Are Low and Middle-Income Country Universities “AI Resilient”: Exploring the Use of ChatGPT among Medicine and Health Sciences Students in Rwanda.

doi:10.21203/rs.3.rs-5150455/v1

Introduction
ChatGPT, launched in 2022, has rapidly become a popular AI tool used in academia and professional settings. This study explores its use, perceived strengths and weakness, perceived benefits and risks, and future potential among students in the College of Medicine and Health Sciences at the University of Rwanda, particularly focusing on its implications for education in Low- and Middle-Income Countries (LMICs).

Methods

A qualitative study was conducted using in-depth structured interviews with 30 purposively selected students during the United for Health Days 2023. Participants who had used ChatGPT were employed. Interviews were transcribed, translated, and analyzed using thematic analysis.

Results

ChatGPT was primarily used for academic assignments, professional growth, and extracurricular activities. It was highly effective for literature reviews and class assignments but less useful for tasks requiring advanced technical skills like scientific computing or clinical case analysis. Major benefits were increased productivity, ease of use, and 24/7 availability. Risks included overreliance on the tool, potential reduction in critical thinking, ethical concerns regarding academic integrity, and accuracy limitations. Recommendations included improving data accuracy, developing AI-related policies, and offering training to users.

Conclusion
As AI technologies like ChatGPT transform education, LMICs face unique challenges in adapting their systems. This study underscores the risk of widening educational disparities between LMICs and High-Income Countries (HICs), emphasizing the urgent need to develop AI resilience in LMIC universities. Strengthening AI integration and policy frameworks will be key to ensuring equitable and competitive education in a rapidly evolving digital landscape.

ChatGPT

AI resilience

higher education

LMICs

qualitative study

academic integrity

Artificial Intelligence (AI) is generating significant transformations in many fields including education (Chan, 2023). Over the past decade, the rapid development of AI technologies has introduced new tools and methodologies that are reshaping traditional educational practices (Guan et al., 2020). Among these advancements, AI-powered conversational agents like Chat Generative Pre-trained Transformer (ChatGPT) have garnered considerable attention due to their potential to revolutionize student engagement, learning processes, and educational outcomes (Montenegro-Rueda et al., 2023).

ChatGPT, launched by OpenAI in November 2022, is a generative AI platform designed to interact with users in a conversational manner and can be used to assist with a wide range of tasks (Haleem et al., 2022). The platform’s growth has been unprecedented. Within five days of its launch, ChatGPT reached one million users, and within a month, it had accumulated 57 million users globally (Wu et al., 2023). According to the World Bank by January 2023, the user base had expanded to 100 million, and by September 2023, it had surpassed 200 million active users per month, making it the fastest-growing AI platform at that time (Liu & Wang, 2024). Predictions indicate that by 2025, ChatGPT could potentially surpass one billion users, reflecting the growing reliance on AI technologies across the globe (Liu & Wang, 2024).

In Rwanda, like everywhere, the adoption of AI technologies, including ChatGPT, is still in its early stages (Pierre, 2022). Despite the growing interest in AI, there is limited nationwide data on the use of large language models (LLM) like ChatGPT, and specific guidelines for their application across different sectors are lacking (Whitestone et al., 2024). According to the Ministry of ICT, the Rwandan government has, however, recognized the potential of AI to drive economic growth and enhance public service delivery as reflected in its AI policy (Baguma et al., 2023). This policy aims to foster inclusive and sustainable development by promoting the responsible use of AI technologies in various sectors, including education (Baguma et al., 2023).

ChatGPT is designed to assist users in generating coherent and contextually relevant text, which can be used for various purposes, including essay writing, content creation, problem-resolving, and even academic research (Dave et al., 2023a) (Mogavi et al., 2023). Several studies have highlighted the utility of ChatGPT in educational settings. Research conducted by Dave (Dave et al., 2023a) evidenced that ChatGPT is effective in managing complex clinical and educational information. For instance, Kung et al (Kung et al., 2023), demonstrated that ChatGPT could perform at or near the passing threshold of the three-step United States Medical Licensing Exam (USMLE). With Generative AI being widely available, it thus functions like a disruptive technology and requires a fundamental re-think of how to organize medical education.

In educational contexts, ChatGPT has been shown to enhance productivity and efficiency, enabling students to conduct research, prepare for practical examinations and other academic activities, and complete assignments more quickly and with greater accuracy (Mogavi et al., 2023), (Sulisworo & Dahlan, 2023) (Tsang, 2023a) (Al-Worafi, Hermansyah, Tan, et al., 2023a) (Adeshola & Adepoju, 2023; Grassini, 2023; Hosseini et al., 2023; Limna et al., 2023; Peng et al., 2023; Sallam, 2023a). This is particularly beneficial in higher education, where students often juggle multiple responsibilities and require tools that can streamline their learning processes. However, the potential benefits of ChatGPT are accompanied by significant concerns (Al-Worafi, Hermansyah, Tan, et al., 2023b). One of the primary issues raised by educators and researchers is the potential for overreliance on AI, which could undermine students’ development of critical thinking, creativity, and problem-solving (Sok & Heng, 2023). The ease with which ChatGPT can generate text and solve problems may lead students to rely on the platform rather than engage deeply with learning materials, potentially diminishing their overall educational experience (Wu et al., 2023). This concern has led some institutions to prohibit the use of ChatGPT (Al-Worafi, Hermansyah, Goh, et al., 2023).

Moreover, there are ethical considerations associated with the use of AI in education (Kunjumuhammed, 2024). ChatGPT, like other AI tools, is prone to producing content that may be inaccurate, biased, or superficial (Kasneci et al., 2023). Studies have shown that AI-generated content can sometimes include false information, or lack the depth and nuance required for complex academic work (Illia et al., 2023). Additionally, the potential for AI to generate plagiarized or non-original content raises significant ethical concerns, particularly in academic settings where integrity and originality are crucial (Chisom et al., 2023). As a result, educators and researchers are increasingly calling for a balanced approach to the use of AI in education to maximize its benefits while mitigating its risks (Rahman et al., 2023).

In Low and Middle-Income contexts, particularly in sub-Saharan Africa, AI tools like ChatGPT present unique opportunities and challenges (Oduoye et al., 2024). On the one hand, ChatGPT has the potential to bridge gaps in access to information and educational resources, particularly in regions where such resources are scarce (Abdaljaleel et al., 2024; Adarkwah et al., 2023; Tarisayi, 2024). By providing tailored educational content and support, ChatGPT can enhance learning outcomes and improve the quality of education. In remote locations, ChatGPT could serve as a valuable resource for students and educators alike, offering guidance on a wide range of topics and supporting self-directed learning (Kremer et al., 2013). In particular, AI tools can play a crucial role in improving healthcare education by providing information, and updated medical knowledge, especially in regions where access to specialized training is limited (Pillai, 2023).

However, the use of ChatGPT in Low and Middle-Income contexts also presents significant challenges. A study conducted by Worafi (Al-Worafi, Hermansyah, Tan, et al., 2023b), highlighted the risks associated with the use of AI in research and education, as users may lack the necessary knowledge or skills to effectively utilize these tools. The study found that many students and educators in sub-Saharan Africa have limited experience with AI technologies like ChatGPT, leading to misuse or overreliance on the platform. Moreover, the absence of localized datasets in developing regions means that AI models like ChatGPT may not always provide accurate or relevant information, further complicating their use in these contexts (Wang et al., 2023). This concern is echoed by Sallam (Sallam et al., 2023), who points out that AI-generated content can sometimes perpetuate biases in the training data, leading to ethical dilemmas.

Significant uncertainty remains regarding the most effective ways to integrate AI into education in Rwanda. While there is evidence of ChatGPT's effectiveness in various fields, including education and healthcare, there is a need for further research to understand its specific impact on students' learning experiences, academic performance, and overall engagement within the context of health sciences education in Rwanda. Therefore, this study aims to explore the use of ChatGPT among Medicine and Health Sciences Students at the University of Rwanda and elicit their perceptions of its future implications in healthcare education. The specific objectives are: (1) To identify the academic tasks for which students use ChatGPT, (2) Examine student perceptions of the strengths and weaknesses of ChatGPT, (3) Assess students’ understanding of the benefits and risks of using ChatGPT, and (4) Gather students’ suggestions for improvements and future implications in healthcare education. These insights will contribute to the informed development and responsible integration of AI tools in education in Rwanda and similar settings.

2.1 Study Design

This study employed an explorative qualitative research design using a phenomenological approach to understand students' experiences and perceptions regarding the use of ChatGPT for academic purposes. The phenomenological approach was selected to capture the lived experiences of the participants, focusing on how they perceive and interact with ChatGPT in their academic activities. The Technology Acceptance Model (TAM), provided the theoretical framework for the study, guiding the development of the interview guide and ensuring that the research addressed both technological and experiential aspects of ChatGPT use.

2.2 Study Setting and Participants

The study was conducted at the University of Rwanda, College of Medicine and Health Sciences (UR-CMHS) during the United for Health Days Exhibition 2023. This event was strategically chosen as it gathers a broad spectrum of students from all health sciences disciplines, offering a diverse participant pool and simplifying logistical arrangements for data collection. A purposive sampling strategy was used to select 30 students who had either heard of or used ChatGPT, ensuring that participants had relevant experience with the technology. The sample size of 30 was chosen based on the principle of data saturation, which was anticipated and confirmed during the data collection process.

2.3 Procedures

Ethical approval

for the study was obtained from the Institutional Review Board of the College of Medicine and Health Sciences at the University of Rwanda, adhering to the ethical guidelines outlined in the Declaration of Helsinki (Association, 2013; Carlson et al., 2004). Participants were approached during the exhibition and written informed consent was obtained.

Data Collection:

Each interview began with the collection of basic demographic information, including age, gender, department, and program of study, followed by questions regarding their familiarity and experience with ChatGPT. Data was collected using a semi-structured interview guide (IIG), developed based on TAM and informed by a review of existing literature on AI in education. The IIG comprised seven open-ended questions designed to explore predefined themes such as the types of academic tasks where ChatGPT is used, perceived performance (both strengths and weaknesses), associated benefits and risks, suggested improvements, and its future role in healthcare education (see Table 1 for the complete interview guide). The interviews were conducted in Kinyarwanda to ensure that participants could express themselves comfortably and clearly. Each interview was conducted face-to-face in a private setting within the exhibition venue, with five trained data collectors performing the interview. The data collectors were final-year students and were thoroughly trained on the study’s objectives, the ethical considerations, and the interview protocol to ensure consistency across interviews. We conducted 30 interviews. After, the data collectors met and confirmed data saturation.

Confidentiality Measures:

To ensure participant confidentiality, interviews were conducted in isolated stands within the exhibition area, preventing others from overhearing the conversations. All collected data were anonymized, with identifying information removed before transcription and analysis.

2.4. Data collection tools

2.4.1 Sociodemographic Characteristics Questionnaire

This tool was used to collect participants' basic sociodemographic information, including sex, age, school, program of study, and their awareness and use of ChatGPT.

2. 4. 2. Semi-structured interview guide

The interview guide, informed by the TAM framework, was organized into seven themes: academic tasks, perceived performance, advantages, risks, suggested improvements, and future implications in healthcare. The interview guide was pilot-tested on five students to ensure that the questions were clear, relevant, and elicited meaningful responses. Table 1 outlines the predefined themes and corresponding research questions used in the interviews.

Table 1

**In-depth structured individual interview guide**
Themes	Heard and Used ChatGPT	Heard and not used ChatGPT
Predefined themes	Research questions	Research questions
1. Academic Tasks for which Students Use ChatGPT.	1. Could you list some of the academic tasks or activities for which you use ChatGPT?	1. Could you list some of the academic tasks or activities for which people use ChatGPT?
2. Academic Tasks for which Students Judge ChatGPT to Perform Excellently.	2. Could you list some of the academic tasks or activities for which you believe ChatGPT is specifically useful and performant?	2. Could you list some of the academic tasks or activities for which you believe ChatGPT is specifically useful and performant?
3. Academic Tasks for which Students Judge ChatGPT to Perform Poorly.	3. Could you list some of the academic tasks or activities for which you believe ChatGPT is not very useful and performant?	3. Could you list some of the academic tasks or activities for which you believe ChatGPT is not very useful and performant?
4. Perceived Advantages of Using ChatGPT.	4. Could you list some of the advantages that you believe are associated with students’ use of ChatGPT in their journey to become better health professionals?	4. Could you list some of the advantages that you believe are associated with students’ use of ChatGPT in their journey to become better health professionals?
5. Perceived Risks of Using ChatGPT.	5. Could you list some of the risks that you believe are associated with students’ use of ChatGPT in their journey to become better health professionals?	5. Could you list some of the risks that you believe are associated with students’ use of ChatGPT in their journey to become better health professionals?
6. Suggestions for Improving ChatGPT.	6. Could you list some improvements you'd like to see in ChatGPT to make it even more helpful for meeting your academic needs?	NA
7. Imagined Future Use of ChatGPT in Healthcare.	7. Could you list how you believe that ChatGPT will change the future of health care in Rwanda?	7. Could you list how you believe that ChatGPT will change the future of health care in Rwanda?

2.5. Data analysis

All interviews were audio-recorded, transcribed verbatim, and translated into English for analysis. The transcripts were subjected to a thematic analysis using NVivo 14 software combining both deductive and inductive coding approaches.

Coding process

Initially, the data were coded according to the seven pre-defined themes: (1) academic tasks where ChatGPT is used, (2) Areas where ChatGPT is perceived to perform excellently, (3) areas where ChatGPT perceived to perform poorly, (4) perceived strengths, (5) perceived risks, (6) suggested improvements, and (7) imagined future use in healthcare. Each transcript was carefully read and re-read to ensure comprehensive coding, and verified by two senior analysts.

Theme Development:

After initial coding, the codes were reviewed and grouped into sub-themes based on their similarities. The research team engaged in several discussions to refine these sub-themes and identify overarching themes. This iterative process continued until no new themes or sub-themes emerged, confirming that all significant patterns in the data had been captured.

Reliability and Validation:

To enhance the reliability of the analysis, the research team conducted cross-checks where different members reviewed the coding and theme development. Discrepancies were discussed and resolved, ensuring a consensus on the final themes. After finalizing the themes, the team revisited the transcripts to ensure that the themes accurately represented the data.

Final Review:

The completed thematic framework was reviewed to ensure it captured the full range of participants' experiences and perceptions regarding the use of ChatGPT in their academic work. The findings were then categorized into overarching and subordinate themes, which were used to structure the study’s results.

3.1 Demographics

The study included 30 students from the University of Rwanda, College of Medicine and Health Sciences, with interview durations ranging from 5 to 23 minutes (Table 1). Participants were primarily aged 18–25 years (18 students), with slightly more males (20 males). Most participants were undergraduate students (25), with others pursuing master's (4) and PhD (1) programs. The students represented diverse disciplines, including Medicine and Pharmacy (7), Nursing and Midwifery (8), Public Health (6), Health Sciences (6), and Dentistry (3). Notably, all participants who had heard of ChatGPT (i.e., inclusion criterion) had also already used ChatGPT.

Table 2

Socio-demographic characteristics
Name	Frequency	Name	Frequency
1. Age categories		2. Gender
18–25 years	18	Male	20
26–35 years	11	Female	10
Above 36 years	1	4. School
		Dentistry	3
		Health Sciences	6
3. Education Program		Medicine and Pharmacy	7
Undergraduate Student	25	Nursing and Midwifery	8
Master’s Student	4	Public Health	6
PhD Student	1
5. Heard and Used	Heard and Not Used
30	0

3.2. Academic Tasks for which Students Use ChatGPT

The students report using ChatGPT for a variety of academic tasks, with class-related tasks being the most common. These included literature reviews, completing class assignments, defining key terms, summarizing texts, self-directed learning, and revisions, writing academic essays, paraphrasing contents, academic writing such as writing academic essays, paraphrasing contents, and crafting the paragraphs. For instance, one participant highlighted, " I find ChatGPT particularly useful, especially in assignments where it provides comprehensive information on given topics. Additionally, I employ ChatGPT for research on different subjects assigned by our lecturers" (P2). Another study participant (P14) said, "All right, the activities where I deploy ChatGPT include assignments, academic research, searching for definitions of key terms, and summarizing extensive texts that are integral to my academic learning”.

Another participant emphasized ChatGPT’s utility in thesis writing: "My primary use of ChatGPT revolves around academic writing, class assignments, and ongoing research, including its current application in my thesis. Thank you"(P22).

In addition to academic tasks, many students highlighted ChatGPT’s role in personal professional development. These activities included writing letters, grant applications and job application such as writing the curriculum vitae, writing personal statements and cover letters. One student remarked, “It is also instrumental in various types of writing, including letters, curriculum vitae, and more (P19). Another added, “………, and in writing applications, curriculum vitae, and other documents“ (P26)

Moreover, a few participants noted using ChatGPT for extracurricular activities, such as writing projects, developing and formulating topics, writing a speech and public announcement, and visual-related tasks such as design. “……It serves as a valuable tool for learning various tasks such as letter writing and design……” said one student (P3). Another participant pointed out, “It performs well in drafting new concepts, such as letters, curriculum vitae, speeches, and announcements, when provided commands are clear and precise”(P27).

Table 3

Frequency of Academic Tasks Students Use ChatGPT
Academic Tasks for which students use ChatGPT		Subcategories
Name	Frequency	Name	Frequency
Class Related Tasks	30/30
		Doing Class Assignment	25/30
		Literature Review	23/30
		Defining Key Terms	8/30
		Summarizing the texts	7/30
		Self-directed learning and revisions	6/30
		Writing academic essays	5/30
		Paraphrasing contents	4/30
		Academic Writing	5/30
Personal Professional Use	16/30
		Writing letters	9/30
		Grant writing and applications	4/30
		Job application	3/30
Extracurricular Activities	6/30
		Writing Projects	3/30
		Developing and Formulating Topics	1/30
		Writing Speeches and public announcements	2/30
Visual Related Activity	1/30
		Creating Designs	1/30

3.3 Academic Tasks for which Students Judge ChatGPT to Perform Excellently

Students generally judged ChatGPT to perform excellently in class-related tasks, particularly in literature review, defining key terms, completing assignments, summarizing texts, and academic writing. One participant observed, " ChatGPT shines in tasks such as setting patient outcome goals for assignments and facilitating brainstorming sessions for ideas in both assignments and research" (P14).

The utility of ChatGPT extended to academic writing, as one student shared, “I've observed that ChatGPT is exceptionally effective in summarizing texts, writing essays paraphrasing content, and aiding in the completion of my assignments (P9). Another student praised ChatGPT's versatility, stating, "ChatGPT best performance revolves around academic writing, class assignments, and ongoing research, including its current application in my thesis" (P22).

ChatGPT was also valued for professional development tasks, particularly in writing letters, personal statements, and curriculum vitae. As one participant stated, "As mentioned earlier, ChatGPT excels in text generation, particularly in crafting text for letters and generating content for various ideas. It proves especially valuable in composing personal statements and essays"(P1). However, its performance in extracurricular activities, such as writing speeches and public announcements, was noted to be less prominent. Only one participant commented, “It performs well in drafting new concepts, such as letters, curriculum vitae, speeches, and announcements, when provided the commands are clear and precise”(P27).

Table 4

Frequency of academic tasks for which students judge ChatGPT to perform excellently
Academic Tasks ChatGPT Perform Excellently		Subcategories
Name	Frequency	Name	Frequency
Class Related Tasks	30/30
		Literature Review	15/30
		Doing Class Assignment	14/30
		Summarizing the texts and articles	4/30
		Defining Key Terms	3/30
		Academic Writing	2/30
		Writing academic essays	2/30
		Self-directed learning and revisions	1/30
		Paraphrasing contents	1/30
		Creating and generating content	1/30
Personal Professional Use	5/30
		Writing letters	3/30
		Writing the Curriculum Vitae	1/30
		Writing Personal Statements and Cover Letters	1/30
Extracurricular Activities	2/30
		Writing Speeches	1/30
		Writing Public Announcements	1/30

3.4. Academic Tasks for which Students Judge ChatGPT to Perform Poorly

While ChatGPT was praised for its effectiveness in many areas, students also highlighted several tasks where its performance was suboptimal, particularly in literature reviews and writing academic essays. One participant explained, "In the context of research, ChatGPT falls short as it does not supply references for the provided information, hindering its effectiveness in producing well-supported academic work" (P10) Another student noted, "In the context of generating academic essays, ChatGPT's performance is suboptimal. It occasionally produces vague and irrelevant information that does not align with the intended request" (P14).

Additionally, about a third of the respondents identified limitations in scientific computing and data visualization tasks such as generating and analyzing visual images, audio, and tables in addition to calculations and balancing equations. One participant remarked "ChatGPT primarily offers written information but it lacks the capability to provide statistical images or additional visual data” (P7). Another student highlighted the tool's limitations in medical imaging, noting, "ChatGPT may not be very useful in tasks involving questions with accompanying images, such as those in medical imaging like chest x-rays. Analyzing visual content is an area where ChatGPT demonstrates limitations"(P4).

Another student added “…ChatGPT is not very proficient in handling calculations and balancing chemical reactions.”-P30

Only one respondent mentioned that ChatGPT exhibited limitations in patient treatment, specifically in presenting and analyzing clinical cases. This student stated, “when presented with clinical cases, ChatGPT may offer varied responses to the same question, raising concerns about its consistency” (P1).

Table 4

Frequency of academic tasks for which students judge ChatGPT to perform poorly
Academic Tasks ChatGPT perform poorly		Subcategories
Name	Frequency	Name	Frequency
Class Related Tasks	16/30
		Literature Review	15/30
		Writing Academic Essay	1/30
Scientific Computing and Data Visualization Tasks	10/30
		Generating and analyzing visual images, audio, and tables.	9/30
		Calculations and balancing equations	4/30
Patient Treatment	1/30
		Presenting and analyzing clinical cases	1/30

3.5. Perceived Benefits of Using ChatGPT

Participants widely acknowledged the significant impact of ChatGPT in boosting student productivity, particularly due to its rapidity, time-saving capabilities, and effectiveness in simplifying various tasks. One participant noted, "Advantages associated with the use of ChatGPT include time savings, quick answers, and the generation of easily understandable content. It also fosters deeper thinking by providing substantial information, prompting thoughtful consideration in the decision-making process" (P15). Similarly, other participants explained “ChatGPT provides specific answers to prompts in a very short period, accompanied by a substantial amount of data.” (P12).

Another participant highlighted, “One advantage of ChatGPT is its rapid delivery of text, enabling users to find information quickly”(P1). This efficiency was echoed by another student who shared, “In my studies using ChatGPT, learning becomes more efficient as it significantly reduces the time spent on studying. It proves useful for learning straightforwardly” (P3)

Many respondents also noted ChatGPT’s role in enhancing their skills and knowledge, with one participant stating, "The advantages of ChatGPT include the rapid development of skills, particularly in professional learning. It facilitates easy searching and knowledge acquisition about diseases, leading to skill enhancement" (P8). Another participant added, “ChatGPT offers advantages in terms of easy searching and providing a wealth of information within a short time, making it a fast and fitting resource” (P13). This underscores the pivotal role of ChatGPT in the students’ perception of optimizing their academic performance and workflow.

Students also highlighted ChatGPT's role in enhancing their skills and knowledge. “The advantages of using ChatGPT include the rapid provision of information, simplifying work, and speeding up research” (P14). Additionally, some respondents appreciated its 24/7 accessibility and ease of use, making it a valuable tool for academic purposes. "The advantages of ChatGPT include providing information quickly, delivering understandable content, and offering an easy way to interpret information" the respondent reported (P5).

Table 5

Frequency of Perceived Advantages of Using ChatGPT
Perceived Advantages of Using ChatGPT		Subcategories
Name	Frequency	Name	Frequency
Boosting Students‘ Productivity	30/30
Skills and Knowledge Enhancement	27/30
		Contribute to the increase of academic knowledge and skills	7/30
		Provides plentiful information	5/30
		Provides accurate and relevant information	5/30
		Provides easy understandable and interpretable information	5/30
		Provides specific answers	3/30
		Provides rich content	2/30
24/7 Accessibility and Ease of Use	7/30
		Easy to access the information for academic purposes	2/30
		ChatGPT is assessable and cost-effective	2/30
		Easy to learn and use	2/30
		User-friendly	1/30

3.6. Perceived Risks of Using ChatGPT

Participants also expressed concerns regarding the risks associated with using ChatGPT, particularly the potential for overreliance and negative learning habits. One participant remarked, "There is a risk of overreliance on ChatGPT for assignments, potentially leading to a decline in critical thinking and learning. Copy-pasting content without verifying sources may contribute to plagiarism”(P4). Another participant echoed this concern, stating, “… If not used to acquire new knowledge, but merely for completing assignments, it fosters laziness and weakens overall learning efforts…..”(P5).

More than half of the respondents expressed concerns about the negative impact of ChatGPT on learning, particularly in reducing students’ critical thinking and creativity. One participant shared, “Relying extensively on ChatGPT for various tasks may lead to decreased creativity and critical thinking as individuals opt for the convenience of the tool over engaging in active learning”(P12). Another added, “Instead of engaging their critical thinking, there's a risk of automatic reliance on ChatGPT for answers, potentially hindering independent thought processes” (P17).

Participants also raised concerns about the reliability and accuracy of information generated by ChatGPT, noting where it provided fake references, biased information, outdated data, and inconsistent responses. “….These include the generation of fake references, fostering laziness and weakness in conducting academic research due to reduced reading, potential bias in generated information, and the occasional production of incorrect answers to prompts,” explained one participant (P13). Another highlighted the tool's limitations, stating, “ChatGPT has limitations in data access, with feedback only available up to 2021, raising concerns about its relevance to current advancements, research, and innovations” (P1)

Concerns related to academic integrity and ethical issues were also raised, with some participants worrying about the potential for plagiarism due to ChatGPT's lack of source attribution. One participant noted, “….This lack of source attribution can lead to uncertainties about the accuracy of the information, and in cases where reference is needed, the absence of proper citations may expose users to accusations of plagiarism” (P10).

Table 5

Frequency of Perceived Risks of Using ChatGPT
Perceived Risks of Using ChatGPT		Subcategories
Name	Frequency	Name	Frequency
Overreliance and Negative Learning Habits	24/30
		Students will become dependent on ChatGPT	12/30
		Promotes laziness and weakness	8/30
		Students will rely on ChatGPT as a single source of information	4/30
Negative Impact on Learning	17/30
		Reduces critical thinking and learning capacity	14/30
		Reduces creativity and innovations	3/30
Reliability and Accuracy Issues.	13/30
		ChatGPT produces fake references	8/30
		ChatGPT introduces bias	2/30
		ChatGPT uses outdated data	2/30
		ChatGPT generates inconsistent responses	1/30
Academic Integrity and Ethical Concerns	4/30
		Concerns around plagiarism	4/30

3.7. Suggestions for Improving ChatGPT

Participants provided valuable suggestions for improving ChatGPT, focusing primarily on enhancing data quality, flexibility and accessibility. Many respondents emphasized the importance of improving the accuracy, relevance, and trustworthiness of the information provided by ChatGPT. “ChatGPT should provide currently updated data and ensure that generated information comes with valid references”, recommended one participant (P13). Another added, “….ChatGPT is updating the information it provides to ensure accuracy, and offering real-time and current information with proper references”(P8).

Several participants suggested that ChatGPT should be more adaptable to diverse academic needs such as generating a variety of content formats and providing user-friendly, easily understandable information. One participant suggested, “..Incorporating features to generate images, videos, and other essential statistics for the given prompt” (P11). Another echoed this sentiment, stating “..Recommending the provision of easily understandable text and the incorporation of image generation capabilities could significantly enhance content comprehension” (P2).

Some participants emphasized the need for establishing policies and providing training for responsible use and integration of ChatGPT in academic settings. “Institutions are encouraged to establish policies supporting, guiding, and regulating AI use, specifically ChatGPT, in healthcare sciences education. This framework ensures responsible and effective utilization of ChatGPT within academic contexts” noted one participant (P5). Another added, “…. Consideration for providing training on the use of generative AI in daily learning activities is also suggested”(P6).

A few respondents also suggested enhancing the accessibility and affordability of ChatGPT, particularly by reducing subscription fees. “considering the subscription fees, institutions could negotiate with ChatGPT developers to secure free access to all versions” suggested one participant (P1)

Table 7

Frequency of Suggestions for Improving ChatGPT
Suggestions for Improving ChatGPT		Subcategories
Name	Frequency	Name	Frequency
Enhancing Data Quality and Trustworthiness	21/30
		Providing references	14/30
		Providing accurate, relevant, and updated data	7/30
Enhancing Flexibility and Adaptability	16/30
		Generating a variety of content formats	11/30
		Generating more information	3/30
		Providing multiple options for answers	1/30
		Providing user-friendly and easily understandable information	1/30
Policy and Training/ Responsible Use and Integration	4/30
		Establishing policies guiding the use of ChatGPT for academic purposes	2/30
		Training the students on the use of artificial intelligence (AI) and ChatGPT	2/30
Enhancing Accessibility and Affordability	3/30
		Reduction of subscription fee	3/30

3.8. Imagined Future Use of ChatGPT in Healthcare

Participants envisioned several future uses for ChatGPT in healthcare, ranging from improving efficiency in patient care to supporting knowledge generation and policy development. “ChatGPT is expected to contribute to keeping us updated rapidly. Its efficient usage simplifies tasks, enabling us to integrate critical thinking into patient care, fostering intellectual growth and quick decision-making” noted one participant (P4).

Another participant highlighted ChatGPT’s potential to provide accurate and timely information, stating, “ChatGPT delivers accurate information quickly, enabling healthcare providers to make interventions promptly. This rapid response is crucial in improving overall healthcare outcomes” (P16).

Some respondents also foresee ChatGPT’s future contribution to supporting knowledge generation, particularly in enhancing the skills and knowledge of healthcare providers. “ChatGPT will help in Rwanda to have the healthcare with deep skills and knowledge being able to give the clients the rationalized feedback” explained one participant (P9). Another added, " As health science students, we anticipate that ChatGPT will enhance our knowledge and skills. It proves beneficial in deciphering complex medical terms by providing examples in its responses, making it easier for us to understand various intricacies.”(P11)

A few respondents suggested that ChatGPT could assist in policy development and implementation by offering diverse strategies and supporting decision-making processes in healthcare settings. “As I mentioned, ChatGPT, being an artificial intelligence system, combines a vast amount of information simultaneously. This capability allows us to offer extensive information for accurate diagnoses and policy formulation in the Ministry of Health. Moreover, ChatGPT can present a variety of strategies to implement formulated policies, providing added value by offering diverse options instead of being confined to a single approach.” explained one participant (P1).

Table 7

Frequency of Imagined Future Use of ChatGPT in Healthcare
Imagined Future Use of ChatGPT in Healthcare		Subcategories
Name	Frequency	Name	Frequency
Assisting in Clinical Decision-Making and Efficiency	23/30
		Rapid and quality patient-centred service delivery	13/30
		Promotion of evidence-based practice and innovation	6/30
		Easy and quick diagnosis support	3/30
		Accurate information for healthcare decision-making	1/30
Supporting knowledge generation enhanced	8/30
		Improvement of healthcare providers' skills and knowledge	8/30
Supporting the policymakers.	2/30
		ChatGPT supports policy formulation and ideas for policy implementation	2/30

The primary objectives of this study were to identify the academic tasks for which Medicine and Health Sciences students at the University of Rwanda use ChatGPT, assess their perceptions of its strengths and weaknesses, understand the perceived benefits and risks of using ChatGPT for academic purposes, and explore students suggestions for improving ChatGPT, as well as its potential future implications in healthcare education.

Our findings indicate that ChatGPT is widely used among students for a variety of academic tasks including class assignments, literature reviews, summarizing text, self-directed learning, and professional development tasks like writing letters, and curriculum vitae. These findings are consistent with studies conducted in other contexts, where ChatGPT has been recognized for its versatility and effectiveness in streamlining academic activities (Al-Worafi, Hermansyah, Tan, et al., 2023b; Dave et al., 2023b; Fauzi et al., 2023; Firaina & Sulisworo, 2023; Hadi Mogavi et al., 2023; Holmes et al., 2023; Hosseini et al., 2023; Kumar et al., 2024; Rahman et al., 2023; Sallam, 2023b; Tsang, 2023b). However, the unique context of the Rwandan education system, particularly in health sciences, presents both challenges and opportunities that distinguish it from similar studies conducted elsewhere.

A key difference between the Rwandan context and studies from more resource-abundant settings is the structural and institutional readiness to integrate AI technologies. What we observed in our study is that students at the University of Rwanda use ChatGPT extensively for completing academic tasks. They are aware of some of the dangers and limitations of using ChatGPT, but this is not stopping them of using this tool. Different from most Global North universities, the University of Rwanda has not put in place policies, guidelines, use of AI detection tools, and other solutions to deal with the changing reality. Also, lecturers have not adapted their teaching practices since the arrival of ChatGPT. As a result, the different tasks and assignments that lectures give to students to contribute to learning outcomes, are now in reality being performed by ChatGPT. We coin the term “AI resilience” to describe the capacity of learning institutions to positively adjust to the increased use of AI technology by students and staff. In this study, we observed that the University of Rwanda does not have high “AI resilience” when following this definition.

Most institutions of High-Income Countries have established policies and support systems to help students and staff adapt to the existence of new AI tools, especially Generative AI models (Chan, 2023; Miao et al., 2021; Saito, 2024). They adapted their curricula and support services to incorporate AI tools like ChatGPT (Focacci & Perez, 2022; Holmes et al., 2023; Miao et al., 2021; Van Noordt et al., 2023). A study conducted in Singapore, for example, noted that structured faculty support and ongoing training were key factors in the successful integration of AI into academic settings (Rasheed, 2020). In contrast, the response from African institutions has often been less proactive toward this disruptive technology, causing significant challenges (Chisom et al., 2023; Hlongwane et al., 2024; “Rethinking the Implementation of Artificial Intelligence for a Sustainable Education in Africa,” 2022). These challenges often do not stem from a lack of resources, as might be expected, but from the absence of proactive institutional strategies and professional habits that facilitate effective technology integration. The issue of institutional response is particularly critical because the students rapidly started to use generative AI in their learning activities, while the learning institutions have not been able to adapt. Similar to findings from studies in other low-resource settings, our participants expressed concerns about over-reliance on AI, and the potential erosion of critical thinking skills; and these concerns were heightened by the perceived lack of institutional guidance in navigating these risks (44–47). However, change is possible. One of the positive outcomes of this study, is that the University of Rwanda is now in the process of establishing an AI Technical Working Group who will formulate new guidelines and policies.

In line with findings from global studies, our participants also noted the potential of ChatGPT to improve healthcare education and clinical practice. In developed regions, AI tools are already being used to support clinical decision-making, assist with patient diagnostics, and streamline administrative tasks (“Artificial Intelligence Applications in Healthcare,” 2023; Maleki Varnosfaderani & Forouzanfar, 2024; Peng et al., 2023). Participants in our study imagined similar applications for ChatGPT in the Rwandan healthcare system but with the added benefit of addressing gaps in healthcare delivery where resources are limited. This underscores the potential for AI to not only improve education but also contribute to more efficient and effective healthcare practices, particularly in under-resourced environments like Rwanda.

Strengths and Limitations

One of the major strengths of this study is its focus on a context that has been underexplored in the literature - namely, the use of AI tools in healthcare education in an African setting. This study provides valuable insights into how students in Rwanda are integrating ChatGPT into their academic routines, offering a perspective that is often missing in global discussions on AI in education. Additionally, the study’s qualitative design allowed for in-depth exploration of students’ experiences, providing rich data that contribute to a nuanced understanding of the benefits and challenges associated with ChatGPT use.

However, the study also has several limitations that need to be considered. First, the sample was limited to students from a single institution, which may restrict the generalizability of the findings to other universities in Rwanda, or wider East Africa. The limited representation of postgraduate students (Master's and PhD) is another limitation, as their perspectives might differ from those of undergraduate students. Furthermore, the study did not include input from lecturers or administrators, and educational stakeholders, whose perspectives could provide a more comprehensive understanding of the impact of ChatGPT in the academic environment. We also conducted a concurrent quantitative data collection (manuscript in preparation) which will allow us to triangulate these findings.

During International Democracy Day 2024, United Nations Secretary-General Antonio Guterres stated that there is a substantial risk that AI can widen the inequalities in the world, stressing that “Artificial Intelligence must serve humanity equitably and safely”. Our study shows that this might already be happening, as higher education systems in LMIC struggle to adjust their teaching methods to the new reality created by AI. By not being “AI resilient”, the quality of LMIC university education is dropping when compared to HIC higher education. LMIC need to strengthen the 'AI resilience' of their universities and other learning institutions to make sure that the education they offer stays globally competitive.

Author Contribution

E.N. generated the idea and wrote the first proposal, E.N., J.N., and S.J. developed and wrote the manuscript text and J.B.N. participated in qualitative data analysis.

Data Availability

The data that support the findings of this study are not openly available due to reasons of request of some participants, and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at the University of Rwanda, College of Medicine and Health Sciences, Directorate of Research and Innovation.

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No competing interests reported.

Are Low and Middle-Income Country Universities “AI Resilient”: Exploring the Use of ChatGPT among Medicine and Health Sciences Students in Rwanda.

Status:

Version 1

Abstract

1. Introduction

2. Methods