Factors Affecting Awareness About E-Health Services in Saudi Arabia

Aim Telemedicine or using e-health applications was maximized during the COVID-19 pandemic. This study aimed to explore awareness and satisfaction with several e-health services provided by the Ministry of Health (MOH), including Seha, Moed, 937 Services, and Wasfati. Methods A population-based social media survey assessed awareness and satisfaction with these applications. The survey gathered information on demographic and socioeconomic characteristics. Binary logistic regression was used to highlight factors that affect awareness of and satisfaction with these services and thus could be a target for future development. Results Overall, 1333 surveys were completed; most (70%) of the participants were female, 44% were between the ages of 18 and 24 years, 83% were of Saudi nationality, and 70% had university degrees or above. Awareness was greatest with the 937 Services, Seha, Moed, and Wasfati applications. Satisfaction was the highest with the Moed application. Factors affecting awareness and satisfaction included age, sex, nationality, and education. Conclusion Awareness of and satisfaction with the four major e-health applications were high. This indicates the readiness of the Saudi population to embrace advances in telemedicine in alliance with the Saudi 2030 vision.


Introduction
Although the traditional method for delivering healthcare is important, telehealth is an alternative with benefits that are maximized in special situations, such as during the 2019 COVID pandemic [1,2].Cassar et al. announced that the Community COVID-19 Initial Assessment Team (CCIAT) project achieved its goals of safe risk stratification of patients with COVID-19, safe management on an outpatient basis, and appropriate and efficient use of hospital resources [3].In addition, the idea of telehealth was explored from the patient's perspective.Patients have reported that the benefits of virtual assessment included reducing the waiting time and less delay in treatment and diagnostic workup.They also highlighted reduced anxiety due to delays and cancellations of appointments.Although the study was conducted four years before the COVID-19 pandemic, they reported high patient satisfaction with telehealth compared to face-to-face appointments [4].
The use of telemedicine during the COVID-19 pandemic has been supported by international bodies, such as the World Health Organization (WHO) [5].Telemedicine is a rapidly evolving field that requires flexibility and creativity in response to challenges.
In alignment with the Saudi Vision 2030, Saudi Arabia aims to deliver better health-related services to its people and provide the health department with the budget required to improve health issues [6].Government-lead institutions have implemented the e-health system throughout the country to promote better and more accessible health services.The COVID-19 pandemic has changed the world, including the Kingdom of Saudi Arabia (KSA), has stretched various healthcare systems to their limits, and has accelerated the advancement of telemedicine.
Although telehealth was implemented, some obstacles were faced, and these were similar to those encountered in other parts of the world.The challenges were mainly related to the lack of a relationship between doctors and patients, concerns regarding the privacy of patients' health data, medical customs, behaviors of KSA citizens, and no clearly administered regulations [7].Alanazy et al.. reported a high level of acceptance and satisfaction with the Ministry of Health (MOH) application (Mawed), indicating community readiness to adapt and utilize such services [8].Although the public's attitude seems to be positive towards e-health use, some reluctance still exists and needs to be addressed with further promotion and education [8].
There was a definite change in the attitudes of healthcare consumers toward e-health, and changes were mainly influenced by the pandemic and slightly influenced by self-interest in adoption [9].To increase the usability of e-health platforms, several factors must be emphasized to increase the number of end users, that is, the patient (consumer), including trust and provided information quality, ease of use, and applicability [10].Therefore, this study aims to examine how satisfied patients in Saudi Arabia are with ehealth services and the platforms available to them.This study also aimed to evaluate consumers' and patients' satisfaction with MOH e-services, including Moed (or Mawed), Seha, 937 Services, and Wasfati.

Study design
This was a cross-sectional population-based survey that collected data using a predesigned form.The study is observational in nature and is guided by the strengthening of the observational studies in epidemiology (STROBE) checklist.The data collection process was conducted through a survey distributed via email and different social media platforms [11].

Setting
An email was sent through the Almaarefa University administration to all enrolled participants.Additionally, the research team posted a survey link through private social media accounts (Instagram, Twitter, and Snapchat).Participants were then asked to send it to other contacts on social media in a process known as snowball recruitment [8].

Participants and recruitment
The study targeted adult participants (>18 years), including Saudi and non-Saudi nationals, who were able to answer the survey questions.The survey link was sent via university email and posted on the research team's private social media accounts.The survey link was opened for recruitment between February and April 2021.

Variables, data source, and measurements
The survey was predesigned using Google Forms (Google, Mountain View, California), subjected to phase validity by two experts, and piloted on 10 students prior to distribution.The survey had several parts, including a consent form, followed by general questions on demographic characteristics.Other survey items included questions on awareness of different MOH electronic platforms: 937 Services, Wasfati, Seha, and Moed.This was followed by a four-item Likert scale for satisfaction with these services.In Saudi Arabia, 937 Services is a telephone service that was launched in 2018 that provides multiple care services to people who call, including consultation, diagnosis, and prescription [12].Seha is a mobile application that gives people access to medical services, such as sick leave and requests for medications that are unavailable in the country [13].Moed (or Mawed) is a mobile application used to book appointments in government-supported primary care and has been changed to the Sehhati app [14,15].Finally, the Wasfat website enables consumers to receive prescriptions from their nearest accredited community pharmacy [16].

Bias
Data recruitment included a valid method of recruitment (snowballing), and the analysis was performed using a complete case.

Study size
Using a proportion of 47% reported by a study done by Alharbi et al. on the use of the Seha application in Saudi Arabia, the calculated population size was 383, with a 95% confidence level and a 5% margin of error.

Statistical analysis
The survey items were exported from Google Forms to Statistical Package for Social Sciences (SPSS) version 28.0 (IBM Inc., Armonk, New York) [16].Data were categorized and coded whenever necessary.Crosscheck tabulation was performed to confirm data accuracy.Data are reported as numbers and percentages for categorical variables and mean standard deviation for continuous variables.The unadjusted odds ratio (OR) was used to determine factors affecting awareness.A p-value of <0.05 was considered significant.

Ethical consideration
This study was approved by the institutional review board of Almaarefa University (approval number: 06-02032021).The participants provided electronic consent once they opened the survey.No participant identifiers were collected; thus, the data were completely anonymous.

Results
A total of 1333 participants completed the survey.The majority were female (70%), aged 18-24 years of age (44%), of Saudi nationality (83%), and single (61%).With regard to education, most participants had a university degree or higher than 70%.The highest percentage of employees is 37%.Demographic data are presented in Table 1.When evaluating the level of awareness of different MOH e-services, the highest awareness was in 937 Services; 77% of participants were aware of such services.This was followed by Seha at 76%, Moed (or Mawed) at 73%, and Wasfati at 41%.The awareness levels are shown in Figure 1.Participants were mostly satisfied with different services, where the highest level of satisfaction was with Moed (or Mawed) (78%); this was followed by Seha (73%), 937 Services (73%), and Wasfati (45%) (Figure 2).

Discussion
This study highlighted multiple factors that affect public awareness and satisfaction with multiple e-health applications used in Saudi Arabia.It was apparent that age, gender, education, and nationality played key roles in the awareness of e-health applications.This study investigated multiple services; however, changes occurred as the application Moed (or Mawed) merged with the Sehhati platform, and the relatively new application, Tawaklna, was developed during the pandemic [15].The purpose of this study was to assess public awareness and satisfaction and to design specific strategies to increase awareness and usability of such important services.
With the goals of Saudi vision 2030, one of the major approaches for improving the delivery of healthcare in Saudi Arabia is the adoption of digital health.As the provision of healthcare through traditional methods has some limitations in terms of access and quality of care, the introduction of technology and the use of ehealth services could be ways to overcome these deficiencies.Patient satisfaction with some MOH services has been evaluated previously.Previous studies have reported inconsistent findings on the satisfaction of the Saudi population, as some studies reported high satisfaction [11] and utilization [15], and others reported reluctance.
While Saudi Arabia has taken a positive direction regarding the enactment of e-health, it must undertake additional measures to improve its implementation.Future plans for the development of e-health states in the Kingdom should be approached holistically, taking into consideration the different parties affecting the process of successful implementation.Regulatory bodies' responsibility, healthcare providers' roles, and patients' acceptance and literacy must be emphasized.Appropriate information and communications technology infrastructure readiness, financing, investment, legalizations, and policies encouraging the cultural adaptation of e-health are highly impactful and crucial for development.Concerns regarding confidentiality and privacy are among the pressing factors that affect users' acceptance and adaptations to e-health systems.Therefore, the incorporation of governmental regulatory bodies would be crucial in promoting confidence in the e-health system.Adapting the delivery of e-health services to Saudi cultural and social values will bridge essential trust in using big data and further impact the development and adoption of e-health systems [16].
This study is the first of its kind in Saudi Arabia, combining multiple MOH e-health services evaluations.It provides insights into the readiness of the population to embrace the transition to e-health.It also has a wide range of population characteristics, which may enhance the generalizability of this study.The limitations of this study include its cross-sectional nature and lack of information on the diseases of the participants, which could have been beneficial to know.

Conclusions
This study indicates the readiness of the population for transition to e-health; however, multiple groups of the population need more awareness and education regarding the services provided.This study could serve as a baseline for future educational campaigns arranged by the MOH to transition to e-health under the Saudi 2030 vision.

FIGURE 1 :FIGURE 2 :
FIGURE 1: Awareness with the Ministry of Health e-health services, with green indicating awareness