PLOS GLOBAL PUBLIC HEALTH RESEARCH ARTICLE Healthcare provider-to-patient perspectives on the uptake of teleconsultation services in the Nigerian healthcare system during the COVID-19 pandemic era Ifeanyi Jude Ezeonwumelu ID1☯*, Ifeanyi Jude Obijiaku ID2, Chukwudi Martin Ogbueche ID3, Reunlearn360 2020 Cohort¶, Ucheoma Nwaozuru ID4☯* 1 AIDS Research Institute-IrsiCaixa and Health Research Institute Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain, 2 Department of Medicine, University of Benin Teaching Hospital, Edo State, Nigeria, 3 Department of Physiotherapy, Glasgow a1111111111 Caledonian University, Glasgow, Scotland, 4 Department of Implementation Science, Wake Forest School of a1111111111 Medicine, Winston-Salem, NC, United States of America a1111111111 ☯ These authors contributed equally to this work. a1111111111 ¶ Membership of Reunlearn360 2020 cohort is provided in the acknowledgments. a1111111111 * iezeonwumelu@irsicaixa.es (IJE); unwaozur@wakehealth.edu (UN) Abstract OPEN ACCESS The urgency to curtail the devastating effects of the ongoing COVID-19 Pandemic has led to Citation: Ezeonwumelu IJ, Obijiaku IJ, Ogbueche the implementation of several measures to limit its spread, including movement restrictions and CM, Reunlearn360 2020 Cohort, Nwaozuru U (2022) Healthcare provider-to-patient perspectives social distancing. As most developing countries rely solely on hospital visitations for their medi- on the uptake of teleconsultation services in the cal needs, this impediment to assessing healthcare services compounded by low uptake of tel- Nigerian healthcare system during the COVID-19 ehealth services could result in dire consequences. This is a cross-sectional study among pandemic era. PLOS Glob Public Health 2(2): Healthcare providers (HCP) and Healthcare consumers (HCC) in Nigeria. We administered a e0000189. https://doi.org/10.1371/journal. pgph.0000189 pre-validated self-administered online questionnaire comprising questions to assess the knowl- edge, use, perceptions, and benefits of telemedicine among study participants. Descriptive sta- Editor: Joao Tiago da Silva Botelho, Egas Moniz Cooperativa de Ensino Superior CRL, PORTUGAL tistics were used to examine participants’ perceptions on telemedicine use and to summarize participants’ characteristics. A total of 158 healthcare providers and 1381 healthcare consum- Received: November 3, 2021 ers completed the online survey. Ninety percent of HCP reported that they used some form of Accepted: January 19, 2022 telemedicine to deliver health care, and 63% of HCC had received healthcare through telemedi- Published: February 9, 2022 cine. A significant proportion of HCP (62%) and HCC (69%) agreed that telemedicine would Peer Review History: PLOS recognizes the improve healthcare consultation experience and satisfaction. However, fewer (21%) HCP benefits of transparency in the peer review agreed that they liked that there would be no physical contact with patients using telemedicine. process; therefore, we enable the publication of In contrast, 52% of HCC agreed that they liked that there would be no physical contact with all of the content of peer review and author responses alongside final, published articles. The healthcare providers while using telemedicine. The majority of the participants believed that editorial history of this article is available here: benefits of telemedicine would include: being a safe way for healthcare delivery during pandem- https://doi.org/10.1371/journal.pgph.0000189 ics (HCP = 62%, HCC = 83%), affordability (HCP = 62%, HCC = 82%), and time-saving (HCP Copyright: This is an open access article, free of all = 54%, HCC = 82%,). Teleconsultation services have been shown to aptly complement face- copyright, and may be freely reproduced, to-face hospital visits in ensuring effective triaging in hospitals and providing adequate health- distributed, transmitted, modified, built upon, or care delivery to patients regardless of geographical and physical barriers. These results support otherwise used by anyone for any lawful purpose. The work is made available under the Creative telemedicine use for the provision of healthcare services during the COVID-19 pandemic. Commons CC0 public domain dedication. PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 1 / 14 PLOS GLOBAL PUBLIC HEALTH Uptake of teleconsultation services in the Nigerian healthcare system Data Availability Statement: All relevant data are within the manuscript and supplementary information. Introduction Funding: The authors received no specific funding The ongoing COVID-19 Pandemic has necessitated the urgent and crucial need to adopt strat- for this work. egies in the healthcare sector that seek to minimize face-to-face consultations, triage hospital Competing interests: The authors have declared visitations, and opt for teleconsultations whenever possible to limit the spread of the SARS-- that no competing interests exist. CoV-2 virus [1, 2]. The adoption of telehealth services during this Pandemic has ensured the continuity of healthcare delivery–breaking down physical and geographical barriers to assess- ing medical care even as most countries worldwide enforced movement restrictions and physi- cal distancing measures aimed at reducing community nosocomial spread [3, 4]. Telehealth refers to the delivery of health care services from healthcare providers (HCP) to patients separated by physical (geographical) distance using information communication tech- nology (ICT) for the diagnosis and treatment of diseases and injuries, research, and evaluation. Telehealth services (teleconsultations), including HCP-to-patient and HCP-to-HCP commu- nications, can be delivered synchronously (real-time telephone and video calls), asynchro- nously (patient portals and e-consults), and through virtual agents (chatbots) [5, 6]. Now, the world must have to adapt to this recent Pandemic; it is time we re-evaluated the emerging role of telehealth as a key player in healthcare service delivery and possibly, revisit the question recently posed by Duffy and Lee—whether face-to-face visits should become the second, third, or even last option rather than the first option for meeting routine patient needs [5]. Although the recent COVID-19 Pandemic has changed world economies and healthcare systems; on the contrary, it could have a knock-on effect on the rapid uptake of telehealth ser- vices [7, 8]. However, there is still a gap in the adoption of telehealth services between devel- oped countries with robust and efficient healthcare facilities and developing countries with less efficient healthcare systems, which has become more evident during this Pandemic [9]. The projection of Africa as the next epicenter of the ongoing COVID-19 Pandemic is indeed worrisome given the devastation this Pandemic could cause to its vulnerable healthcare sys- tems [10]. The region’s healthcare system is faced with limited health care facilities and health provider shortages [11]. Hence, as COVID-19 cases in Nigeria continues to surge [12], the increasing burden of this Pandemic to its fragile healthcare system and resources necessitates proactive measures to rescue its healthcare system from eventual collapse. The uptake of teleconsultation services in the Nigerian healthcare system is yet to gain trac- tion in recent times due to several challenges, including poor telecommunication infrastruc- ture, socio-cultural influence, change resistance, lack of awareness, fear of privacy and confidentiality breaches, and impersonation due to quackery, medico-legal issues and willing- ness to pay for telehealth services [13, 14]. However, smartphone penetration in Nigeria has been increasing over the years, with over 196 million and 143 million active telephone and internet subscribers recorded in June 2020, corresponding to an increase of 12.6% and 17.2%, respectively, from a comparable period the previous year [15]. This trend is promising and could be leveraged to improve the teleconsultation infrastructure in Nigeria. This study aimed to evaluate the perception of the acceptability and usefulness of telecon- sultations in the Nigerian healthcare system from both the HCP and healthcare consumers’ (HCC) perspectives and determine the influential role of the COVID-19 Pandemic on the uptake of teleconsultation services in Nigeria. Methods This study was an observational, cross-sectional study using an online, self-administered questionnaire. PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 2 / 14 PLOS GLOBAL PUBLIC HEALTH Uptake of teleconsultation services in the Nigerian healthcare system Study participants, sample size, and sampling The Open-Source Epidemiologic Statistics for Public Health (OpenEpi), v.3.01 (updated 2013/ 04/06) was used to calculate the sample size for this survey. Here, we hypothesized that at a 95% confidence level, 50% of the respondents must have been exposed to teleconsultations and are twice as likely to have positive acceptability and perception towards the uptake of tele- consultation services. The required sample size was estimated to be 1034 respondents, and with an additional 30% contingency, 1345 respondents from the public were assumed as an appropriate sample size. Assuming an HCP: Patient ratio of 1:10 in Nigeria, an additional 135 respondents from the HCP population were targeted for the HCP survey. Data collection was performed online using the google forms survey tool (Alphabet Inc., California, USA). The call for participation was made on social media (WhatsApp, Telegram, Facebook, LinkedIn, and Twitter) and was open for 3 months or until the required sample size was reached (02/11/ 2020-31/12/2020). Participation in this survey was voluntary, anonymous and participants could exit the survey at any time. Research instrument The research instrument for this study includes two online self-developed questionnaires. Two sets of survey tools (S1 and S2 Surveys), one for each of the target respondent groups–HCP and HCC and was pre-validated by at least three independent reviewers followed by a pre-test survey of 200 respondents from the outpatient clinics at University of Benin Teaching Hospital (UBTH). The questionnaire consists of five sections: a) a consent and approval page, b) demography of respondents, c) healthcare background check, d) acceptability and usability of telephone-delivered medical consultations, e) teleconsultations during the COVID-19 Pan- demic. Sections 4 and 5 of the questionnaires were structured as positively framed statements, with respondents being asked to rate their agreement with each statement on a 5-point Likert scale ranging from strongly agree to disagree strongly. In addition, to ascertain the willingness to pay for teleconsultations, respondents were asked to respond to a statement regarding an appropriate fee to pay for teleconsultations rated on a 5-point Likert scale, ranging from "50% more than the cost of a face-to-face hospital visitation" to "50% less than the cost of a face-to- face hospital visitation." Data analysis Data were summarized using Microsoft Excel 2019 and analyzed utilizing the Statistical Pack- age for the Social Sciences (SPSS) software, v.22, and the OpenEpi. Data were analyzed using descriptive statistics and frequencies to examine the characteristics of study participants and their responses to the survey items. Data are presented as frequencies and proportions. Bivari- ate analyses were conducted to examine whether there were differences in participants’ responses to overall perceptions on telemedicine and benefits of telemedicine across partici- pants’ demographic factors. For bivariate comparison, chi-square or Fisher’s exact for smaller sample groupings was used. For comparative analysis, participants perceptions were dichoto- mized by aggregating the categories “agree” and “strongly agree” to “agree” in the text, while “neutral”, “disagree” and “strongly disagree” were combined to “disagree.” Statistical signifi- cance was defined at the level of a p-value equal to or less than 0.05. Ethical approval This study was approved by the health research ethics committee of the University of Benin Teaching hospital with the protocol number: ADM/E22/A/VOL.VII/14830854. Per our PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 3 / 14 PLOS GLOBAL PUBLIC HEALTH Uptake of teleconsultation services in the Nigerian healthcare system study protocol, participation was completely voluntary. All questions were self-adminis- tered and anonymous. Participants were not compensated for completing the survey and were free to withdraw or not answer any questions they did not want to with no professional or other consequences. Informed consent (written) was obtained from all subjects involved in the study. Results Characteristics of healthcare providers Of the 168 HCP who completed the response, 158 of them resided in Nigeria. The results are based on the 158 HCP who reside in Nigeria. The mean age of the HCP is 31years (S.D = 4.9). Most of the HCP were male 95(60%) and resided in the South-South region of Nigeria 67 (42%). About half (52%) of the HCP practiced exclusively in public health systems, 16% exclu- sively in private health settings, and 32% practiced in a combination of public health and pri- vate health settings. The majority of the HCP 115(73%) had experience with telemedicine consultation over the phone and had experience with telemedicine involving video 28(17%). A summary of HCP characteristics is provided in Table 1. Healthcare providers overall perceptions on telemedicine for healthcare delivery Healthcare providers (HCP) who participated in the study expressed opinions regarding their perceptions on using telemedicine for healthcare delivery (Fig 1). The results are pre- sented for participants who agreed or strongly agreed to the statements. Less than half of the HCP (45%, 71) indicated that they would be interested in healthcare services offering medi- cal consultations over the phone for patients. A good number of the HCP (45%, 70) agreed or strongly agreed that they would only prefer to use teleconsultation services during pan- demics such as COVID-19. Only a few participants (24%, 39) perceived that they would be as satisfied talking to patients over the phone as they would talking to a patient during an in-person consultation. Additionally, 62% (98) agreed or strongly agreed that video over the internet services such as WhatsApp, Skype, or Zoom will improve their teleconsultation experience and sat- isfaction. Forty-two percent (67) of the participants expressed that using a phone to consult with a patient and prescribe medications would be an easy process. Very few (21%, 34) of the HCP liked that there would be no physical contact with patients when consulting over the phone. In this section, we also highlight the notable differences in perception of telemedicine use by HCP demographics. The bivariate categorical test shows no relationship with HCP’s age, location (geopolitical zone), gender, recent professional development status, and healthcare service delivery setting on their responses to the perception statements (whether they agreed or disagreed with perception statements). The only exception was the perception statement on whether HCP agreed or disagreed that videos would improve their teleconsultation experience and satisfaction. There was a statistically significant association between participants’ geopolit- ical zone and their responses to the aforementioned statement (p-value = 0.042). Likewise, there was a statistically significant association between participants’ current professional devel- opment status and their responses to the statement on if they agreed or disagreed that videos would improve their teleconsultation experience and satisfaction (p-value = <0.0001). A com- plete list of comparisons can be found in the S1 Table. PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 4 / 14 PLOS GLOBAL PUBLIC HEALTH Uptake of teleconsultation services in the Nigerian healthcare system Table 1. Healthcare providers characteristics (n = 158). Variables n (%) Age 30.5±4.9 (Mean ±S.D) Geopolitical Zone Northeast 5(3%) North-West 5(3%) North Central 7(4%) South-West 20(13%) South-East 54(34%) South-south 67(42%) Gender Female 63(40%) Male 95(60%) Highest Educational Qualifications MBBS+ PhD 1(1%) MBBS+ Masters 16(10%) Other Degrees 38(24%) MBBS 103 (65%) Most Recent Professional Development Status Consultancy 4(3%) Residency 37(23%) Internship 45(29%) Other Trainings 72 (46%) Healthcare Service Delivery setting Exclusively in private health settings 25(16%) In a combination of public health and private health settings 51(32%) Exclusively in public health system 82(52%) Frequency treating patients in hospital/healthcare facility in the last 6 months before the COVID-19 Pandemic Infrequently, at most 1 in the last 6 months 4(3%) Somewhat frequently, between 2 and 5 times in the last 6 months 7(4%) Frequently; at least 1 per month 8(5%) None 13(8%) Very frequently; at least 1 per week 126(80%) Frequency treating patients in hospital/healthcare facility since the onset of the COVID-19 Pandemic Infrequently, at most 1 in the last 6 months 5(3%) None 6(4%) Somewhat frequently, between 2 and 5 times in last 6 months 12(8%) Frequently; at least 1 per month 14(9%) Very frequently; at least 1 per week 121(77%) Experience with telemedicine consultation Yes, via video over internet (e.g., WhatsApp, Skype) 10(6%) None 15(10%) Yes, over the Phone, Yes, via video over the internet (e.g., WhatsApp, Skype) 18(11%) Yes, over the Phone 115(73%) A session of medical consultations over the phone should cost patients . . . 50% more than the cost of a face-to-face hospital visitations 10(6%) 25% more than the cost of a face-to-face hospital visitations 24(15%) (Continued ) PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 5 / 14 PLOS GLOBAL PUBLIC HEALTH Uptake of teleconsultation services in the Nigerian healthcare system Table 1. (Continued) Variables n (%) The same cost as a face-to-face hospital visitation 37(23%) 25% less than the cost of a face-to-face hospital visitations 42(27%) 50% less than the cost of a face-to-face hospital visitations 45(29%) https://doi.org/10.1371/journal.pgph.0000189.t001 Healthcare providers perceptions on benefits of telemedicine for healthcare delivery The majority of the HCP expressed opinions regarding the perceived benefits of using telemedi- cine for healthcare delivery (Fig 2). Most of the participants, 54% (86), indicated that delivering medical consultations and prescriptions to patients over the phone would help in saving the patients’ time. However, less than half (40%,64) indicated that delivering medical consultations and prescriptions to patients over the phone would be a convenient form of healthcare for patients. Sixty-four percent (102) of the participants expressed that using phones for healthcare service delivery during the COVID-19 Pandemic would be a safe strategy for patients to receive care. Additionally, sixty-one percent (96) of the participants indicated that using the phone would be an affordable way for patients to receive healthcare services during the COVID-19 Pandemic. Fifty-three percent (84) of participants either agreed or strongly agreed with the state- ment that using a phone would be a useful, practical, and effective way for patients to receive healthcare service from a doctor or health professional during the COVID-19 Pandemic. In addition, there were some notable differences in perception on the benefits of telemedi- cine use by HCP demographics. There was a statistically significant association between partic- ipants recent professional development status (p-value = 0.008), healthcare service delivery setting (p-value = 0.033), and if participants agreed or disagreed, using the phone would be a useful (practical) and effective way for patients to receive healthcare service from a Doctor/ Health professional during COVID-19 pandemic. There was no relationship between this response and participants’ age, geopolitical zone, and gender. Also, participants’ recent profes- sional development status and healthcare service delivery setting were associated with whether Fig 1. Overall perceptions on the use of telemedicine among healthcare providers. https://doi.org/10.1371/journal.pgph.0000189.g001 PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 6 / 14 PLOS GLOBAL PUBLIC HEALTH Uptake of teleconsultation services in the Nigerian healthcare system Fig 2. Perception on the benefits of telemedicine among healthcare providers. https://doi.org/10.1371/journal.pgph.0000189.g002 they agreed or disagreed that phone would be an affordable way for patients to receive health- care services during the COVID-19 pandemic. Complete details of results can be found in the S2 Table. Characteristics of healthcare consumers A total of 1381 participants who were not physicians or HCP completed the survey. The mean age of the participants is 28.81 years (S.D = 6.3). The majority of the participants were male, 799(57.9%), and resided in the South-East region of Nigeria 560(40.6%). Most participants had a formal education with an almost equal split in non-scientific/non-medical and scientific/ medical fields. The majority of the participants, 546(39.6%), visited a combination of public health and private health settings for their healthcare needs. About 42% (576) participants vis- ited health facilities infrequently, at most once in six months preceding the COVID-19 Pan- demic. Also, about half of the participants indicated that they did not experience more hospital cancellations or long-term rescheduling of appointments due to the pandemic. The majority of the participants, 510(37%), had never received telemedicine consultation during the data collection. The Summary of study participants’ characteristics is provided in Table 2. Healthcare consumers overall perceptions on telemedicine for healthcare delivery Healthcare consumers who participated in the study expressed their perceptions of using tele- medicine for healthcare services (Fig 3). The results are presented for participants who agreed or strongly agreed to the statements. Most of the participants agreed 774 (56%) that they would be interested in healthcare services offering medical consultations over the phone for patients. Fifty-eight percent of the participants agreed 576(42%) or strongly agreed 215(16%) that they would only prefer teleconsultation services during pandemics such as COVID-19. Most of the participants perceived that they would be satisfied talking to a healthcare provider over the phone as they would during in-person consultation (agree 659(48%); strongly agree 338(21%)). Healthcare consumers perceptions on benefits of telemedicine for healthcare delivery Eighty-three percent (n = 1150) of the participants expressed that using phones to receive healthcare service during the COVID-19 Pandemic would be a safe strategy. The majority of the participants indicated that using a phone would be an affordable 1135(82%) and practical PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 7 / 14 PLOS GLOBAL PUBLIC HEALTH Uptake of teleconsultation services in the Nigerian healthcare system Table 2. Healthcare consumers characteristics (N = 1381). Variables n (%) Age 28.81±6.3 (Mean ±S.D) Geopolitical Zone South-East 560(40.6) South-West 402 (29.1) South-South 282 (20.4) North-Central 90 (6.5) North-West 27 (2.0) North-East 14 (1.0) Gender Male 799 (57.9) Female 573 (41.9) Highest Education Level Bachelors 716 (51.9) Secondary 291 (21.1) Masters 283 (20.5) Doctorate 41 (3.0) Others 35 (2.5) No Formal Education 9 (0.7) Academic Background Non-Scientific/Non-medical 686 (49.7) Scientific/Medical 689 (49.9) Frequency in Visiting Health Facility 6 months Prior to the COVID-19 Pandemic Infrequently; at most 1 in the last 6 months 576 (41.7) None 315 (22.8) Somewhat frequently, between 2 and 5 in the last 6 months 182 (13.2) Very frequently; at least 1 per week 166 (12.0) Frequently; at least 1 per month 136 (9.9) How frequently did you visit a hospital/healthcare facility since the onset of the COVID- 19 Pandemic? None 503 (36.4) Infrequently, at most 1 in the last 6 months 483 (35.0) Somewhat frequently, between 2 and 5 in the last 6 months 162 (11.7) Very frequently; at least 1 per week 147 (10.7) Frequently; at least 1 per month 80 (5.8) Had more Hospital visitation cancellations or long-term rescheduling of appointments since the COVID-19 Pandemic No 704 (51.0) Yes 510 (37.0) Maybe 161 (11.7) Usual Healthcare Service Location In a combination of public health and private health settings 546 (39.6) Exclusively in private health settings 377 (27.3) Other (e.g., Pharmacy stores, Self-medication, Referrals, etc.) 294 (21.3) Exclusively in the public health system 158 (11.4) Ever received telemedicine consultation None 510 (37.0) Yes, over the Phone 393 (28.4) (Continued ) PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 8 / 14 PLOS GLOBAL PUBLIC HEALTH Uptake of teleconsultation services in the Nigerian healthcare system Table 2. (Continued) Variables n (%) Yes, over the Phone, Yes, via video over the internet (e.g., WhatsApp, Skype) 307 (22.2) Yes, via video over internet (e.g., WhatsApp, Skype) 165 (12.0) A session of medical consultations over the phone should cost 50% less than the cost of a face-to-face hospital visitations 480 (34.8) 25% less than the cost of a face-to-face hospital visitations 530 (38.4) The same cost as a face-to-face hospital visitation 187 (13.6) 25% more than the cost of a face-to-face hospital visitations 92 (6.7) 50% more than the cost of a face-to-face hospital visitations 86 (6.2) https://doi.org/10.1371/journal.pgph.0000189.t002 1135(82%) way to receive healthcare service during the pandemic. Also, most of the partici- pants, 82% (n = 1135), indicated that receiving medical consultations and prescriptions over the phone would help in saving time. Additionally, 69% (n = 954) of the participants agreed that receiving medical consultations over the phone would be convenient for them (Fig 4). Comparison of healthcare providers and healthcare consumers responses on overall perceptions and benefits of telemedicine use Table 3 presents the results of the bivariate comparison of HCP and HCC responses on overall perceptions of telemedicine use. There was a statistically significant association in the propor- tion of HCP and HCC who agreed to the overall telemedicine perception statements (p<0.05). The exception was for the proportion of HCP or HCC who agreed that they prefer to use tele- consultation services ONLY during pandemics. There was no statistically significant associa- tion in the proportion for the two groups (p = 0.497). In addition, Table 4 presents the results of the bivariate comparison of HCP and HCC responses on the benefits of telemedicine use. There was a statistically significant association in the propor- tion of HCP and HCC who agreed to the benefits of telemedicine use statements (p<0.05). Discussion Main findings Telemedicine is garnering attention given the prominence of mobile technologies in sub-Saharan Africa countries, including Nigeria [16]. The emergence of the COVID-19 pandemic has further Fig 3. Healthcare consumers overall perceptions on telemedicine use. https://doi.org/10.1371/journal.pgph.0000189.g003 PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 9 / 14 PLOS GLOBAL PUBLIC HEALTH Uptake of teleconsultation services in the Nigerian healthcare system Fig 4. Healthcare consumers perception on the benefits of telemedicine use. https://doi.org/10.1371/journal.pgph.0000189.g004 highlighted the need to consider telemedicine for healthcare delivery [17, 18]. This study explored healthcare providers’ and consumers’ perceptions of telemedicine utilization during Nigeria’s ongoing COVID-19 pandemic. Overall, the results suggest that HCP and HCC are receptive to the use of telemedicine for health consultation and found it to be a useful and practi- cal tool. Most HCP had experience with telemedicine (90%), and fewer HCC (63%) had used telemedicine but believed telemedicine should be expanded beyond the COVID-19 Pandemic. Comparison with previous work Telemedicine service involving cellphone use appears to be the most popular form, with 84% of HCP and 50.6% of HCC reporting using this modality for teleconsultation or healthcare ser- vice. This is consistent with the study by Shittu et al. (2007) [19] in Lagos, Nigeria, where phones were the most popular form of telemedicine communication among study participants (85.9% of healthcare providers in the study). Our study findings showed that HCP and HCC have favorable attitudes towards telemedi- cine use. This is congruent with previous studies in Nigeria [20] and other sub-Saharan Afri- can countries [21] that had assessed perceptions of telemedicine use. In addition, our study suggests that HCP and HCC perceived that telemedicine carried certain benefits for healthcare delivery. Most of the participants (both HCP and HCC) agreed that telemedicine could enhance the healthcare delivery experience by saving time and convenience. Specific to the healthcare delivery during the COVID-19 pandemic, most of the participants agreed that Table 3. Comparison of healthcare providers and health care consumers overall perceptions on telemedicine use. Perceptions of Telemedicine Use Healthcare Healthcare P-Value Providers Consumers Agreed that they liked that there would be no physical contact with receiving or delivering health service when 34 (21.5) 708 (51.5) <0.001 consulting over the phone Agreed that using the phone to consult will be easy for delivering or receiving health service 67 (42.4) 1085 (78.9) <0.001 Agreed that video over the internet will improve teleconsultation experience and satisfaction 98 (62.0) 1133 (82.4) <0.001 Agreed that they would be as satisfied receiving or delivering service over the phone as they would in a 39 (24.7) 957 (69.6) <0.001 consulting room at a healthcare facility Agreed that they prefer to use teleconsultation services ONLY during pandemics 86 (54.4) 791 (57.9) 0.497 Agreed that they would be interested in being involved in a service offering medical consultations over the 71 (44.9) 997 (72.5) <0.001 phone https://doi.org/10.1371/journal.pgph.0000189.t003 PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 10 / 14 PLOS GLOBAL PUBLIC HEALTH Uptake of teleconsultation services in the Nigerian healthcare system Table 4. Comparison of healthcare providers and healthcare consumers perceptions on benefits of telemedicine use. Benefits of Telemedicine Use Healthcare Healthcare P-Value Providers Consumers Agreed that using phone would be a useful (practical) and effective way to deliver or receive healthcare service 84 (53.2) 1135 (82.5) <0.001 during COVID-19 Pandemic Agreed that using the phone would be an affordable way to receive or deliver healthcare services during 96 (60.8) 1135 (82.5) <0.001 COVID-19 Pandemic Agreed that using the phone would be a safe way to deliver or to receive healthcare services during COVID-19 102 (64.6) 1150 (83.6) <0.001 Pandemic Agreed that delivering and receiving medical consultations and prescriptions would be a convenient form of 64 (40.5) 954 (62.2) <0.001 healthcare delivery Agreed that delivering and receiving medical consultations and prescriptions over the phone would save me 94 (59.5) 1127 (82.0) <0.001 time https://doi.org/10.1371/journal.pgph.0000189.t004 telemedicine would be an affordable, safe, and effective way to deliver or receive healthcare ser- vices. These benefits are similar to those in existing literature [22]. Notably, there were statisti- cally significant differences in the proportions of HCP and HCC that agreed on the benefits of telemedicine use for healthcare service delivery. This difference in proportion could be attrib- uted to differences between HCP and HCC overall knowledge of telehealth services. Ideally, HCP are more likely to be well informed about the challenges associated with the implementa- tion of teleconsultation services in Nigeria more than the HCC, hence being more reluctant to acknowledge the uptake and benefits of these services. However, this difference in proportion could also be attributed to the difference in sample size between the two groups and might rep- resent a confounding factor in this study. Regarding participants’ views on the cost of telemedicine, there were mixed responses from HCP and HCC, with the majority from each group indicating the cost should be less than in- person healthcare service. Although this study did not assess the influence of cost on telemedi- cine uptake, previous studies have reported that HCP are less likely to use telemedicine services if they are not adequately compensated for their time and effort [23, 24]. Likewise, the afford- ability of telemedicine for HCC is a critical factor in telemedicine uptake [24]. Overall, findings from this study support the acceptability of telemedicine for healthcare service delivery and consultation. This underscores the need for future work to evaluate how the acceptability of telemedicine translates to the implementation and adoption of healthcare systems. A recent review highlights technological, organizational, legal and regulatory, individ- ual, financial, and cultural aspects as key barriers to the successful implementation of telemedi- cine in sub-Saharan Africa [24]. Hence concerted efforts are needed to address these barriers to facilitate the adoption of telemedicine for healthcare delivery during and beyond the COVID-19 pandemic. Strengths and limitations The strengths of this study include, to the best of our knowledge, this is one of the first studies to explore the acceptability, perceptions of telemedicine among Nigerian HCP and the general public. This information is critical as we make sense of healthcare service delivery during the COVID-19 Pandemic and post-pandemic. Our study has some limitations worth noting. First, it is subject to selection bias due to the convenience sampling and recruitment approach. This means that the survey was limited to individuals who have smartphone devices and were tech- nologically savvy to complete online surveys. This excludes the perspectives of individuals without access to the internet. PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 11 / 14 PLOS GLOBAL PUBLIC HEALTH Uptake of teleconsultation services in the Nigerian healthcare system Therefore, findings from this study should be considered exploratory and may not be gen- eralizable to the HCP and the public in Nigeria. However, considering the ongoing COVID-19 pandemic, this approach was the safest strategy and had the potential for a wider reach. Sec- ondly, this study was also limited by the study’s cross-sectional design, which precludes the investigation of causal relationships. Particularly, follow-up research, using a longitudinal design, could determine to what extent specific telehealth applications continue and evolve over time and after the Pandemic, assessing their perceived benefits and challenges for health- care provision in the long term. Thirdly, all data was collected using an online survey. Not- withstanding the limitations, the results of this study provide information regarding providers’ and individuals’ perceptions on the use of telemedicine due to the COVID-19 pandemic. This can inform relevant public health response. Other variables of interest to consider in future studies include additional information on the challenges and nuanced benefits. Despite these limitations, this study adds new and important information to the literature on perception, acceptability, and uptake of telemedicine in Nigeria. Conclusions Technology is playing an increasingly important role in enhancing patient healthcare access and delivery, particularly with the emergence of the ongoing COVID-19 pandemic. Telemedi- cine has been shown to aptly complement face-to-face hospital visits in ensuring effective tri- aging in hospitals and providing adequate healthcare delivery to patients regardless of geographical and physical barriers. In this study, most participants, HCP, and HCC expressed positive views towards telemedicine consultations. These results support telemedicine use for the provision of healthcare services during the COVID-19 pandemic. Future studies can inves- tigate implementation strategies for the adoption of telemedicine and how perceptions evolve post COVID-19 pandemic. Supporting information S1 Survey. HCP questionnaire. (DOCX) S2 Survey. HCC questionnaire. (DOCX) S1 Checklist. PLOS questionnaire on inclusivity in global research. (DOCX) S1 Table. Results-association between healthcare providers demographic characteristics and perceptions on telemedicine use. (DOCX) S2 Table. Results-association between healthcare providers demographic characteristics and perceptions on benefits of telemedicine use. (DOCX) S3 Table. Results-association between healthcare consumers demographic characteristics and perceptions on telemedicine use. (DOCX) S4 Table. Results-association between healthcare consumers demographic characteristics and perceptions on benefits of telemedicine use. (DOCX) PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 12 / 14 PLOS GLOBAL PUBLIC HEALTH Uptake of teleconsultation services in the Nigerian healthcare system Acknowledgments We thank all healthcare providers and healthcare consumers who participated in the study and the Reunlearn360 2020 Mentee cohort (Kikelomo Adetola Omotoye, Ebuka Samuel Any- aso, Fatima Zara Abdurahaman and Zainab Olamide Olaniyan) who helped in the survey dissemination. Author Contributions Conceptualization: Ifeanyi Jude Ezeonwumelu. Data curation: Ucheoma Nwaozuru. Formal analysis: Ifeanyi Jude Ezeonwumelu, Ucheoma Nwaozuru. Investigation: Ifeanyi Jude Ezeonwumelu, Ifeanyi Jude Obijiaku, Chukwudi Martin Ogbueche, Ucheoma Nwaozuru. Methodology: Ifeanyi Jude Ezeonwumelu, Ifeanyi Jude Obijiaku, Chukwudi Martin Ogbueche, Ucheoma Nwaozuru. Project administration: Ifeanyi Jude Ezeonwumelu. Supervision: Ifeanyi Jude Ezeonwumelu, Ucheoma Nwaozuru. Validation: Ifeanyi Jude Ezeonwumelu, Ucheoma Nwaozuru. Writing – original draft: Ifeanyi Jude Ezeonwumelu, Ucheoma Nwaozuru. Writing – review & editing: Ifeanyi Jude Ezeonwumelu, Ucheoma Nwaozuru. References 1. Sutherland AE, Stickland J, Wee B. Can video consultations replace face-to-face interviews? Palliative medicine and the Covid-19 pandemic: rapid review. BMJ supportive & palliative care. 2020; 10(3):271– 5. https://doi.org/10.1136/bmjspcare-2020-002326 PMID: 32457086 2. Imlach F, McKinlay E, Middleton L, Kennedy J, Pledger M, Russell L, et al. Telehealth consultations in general practice during a pandemic lockdown: survey and interviews on patient experiences and prefer- ences. BMC family practice. 2020; 21(1):1–14. https://doi.org/10.1186/s12875-019-1070-0 PMID: 31901226 3. Wosik J, Fudim M, Cameron B, Gellad ZF, Cho A, Phinney D, et al. Telehealth transformation: COVID- 19 and the rise of virtual care. Journal of the American Medical Informatics Association. 2020; 27 (6):957–62. https://doi.org/10.1093/jamia/ocaa067 PMID: 32311034 4. Annis T, Pleasants S, Hultman G, Lindemann E, Thompson JA, Billecke S, et al. Rapid implementation of a COVID-19 remote patient monitoring program. Journal of the American Medical Informatics Associ- ation. 2020; 27(8):1326–30. https://doi.org/10.1093/jamia/ocaa097 PMID: 32392280 5. Duffy S, Lee TH. In-person health care as option B. The New England journal of medicine. 2018; 378 (2):104–6. https://doi.org/10.1056/NEJMp1710735 PMID: 29320653 6. CDC. Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic. June 10, 2020. Updated: Accessed Feb. 2021;1. 7. Hollander JE, Carr BG. Virtually perfect? Telemedicine for COVID-19. New England Journal of Medi- cine. 2020; 382(18):1679–81. https://doi.org/10.1056/NEJMp2003539 PMID: 32160451 8. Schinköthe T, Gabri MR, Mitterer M, Gouveia P, Heinemann V, Harbeck N, et al. A web-and app-based connected care solution for COVID-19 in-and outpatient care: qualitative study and application develop- ment. JMIR public health and surveillance. 2020; 6(2):e19033. https://doi.org/10.2196/19033 PMID: 32406855 9. Webster P. Virtual health care in the era of COVID-19. The Lancet. 2020; 395(10231):1180–1. https:// doi.org/10.1016/S0140-6736(20)30818-7 PMID: 32278374 10. Tshangela A, Salyer S, Varma J, Ouma A, Nkengasong J. COVID-19 in Africa: the spread and response. Nature Medicine. 2020. https://doi.org/10.1038/s41591-020-0961-x PMID: 32528154 PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 13 / 14 PLOS GLOBAL PUBLIC HEALTH Uptake of teleconsultation services in the Nigerian healthcare system 11. Willcox ML, Peersman W, Daou P, Diakité C, Bajunirwe F, Mubangizi V, et al. Human resources for pri- mary health care in sub-Saharan Africa: progress or stagnation? Human resources for health. 2015; 13 (1):1–11. https://doi.org/10.1186/s12960-015-0073-8 PMID: 26358250 12. NCDC. Nigeria centre for Disease Control (NCDC). Confirmed COVID19 Cases—Nigeria 2020. https:// covid19.ncdc.gov.ng/state/2020 [cited 2021 October 10 ]. 13. Adenuga K, Iahad N, Miskon S. Telemedicine system: service adoption and implementation issues in Nigeria. Indian Journal of Science and Technology. 2020; 13(12):1321–7. 14. Arize I, Onwujekwe O. Acceptability and willingness to pay for telemedicine services in Enugu state, southeast Nigeria. Digital health. 2017; 3:2055207617715524. https://doi.org/10.1177/ 2055207617715524 PMID: 29942606 15. NCC. Nigerian Communications Commission (NCC). Industry Statistics, 2020 https://www.ncc.gov.ng/ stakeholder/statistics-reports/industry-overview#monthly2020. 16. Wamala DS, Augustine K. A meta-analysis of telemedicine success in Africa. Journal of pathology infor- matics. 2013;4. https://doi.org/10.4103/2153-3539.108542 PMID: 23599904 17. Bashshur R, Doarn CR, Frenk JM, Kvedar JC, Woolliscroft JO. Telemedicine and the COVID-19 pan- demic, lessons for the future. Mary Ann Liebert, Inc., publishers 140 Huguenot Street, 3rd Floor New; 2020. 18. Bahl S, Singh RP, Javaid M, Khan IH, Vaishya R, Suman R. Telemedicine technologies for confronting COVID-19 pandemic: a review. Journal of Industrial Integration and Management. 2020; 5(04):547–61. 19. Shittu L, Adesanya O, Izegbu M, Oyewopo A, Ade A, Ashiru O. Knowledge and perception of health workers towards tele-medicine application in a new teaching hospital in Lagos. Scientific Research and Essay. 2007; 2(1):016–9. 20. Abodunrin O, Akande T. Knowledge and perception of e-health and telemedicine among health profes- sionals in LAUTECH teaching hospital, Osogbo, Nigeria. International Journal of Health Research. 2009; 2(1). 21. Biruk K, Abetu E. Knowledge and attitude of health professionals toward telemedicine in resource-lim- ited settings: a cross-sectional study in North West Ethiopia. Journal of healthcare engineering. 2018;2018. https://doi.org/10.1155/2018/2389268 PMID: 30581547 22. WHO Global Observatory for eHealth. Telemedicine: opportunities and developments in Member States: report on the second global survey on eHealth. (2010). https://apps.who.int/iris/handle/10665/ 44497 [cited 2021 October 10]. 23. De Grood C, Raissi A, Kwon Y, Santana MJ. Adoption of e-health technology by physicians: a scoping review. Journal of multidisciplinary healthcare. 2016; 9:335. https://doi.org/10.2147/JMDH.S103881 PMID: 27536128 24. Dodoo JE, Al-Samarraie H, Alzahrani AI. Telemedicine use in Sub-Saharan Africa: Barriers and policy recommendations for Covid-19 and beyond. International Journal of Medical Informatics. 2021; 151:104467. https://doi.org/10.1016/j.ijmedinf.2021.104467 PMID: 33915421 PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000189 February 9, 2022 14 / 14