ICT applications as e-health solutions in rural healthcare in the Eastern Cape Province of South Africa.
The potential of ICT for rural communities
Information and Communication Technologies (ICTs) have the
potential to improve the lives of people in rural communities. According
to the United Nations Development Program (United Nations Development
Program 2006, cited in Ruxwana 2009), increased use of ICTs enhances
service delivery by:
* delivering economies of scale to improve access to basic services
* optimising service delivery
* providing incentives for development and transfer of new
technologies and products
* increasing efficiency through enhanced connectivity and exchange
of knowledge
* enabling regions to focus on delivering services where they have
a comparative advantage
* providing access to digital development for continuous
improvement.
ICTs are changing rapidly, as are businesses surrounding their
implementation (Louw & Hanmer 2002). The need to develop and
organise new ways to provide efficient healthcare services has thus been
accompanied by major technological advances, resulting in a dramatic
increase in the use of ICT applications in healthcare and e-health.
e-Health
Integration and assimilation of e-health into the everyday life of
healthcare workers is becoming a reality in developing as well as
developed countries (World Health Organisation 2004). ICTs enable online
communication about medical issues and diagnosis of complicated diseases
by linking medical practitioners who are separated geographically. They
have the potential to change the delivery of healthcare services and
patient care, as well as the management of healthcare systems. According
to Eysenbach (2001), e-health is an emerging field in the intersection
of medical informatics, public health and business, with referral and
information delivery enhanced through the Internet and related
technologies. In a broader sense, the term characterises not only a
technical development, but also a state-of-mind, a way of thinking, an
attitude, and a commitment for networked, global thinking to improve
healthcare locally, regionally and worldwide by using information and
communication technologies. Thus, ICTs are widely perceived to have the
capability, if used effectively, to bridge social and economic gaps that
divide rural and urban communities (Gurstein 2000, 2005), improving
access and providing a wider range of health services to enhance the
wellbeing of underprivileged people, such as those in the Eastern Cape
Province of South Africa.
Implementation of ICTs in South Africa
The Presidential National Commission (PNC) on Information Society
and Development (2006) states that ICT applications such as e-health are
suitable for addressing the digital divide between rural and urban
populations, including rich and poor, young and old, males and females,
and unequal distribution of health professionals, particularly in
specialist healthcare. Computerised health information systems can
improve treatment of patients, management of health institutions, and
provide up-to-date information for policy and decision making. The PNC
defines e-health as the combined utilisation of electronic communication
and information technology to generate, transmit, store and retrieve
digital data for clinical, educational and administrative purposes
(Presidential National Commission on Information Society and Development
2006).
According to the Municipal Demarcation Board (2007), the Eastern
Cape Province is generally regarded as one of the poorer provinces in
the country, even though it has played a significant historical role. It
consists of six district municipalities and 38 local municipalities. The
vision of the Department of Economic Development and Environmental
Affairs in the Eastern Cape Province states that:
... the province strives to be devoid of the inequalities of the
past, to be unified through an integrated and sustainable, economic,
social and cultural development; and thus to provide an acceptable
quality of life for its entire people in the context of a united,
non-racial, non-sexist and democratic South Africa (Eastern Cape
Province 2007:3).
In contrast, Thom (2007) states that this province is known as
'home to the poorest districts in the country'. Similarly, the
Eastern Cape Department of Health (2006) is committed to attracting
appropriately qualified employees to areas of service delivery with
greatest need, to retaining good employees through a program of
compensation and personal development in order to sustain quality
healthcare, and to implementing e-health solutions through telemedicine
programs that support education, training and academic services. In
spite of these efforts, the Eastern Cape health system has continued to
be plagued by challenges such as staff shortages, poor management and
weak primary care, coupled with high levels of poverty and
unsatisfactory access to basic services such as piped water (Thom 2007).
The research problem
Although there are many ICT solutions available (e.g. electronic
health records (EHR), hospital information systems, district health
information systems, telemedicine, patient portals, OpenMRS [Hanseth
& Aanestad 2003]), they are neither well-known nor much used in
developing rural areas in South Africa. One possible explanation for
this anomaly is the limited availability of suitable technologies.
According to Herselman and Jacobs (2003), the development of the local
economy in rural South Africa, and Africa in general, is severely
compromised by lack of infrastructure, services and expertise. This is
especially the case for enabling technologies in the information and
communication technology arena.
Although it is generally accepted that ICTs have the potential to
promote rural development in a number of ways, most scholars believe
that the mere presence of ICTs, although vital, is not enough to realise
development (Heeks 2002; Herselman & Jacobs 2003; Littlejohns, Wyatt
& Garvican 2003; Olugbara et al 2006; Uys 2006). What is needed is
the effective use of ICTs in rural developmental interventions (Gurstein
2005), and attention to prerequisite variables that facilitate this.
Mansell and Wehn (1998) suggest prerequisites include access to ICTs, a
variety of ICT-related skills (for producing and using ICTs and ICT
services), and an appropriate policy framework. Conradie and Jacobs
(2003) mention access to a supporting communication infrastructure that
can serve as a link to relevant networks such as the Internet, while van
Audenhove (2001) adds an appropriate 'infostructure' system
that can provide suitable content and applications via the ICTs.
Another approach is to consider individual psychological variables
that might underlie technology acceptance and use. According to the
Technology Acceptance Model (TAM) (Davis 1989, 1993) and the Unified
Theory of Acceptance and Use of Technology (UTAUT) (Venkatesh et al.
2003), two variables impact on the decision to actually use available
ICTs: the Perceived Usefulness (PU) of that technology and the Perceived
Ease of Use (PEU). PU can be described as the extent to which a person
believes that using a particular technology will meet that person's
need(s) or enhance job performance. Thus, PU is largely to do with
perceived benefits of using the technology and it is possible that some
of the above-mentioned prerequisites for effective ICT use might also be
perceived to be such benefits. Availability of useful information (the
content of an ICT application) could heighten its perceived usefulness,
as could a supportive policy framework. The PEU variable describes the
extent to which a person believes that using a particular technology
will be free of effort. Even a useful technology application may not be
used if users perceive it too complicated to use or that performance
benefits of usage are outweighed by the effort involved (Davis, Bagozzi
& Warshaw 1989; Sandberg & Wahlberg 2006). PEU has to do with
perceived barriers to using the technology; it is also affected by
variables relating to levels of ICT access, access to supporting
communication infrastructures and the Internet, and ICT-related skills.
There are many barriers to the implementation of e-health solutions
that cause delays or hinder its use. The Commission of the European
Communities (2004) stated that healthcare systems around the world are
faced with major challenges, although their nature and scale differ
between developed and developing countries. The challenges and setbacks
facing implementation of e-health in rural areas of South Africa are the
focus of the present study and warrant further detailing here.
Challenges facing adoption of e-health solutions in South Africa
The South African health sector faces many challenges, such as
epidemics, historical issues, and factors that impact directly on the
digital divide between developed and developing countries. Rural
communities in particular are compromised by lack of infrastructure,
services and expertise, limited resources, low literacy levels and
professional isolation (Herselman & Jacobs 2003; Littlejohns Wyatt
& Garvican 2003; Olugbara et al. 2006; Uys 2006). Adoption and
implementation of e-health solutions is often delayed when underlying
problems are not resolved. For instance:
* According to IT-Online (2007), the four fundamentals of e-health
solutions are improved access to healthcare, improved quality of care,
illness prevention and health promotion, and better efficiency (i.e.
better healthcare for the same or lower costs). However, the healthcare
sector does not fully benefit from these fundamentals due to delays in
reaching agreement on best practice and processes. In South Africa,
there appears to be no uniform healthcare approach, let alone a system
that can be truly proffered as a proven template for reform that enables
by means of technology. Yet the recognised benefits of reform and
automation go hand-in-hand.
* The lack of standardisation and integration between health
information systems are major barriers to the full realisation of the
benefits of e-health solutions. When systems are integrated and there is
a standard way of keeping and updating patient records, only one entry
is necessary for each patient. Thus, duplication of diagnosis and
patient history is avoided, medical errors reduced and costs saved.
* Further challenges in providing access to healthcare services are
due to geographic distribution, as much of the population resides in
rural areas. One way to keep information in one place is to implement a
card system. A 'smartcard' can be read electronically when a
patient goes to a hospital or clinic (IT-Online 2007).
* ICT infrastructure across the country needs to be improved in
order to support not only transfer of information across the country,
but also a successful e-health solution such as EHR. Some rural
hospitals have little or no access to technological resources, a major
barrier to implementing solutions (Jacobs 2003).
* Establishing a unique patient identifier is another challenge. In
rural areas, some adults and children do not have ID documents, while
those that do might not have ready access to their ID documents when
hospitalised. Moreover, some people have the same names. Date of birth
can also be problematic, as many of the rural aged population have no
idea of their birth date, but know instead that they were born, for
example, 'on the day of rain'. Identifying the right person
quickly when searching for medical information is essential if the
system is to be trusted by those who use it. IT-Online (2007) believes
the right search mechanism, which is fast and accurate, should be built
into the solutions.
In addition to these inherent problems, shortcomings in the
knowledge and the skills of patients and health professionals to use ICT
solutions represent other challenges. Even when implemented, the
benefits of ICT cannot be realised if people are unable to use it. One
challenge is to train people in the use of ICT solutions so they can
improve their health or quality of service. However, there are other
challenges that also need to be addressed before e-health solutions can
be implemented in rural areas in South Africa.
The present study
The present paper focuses on factors perceived to impinge on
effective use of ICTs as e-health solutions in a Province of South
Africa. The aim of the study was to better understand how ICTs can be
used more effectively to improve the health system in a selected number
of rural Eastern Cape healthcare centres and to make recommendations for
their implementation.
The following general question and sub-questions were posed:
What factors influence effective use of ICTs as e-health solutions
in specified healthcare centres?
* Sub-question 1: What technologies are currently in place that can
support e-health solutions?
* Sub-question 2: What is the level of access to computer equipment
at healthcare centres?
* Sub-question 3: What is the level of access to the Internet at
healthcare centres?
* Sub-question 4: What are the perceived benefits of ICT
applications in rural healthcare centres?
* Sub-question 5: What are the perceived barriers to ICT
applications in rural healthcare centres?
Methodology
Methodological approach and measures
A multiple-case study methodology was applied. This is a type of
qualitative research design whereby the researcher investigates a chain
of single entities, phenomena or cases confined by time and activity and
collects detailed information by using a variety of data collection
procedures during a sustained period of time (Creswell 2003:12).
According to Yin (2002), a case study of this nature is an empirical
investigation of an existing event within its environment. It is mainly
used when the boundaries between the event and its environment are not
clearly evident. Several means can be applied to collect data using this
approach (e.g. interviews, surveys, document analysis, observation,
focus groups, questionnaires [Cooper & Schindler 2003]). It allows
specific cases to be studied in greater detail from the viewpoint of the
participant by using multiple sources of data (Feagin, Orum &
Sjoberg 1991). For the present purposes, questionnaire items and
interviews were formulated in accordance with the sub-questions of this
study to yield information about the perceptions of the participants on
the following matters:
* the different types of ICTs currently available at the healthcare
centres
* the current access to computer equipment at the healthcare
centres
* the current access to the Internet a the healthcare centres
* the benefits that ICT applications can bring to healthcare
services and communities in the rural healthcare centres, and
* the perceived barriers for ICT applications in rural healthcare
centres.
[FIGURE 1 OMITTED]
Rural areas and healthcare centres
Five healthcare centres in the Eastern Cape Province were selected
from two of the most underprivileged districts, namely, OR Tambo and
Alfred Nzo districts. The OR Tambo district, with a population of nearly
two million people, is regarded as the poorest district in the country
with virtually only a quarter of residents having access to piped water
(Thom 2007). Similarly, only 40% of residents in Alfred Nzo district
have access to piped water. Health indicators in this district are also
poor, with the tuberculosis cure rate at 36% and the district having
very high and increasing stillbirth and prenatal mortality rates (Thom
2007). Figure 1 contains a map of the Eastern Cape Province in which
these two selected districts have been highlighted.
The five rural healthcare centres that participated in this
research were the Nessie Knight Hospital, the St. Lucy's Hospital,
the Madzikane Ka-Zulu Memorial Hospital, the Nelson Mandela General
Hospital and the Tsilitwa Clinic. Table 1 illustrates their locations.
These centres are difficult to access due to road and transport issues.
Each hospital is the only centre to render healthcare services in its
specific village (except for a few clinics that focus on welfare of
children). Communities have to travel for long distances to get to these
healthcare centres. Issues such as the quality of service, efficiency
and the standard of health care provided, as well as cost reduction in
these healthcare centres, are of vital importance. Thus, these
healthcare centres were selected due to their remoteness; the large
community each has to serve, and the fact that some already have
telemedicine solutions implemented (Eastern Cape Department of Health
2006).
Participants
A total of 56 people were interviewed, 38 of whom had completed a
questionnaire prior to interview. Participants were grouped into three
categories: (a) hospital managers, (b) staff (doctors, nurses and
administration clerks/personnel), and (c) hospital inpatients at the
time of data collection. (Tables 2 and 3 refer).
Sample selection
Care was taken to ensure that each of the three groups contained a
range of people from different backgrounds for both the interview and
the questionnaire. Participants consisted of a mix of youths or
students, elderly people, professional nurses, assistant nurses, clerks,
doctors, matrons and hospital managers. It was hoped that this broad
range of respondents would contribute to the generalisability of the
results.
Survey instruments
For each group, a detailed questionnaire and interview schedule was
drafted. (Summary details of these survey instruments are included in
Appendix A. For the purposes of this publication, only information
relating to responses of direct relevance to the present research
questions has been reported). Managers and staff provided information on
all research questions, while patients' responses generally yielded
data on perceived benefits of and barriers to ICT applications in rural
areas.
* Questionnaires: A total of 38 completed questionnaires were
received: 9 from Madzikane Ka-Zulu Memorial Hospital; 12 from Nelson
Mandela General Hospital; 8 from Nessie Knight Hospital; 7 from St.
Lucy's Hospital and the remaining 2 from the Tsilitwa Clinic. Table
2 indicates the distribution and response rate from each hospital.
* Face-to-face interviews: Table 3 details the number and
distribution of face-to-face interviews conducted by the researcher
(NLR) between January and March, 2007. A total of 56 people were
interviewed in five rural healthcare centres: 12 from Madzikane Ka-Zulu
Memorial Hospital, 12 from Nelson Mandela General Hospital, 11 from
Nessie Knight Hospital, 12 from St. Lucy's Hospital, and 9 from the
Tsilitwa Clinic. Interviews conducted among hospital staff and
administrators were mostly a follow-up to previously administered
questionnaires.
Ethics approval
Ethics approval from the Eastern Cape Department of Health was
obtained before any information was gathered from any of the healthcare
centres concerned.
Results
Responses obtained through questionnaires and interviews are
combined and presented in terms of the light they shed on the five
research sub-questions, the main goal being to identify factors
perceived to influence the use of e-health solutions in specified rural
areas of South Africa.
Sub-question 1: ICTs currently available at the healthcare centres
The purpose of the first sub-question was to investigate the number
and type of ICTs that were available and could support e-health
solutions in each of the healthcare centres. The main findings obtained
by means of the questionnaires completed by the managers of the five
healthcare centres studied are presented in Table 4 (due to security
constraints the exact number could not be disclosed).When questionnaire
data were interpreted in combination with subsequent interview data, the
following details became evident with regard to each hospital:
* Nessie Knight Hospital had telemedicine equipment and Internet
capabilities but there were few computers in the hospital, which would
limit the realisation of any benefits ICTs might offer. This was
illustrated by a respondent: 'The hospital has a few computers that
are only available for telemedicine services, which are out of order due
to unreliable Internet service'.
* Technology levels in St. Lucy's Hospital were slightly
better, but still seen as limited (e.g. 'The hospital has few
computers and unreliable telephone').
* Tsilitwa Clinic had a computer used mostly for telemedicine
services (e.g. 'The computer, digital camera, telephone and
Internet ... are only used for telemedicine services'). These
services were also hampered by unreliable Internet service.
* Madzikane Ka-Zulu Hospital had a larger number of ICTs available
(computers, printers, a Local Area Network (LAN), telemedicine equipment
and a computerised radiology system). However, they were distributed in
such a way that only certain departments could reap benefits (e.g.
'Computers, telemedicine equipment and Internet services are there
in selected departments'). Lack of maintenance and technical
support was seen as a barrier to the effective use of these
technologies.
* Nelson Mandela General Hospital had a relatively wide range of
ICTs and telemedicine equipment (e.g. 'computers and telephone
services'), and had adopted and implemented some technology
solutions, such as a computerised patient administration system.
However, several departments did not have computerised facilities, which
limits the realisation of benefits (e.g. 'The hospital has limited
and unreliable technologies; computers and Internet services are only
available in selected departments').
Sub-question 2: Actual access to computers at the healthcare
centres
A total of 56 participants were interviewed to answer this
question. Although almost all centres had some existing ICTs and
telemedicine services, lack of access to computers by staff and
management was seen as a common problem. For example, in only two of the
five healthcare centres (Madzikane and Tsilitwa) did managers have any
access to a computer, while access level of staff members to computers
was zero at Nessie Knight and only 17% at both St. Luc/ s and Madzikane
healthcare centres. Even at Nelson Mandela General Hospital,
staff's 33% access to computers was considerably lower than access
levels of their patients to computers elsewhere. The seemingly high 50%
level of access at Tsilitwa merely meant that one of the two
participating staff members there could use the clinic's only
computer.
Sub-question 3: Actual access to the Internet at the healthcare
centres
The purpose was to investigate how many participants at healthcare
centres had access to the Internet. Again, 56 participants were
interviewed and answered that there was limited access to Internet
services in the healthcare centres. None of the participants from St.
Lucy's and Nessie Knight Hospitals had Internet access. At hospital
management level, only the manager of Madzikane Ka-Zulu Memorial
Hospital had access. With regard to hospital staff, one person from
Tsilitwa Clinic could access the Internet, and about a sixth of staff at
Madzikane Ka-Zulu and Nelson Mandela healthcare centres. In only one
hospital (Nelson Mandela) did patients have Internet access.
Sub-question 4: Perceived benefits of ICTs in rural healthcare
centres
A total of 25 participants (hospital staff) were asked by means of
questionnaires and interviews to indicate what benefits applications of
ICTs (computers, Internet, telephones) could have for improving
healthcare in rural healthcare centres. Responses indicated that rural
healthcare professionals believed in technology's capability to
provide some resolution to many challenges facing rural healthcare
services. More than 80% of questionnaire respondents (staff working in
five selected rural healthcare centres) believed that ICTs could provide
all six of the following benefits: enhancing quality of rural healthcare
services, reducing costs, eliminating errors, providing a platform for
personal development of hospital staff, speeding up health services, and
making it easier to store and access health-related information.
Patients were also interviewed with regard to possible benefits of
ICTs. Most believed ICTs to be a potentially critical factor for their
wellness. From the patients' viewpoint, ICTs could save time and
travelling costs, could provide timely access to emergency services and
provide telemedicine services and other specialised services in hospital
theatres. The following are some examples of their comments on how ICTs
could help:
* Nelson Mandela General Hospital: 'Technology provides a safe
environment to store information and easier access', and
'Computers save time: we wait in queues as they just check your
name'.
* Madzikane ka-Zulu Memorial Hospital: 'Cellular phones help
to call ambulance or a special car in cases of emergency; ... (better)
than sending someone to go to the hospital or (to) look for a car'.
* Nessie Knight Hospital: 'Technologies help doctors to
diagnose the complex medical cases'.
* Tsilitwa Clinic: 'Telemedicine saves money and time spent on
travelling long distances to doctors, here in Tsilitwa they use computer
and camera to get help from a doctor in East London (a well-resourced
city located about 400km away) about dermatological problems'.
* St Lucy's Hospital: 'Technology saves time, saves life
and reduces the work load to the nurses ... it helps them'.
Sub-question 5: Perceived barriers for using ICT applications
The 25 participating hospital staff members were asked in
questionnaires and during interviews to indicate, from a list of
options, which barriers they felt were preventing them from using ICTs
for e-health purposes. Table 5 shows that all staff members interviewed
believed that a lack of information (i.e. a lack of relevant content for
ICT applications) was a major barrier to using ICT applications as
e-health solutions. ICT and telemedicine equipment was generally
perceived to be old and unreliable. Almost all participants believed
that a lack of computer equipment was still a major barrier to adoption
of e-health solutions. Another perceived barrier was the lack of
computer skills among the staff. Interestingly, nobody considered fear
of computers, or the possibility that ICT applications might disagree
with their working style, as being barriers. Similarly, the cost of ICT
applications was not seen as a problem.
From responses of patients interviewed, it is evident they also
believed the following to be barriers:
* A lack of sufficient ICT equipment, as illustrated by the
following comments: 'There is no technology in rural healthcare
centres.' 'Rural hospitals have no computers used.'
'Technology needs resources such as power, phones and computers,
and those resources are not there or are unreliable in rural healthcare
centres; hence advanced technologies are only in the cities.'
* A lack of ICT-related skills and knowledge among staff (e.g.
'They don't have information about them, including the nurses,
I'm sure there are some who don't know how a computer looks
like here.' 'The rural hospital staff have limited information
about them (technologies) I guess.').
* Unreliable equipment (e.g. 'The unreliable telephone stopped
the telemedicine use in this clinic and now we have to travel for
help.' 'They bring unreliable technologies into rural
healthcare centres.').
* Inadequate maintenance of ICTs ('They [technologies] stay
out of order without support.').
Discussion
The present study has attempted to better understand how ICTs can
be used more effectively to improve the health system in a selected
number of rural Eastern Cape healthcare centres. The main research
question was to determine what factors were perceived to influence
effective use of ICT applications as e-health solutions. Although all
centres had some ICTs or telemedicine services, these were generally
perceived (by hospital staff and patients) to be inadequate. Reasons for
this view included that too few computers available and that ICTs were
unreliable. A second factor investigated was access to computers by
healthcare centre staff and management; a third factor was the access to
Internet. Both of these factors appear to be relevant for adoption of
e-health solutions. Only two of five healthcare managers had access to a
computer, and at most centres remaining staff's lack of access to
computers was seen by them as a problem. Internet access was limited in
all centres studied; only one hospital manager and a small number of
staff had Internet access.
Successful ICT applications in rural areas require investment in
infrastructure on three levels: (a) access to ICTs (Mansell & When
1998); (b) access to supporting communication infrastructure and
networks (Conradie & Jacobs 2003); and (c) a supportive policy
framework. According to Gurstein (2005), the mere presence of and access
to ICTs in rural areas is unlikely to be effective without relevant
ICT-related skills, promotion of relevant content/information for ICT
applications, and a policy framework in which interventions can function
(Mansell & Wehn 1998; van Audenhove 2001).
Results of the present study indicate the following:
* A majority of participating staff perceived their level of
ICT-related skills to be a problem that could hamper application of
e-health solutions.
* All staff believed that lack of information (i.e. lack of
relevant content for ICT applications) was a barrier to e-health
solutions.
* In spite of some positive e-health policies that have resulted in
ICT-related applications (e.g. computerised patient administration
system) at some centres, there were also several indications of e-health
policies perceived as inappropriate (e.g. policies that distributed ICTs
to only certain selected departments and inadequate technical support
and maintenance policies).
In summary, there were factors perceived to make ICTs less
user-friendly, as shown by participants' negative perceptions
regarding certain structural variables (especially staff's lack of
ICT-related skills, lack of access to ICTs and the Internet at
healthcare centres, and the old and unreliable state of computer
equipment). On the positive side, none of the staff had a fear of
computers, and nobody thought ICT applications might disagree with their
working style. Apart from structural variables shown to impact on
e-health solutions, psychological variables that underlie
individuals' technology acceptance and use appear to have a decided
influence. Participating healthcare professionals (and most patients
interviewed) strongly believed (a) in ICTs' potential to provide a
variety of useful benefits in the healthcare centres, and (b) that ICTs
could help resolve some of the challenges facing rural healthcare. These
optimistic expectations were qualified by the respondents' more
negative perceptions relating to certain structural requirements for
effective ICT use, namely: perceived lack of a supportive policy
framework governing the use of ICT applications, as well as perceived
lack of useful information as basic to the content of these
applications.
Conclusion
It is evident that more effective use of ICTs as part of e-health
initiatives at the rural healthcare centres was seen to be distinctly
possible, but only if perceived shortcomings with regard to structural
variables were addressed. Especially relevant was better access to more
e-facilities, more health-related information made available via ICTs,
ongoing ICT skills training programs and policies for improved
technology maintenance and support.
In conclusion, all structural and psychological factors
investigated were seen to impinge to some extent on effective use of ICT
applications as e-health solutions in the rural healthcare centres
involved in the study. Furthermore, there was a distinct interplay
between the various variables, with perceived ICT-related shortcomings
having a negative impact on perceived usefulness and ease-of-use
variables and thus decreasing the likelihood of effective e-health
solutions. This means that to increase effective use of ICTs that form
part of e-health initiatives in the healthcare centres, a vital first
step is to address reported perceived shortcomings. Broad-based
recommendations covering shortcomings common across the various centres
and are that:
* special attention be given to improving basic infrastructure:
hardware, appropriate software and telecommunications
* skills and knowledge development, ICT skills training programs
and policies for technology maintenance and support be
introduced/upgraded.
Fully detailed recommendations specific to the unique situation of
each centre belong in reports to the relevant authorities, rather than
to the present forum. Briefly, these include type and amount of
equipment needed, space and training requirements, water shortages and
catering inadequacies. Having obtained a clear picture of how ICTs can
be used more effectively to improve the healthcare systems in selected
rural Eastern Cape healthcare centres, it is hoped that the findings and
recommendations will in some way contribute to better conditions.
Closely related and equally pertinent issues are being addressed by
research in progress. These issues have to do with quality assurance.
Limited user participation and lack of information about initiatives
appear to be major contributors to e-health project failure in rural
South Africa. There is an urgent need for a quality assurance model that
will aid successful acquisition of e-health solutions in developing
countries.
Appendix A
Edited summary of selected questions/items from survey instruments
(interview schedule, questionnaires) to provide an overview of data
collected for this study (1)
INTERVIEW SCHEDULE:
Summary of questions
* How can ICT be applied in rural hospitals to support E-Health
solutions?
* What basic technologies are currently in place that can support
E-Health solutions?
* Do you have access and use a computer?
* Do you have access to a computer with Internet connection?
* Do you have access and use a telephone?
* Where do you access the computer; home, work or community centre?
* How would you rate your knowledge of computers?
* What ICTs or e-health solutions does the community/ hospital
have?
* How can e-health solutions be applied to improve quality or
service delivery, improve-decision making, and reduce costs of
healthcare in the selected five rural communities?
* How can technology improve the quality of services in this
hospital?
* How can technology reduce cost of services?
* What are the benefits that ICTs (computers, telephones, Internet)
and e-health solutions bring to the rural community?
* What are the barriers for these benefits in your community or
hospital?
QUESTIONNAIRES
Questionnaire for CEO/Managers: summary of items
1 BACKGROUND AND HISTORY TO THE CLINIC/ HOSPITAL:
* Ownership of clinic/hospital (private, provincial, other).
* Type of geographical area (rural, township, informal settlement,
town/city).
* Clinic/hospital contact person(s) details.
* Demographics for management staff, doctors, nurses, interns,
clinic staff (gender, race), and quality of their scientific capacity (
teamwork between groups).
* How many people make use of the clinic/hospital services per day?
* Demographics for clinic/hospital daily patients (age, gender and
race of patient).
* What are the major complaints/diseases of patients
(injury/trauma; surgical; internal/organic; paediatrics;
obstetrics/gynaecology)?
2 LANGUAGES USED IN THE CENTRE:
* Languages used by staff on a daily basis.
* Languages used by patients on a daily basis.
3 SITUATION OF THE CLINIC/HOSPITAL:
* What kind of infrastructure is available to the hospital/ clinic
(transport, access to education, community centres, business/offices,
industry/mining)?
4 HISTORY:
* When was the clinic/hospital established?
* Who started the clinic/hospital?
* Main projects so far (food gardens, aids campaign, inoculation,
prevention).
* Relationship between main projects and main achievements to date
at the clinic/hospital.
5 FACILITIES AND EQUIPMENT:
* Do you have access to a telephone at the clinic/hospital?
* If no, how close is the nearest phone you can use?
* What equipment and facilities does the clinic/hospital have
(desk, chairs; fax; photocopier; computers; printer; modem; computer
network; digital camera; medical library; security; consultation rooms;
beds in wards; beds in ICU; operating theatres/surgery; blood pressure
equipment; ECG; lung function tests; untrasound imaging; x-ray
facilities; blood tests)?
* Specify equipment out of order and period out of order.
* Specify how regularly and which equipment is replaced or
upgraded?
* What kind of equipment is needed?
* What treatment facilities (medicine, surgical facilities) do you
have in your clinic/hospital?
* Which treatments do you normally provide to your patients?
6 SERVICES PROVIDED BY THE CENTRE:
* What are the main services that the clinic/hospital provides to
the community?
* What percentage of your patients belong to a medical aid?
* How frequently do you see the patients after their first visit to
the clinic/hospital?
* What are the typical complaints of patients? Specify the
procedures you follow to address these typical complaints?
* If a doctor makes specific diagnoses, is the hospital able/
equipped to realise the treatment or procedure? (Please specify cases
where this is impossible).
* How is the compliance/obedience of patients addressed?
* What is the general expectancy of your patients in this hospital?
Do some of your patients seek traditional medication? If yes, when, how
often, before coming to you?
* Did the traditional medicine help/work? If yes, in which cases?
* What is your view regarding the combination of traditional and
scientific medicine?
* How often have the following resources been used (phone calls to
other experts; general information at the clinic/ hospital; advice from
other colleagues; referral to other clinics or hospitals)?
7 LINKAGES TO OTHER CENTRES:
* What is your relationship with other clinics or hospitals in the
area? How often do you communicate with other clinics or hospitals
(formal letters; informal meetings; phone; workshops)?
* What are the main topics communicated with other clinics or
hospitals?
8 PROBLEMS:
* What are the main problems that your clinic/hospital has now, or
has had in the past?
9 NEEDS:
* What are the needs of your clinic/hospital currently (training,
advice, equipment, tools)?
10 VISION AND PLANS:
* Do you have any plans or vision for the future of the
clinic/hospital?
11 OTHER INFORMATION:
* Is there anything else you would like to add?
12 E-HEALTH SOLUTIONS:
* How do you think your department could benefit from e-health?
* What do you think the barriers are to your department when making
the most of e-health (.lack of computer equipment; lack of computer
skills; lack of Internet access)?
* How many in your department use the e-health solutions?
* What benefits could e-health bring to the department?
13 E-HEALTH FOR THE COMMUNITY:
* In your own words, please define e-health.
* What is your current view of the reliability, quality, and
validity of e-health technology for healthcare in a rural community?
* In general, do you believe e-health to be effective? Why or why
not?
* How can e-health assist rural communities?
* What services does e-health provide for better health care?
* What benefit does e-health bring to the department and the
community served?
* What solutions does e-health provide?
* When are e-health solutions used?
* Which of these solutions have you used?
* Why is it important to use e-health?
* How often do you use the e-health solutions (daily, weekly,
monthly, seldom, never)?
* For what function do you normally use e-health solutions?
* Could you provide examples of current e-health solutions for
healthcare that you believe to be effective? How do these work? How do
you know they are effective? How are they evaluated?
* How would you go about evaluating the cost-effectiveness and
quality of e-health solutions? Define what you mean by quality in this
context.
* How can ICT be used to improve quality or reduce costs of
services in rural healthcare centres?
Questionnaire for Staff members: Summary of items
1 PERSONAL DETAILS:
* Description of your area (rural, township, informal settlement,
town/city).
* Do you have access to telephone services?
* Do you have access to a computer?
* What connection does it have (broadband, dial-up, without
Internet connection)?
2 DEPARTMENT INFORMATION:
A About department:
* In what field does your department specialise? Please specify.
* How many patients can your department accommodate at a time?
* What treatment facilities (medicine, surgical facilities) do you
have in your department/ward?
* Which treatments do you normally provide to you patients?
* How often do you transfer your patients to other
hospitals/clinics and common reasons
* What are the major complaints/diseases of your patients?
B Facilities & Equipment:
* Do you have access to a telephone at the department/ ward? If no,
how close is the nearest phone you can use?
* What equipment and facilities does the department/ward have?
* Specify equipment out of order and period out of order.
* Specify how regularly equipment (specify type) is replaced or
upgraded?
* What kind of equipment is needed?
C e-Health Solutions:
* What basic technologies are currently in place that can support
e-health solutions?
* How can ICT help improve quality or reduce costs of services in
rural healthcare centres?
* How do you think your department could benefit from e-health?
Please specify.
* What do you think can be the barriers to your department when
making the most of e-health?
* How many people in your department use the e-health solutions?
* What benefits does e-health bring to the department?
3 E-HEALTH FOR THE COMMUNITY:
* In your own words, please define e-health.
* What is your current view of the reliability, quality, and
validity of e-health technology (defined how) for healthcare in rural
community?
* In general, do you believe e-health to be effective? Why or why
not?
* How can e-health assist rural communities?
* What services does e-health provide for better health care?
* What are the benefits e-health brings to the department and the
community served?
* What solutions does e-health provide?
* When are e-health solutions used?
* Which solutions have you used?
* Why is it important to use e-health?
* How often do you use e-health solutions?
* For what function do you normally use e-health solutions?
* Could you provide examples of current e-health solutions for
healthcare that you believe to be effective? How do these work? How do
you know they are effective? How are they evaluated?
* How would you go about evaluating the cost-effectiveness and
quality (defined how) of e-health solutions?
Questionnaire for Patients: Summary of items
1 PERSONAL DETAILS:
* Description of your area (rural, township, informal settlement,
town/city).
* Do you have access to telephone services (home, work, community
centre)?
* Do you have access to a computer (home, work, community centre)?
* What connection does it have (broadband, dial-up, without
Internet connection)?
2 HEALTH INFORMATION:
* How many times do you come to the hospital/clinic in a year?
* How do you usually get to the hospital/clinic (own car, hired
car, public transport, other)?
* How much do you spend getting to the hospital/clinic?
* Is access to public transport to the healthcare centres: hard to
find, average, always available?
* Have you ever been transferred to another hospital/ healthcare
institution for service? If yes, how many times?
* How did you get to there?
* How would you rate the cost involved?
* What was the reason for your transfer?
* Do you have any access to your medical record (limited, average,
no access)?
* How do you gain access to your health information (lab results,
disease information)?
* How do you rate the service provided by the hospital (excellent,
good, average, poor, very bad)?
* Please supply any further comments you wish to make or name any
other issues to do with the healthcare services provided by rural
hospital that you think are important.
3 TECHNOLOGY UNDERSTANDING:
* What is your level of understanding of ICT technologies (very
good, good, average, poor)?
* How do you rate your computer literacy (very good, good, average,
poor)?
* What do you usually do with the computer?
* Is your computer, or the one you usually use, connected to
Internet?
* How much does it cost for you to have an access to ICT
technologies (very expensive, expensive, affordable, cheap)?
* Do you have any understanding of e-health and its solutions? If
yes:
* How do you define e-health?
* What are the benefits it brings for rural communities?
* Which solutions are you familiar with?
* What impact do these solution have on rural communities?
* What are the limitations to these solutions?
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(1) The full survey instrument including interview schedule and
three questionnaires is available from the author upon request.
Corresponding author:
Nkqubela L Ruxwana MTech
Doctoral candidate
Nelson Mandela Metropolitan University
Senior Business Analyst and Part-time Lecturer
Faculty of ICT, Business Informatics Department
Tshwane University of Technology, Pretoria Campus
Staatsartillery Road
Pretoria 0001
SOUTH AFRICA
email: RuxwanaNL@tut.ac.za; Nkqubz@yahoo.co.uk
Marlien E Herselman PhD
Professor and Research Group Leader of Living Labs
Meraka Institute, CSIR
PO Box 395
Pretoria 0001
Adjunct Professor
Nelson Mandela Metropolitan University
PO Box 77000
Port Elizabeth 6031
SOUTH AFRICA
email: mherselman@csir.co.za
D Pieter Conradie PhD
Professor, Research and Innovation
Faculty of Humanities
Tshwane University of Technology, Pretoria Campus
Staatsartillery Road
Pretoria 0001
SOUTH AFRICA
email: ConradieDP@tut.ac.za
Table 1: Hospital locations
DISTRICT VILLAGE/TOWN HOSPITAL
Alfred Nzo Mount Frere Madzikane Ka-Zulu Memorial
Hospital
OR Tambo Mthatha Nelson Mandela General
(former Umtata) Hospital
Qumbu Nessie Knight Hospital
Tsolo St. Lucy's Hospital
Qumbu Tsilitwa Clinic
Table 2: Number and distribution of questionnaires completed
NUMBER OF QUESTIONNAIRES COMPLETED
MADZIKANE
NESSIE KNIGHT ST. LUCY'S TSILITWA KA-ZULU MEMORIAL
CATEGORY HOSPITAL HOSPITAL CLINIC HOSPITAL
Manager 1 1 1 1
Staff 5 6 1 4
Patient 2 0 0 4
Total 8 7 2 9
NUMBER OF QUESTIONNAIRES COMPLETED
NELSON
MANDELA
CATEGORY GENERAL HOSPITAL TOTAL
Manager 1 5
Staff 6 22
Patient 5 11
Total 12 38
Table 3: Number and distribution of interviews conducted
NUMBER OF INTERVIEWS CONDUCTED
MADZIKANE
NESSIE KNIGHT ST. LUCY'S TSILITWA KA-ZULU MEMORIAL
CATEGORY HOSPITAL HOSPITAL CLINIC HOSPITAL
Manager 1 1 2 1
Staff 5 6 2 6
Patient 5 5 5 5
Total 11 12 9 12
NUMBER OF INTERVIEWS CONDUCTED
NELSON
MANDELA
CATEGORY GENERAL HOSPITAL TOTAL
Manager 1 6
Staff 6 25
Patient 5 25
Total 12 56
Table 4: Number and types of ICTs available at the healthcare centres
NESSIE KNIGHT
HOSPITAL ST LUCY'S HOSPITAL
Limited number of Computers, telephone
computers, telephone service for a limited number
services, a photocopier, fax, of users. A fax, printer and
printer and telemedicine photocopier.
equipment with Internet
capabilities.
MADZIKANE KA-ZULU
TSILITWA CLINIC HOSPITAL
A computer, a telephone, a Relatively large number
digital camera and Internet of computers, printers,
services that are only used a Local Area Network
for telemedicine services. (LAN), a fax, photocopier, a
digital camera, and Internet
services in the offices, plus
telemedicine equipment and
a computerized radiology
system.
NELSON MANDELA
ACADEMIC HOSPITAL
The hospital has a wide
range of computers, a
fax, printers, photocopier,
telemedicine equipment
and videoconferencing
services.
Table 5: Perceived barriers for using ICT applications in rural
healthcare centres
HOSPITAL
NESSIE
BARRIERS TSILITWA KNIGHT ST. LUCY'S
Lack computer equipment 100% 100% 100%
Lack computer skills 0% 71% 67%
Lack Internet connection 100% 100% 83%
Old/unreliable equipment 100% 86% 100%
Lack broadband connection 0% 29% 17%
Unsuitable working style 0% 0% 0%
Cost 0% 0% 0%
Fear of computers 0% 0% 0%
Lack of information 100% 100% 100%
HOSPITAL
NELSON
BARRIERS MADZIKANE MANDELA
Lack computer equipment 100% 91%
Lack computer skills 75% 82%
Lack Internet connection 88% 73%
Old/unreliable equipment 75% 64%
Lack broadband connection 0% 9%
Unsuitable working style 0% 0%
Cost 25% 9%
Fear of computers 0% 0%
Lack of information 100% 100%
Information and Communication Technologies (ICTs) have the
potential to improve the lives of people in rural communities. According
to the United Nations Development Program (United Nations Development
Program 2006, cited in Ruxwana 2009), increased use of ICTs enhances
service delivery by:
* delivering economies of scale to improve access to basic services
* optimising service delivery
* providing incentives for development and transfer of new
technologies and products
* increasing efficiency through enhanced connectivity and exchange
of knowledge
* enabling regions to focus on delivering services where they have
a comparative advantage
* providing access to digital development for continuous
improvement.
ICTs are changing rapidly, as are businesses surrounding their
implementation (Louw & Hanmer 2002). The need to develop and
organise new ways to provide efficient healthcare services has thus been
accompanied by major technological advances, resulting in a dramatic
increase in the use of ICT applications in healthcare and e-health.
e-Health
Integration and assimilation of e-health into the everyday life of
healthcare workers is becoming a reality in developing as well as
developed countries (World Health Organisation 2004). ICTs enable online
communication about medical issues and diagnosis of complicated diseases
by linking medical practitioners who are separated geographically. They
have the potential to change the delivery of healthcare services and
patient care, as well as the management of healthcare systems. According
to Eysenbach (2001), e-health is an emerging field in the intersection
of medical informatics, public health and business, with referral and
information delivery enhanced through the Internet and related
technologies. In a broader sense, the term characterises not only a
technical development, but also a state-of-mind, a way of thinking, an
attitude, and a commitment for networked, global thinking to improve
healthcare locally, regionally and worldwide by using information and
communication technologies. Thus, ICTs are widely perceived to have the
capability, if used effectively, to bridge social and economic gaps that
divide rural and urban communities (Gurstein 2000, 2005), improving
access and providing a wider range of health services to enhance the
wellbeing of underprivileged people, such as those in the Eastern Cape
Province of South Africa.
Implementation of ICTs in South Africa
The Presidential National Commission (PNC) on Information Society
and Development (2006) states that ICT applications such as e-health are
suitable for addressing the digital divide between rural and urban
populations, including rich and poor, young and old, males and females,
and unequal distribution of health professionals, particularly in
specialist healthcare. Computerised health information systems can
improve treatment of patients, management of health institutions, and
provide up-to-date information for policy and decision making. The PNC
defines e-health as the combined utilisation of electronic communication
and information technology to generate, transmit, store and retrieve
digital data for clinical, educational and administrative purposes
(Presidential National Commission on Information Society and Development
2006).
According to the Municipal Demarcation Board (2007), the Eastern
Cape Province is generally regarded as one of the poorer provinces in
the country, even though it has played a significant historical role. It
consists of six district municipalities and 38 local municipalities. The
vision of the Department of Economic Development and Environmental
Affairs in the Eastern Cape Province states that:
... the province strives to be devoid of the inequalities of the
past, to be unified through an integrated and sustainable, economic,
social and cultural development; and thus to provide an acceptable
quality of life for its entire people in the context of a united,
non-racial, non-sexist and democratic South Africa (Eastern Cape
Province 2007:3).
In contrast, Thom (2007) states that this province is known as
'home to the poorest districts in the country'. Similarly, the
Eastern Cape Department of Health (2006) is committed to attracting
appropriately qualified employees to areas of service delivery with
greatest need, to retaining good employees through a program of
compensation and personal development in order to sustain quality
healthcare, and to implementing e-health solutions through telemedicine
programs that support education, training and academic services. In
spite of these efforts, the Eastern Cape health system has continued to
be plagued by challenges such as staff shortages, poor management and
weak primary care, coupled with high levels of poverty and
unsatisfactory access to basic services such as piped water (Thom 2007).
The research problem
Although there are many ICT solutions available (e.g. electronic
health records (EHR), hospital information systems, district health
information systems, telemedicine, patient portals, OpenMRS [Hanseth
& Aanestad 2003]), they are neither well-known nor much used in
developing rural areas in South Africa. One possible explanation for
this anomaly is the limited availability of suitable technologies.
According to Herselman and Jacobs (2003), the development of the local
economy in rural South Africa, and Africa in general, is severely
compromised by lack of infrastructure, services and expertise. This is
especially the case for enabling technologies in the information and
communication technology arena.
Although it is generally accepted that ICTs have the potential to
promote rural development in a number of ways, most scholars believe
that the mere presence of ICTs, although vital, is not enough to realise
development (Heeks 2002; Herselman & Jacobs 2003; Littlejohns, Wyatt
& Garvican 2003; Olugbara et al 2006; Uys 2006). What is needed is
the effective use of ICTs in rural developmental interventions (Gurstein
2005), and attention to prerequisite variables that facilitate this.
Mansell and Wehn (1998) suggest prerequisites include access to ICTs, a
variety of ICT-related skills (for producing and using ICTs and ICT
services), and an appropriate policy framework. Conradie and Jacobs
(2003) mention access to a supporting communication infrastructure that
can serve as a link to relevant networks such as the Internet, while van
Audenhove (2001) adds an appropriate 'infostructure' system
that can provide suitable content and applications via the ICTs.
Another approach is to consider individual psychological variables
that might underlie technology acceptance and use. According to the
Technology Acceptance Model (TAM) (Davis 1989, 1993) and the Unified
Theory of Acceptance and Use of Technology (UTAUT) (Venkatesh et al.
2003), two variables impact on the decision to actually use available
ICTs: the Perceived Usefulness (PU) of that technology and the Perceived
Ease of Use (PEU). PU can be described as the extent to which a person
believes that using a particular technology will meet that person's
need(s) or enhance job performance. Thus, PU is largely to do with
perceived benefits of using the technology and it is possible that some
of the above-mentioned prerequisites for effective ICT use might also be
perceived to be such benefits. Availability of useful information (the
content of an ICT application) could heighten its perceived usefulness,
as could a supportive policy framework. The PEU variable describes the
extent to which a person believes that using a particular technology
will be free of effort. Even a useful technology application may not be
used if users perceive it too complicated to use or that performance
benefits of usage are outweighed by the effort involved (Davis, Bagozzi
& Warshaw 1989; Sandberg & Wahlberg 2006). PEU has to do with
perceived barriers to using the technology; it is also affected by
variables relating to levels of ICT access, access to supporting
communication infrastructures and the Internet, and ICT-related skills.
There are many barriers to the implementation of e-health solutions
that cause delays or hinder its use. The Commission of the European
Communities (2004) stated that healthcare systems around the world are
faced with major challenges, although their nature and scale differ
between developed and developing countries. The challenges and setbacks
facing implementation of e-health in rural areas of South Africa are the
focus of the present study and warrant further detailing here.
Challenges facing adoption of e-health solutions in South Africa
The South African health sector faces many challenges, such as
epidemics, historical issues, and factors that impact directly on the
digital divide between developed and developing countries. Rural
communities in particular are compromised by lack of infrastructure,
services and expertise, limited resources, low literacy levels and
professional isolation (Herselman & Jacobs 2003; Littlejohns Wyatt
& Garvican 2003; Olugbara et al. 2006; Uys 2006). Adoption and
implementation of e-health solutions is often delayed when underlying
problems are not resolved. For instance:
* According to IT-Online (2007), the four fundamentals of e-health
solutions are improved access to healthcare, improved quality of care,
illness prevention and health promotion, and better efficiency (i.e.
better healthcare for the same or lower costs). However, the healthcare
sector does not fully benefit from these fundamentals due to delays in
reaching agreement on best practice and processes. In South Africa,
there appears to be no uniform healthcare approach, let alone a system
that can be truly proffered as a proven template for reform that enables
by means of technology. Yet the recognised benefits of reform and
automation go hand-in-hand.
* The lack of standardisation and integration between health
information systems are major barriers to the full realisation of the
benefits of e-health solutions. When systems are integrated and there is
a standard way of keeping and updating patient records, only one entry
is necessary for each patient. Thus, duplication of diagnosis and
patient history is avoided, medical errors reduced and costs saved.
* Further challenges in providing access to healthcare services are
due to geographic distribution, as much of the population resides in
rural areas. One way to keep information in one place is to implement a
card system. A 'smartcard' can be read electronically when a
patient goes to a hospital or clinic (IT-Online 2007).
* ICT infrastructure across the country needs to be improved in
order to support not only transfer of information across the country,
but also a successful e-health solution such as EHR. Some rural
hospitals have little or no access to technological resources, a major
barrier to implementing solutions (Jacobs 2003).
* Establishing a unique patient identifier is another challenge. In
rural areas, some adults and children do not have ID documents, while
those that do might not have ready access to their ID documents when
hospitalised. Moreover, some people have the same names. Date of birth
can also be problematic, as many of the rural aged population have no
idea of their birth date, but know instead that they were born, for
example, 'on the day of rain'. Identifying the right person
quickly when searching for medical information is essential if the
system is to be trusted by those who use it. IT-Online (2007) believes
the right search mechanism, which is fast and accurate, should be built
into the solutions.
In addition to these inherent problems, shortcomings in the
knowledge and the skills of patients and health professionals to use ICT
solutions represent other challenges. Even when implemented, the
benefits of ICT cannot be realised if people are unable to use it. One
challenge is to train people in the use of ICT solutions so they can
improve their health or quality of service. However, there are other
challenges that also need to be addressed before e-health solutions can
be implemented in rural areas in South Africa.
The present study
The present paper focuses on factors perceived to impinge on
effective use of ICTs as e-health solutions in a Province of South
Africa. The aim of the study was to better understand how ICTs can be
used more effectively to improve the health system in a selected number
of rural Eastern Cape healthcare centres and to make recommendations for
their implementation.
The following general question and sub-questions were posed:
What factors influence effective use of ICTs as e-health solutions
in specified healthcare centres?
* Sub-question 1: What technologies are currently in place that can
support e-health solutions?
* Sub-question 2: What is the level of access to computer equipment
at healthcare centres?
* Sub-question 3: What is the level of access to the Internet at
healthcare centres?
* Sub-question 4: What are the perceived benefits of ICT
applications in rural healthcare centres?
* Sub-question 5: What are the perceived barriers to ICT
applications in rural healthcare centres?
Methodology
Methodological approach and measures
A multiple-case study methodology was applied. This is a type of
qualitative research design whereby the researcher investigates a chain
of single entities, phenomena or cases confined by time and activity and
collects detailed information by using a variety of data collection
procedures during a sustained period of time (Creswell 2003:12).
According to Yin (2002), a case study of this nature is an empirical
investigation of an existing event within its environment. It is mainly
used when the boundaries between the event and its environment are not
clearly evident. Several means can be applied to collect data using this
approach (e.g. interviews, surveys, document analysis, observation,
focus groups, questionnaires [Cooper & Schindler 2003]). It allows
specific cases to be studied in greater detail from the viewpoint of the
participant by using multiple sources of data (Feagin, Orum &
Sjoberg 1991). For the present purposes, questionnaire items and
interviews were formulated in accordance with the sub-questions of this
study to yield information about the perceptions of the participants on
the following matters:
* the different types of ICTs currently available at the healthcare
centres
* the current access to computer equipment at the healthcare
centres
* the current access to the Internet a the healthcare centres
* the benefits that ICT applications can bring to healthcare
services and communities in the rural healthcare centres, and
* the perceived barriers for ICT applications in rural healthcare
centres.
[FIGURE 1 OMITTED]
Rural areas and healthcare centres
Five healthcare centres in the Eastern Cape Province were selected
from two of the most underprivileged districts, namely, OR Tambo and
Alfred Nzo districts. The OR Tambo district, with a population of nearly
two million people, is regarded as the poorest district in the country
with virtually only a quarter of residents having access to piped water
(Thom 2007). Similarly, only 40% of residents in Alfred Nzo district
have access to piped water. Health indicators in this district are also
poor, with the tuberculosis cure rate at 36% and the district having
very high and increasing stillbirth and prenatal mortality rates (Thom
2007). Figure 1 contains a map of the Eastern Cape Province in which
these two selected districts have been highlighted.
The five rural healthcare centres that participated in this
research were the Nessie Knight Hospital, the St. Lucy's Hospital,
the Madzikane Ka-Zulu Memorial Hospital, the Nelson Mandela General
Hospital and the Tsilitwa Clinic. Table 1 illustrates their locations.
These centres are difficult to access due to road and transport issues.
Each hospital is the only centre to render healthcare services in its
specific village (except for a few clinics that focus on welfare of
children). Communities have to travel for long distances to get to these
healthcare centres. Issues such as the quality of service, efficiency
and the standard of health care provided, as well as cost reduction in
these healthcare centres, are of vital importance. Thus, these
healthcare centres were selected due to their remoteness; the large
community each has to serve, and the fact that some already have
telemedicine solutions implemented (Eastern Cape Department of Health
2006).
Participants
A total of 56 people were interviewed, 38 of whom had completed a
questionnaire prior to interview. Participants were grouped into three
categories: (a) hospital managers, (b) staff (doctors, nurses and
administration clerks/personnel), and (c) hospital inpatients at the
time of data collection. (Tables 2 and 3 refer).
Sample selection
Care was taken to ensure that each of the three groups contained a
range of people from different backgrounds for both the interview and
the questionnaire. Participants consisted of a mix of youths or
students, elderly people, professional nurses, assistant nurses, clerks,
doctors, matrons and hospital managers. It was hoped that this broad
range of respondents would contribute to the generalisability of the
results.
Survey instruments
For each group, a detailed questionnaire and interview schedule was
drafted. (Summary details of these survey instruments are included in
Appendix A. For the purposes of this publication, only information
relating to responses of direct relevance to the present research
questions has been reported). Managers and staff provided information on
all research questions, while patients' responses generally yielded
data on perceived benefits of and barriers to ICT applications in rural
areas.
* Questionnaires: A total of 38 completed questionnaires were
received: 9 from Madzikane Ka-Zulu Memorial Hospital; 12 from Nelson
Mandela General Hospital; 8 from Nessie Knight Hospital; 7 from St.
Lucy's Hospital and the remaining 2 from the Tsilitwa Clinic. Table
2 indicates the distribution and response rate from each hospital.
* Face-to-face interviews: Table 3 details the number and
distribution of face-to-face interviews conducted by the researcher
(NLR) between January and March, 2007. A total of 56 people were
interviewed in five rural healthcare centres: 12 from Madzikane Ka-Zulu
Memorial Hospital, 12 from Nelson Mandela General Hospital, 11 from
Nessie Knight Hospital, 12 from St. Lucy's Hospital, and 9 from the
Tsilitwa Clinic. Interviews conducted among hospital staff and
administrators were mostly a follow-up to previously administered
questionnaires.
Ethics approval
Ethics approval from the Eastern Cape Department of Health was
obtained before any information was gathered from any of the healthcare
centres concerned.
Results
Responses obtained through questionnaires and interviews are
combined and presented in terms of the light they shed on the five
research sub-questions, the main goal being to identify factors
perceived to influence the use of e-health solutions in specified rural
areas of South Africa.
Sub-question 1: ICTs currently available at the healthcare centres
The purpose of the first sub-question was to investigate the number
and type of ICTs that were available and could support e-health
solutions in each of the healthcare centres. The main findings obtained
by means of the questionnaires completed by the managers of the five
healthcare centres studied are presented in Table 4 (due to security
constraints the exact number could not be disclosed).When questionnaire
data were interpreted in combination with subsequent interview data, the
following details became evident with regard to each hospital:
* Nessie Knight Hospital had telemedicine equipment and Internet
capabilities but there were few computers in the hospital, which would
limit the realisation of any benefits ICTs might offer. This was
illustrated by a respondent: 'The hospital has a few computers that
are only available for telemedicine services, which are out of order due
to unreliable Internet service'.
* Technology levels in St. Lucy's Hospital were slightly
better, but still seen as limited (e.g. 'The hospital has few
computers and unreliable telephone').
* Tsilitwa Clinic had a computer used mostly for telemedicine
services (e.g. 'The computer, digital camera, telephone and
Internet ... are only used for telemedicine services'). These
services were also hampered by unreliable Internet service.
* Madzikane Ka-Zulu Hospital had a larger number of ICTs available
(computers, printers, a Local Area Network (LAN), telemedicine equipment
and a computerised radiology system). However, they were distributed in
such a way that only certain departments could reap benefits (e.g.
'Computers, telemedicine equipment and Internet services are there
in selected departments'). Lack of maintenance and technical
support was seen as a barrier to the effective use of these
technologies.
* Nelson Mandela General Hospital had a relatively wide range of
ICTs and telemedicine equipment (e.g. 'computers and telephone
services'), and had adopted and implemented some technology
solutions, such as a computerised patient administration system.
However, several departments did not have computerised facilities, which
limits the realisation of benefits (e.g. 'The hospital has limited
and unreliable technologies; computers and Internet services are only
available in selected departments').
Sub-question 2: Actual access to computers at the healthcare
centres
A total of 56 participants were interviewed to answer this
question. Although almost all centres had some existing ICTs and
telemedicine services, lack of access to computers by staff and
management was seen as a common problem. For example, in only two of the
five healthcare centres (Madzikane and Tsilitwa) did managers have any
access to a computer, while access level of staff members to computers
was zero at Nessie Knight and only 17% at both St. Luc/ s and Madzikane
healthcare centres. Even at Nelson Mandela General Hospital,
staff's 33% access to computers was considerably lower than access
levels of their patients to computers elsewhere. The seemingly high 50%
level of access at Tsilitwa merely meant that one of the two
participating staff members there could use the clinic's only
computer.
Sub-question 3: Actual access to the Internet at the healthcare
centres
The purpose was to investigate how many participants at healthcare
centres had access to the Internet. Again, 56 participants were
interviewed and answered that there was limited access to Internet
services in the healthcare centres. None of the participants from St.
Lucy's and Nessie Knight Hospitals had Internet access. At hospital
management level, only the manager of Madzikane Ka-Zulu Memorial
Hospital had access. With regard to hospital staff, one person from
Tsilitwa Clinic could access the Internet, and about a sixth of staff at
Madzikane Ka-Zulu and Nelson Mandela healthcare centres. In only one
hospital (Nelson Mandela) did patients have Internet access.
Sub-question 4: Perceived benefits of ICTs in rural healthcare
centres
A total of 25 participants (hospital staff) were asked by means of
questionnaires and interviews to indicate what benefits applications of
ICTs (computers, Internet, telephones) could have for improving
healthcare in rural healthcare centres. Responses indicated that rural
healthcare professionals believed in technology's capability to
provide some resolution to many challenges facing rural healthcare
services. More than 80% of questionnaire respondents (staff working in
five selected rural healthcare centres) believed that ICTs could provide
all six of the following benefits: enhancing quality of rural healthcare
services, reducing costs, eliminating errors, providing a platform for
personal development of hospital staff, speeding up health services, and
making it easier to store and access health-related information.
Patients were also interviewed with regard to possible benefits of
ICTs. Most believed ICTs to be a potentially critical factor for their
wellness. From the patients' viewpoint, ICTs could save time and
travelling costs, could provide timely access to emergency services and
provide telemedicine services and other specialised services in hospital
theatres. The following are some examples of their comments on how ICTs
could help:
* Nelson Mandela General Hospital: 'Technology provides a safe
environment to store information and easier access', and
'Computers save time: we wait in queues as they just check your
name'.
* Madzikane ka-Zulu Memorial Hospital: 'Cellular phones help
to call ambulance or a special car in cases of emergency; ... (better)
than sending someone to go to the hospital or (to) look for a car'.
* Nessie Knight Hospital: 'Technologies help doctors to
diagnose the complex medical cases'.
* Tsilitwa Clinic: 'Telemedicine saves money and time spent on
travelling long distances to doctors, here in Tsilitwa they use computer
and camera to get help from a doctor in East London (a well-resourced
city located about 400km away) about dermatological problems'.
* St Lucy's Hospital: 'Technology saves time, saves life
and reduces the work load to the nurses ... it helps them'.
Sub-question 5: Perceived barriers for using ICT applications
The 25 participating hospital staff members were asked in
questionnaires and during interviews to indicate, from a list of
options, which barriers they felt were preventing them from using ICTs
for e-health purposes. Table 5 shows that all staff members interviewed
believed that a lack of information (i.e. a lack of relevant content for
ICT applications) was a major barrier to using ICT applications as
e-health solutions. ICT and telemedicine equipment was generally
perceived to be old and unreliable. Almost all participants believed
that a lack of computer equipment was still a major barrier to adoption
of e-health solutions. Another perceived barrier was the lack of
computer skills among the staff. Interestingly, nobody considered fear
of computers, or the possibility that ICT applications might disagree
with their working style, as being barriers. Similarly, the cost of ICT
applications was not seen as a problem.
From responses of patients interviewed, it is evident they also
believed the following to be barriers:
* A lack of sufficient ICT equipment, as illustrated by the
following comments: 'There is no technology in rural healthcare
centres.' 'Rural hospitals have no computers used.'
'Technology needs resources such as power, phones and computers,
and those resources are not there or are unreliable in rural healthcare
centres; hence advanced technologies are only in the cities.'
* A lack of ICT-related skills and knowledge among staff (e.g.
'They don't have information about them, including the nurses,
I'm sure there are some who don't know how a computer looks
like here.' 'The rural hospital staff have limited information
about them (technologies) I guess.').
* Unreliable equipment (e.g. 'The unreliable telephone stopped
the telemedicine use in this clinic and now we have to travel for
help.' 'They bring unreliable technologies into rural
healthcare centres.').
* Inadequate maintenance of ICTs ('They [technologies] stay
out of order without support.').
Discussion
The present study has attempted to better understand how ICTs can
be used more effectively to improve the health system in a selected
number of rural Eastern Cape healthcare centres. The main research
question was to determine what factors were perceived to influence
effective use of ICT applications as e-health solutions. Although all
centres had some ICTs or telemedicine services, these were generally
perceived (by hospital staff and patients) to be inadequate. Reasons for
this view included that too few computers available and that ICTs were
unreliable. A second factor investigated was access to computers by
healthcare centre staff and management; a third factor was the access to
Internet. Both of these factors appear to be relevant for adoption of
e-health solutions. Only two of five healthcare managers had access to a
computer, and at most centres remaining staff's lack of access to
computers was seen by them as a problem. Internet access was limited in
all centres studied; only one hospital manager and a small number of
staff had Internet access.
Successful ICT applications in rural areas require investment in
infrastructure on three levels: (a) access to ICTs (Mansell & When
1998); (b) access to supporting communication infrastructure and
networks (Conradie & Jacobs 2003); and (c) a supportive policy
framework. According to Gurstein (2005), the mere presence of and access
to ICTs in rural areas is unlikely to be effective without relevant
ICT-related skills, promotion of relevant content/information for ICT
applications, and a policy framework in which interventions can function
(Mansell & Wehn 1998; van Audenhove 2001).
Results of the present study indicate the following:
* A majority of participating staff perceived their level of
ICT-related skills to be a problem that could hamper application of
e-health solutions.
* All staff believed that lack of information (i.e. lack of
relevant content for ICT applications) was a barrier to e-health
solutions.
* In spite of some positive e-health policies that have resulted in
ICT-related applications (e.g. computerised patient administration
system) at some centres, there were also several indications of e-health
policies perceived as inappropriate (e.g. policies that distributed ICTs
to only certain selected departments and inadequate technical support
and maintenance policies).
In summary, there were factors perceived to make ICTs less
user-friendly, as shown by participants' negative perceptions
regarding certain structural variables (especially staff's lack of
ICT-related skills, lack of access to ICTs and the Internet at
healthcare centres, and the old and unreliable state of computer
equipment). On the positive side, none of the staff had a fear of
computers, and nobody thought ICT applications might disagree with their
working style. Apart from structural variables shown to impact on
e-health solutions, psychological variables that underlie
individuals' technology acceptance and use appear to have a decided
influence. Participating healthcare professionals (and most patients
interviewed) strongly believed (a) in ICTs' potential to provide a
variety of useful benefits in the healthcare centres, and (b) that ICTs
could help resolve some of the challenges facing rural healthcare. These
optimistic expectations were qualified by the respondents' more
negative perceptions relating to certain structural requirements for
effective ICT use, namely: perceived lack of a supportive policy
framework governing the use of ICT applications, as well as perceived
lack of useful information as basic to the content of these
applications.
Conclusion
It is evident that more effective use of ICTs as part of e-health
initiatives at the rural healthcare centres was seen to be distinctly
possible, but only if perceived shortcomings with regard to structural
variables were addressed. Especially relevant was better access to more
e-facilities, more health-related information made available via ICTs,
ongoing ICT skills training programs and policies for improved
technology maintenance and support.
In conclusion, all structural and psychological factors
investigated were seen to impinge to some extent on effective use of ICT
applications as e-health solutions in the rural healthcare centres
involved in the study. Furthermore, there was a distinct interplay
between the various variables, with perceived ICT-related shortcomings
having a negative impact on perceived usefulness and ease-of-use
variables and thus decreasing the likelihood of effective e-health
solutions. This means that to increase effective use of ICTs that form
part of e-health initiatives in the healthcare centres, a vital first
step is to address reported perceived shortcomings. Broad-based
recommendations covering shortcomings common across the various centres
and are that:
* special attention be given to improving basic infrastructure:
hardware, appropriate software and telecommunications
* skills and knowledge development, ICT skills training programs
and policies for technology maintenance and support be
introduced/upgraded.
Fully detailed recommendations specific to the unique situation of
each centre belong in reports to the relevant authorities, rather than
to the present forum. Briefly, these include type and amount of
equipment needed, space and training requirements, water shortages and
catering inadequacies. Having obtained a clear picture of how ICTs can
be used more effectively to improve the healthcare systems in selected
rural Eastern Cape healthcare centres, it is hoped that the findings and
recommendations will in some way contribute to better conditions.
Closely related and equally pertinent issues are being addressed by
research in progress. These issues have to do with quality assurance.
Limited user participation and lack of information about initiatives
appear to be major contributors to e-health project failure in rural
South Africa. There is an urgent need for a quality assurance model that
will aid successful acquisition of e-health solutions in developing
countries.
Appendix A
Edited summary of selected questions/items from survey instruments
(interview schedule, questionnaires) to provide an overview of data
collected for this study (1)
INTERVIEW SCHEDULE:
Summary of questions
* How can ICT be applied in rural hospitals to support E-Health
solutions?
* What basic technologies are currently in place that can support
E-Health solutions?
* Do you have access and use a computer?
* Do you have access to a computer with Internet connection?
* Do you have access and use a telephone?
* Where do you access the computer; home, work or community centre?
* How would you rate your knowledge of computers?
* What ICTs or e-health solutions does the community/ hospital
have?
* How can e-health solutions be applied to improve quality or
service delivery, improve-decision making, and reduce costs of
healthcare in the selected five rural communities?
* How can technology improve the quality of services in this
hospital?
* How can technology reduce cost of services?
* What are the benefits that ICTs (computers, telephones, Internet)
and e-health solutions bring to the rural community?
* What are the barriers for these benefits in your community or
hospital?
QUESTIONNAIRES
Questionnaire for CEO/Managers: summary of items
1 BACKGROUND AND HISTORY TO THE CLINIC/ HOSPITAL:
* Ownership of clinic/hospital (private, provincial, other).
* Type of geographical area (rural, township, informal settlement,
town/city).
* Clinic/hospital contact person(s) details.
* Demographics for management staff, doctors, nurses, interns,
clinic staff (gender, race), and quality of their scientific capacity (
teamwork between groups).
* How many people make use of the clinic/hospital services per day?
* Demographics for clinic/hospital daily patients (age, gender and
race of patient).
* What are the major complaints/diseases of patients
(injury/trauma; surgical; internal/organic; paediatrics;
obstetrics/gynaecology)?
2 LANGUAGES USED IN THE CENTRE:
* Languages used by staff on a daily basis.
* Languages used by patients on a daily basis.
3 SITUATION OF THE CLINIC/HOSPITAL:
* What kind of infrastructure is available to the hospital/ clinic
(transport, access to education, community centres, business/offices,
industry/mining)?
4 HISTORY:
* When was the clinic/hospital established?
* Who started the clinic/hospital?
* Main projects so far (food gardens, aids campaign, inoculation,
prevention).
* Relationship between main projects and main achievements to date
at the clinic/hospital.
5 FACILITIES AND EQUIPMENT:
* Do you have access to a telephone at the clinic/hospital?
* If no, how close is the nearest phone you can use?
* What equipment and facilities does the clinic/hospital have
(desk, chairs; fax; photocopier; computers; printer; modem; computer
network; digital camera; medical library; security; consultation rooms;
beds in wards; beds in ICU; operating theatres/surgery; blood pressure
equipment; ECG; lung function tests; untrasound imaging; x-ray
facilities; blood tests)?
* Specify equipment out of order and period out of order.
* Specify how regularly and which equipment is replaced or
upgraded?
* What kind of equipment is needed?
* What treatment facilities (medicine, surgical facilities) do you
have in your clinic/hospital?
* Which treatments do you normally provide to your patients?
6 SERVICES PROVIDED BY THE CENTRE:
* What are the main services that the clinic/hospital provides to
the community?
* What percentage of your patients belong to a medical aid?
* How frequently do you see the patients after their first visit to
the clinic/hospital?
* What are the typical complaints of patients? Specify the
procedures you follow to address these typical complaints?
* If a doctor makes specific diagnoses, is the hospital able/
equipped to realise the treatment or procedure? (Please specify cases
where this is impossible).
* How is the compliance/obedience of patients addressed?
* What is the general expectancy of your patients in this hospital?
Do some of your patients seek traditional medication? If yes, when, how
often, before coming to you?
* Did the traditional medicine help/work? If yes, in which cases?
* What is your view regarding the combination of traditional and
scientific medicine?
* How often have the following resources been used (phone calls to
other experts; general information at the clinic/ hospital; advice from
other colleagues; referral to other clinics or hospitals)?
7 LINKAGES TO OTHER CENTRES:
* What is your relationship with other clinics or hospitals in the
area? How often do you communicate with other clinics or hospitals
(formal letters; informal meetings; phone; workshops)?
* What are the main topics communicated with other clinics or
hospitals?
8 PROBLEMS:
* What are the main problems that your clinic/hospital has now, or
has had in the past?
9 NEEDS:
* What are the needs of your clinic/hospital currently (training,
advice, equipment, tools)?
10 VISION AND PLANS:
* Do you have any plans or vision for the future of the
clinic/hospital?
11 OTHER INFORMATION:
* Is there anything else you would like to add?
12 E-HEALTH SOLUTIONS:
* How do you think your department could benefit from e-health?
* What do you think the barriers are to your department when making
the most of e-health (.lack of computer equipment; lack of computer
skills; lack of Internet access)?
* How many in your department use the e-health solutions?
* What benefits could e-health bring to the department?
13 E-HEALTH FOR THE COMMUNITY:
* In your own words, please define e-health.
* What is your current view of the reliability, quality, and
validity of e-health technology for healthcare in a rural community?
* In general, do you believe e-health to be effective? Why or why
not?
* How can e-health assist rural communities?
* What services does e-health provide for better health care?
* What benefit does e-health bring to the department and the
community served?
* What solutions does e-health provide?
* When are e-health solutions used?
* Which of these solutions have you used?
* Why is it important to use e-health?
* How often do you use the e-health solutions (daily, weekly,
monthly, seldom, never)?
* For what function do you normally use e-health solutions?
* Could you provide examples of current e-health solutions for
healthcare that you believe to be effective? How do these work? How do
you know they are effective? How are they evaluated?
* How would you go about evaluating the cost-effectiveness and
quality of e-health solutions? Define what you mean by quality in this
context.
* How can ICT be used to improve quality or reduce costs of
services in rural healthcare centres?
Questionnaire for Staff members: Summary of items
1 PERSONAL DETAILS:
* Description of your area (rural, township, informal settlement,
town/city).
* Do you have access to telephone services?
* Do you have access to a computer?
* What connection does it have (broadband, dial-up, without
Internet connection)?
2 DEPARTMENT INFORMATION:
A About department:
* In what field does your department specialise? Please specify.
* How many patients can your department accommodate at a time?
* What treatment facilities (medicine, surgical facilities) do you
have in your department/ward?
* Which treatments do you normally provide to you patients?
* How often do you transfer your patients to other
hospitals/clinics and common reasons
* What are the major complaints/diseases of your patients?
B Facilities & Equipment:
* Do you have access to a telephone at the department/ ward? If no,
how close is the nearest phone you can use?
* What equipment and facilities does the department/ward have?
* Specify equipment out of order and period out of order.
* Specify how regularly equipment (specify type) is replaced or
upgraded?
* What kind of equipment is needed?
C e-Health Solutions:
* What basic technologies are currently in place that can support
e-health solutions?
* How can ICT help improve quality or reduce costs of services in
rural healthcare centres?
* How do you think your department could benefit from e-health?
Please specify.
* What do you think can be the barriers to your department when
making the most of e-health?
* How many people in your department use the e-health solutions?
* What benefits does e-health bring to the department?
3 E-HEALTH FOR THE COMMUNITY:
* In your own words, please define e-health.
* What is your current view of the reliability, quality, and
validity of e-health technology (defined how) for healthcare in rural
community?
* In general, do you believe e-health to be effective? Why or why
not?
* How can e-health assist rural communities?
* What services does e-health provide for better health care?
* What are the benefits e-health brings to the department and the
community served?
* What solutions does e-health provide?
* When are e-health solutions used?
* Which solutions have you used?
* Why is it important to use e-health?
* How often do you use e-health solutions?
* For what function do you normally use e-health solutions?
* Could you provide examples of current e-health solutions for
healthcare that you believe to be effective? How do these work? How do
you know they are effective? How are they evaluated?
* How would you go about evaluating the cost-effectiveness and
quality (defined how) of e-health solutions?
Questionnaire for Patients: Summary of items
1 PERSONAL DETAILS:
* Description of your area (rural, township, informal settlement,
town/city).
* Do you have access to telephone services (home, work, community
centre)?
* Do you have access to a computer (home, work, community centre)?
* What connection does it have (broadband, dial-up, without
Internet connection)?
2 HEALTH INFORMATION:
* How many times do you come to the hospital/clinic in a year?
* How do you usually get to the hospital/clinic (own car, hired
car, public transport, other)?
* How much do you spend getting to the hospital/clinic?
* Is access to public transport to the healthcare centres: hard to
find, average, always available?
* Have you ever been transferred to another hospital/ healthcare
institution for service? If yes, how many times?
* How did you get to there?
* How would you rate the cost involved?
* What was the reason for your transfer?
* Do you have any access to your medical record (limited, average,
no access)?
* How do you gain access to your health information (lab results,
disease information)?
* How do you rate the service provided by the hospital (excellent,
good, average, poor, very bad)?
* Please supply any further comments you wish to make or name any
other issues to do with the healthcare services provided by rural
hospital that you think are important.
3 TECHNOLOGY UNDERSTANDING:
* What is your level of understanding of ICT technologies (very
good, good, average, poor)?
* How do you rate your computer literacy (very good, good, average,
poor)?
* What do you usually do with the computer?
* Is your computer, or the one you usually use, connected to
Internet?
* How much does it cost for you to have an access to ICT
technologies (very expensive, expensive, affordable, cheap)?
* Do you have any understanding of e-health and its solutions? If
yes:
* How do you define e-health?
* What are the benefits it brings for rural communities?
* Which solutions are you familiar with?
* What impact do these solution have on rural communities?
* What are the limitations to these solutions?
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(1) The full survey instrument including interview schedule and
three questionnaires is available from the author upon request.
Corresponding author:
Nkqubela L Ruxwana MTech
Doctoral candidate
Nelson Mandela Metropolitan University
Senior Business Analyst and Part-time Lecturer
Faculty of ICT, Business Informatics Department
Tshwane University of Technology, Pretoria Campus
Staatsartillery Road
Pretoria 0001
SOUTH AFRICA
email: RuxwanaNL@tut.ac.za; Nkqubz@yahoo.co.uk
Marlien E Herselman PhD
Professor and Research Group Leader of Living Labs
Meraka Institute, CSIR
PO Box 395
Pretoria 0001
Adjunct Professor
Nelson Mandela Metropolitan University
PO Box 77000
Port Elizabeth 6031
SOUTH AFRICA
email: mherselman@csir.co.za
D Pieter Conradie PhD
Professor, Research and Innovation
Faculty of Humanities
Tshwane University of Technology, Pretoria Campus
Staatsartillery Road
Pretoria 0001
SOUTH AFRICA
email: ConradieDP@tut.ac.za
Table 1: Hospital locations
DISTRICT VILLAGE/TOWN HOSPITAL
Alfred Nzo Mount Frere Madzikane Ka-Zulu Memorial
Hospital
OR Tambo Mthatha Nelson Mandela General
(former Umtata) Hospital
Qumbu Nessie Knight Hospital
Tsolo St. Lucy's Hospital
Qumbu Tsilitwa Clinic
Table 2: Number and distribution of questionnaires completed
NUMBER OF QUESTIONNAIRES COMPLETED
MADZIKANE
NESSIE KNIGHT ST. LUCY'S TSILITWA KA-ZULU MEMORIAL
CATEGORY HOSPITAL HOSPITAL CLINIC HOSPITAL
Manager 1 1 1 1
Staff 5 6 1 4
Patient 2 0 0 4
Total 8 7 2 9
NUMBER OF QUESTIONNAIRES COMPLETED
NELSON
MANDELA
CATEGORY GENERAL HOSPITAL TOTAL
Manager 1 5
Staff 6 22
Patient 5 11
Total 12 38
Table 3: Number and distribution of interviews conducted
NUMBER OF INTERVIEWS CONDUCTED
MADZIKANE
NESSIE KNIGHT ST. LUCY'S TSILITWA KA-ZULU MEMORIAL
CATEGORY HOSPITAL HOSPITAL CLINIC HOSPITAL
Manager 1 1 2 1
Staff 5 6 2 6
Patient 5 5 5 5
Total 11 12 9 12
NUMBER OF INTERVIEWS CONDUCTED
NELSON
MANDELA
CATEGORY GENERAL HOSPITAL TOTAL
Manager 1 6
Staff 6 25
Patient 5 25
Total 12 56
Table 4: Number and types of ICTs available at the healthcare centres
NESSIE KNIGHT
HOSPITAL ST LUCY'S HOSPITAL
Limited number of Computers, telephone
computers, telephone service for a limited number
services, a photocopier, fax, of users. A fax, printer and
printer and telemedicine photocopier.
equipment with Internet
capabilities.
MADZIKANE KA-ZULU
TSILITWA CLINIC HOSPITAL
A computer, a telephone, a Relatively large number
digital camera and Internet of computers, printers,
services that are only used a Local Area Network
for telemedicine services. (LAN), a fax, photocopier, a
digital camera, and Internet
services in the offices, plus
telemedicine equipment and
a computerized radiology
system.
NELSON MANDELA
ACADEMIC HOSPITAL
The hospital has a wide
range of computers, a
fax, printers, photocopier,
telemedicine equipment
and videoconferencing
services.
Table 5: Perceived barriers for using ICT applications in rural
healthcare centres
HOSPITAL
NESSIE
BARRIERS TSILITWA KNIGHT ST. LUCY'S
Lack computer equipment 100% 100% 100%
Lack computer skills 0% 71% 67%
Lack Internet connection 100% 100% 83%
Old/unreliable equipment 100% 86% 100%
Lack broadband connection 0% 29% 17%
Unsuitable working style 0% 0% 0%
Cost 0% 0% 0%
Fear of computers 0% 0% 0%
Lack of information 100% 100% 100%
HOSPITAL
NELSON
BARRIERS MADZIKANE MANDELA
Lack computer equipment 100% 91%
Lack computer skills 75% 82%
Lack Internet connection 88% 73%
Old/unreliable equipment 75% 64%
Lack broadband connection 0% 9%
Unsuitable working style 0% 0%
Cost 25% 9%
Fear of computers 0% 0%
Lack of information 100% 100%
