor knowledge to the lack of, and thus failure of, educational courses in this field. ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² In this regard, Mousavi Baigi et al. investigated the challenges and recommendations for employing and developing telemedicine technologies during the COVID‐19 pandemic period. They concluded that training was a crucial human factor in applying telemedicine technology and asserted that human and management challenges played more fundamental and significant roles in using telemedicine approaches than technical challenges. Despite the fact that these studies show that patients and students use telemedicine, the complexity of this technology and patients' lack of mastery have resulted in resisted utilization and decreased interest in technological transformations. ¹⁵ , ¹⁷ , ³¹ As a result, it is critical to train patients and healthcare providers on how to use telemedicine technology correctly ³² ; notably, the attainment of this objective obliges health systems, hospitals, employers, and the media to make efforts to remove this deficit. ³³ Hence, in‐person learning, pamphlets, step‐by‐step execution instructions, and perceiving how telemedicine operates contribute to enhancing individuals' awareness of telemedicine's advantages. ³⁴ Therefore, future studies should look into the way telemedicine‐related training can be incorporated.

Connolly et al. investigated telemental health conducted via videoconferencing (TMH‐V) using the unified theory of acceptance and use of technology, which was consistent with the findings of this systematic review. Their findings showed that, despite describing many difficulties, providers positively viewed TMH‐V. Thus, the relative advantages of TMH‐V, such as increased access to care, may override its disadvantages, including technological problems, increased confusion, and impersonality perceptions. ³⁵

In summary, although medical students possessed positive and promising attitudes toward the extensive use and spread of telemedicine approaches, they revealed low levels of knowledge, skills, and performance. In many of the included studies, students declared that they had not passed the respective educational courses and demanded the incorporation of telemedicine training into their curricula. Such results highlight the responsibility of health and education policymakers for planning, training, and empowering digital health and telemedicine literacy among medical students as the primary players in social health.

4.2. Strengths and limitations

Among the limitations of this review, we can refer to the diversity of the questionnaires used by the examined studies since one questionnaire may tackle awareness in terms of preliminary medical approaches, such as emailing, messaging, and so forth, while another may identify awareness through advanced medical practices, like telerobotic technologies. Similarly, differences in study timing may lead to bias in the results, as society's digital literacy has increased in tandem with technological advancements in recent years, and telemedicine literacy is no exception in this regard. Nevertheless, this was the first systematic review that evaluated medical students' attitudes, awareness, and knowledge of telemedicine as the key player in health and digital health and provided domain policymakers and planners with valuable prospects.

5. CONCLUSION

The evidence obtained from this review reveals that medical students possess positive and promising attitudes toward telemedicine technology for education, treatment, and care. However, their knowledge levels were extremely insufficient, and many had not passed any educational courses in this respect. Such results can foreground the health and education policymakers' obligations for planning, training, and empowering digital health and telemedicine literacy among medical students as the primary players in social health.

AUTHOR CONTRIBUTIONS

Kosar Ghaddaripouri: Data curation; formal analysis; investigation; writing—original draft. Seyyedeh Fatemeh Mousavi Baigi: Data curation; formal analysis; visualization; writing—original draft. Ali Abbaszadeh: Data curation; formal analysis; methodology. Mohammad Reza Mazaheri Habibi: Conceptualization; investigation; project administration; supervision; writing—review and editing.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

TRANSPARENCY STATEMENT

Mohammad Reza Mazaheri Habibi affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

APPENDIX A.

See Table A1.

Table A1.

Preferred Reporting Items for Systematic Reviews and Meta‐Analyses checklist.

Section/topic	#	Checklist item	Reported on page #
TITLE
Title	1	Identify the report as a systematic review, meta‐analysis, or both.	1
ABSTRACT
Structured summary	2	Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.	1
INTRODUCTION
Rationale	3	Describe the rationale for the review in the context of what is already known.	2
Objectives	4	Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).	2
METHODS
Protocol and registration	5	Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.	N/A
Eligibility criteria	6	Specify study characteristics (e.g., PICOS, length of follow‐up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.	3
Information sources	7	Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.	3
Search	8	Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.	3
Study selection	9	State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta‐analysis).	3‐4
Data collection process	10	Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.	3
Data items	11	List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.	5‐9
Risk of bias in individual studies	12	Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.	3
Summary measures	13	State the principal summary measures (e.g., risk ratio, difference in means).	N/A
Synthesis of results	14	Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I2) for each meta‐analysis.	N/A
Risk of bias across studies	15	Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).	N/A
Additional analyses	16	Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta‐regression), if done, indicating which were pre‐specified.	N/A
RESULTS
Study selection	17	Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.	4
Study characteristics	18	For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow‐up period) and provide the citations.	5‐9
Risk of bias within studies	19	Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12).	6‐9
Results of individual studies	20	For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.	5‐9
Synthesis of results	21	Present results of each meta‐analysis done, including confidence intervals and measures of consistency.	N/A
Risk of bias across studies	22	Present results of any assessment of risk of bias across studies (see Item 15).	N/A
Additional analysis	23	Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta‐regression [see Item 16]).	N/A
DISCUSSION
Summary of evidence	24	Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).	9‐10
Limitations	25	Discuss limitations at study and outcome level (e.g., risk of bias), and at review‐level (e.g., incomplete retrieval of identified research, reporting bias).	10
Conclusions	26	Provide a general interpretation of the results in the context of other evidence, and implications for future research.	10
FUNDING
Funding	27	Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review.	11

Ghaddaripouri K, Mousavi Baigi SF, Abbaszadeh A, Mazaheri Habibi MR. Attitude, awareness, and knowledge of telemedicine among medical students: a systematic review of cross‐sectional studies. Health Sci Rep. 2023;6:e1156. 10.1002/hsr2.1156

DATA AVAILABILITY STATEMENT

The authors stated that all information provided in this article could be shared. All authors have read and approved the final version of the manuscript. Mohammad Reza Mazaheri Habibi had full access to all of the data in this study and take complete responsibility for the integrity of the data and the accuracy of the data analysis.