Healthcare professionals´ perspectives on teledermatology in Hawassa, Ethiopia: a cross-sectional study

¹Department of Dermatology and Venereology, Hawassa University, Hawassa, Ethiopia, ²Department of Pathology, Hawassa University, Hawassa, Ethiopia, ³School of Public Health, Hawassa University, Hawassa, Ethiopia

^&Corresponding author
Girum Tedla Assefa, Department of Dermatology and Venereology, Hawassa University, Hawassa, Ethiopia

Introduction    

The global and local burden of skin disease: skin diseases affect an estimated 1.8 billion people worldwide, representing a leading cause of non-fatal disease burden that contributes to disability, disfigurement, and reduced quality of life [1,2]. The burden is particularly severe in sub-Saharan Africa, where poverty, tropical climates, and high rates of infectious diseases create fertile ground for a wide spectrum of dermatological conditions [3]. Ethiopia, with a population exceeding 120 million, faces a critical shortage of dermatologists. With approximately 210 specialists nationwide, the ratio stands at roughly one dermatologist per 570,000 people, a stark contrast to the 1:20,000 ratio in many high-income countries [4,5]. The concentration of these specialists in major urban centres leaves rural and remote populations with virtually no access to specialised care [6]. Consequently, patients are primarily managed by general practitioners and health officers who often lack the specialised training for accurate diagnosis, leading to misdiagnosis, delayed treatment, and increased morbidity [7].

Teledermatology as a Strategic Solution: telemedicine, the use of information technology to provide remote clinical care, has emerged as a transformative solution, and teledermatology is one of its most successful applications [8,9]. It operates through store-and-forward (asynchronous) or real-time (synchronous) modalities, both of which have been shown to improve patient access, reduce costs, decrease wait times, and enhance educational opportunities for primary care providers [10,11]. Studies consistently demonstrate high diagnostic concordance between teledermatology and in-person consultations, affirming its clinical reliability [12,13]. The visual nature of dermatology makes it uniquely suited for remote diagnosis, allowing for effective management even with basic imaging tools like smartphone cameras.

The implementation challenge in resource-limited settings: despite its potential, implementing teledermatology in low- and middle-income countries (LMICs) is challenging due to technological, financial, and organisational barriers [14]. These include unreliable internet, inadequate IT infrastructure, and financial constraints [15,16]. Critically, success hinges on the engagement of frontline healthcare professionals. Their attitudes, perceived barriers, and confidence are paramount determinants of adoption [17]. Provider concerns often revolve around diagnostic accuracy, data privacy, and increased workload [18,19]. While the Ethiopian Ministry of Health has prioritised telemedicine in its National Digital Health Strategy, and early initiatives have shown promise, scaling these efforts is hampered by poor infrastructure and lack of clear policy [20,21]. This indicates a gap between strategic intent and operational reality, underscoring the need to address foundational implementation challenges.

Rationale and objectives of the study: limited research on teledermatology exists from sub-Saharan Africa, particularly Ethiopia. This study aims to address this gap by examining: healthcare professionals' perceived need for teledermatology services; their comfort with and confidence in using telemedicine technologies; perceived barriers to implementation; attitudes toward teledermatology and its potential benefits; and factors contributing to sustainable teledermatology services in Ethiopia.

Methods     

Study design and setting: this cross-sectional study was conducted among healthcare professionals working in ten public health centres in Hawassa, the capital city of the Sidama Regional State, Ethiopia. The survey was administered between March and April 2025, with data analysis performed in May 2025.

Study population and sampling: participants included physicians, nurses, health officers, and other healthcare professionals who provide primary care services, as well as administrative, IT, and other supporting staff.

Eligibility criteria: inclusion criteria for participants were full-time employment at one of the selected public health centres for a minimum of six months. Exclusion criteria included students, temporary staff, and individuals who were on leave during the data collection period.

Sampling: a two-stage sampling approach was employed. In the first stage, ten health centres were randomly selected from a list of all available health centres, with stratification to ensure a representative mix of urban (6) and suburban (4) locations. In the second stage, a convenience sampling approach was used.

Study size: no a priori sample size calculation was performed. The study aimed to include all professionals available at the time of the visit to each health centre who met the eligibility criteria and were willing to participate. This recruitment process resulted in a final sample of 144 healthcare professionals.

Variables and data sources: a structured, interviewer-administered questionnaire was the primary data source. The questionnaire was developed by the research team based on a review of existing literature on telemedicine adoption and covered demographics, current practice, technology access and comfort, attitudes toward teledermatology, perceived barriers, patient-related considerations, and sustainability factors. Key variables were defined and measured as follows:

Perceived need: assessed by questions on the frequency of needing dermatology consultations and the perceived adequacy of current specialist access.

Technology readiness: a composite measure including self-reported smartphone ownership, access to a computer at work, and comfort with technology on a 5-point Likert scale.

Perceived barriers: assessed using a series of questions on potential barriers, rated on a 5-point Likert scale from 1 (not a barrier) to 5 (an extremely significant barrier).

The questionnaire was translated into Amharic, the local working language, and then back-translated to English to ensure consistency. It was pre-tested for clarity and cultural appropriateness on 15 healthcare professionals at a non-participating health centre, leading to minor revisions in the wording of three questions to improve comprehension.

Addressing potential bias: efforts were made to minimise potential sources of bias. To mitigate selection bias inherent in convenience sampling, we included a diverse range of health centres (urban and suburban) and professional roles. To reduce information bias, data collectors were trained to administer the questionnaire in a neutral manner, without leading participants. The assurance of anonymity and confidentiality was intended to reduce social desirability bias and encourage honest responses.

Statistical methods: data were entered and analysed using SPSS version 27.0. Descriptive statistics (frequencies, percentages, means, standard deviations) were used for summarisation. Inferential statistics were used to examine relationships between variables, including the Chi-Square Test for associations between categorical variables, and the Mann-Whitney U Test and Kruskal-Wallis H Test for comparing groups on ordinal data. Spearman's Correlation was used to assess relationships between ordinal variables, and the Friedman Test was used to rank perceived barriers and attitudes. A p-value < 0.05 was considered statistically significant. The dataset was checked for completeness, and no missing data were found for the variables included in the final analysis.

Ethical considerations: the study received ethical approval from the Institutional Review Board of Hawassa University, College of Health Sciences (#HU/IRB/268/16). Permission was obtained from each health centre, and oral informed consent was secured from all participants. Anonymity and confidentiality were strictly maintained.

Results     

Participant recruitment and demographics: a total of 158 healthcare professionals were identified and assessed for eligibility across the ten selected health centres. Of these, 150 were deemed eligible to participate. Six individuals declined to participate, citing time constraints, resulting in a response rate of 96%. The final sample included 144 healthcare professionals. The participant cohort was relatively young (85% aged 35 or younger) and predominantly female (62.5%). Nurses were the largest professional group (50.7%), followed by health officers (23.6%). Most participants (76.4%) worked in urban health centers. Detailed demographic information is presented in Table 1.

Current dermatological practice and teledermatology needs: a strong need for specialist support was evident, with 93.0% of respondents requiring dermatology consultations. The frequency was high, with 43.1% needing weekly consultations and 25.0% multiple times a week. A near-unanimous 93.1% (95% CI: 88.0% - 96.4%) strongly disagreed that their current access to specialists was adequate. Confidence in managing skin conditions was moderate, with "Somewhat confident" being the most common response.

Technology readiness and prior experience: a high proportion of professionals (81.3%) owned a smartphone with internet access, and 45.1% had access to a computer at work. Despite this, 62.1% had no prior experience with telemedicine. General comfort with technology was high (75.7% "comfortable" or "very comfortable"). Trust in telemedicine's reliability and confidentiality was predominantly "Neutral" (57.6%).

Perceived barriers to teledermatology implementation: a Friedman test revealed a statistically significant difference among perceived barriers (χ² (8) = 315.7, p < 0.001). As shown in Table 2, the top-ranked barriers were systemic and infrastructural.

Perceived patient resistance to teledermatology: providers anticipated patient resistance primarily due to "Concerns about exposing their body through images" (76.8%) and a "Preference for face-to-face interaction" (73.2%). Other reasons included a "Lack of trust in the effectiveness" (64.3%) and "Difficulty using the technology" (30.4%).

Attitudes towards teledermatology and perceived benefits: despite barriers, attitudes were overwhelmingly positive (93.1% "positive" or "very positive"). A Friedman test showed a significant difference among the reasons for this attitude (χ² (5) = 221.4, p < 0.001). As shown in Table 3, the primary drivers were the potential for improved efficiency and patient access.

Factors contributing to teledermatology sustainability: "Reliable technology" (98.6%), "Continued training and support for staff" (97.2%), "Positive patient outcomes" (96.5%), and "Ongoing funding" (93.8%) were identified as the most critical factors for long-term sustainability.

Discussion     

This study reveals a compelling duality: a highly motivated and digitally-literate workforce in Hawassa is constrained by significant infrastructural and systemic barriers. The findings align with research from other LMICs yet offer context-specific insights for Ethiopia. The overwhelmingly positive attitude (93.1%) and the recognised need for specialist support are cornerstones for successful implementation. This intrinsic motivation, driven by a desire to improve patient access and enhance professional skills, is a critical asset. This mirrors findings from Kenya, where providers view telemedicine as a value-adding tool rather than a burden [22,23]. The widespread informal use of smartphones for clinical communication, also documented in Nigeria [15], suggests a "mobile-first" strategy is not only feasible but practical.

However, enthusiasm cannot overcome the formidable barriers identified. As shown in Table 2, the top-ranked obstacles were systemic, not individual. Unreliable internet, lack of equipment, and power instability are consistently ranked as primary impediments to telehealth across sub-Saharan Africa [24]. This underscores that grassroots enthusiasm alone cannot overcome fundamental infrastructural deficits; top-down strategic investment is required. Equally critical are the systemic and policy gaps. The absence of dedicated funding and a clear legal framework, ranked as the top barrier, creates a high-risk environment. This policy vacuum has stalled telemedicine in other African nations, whereas the formalisation of national guidelines in countries like India has catalysed adoption [25]. For teledermatology to become routine care in Ethiopia, the Ministry of Health must develop and enforce clear protocols for data privacy, liability, and reimbursement, moving beyond the strategy outlined in its Digital Health Blueprint [20].

Providers' perception of patient-related barriers, particularly privacy concerns and a preference for in-person visits, highlights a crucial awareness of the end-user experience. These concerns are well-documented globally; a study in the Philippines found nearly 90% of patients expressed privacy concerns [23]. The solution lies in proactive community engagement and patient education to build trust, a best practice endorsed in other African contexts [24].

This study also revealed a nuanced finding: professionals with prior telemedicine experience perceived systemic barriers like internet reliability and medicolegal issues more acutely. This "reality check" suggests that direct engagement exposes the practical frictions of a new system. In contrast, those with a high clinical need for consultations were less deterred by operational hurdles, indicating a strong "need-driven enthusiasm." Implementation strategies must balance addressing the pragmatic concerns of experienced users with harnessing the motivation of high-need clinicians, who can serve as effective champions.

Finally, the concern about diagnostic accuracy, particularly with low-quality images, is valid. A systematic review by Delaigue et al. [13] found that diagnostic agreement in teledermatology improves significantly when providers receive specific training on image acquisition. This underscores the need for comprehensive training that extends beyond technical skills to include clinical photography and workflow integration. The suggestion of a hybrid model, incorporating periodic in-person visits from specialists, is an excellent strategy to build confidence and ensure quality, a model that has proven successful in other resource-limited settings [25].

Limitations of the study: as a study conducted in a specific urban and suburban setting, findings may not be generalizable to rural areas with greater infrastructural challenges. The reliance on a convenience sample and the absence of a formal sample size calculation may limit the statistical power to detect more subtle associations and affect the generalizability of the findings. The reliance on self-reported data may be subject to social desirability bias, despite our efforts to ensure anonymity. Finally, the study captures pre-implementation perceptions; future research should evaluate the actual experiences of providers and patient's post-implementation.

To realise the full promise of teledermatology, a deliberate, coordinated, and sustained effort is required from all stakeholders. This effort should be guided by the following recommendations:

Prioritise systemic investment in foundational infrastructure: focus on securing high-level management support, dedicated funding, robust internet and a stable power supply.

Develop comprehensive, continuous training programs: training must cover both foundational telemedicine concepts and specific teledermatology protocols, including clinical photography and documentation standards, with ongoing technical support.

Implement patient-centric communication strategies: design patient education campaigns that proactively address privacy concerns and clearly articulate the benefits of teledermatology to build trust.

Leverage existing strengths and foster champions: engage early adopters and highly motivated clinicians as champions to facilitate peer-to-peer learning and advocate for the service.

Establish clear policy and legal frameworks: the Ministry of Health should accelerate the development of a comprehensive legal framework for telemedicine addressing data privacy, liability, and reimbursement.

Adopt a holistic and integrated planning approach: recognise the interdependence of funding, training, technology, and patient outcomes, and develop strategies that address these factors synergistically.

Conclusion     

This study demonstrates that teledermatology has transformative potential to address the significant gap in dermatological care in Hawassa, Ethiopia. Healthcare professionals in the region are highly motivated and possess the foundational digital literacy to embrace this innovation, driven by a desire to improve patient outcomes. However, this enthusiasm is currently hindered by significant systemic and infrastructural barriers. The most critical obstacles are not related to individual willingness but rather to managerial and infrastructural issues, such as unreliable internet access, a lack of necessary equipment, and insufficient management support.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Girum Tedla: conceptualisation, project administration, writing the original draft. Girum Tedla and Birhanu Jikamo: methodology. Alemwosen Teklehaimanot and Birhanu Jikamo: supervision. Girum Tedla and Sara Ayele: investigation. Girum Tedla, Alemwosen Teklehaimanot, Sara Ayele and Birhanu Jikamo: writing, review and editing. Birhanu Jikamo: formal analysis. All authors have read and approved the final version of the manuscript.

Acknowledgments     

We extend our sincere gratitude to all the healthcare professionals from the public health centres in Hawassa for their cooperation and for participating in this study. The authors declare that all individuals mentioned have permitted their inclusion in this acknowledgements section.

Tables and figures     

Table 1: demographic characteristics of study participants
Table 2: ranking of perceived barriers to teledermatology implementation
Table 3: attitudes towards teledermatology: ranking and key comparisons

References