Asemahagn, M. A. (July, 2016). Health professionals’ Challenge in using ICTs to manage their Patients: the case of Hospitals in Addis Ababa, Ethiopia. Online Journal of Nursing Informatics (OJNI), 20 (2), Available at http://www.himss.org/ojni
Mulusew A. Asemahagn, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University
I would like to express my heartfelt thanks to the Addis Ababa health bureau, hospital managers, health professionals, data collectors and supervisors for their unreserved supports in securing ethical clearance and data collection process. I would also like to be grateful to all senior advisors/researchers who supported in all steps of the research process.
Person to contact:
Author and Corresponding author
Email address: Muler.email@example.com
Phone: +251-913814608/ 924305232
Background: Information Communication Technologies (ICTs) play significant roles in enhancing the effectiveness and efficiency of health care. However, its utilization in developing countries is very limited. This study was conducted to identify challenges of ICTs utilization among health professionals working in hospitals in Addis Ababa, Ethiopia.
Methods: A cross-sectional study was conducted among 320 health professionals in March 2015. Study participants were selected systematically from health professional alphabetical lists from five hospitals. A pretested questionnaire was used to collect the data. Data were tabulated and analyzed using SPSS version 20 software. Descriptive statistics and Bi/multivariate analyses were used to describe study objectives and identify factors in ICT utilization. An odds ratio of 95% CI was used to describe the association between the dependant and independent variables.
Results: A total of 312 (97.5%) of the health professionals responded to the study questionnaire. More than half (58.0%) of the respondents were between 25-30 years of age. Only 141 (45.0%) and 135 (43.0%) were computer literate and had computer access, respectively. 115 (85.0%) of the staff with computer access used it daily. About 63.0% of the respondents accessed mobile/computer internet. Only 148 (47.0%) knew the importance of ICTs in healthcare. Age, educational status, computer access, personal initiation, infrastructure, computer literacy, poor internet access, budget restraints and management style were significant factors to ICTs utilization.
Conclusions: Health professionals in this study accessed and utilized ICTs inadequately. Personal (age, education, computer skills and awareness), management style, infrastructure and resource shortage were factors for limited ICTs utilization. Improving ICT access, computer literacy, internet connections, infrastructure, ICT awareness and management are important to improve access and utilization.
Information and Communication Technologies (ICTs) have been defined as “any product that will process, store, manipulate and communicate information electronically in a digital form” (International Telecommunication Union [ITU], 2007, p. 1). ICTs are crucial to facilitate data management, poor evidence based decision-making and clinical communication challenges (Soar, Gow, & Caniogo, 2012; Hughes, Bellis, & Tocque, 2003; Samuel M.et al, 2004). Health information technologies are critical to improve the efficiency and effectiveness of healthcare management (Gibson & Silverberg, 2000; Ministry of Finance and Economic Development [MoFED], 2006; Dubow & Chetley, 2006). Patient and educational need, competition, communication demands and innovation of different healthcare software all support the adoption of ICTs in healthcare systems worldwide (Nonaka, Toyama, & Byosière, 2001; World Health Organization [WHO], 2006; Eid & Nuraddeen, 2009; Mandruleanu, 2008; Adem, 2010).
Appropriate health information resources are needed to support informed health professionals (Wilson, 2000; Mohamed-Arraid, 2011). Various scholars agree that ICTs are invaluable for accessing, retrieving and circulating recent and relevant information among health professionals (Mandruleanu, 2008; Abidi, 2001; Daly, 2003). Hospitals and health centers become more relevant and useful to patients and health professionals with the adoption of ICTs (Dzenowagis, 2005; Cornia, 2001; Federal Ministry of Health Planning and Programming Department [FMoHPD], 2005). Medical record systems, telemedicine, video conferencing, audio-video teaching materials, internet access and e-learning are some of the ICT applications now being used in healthcare (Hofmann, 2002; Chandrasekhar & Ghosh, 2001; Ahmed, 2004; Federal Ministry of Health [FMoH], World Health Organization [WHO], 2006).
Even though ICTs are important for efficient healthcare systems, adoption rates are still very low in resource-limited countries (Mulat, 2002; Ibrahim, Phing & Palaian, 2010; Zhang, Faerman &, Cresswell, 2006). Healthcare facilities in developing countries often experience poor data management, weak evidence-based decision-making practices, high medical errors and poor planning (Musoke, 2006; Aminali, 2007; Ye-Ebiyo, et al, 2007; Cork, Delmer & Friedman, 1998).
The aim of this study was to identify important ICTs utilization challenges among health professionals working in hospitals led by the Addis Ababa Health Bureau (AAHB) in Ethiopia. Findings of this study can provide important evidence for the Federal Ministry of Health, the Addis Ababa Health Bureau, hospital administrators and Non-governmental organizations (NGOs) to identify hindering factors for ICT access and use and plan for appropriate interventions to solve the problem. It can also provide crucial evidence for future researchers interested in the issue.
Study Design and Place
An institution based cross-sectional study was conducted in March 2015 to assess factors in accessing and utilizing ICTs among healthcare professionals working in public hospitals under the AAHB. Addis Ababa is the capital city of the Federal Democratic Republic of Ethiopia with a population of 2,738,248 (Addis Ababa Health Bureau [AAHB], 2011; Federal Democratic Republic of Ethiopia [FDRE], 2008). The city has 10 administrative sub-cities and 99 Kebeles. There are 38 hospitals (10 public and 28 NGO and private). Five of the public hospitals are owned by the AAHB (Asemahagn, 2014). During the study period, there were a total of 1,200 healthcare professionals working in different departments of these five AAHB-owned hospitals.
Study Population and Sample size Determination
The study population were the healthcare professionals who worked in the five AAHB-owned hospitals during the study period. The sample size of the study was determined using Epi Info version 3.5.4 by inputting the total population N=1200 and the challenges of ICT utilization by healthcare professionals (p) = 50%, precision error (d) = 0. 05 at 95% CI, and 10% contingency. Thus the actual sample size for this study was 291+29 =320.
The five participating hospitals included Zewuditu Memorial Hospital (with a total of 279 health professionals), Ras-desta Damtew Memorial Hospital (169), Gandi Memorial Hospital (156), Minillik II Hospital (275) and Yekatit 12 Hospital (303). The sample size for each hospital was determined proportionally based on the total number of health professionals in each hospital. Each hospital’s sample was selected randomly from the alphabetical databases of health professionals.
‘Data Collection Tool and Procedure
Data were collected using a pretested self-administered questionnaire. The questionnaire was developed by referring to different related studies from the literature (Asemahagn, 2014; Olatokun & Adeboyejo, 2009; Edejer, 2000; Lemma, 2009) and was focused on socio-demographic characteristics, ICTs utilization practices and challenges for ICTs. The tool was prepared in English, translated into Amharic (local language) and then translated back to English to check its consistency. The tool was validated through pretesting at the Black Lion Hospital, which is similar in infrastructure to the five hospitals in the study. Three data collectors and two supervisors participated in the data collection process.
Ethical approval of this study was obtained from the AAHB Ethical Reviewing Committee. Informed verbal consent was gathered from the head administrator of each hospital. Written consent was also collected from each study participant following a clear explanation of the purpose, data collection procedures and data confidentiality issues of the study.
The author conducted a one day training on study objectives, data collection procedures, contents of the questionnaire, data confidentiality, respondent rights and data quality issues with the data collectors and supervisors prior to the actual data collection. Data collectors also informed participating health professionals about the objectives of the study, data collection procedures, data confidentiality and their rights during data collection. Data collection and data quality were monitored consistently by the author and supervisors.
Data Processing and Analysis Techniques
After data collection was completed, the author tabulated the data manually and entered it into a computer using SPSS version 20 software for analysis. Descriptive statistics were used to describe the study population in relation to relevant variables. Binary logistic regression analysis was conducted to discover the effect of each study variable on the outcome variable. Variables having a p value <0.2 on the bivariate analysis were entered into a multivariate logistic regression analysis to check for confounding effects on the association from bivariate analysis. The strength of association was described using an odds ratio analysis at 95% CI.
Socio-Demographic Characteristics of Study Participants
320 self-administered questionnaires were distributed among the health professionals in the study across the five AAHB hospitals. The majority (97.5%) of these were completed, returned and analysed as part of this study. Nearly two-thirds, 189 (61.0%) of these health professionals were female. More than half (58.0%) were within 25-30 years of age. The mean standard age of was 28±4 years. Three-fourths (74.0%) of the health professionals had an education level of a degree or higher. More than half, 181 (58.0%) of the respondents were nurses and 37 (12.0%) were medical laboratory personnel. More than half (54.0%) of the health professionals had more than five years of professional working experience. About four fifths (81.0%) of the health professionals earned 1450.00 Ethiopian Birr/ETB/ (about $70 USD) per month (see Table1).
Of the 320 study participants, only 141 (45.0%) were computer literate (can perform at least office applications and use internet services). Participants reported an absence of computer centers (70 = 41.0%), financial problems (58 = 34.0%), time shortage (32 =19.0%) and less attention to ICTs (11 = 6.0%) were key reasons for this low level of literacy. Less than half (47.0%) of these health professionals were familiar with ICTs and their applications in health system. Only 104 (33.0%) of the health professionals were satisfied with their current job. Poor salary 65 (37.0%), poor learning opportunities 52 (30.0%), management problems 32 (18.0%) and facility related problems 26 (15.0%) were some of the identified causes for job dissatisfaction (see Table1).
ICTs access and utilization among healthcare professionals 135 (43.0%) health professionals in this sample reported that they had computers in their office. Of those who had computer access, 115 (85.0%) used it in their daily activities. Recording and storing documents 45 (39.1%), report writing 48 (41.8%) and 22 (19.1%) accessing internet services were major activities performed using these computers (see Table2).
The majority of these health professionals (89.0%) had access to fax services but very few respondents (39.0%) had access to printer or photocopying services. Ink shortage 28 (51.0%), electrical problems 19 (35.0%) and management problems 8 (14.0%) were reasons identified for not being able to use printers or photocopiers. Only 62 (20.0%) and 54 (17.3%) of health professionals reported the presence of mini library services in Minillik and Zewuditu Memorial Hospitals, respectively. Similarly, 51(16.0%) from Minillik and 42(13.0%) from Zewuditu Memorial Hospitals mentioned that they could use Internet connections inside the hospitals (see Table 2).
Of the total study participants, 197(63.0%) had access to mobile/computer internet services (via the Google search engine) inside and outside the hospital where they worked. Half (50.0%) of them encountered problems while using the internet. Skill problems 48(50.0%), poor internet connection 29(29.0%) and internet cost 21(21%) were challenges faced by users.
Challenges of ICTs utilization among the healthcare professionals
The health professionals in this study identified several challenges that contributed to poor ICT utilization in daily activities. Primary challenges included educational status, poor infrastructure, management problems, computer illiteracy, resource shortages, poor staff initiation, absence of or poor internet connection, poor ICT awareness, poor computer access, heavy workloads and absence of a responsible body for ICT inclusion (see Table 3).
The majority (76.0%) of the health professionals described poor ICT infrastructure. More than half, 187 (60.0%) of the respondents indicated management problems in relation to ICT access and utilization. A large number of health professionals (80.0%) mentioned that resource shortages were also factors that inhibited ICT utilization. About 191 (61.0%) and 119 (38.0%) respondents indicated that poor staff initiation and time shortages were other limitations. The majority (70.0%) of the respondents reported an absence of internet connection within their organizations. Only 121 (39.0%) health professionals indicated access and the use of computer and related technologies to assist their activities. More than half, 189 (61.0%) of health professionals reported the absence of a responsible body/office for ICTs in their working area (see Table 3).
Based on bivariate and multivariate logistic regression analysis, the respondents’ age, educational status, computer literacy, resource availability, management style, computer access, internet connection, staff initiation, ICT awareness and infrastructure were statistically significant to ICTs utilization by these health professionals. Participants aged ≤ 30 years were more likely to use ICTs to manage their patients than their counter parts (AOR=2.57, 95% CI= [1.45, 4.56]). Degree and above holders were more likely to use ICTs compared with diploma holders (AOR=3.17, 95% CI= [1.80, 5.59]). Computer literates were more likely to use ICTs than illiterates (AOR=2.78, 95%CI= [2.01, 5.10]. Respondents who have computer access and ICTs awareness were better able to use ICTs in their work activities than their counterparts (AOR=7.12, 95% CI= [5.32, 13.56] and AOR=3.02, 95% CI= [2.15, 6.27]), respectively.
Even though computer literacy is the backbone of ICT utilization, more than half (55.0%) of health professionals in the study were computer illiterate due to the absence of a computer training center, monetary problems, time shortages and the inability to pay attention to trends. This finding was in line with other study findings from Ethiopia (Lemma, 2009) and Nigeria (Bello et al, 2004) where 53.0% and 52.0% of health professionals were computer illiterate, respectively. These results are quite different compared to a study conducted by Ajuwon (2006) at a Nigerian teaching hospital, where 93.0% of the hospital doctors were computer literate. This may be due to the variations in infrastructure, computer access, resource and training centers between the two countries. In addition, variations in the working environment and that fact that it was a teaching hospital could be potential reasons for this variation.
In this study, only 135 (43.0%) of the health professionals had access to computers in the study area. It clearly showed that most of the respondents did not have computers in their offices. This is very low compared with other study findings from Black Lion Hospital, Addis Ababa (Berhane Selassie, 2009), where 75.0% of physicians used computers in managing their patients. The variation could be related to the status of study areas, since the Black Lion Hospital is a teaching hospital for medical students and it is also the only central hospital for any referral cases from different regions of Ethiopia. Black Lion Hospital also provides telemedicine services which is not available at the five hospitals in this study. As a result, Black Lion hospital may have relatively better facilities such as computers, internet access, technology specialists, consultation services and management than the hospitals in this study.
Computer access in the Nigeria teaching hospital studied by Ajuwon (2006) was more than double (94%) the current findings in this study (43%). The most probable reasons for this huge gap include geographical, resource, management style, personal and governmental commitments, donors, computer literacy, policy and infrastructure variations between the two countries. In addition to these variations, the Nigerian hospital is a teaching hospital, which tend to have better working environments to access evidence and more skilled manpower. However, the 43% computer access findings in this study is relatively higher compared with study findings from South Africa (Edejer, 2000), where 31.0% of health professionals accessed computers to assist their work. However, the potential reason for this variation may simply be study period variation (2000 compared to 2015).
In the case of computer utilization for daily activities, only 37.0% out of the total respondents used computers to assist their daily tasks. These results are very low compared to various other studies on health professional access (Olatokun & Adeboyejo, 2009; Edejer, 2000; Ajuwon, 2006; Berhane Selassie, 2009). Poor computer access, managerial problems, computer illiteracy, resource shortage, less attention to ICTs by staff and poor infrastructure are the most common reasons for low computer utilization in this study area.
It is interesting that only a handful of departments, including the TB clinics, ART clinics, TB-HIV, pharmacy and laboratory housed the limited number of computers reported in this study. These findings were also supported by other studies (Bello et al, 2004; Anwar, Shamim & Khan, 2011). This is most likely due to the presence of sensitive public health case data including relevant epidemiological and confidential data in those departments. All of these cases are included in global health statistics thus computer systems are routinely used to process and handle such vital data. For this reason, there are relatively better interventions/supports (computer and relative devices, internet, installation of medical recording systems, training and budget) from government and various NGOs to those departments in developing countries.
More than half (63.0%) of the health professionals in this study can access internet services using their mobile devices and desktop computers (via the Google search engine). This is a relatively larger figure compared with other Ethiopian study findings (Mulat, & Tadesse, 2002; Ghebr, 2005), where internet access among health professionals during need assessments were 33.0% and 45% respectively. The most acceptable reasons for this variation could be study period variation (2002, 2005 and 2015), infrastructure, computer literacy, personal initiation and management concerns in the respective study time frames. On the other hand, the magnitude of current internet access among health professionals is lower compared with results from other studies in Ethiopia (Berhane Selassie, 2009), and Nigeria (Olatokun & Adeboyejo, 2009; Ajuwon, 2006), where 88.0%, 98.0% and 96.0% of physicians used internet services to access information for their daily activities. The logical reason for this discrepancy is the nature of the hospitals (the current studied hospitals are not teaching hospitals, but Black Lion Hospital (Berhane Selassie, 2009) and Nigerian Hospital (Ajuwon, 2006) are, thus they have better infrastructure to access the internet. These differences may also be due to limited computer access and illiteracy, budget constraints, absence of or limited internet connection, and poor personal initiation in this study area.
Of those who used internet services, 98(50.0%) encountered problems while going online due to skill problems, poor internet connections and high internet costs. These hindering factors were also mentioned as determinant factors in other study findings from Ethiopia (Mulat & Tadesse, 2002; Lemma, 2009; Berhane Selassie, 2009) and South Africa (Edejer, 2000).
Age, educational status, computer literacy, computer access, poor internet connections, lack of ICT training, poor staff initiation, management problems, infrastructure and resource shortages were significant variables (P-value <0.05) related to ICT utilization among health professionals in this study. This finding is highly supported by various study findings from both developed and resource-limited countries (Ibrahim, Phing & Palaian, 2010; Cork, Delmer & Friedman, 1998; Olatokun & Adeboyejo, 2009; Bello et al, 2004; Anwar et al, 2011). It seems obvious that personal awareness and interest, computer skills, hospital setup, computer access, management concern, and internet access/connection are interconnected factors that influence ICT access and utilization in hospitals. Therefore, the above-mentioned determinant factors must be considered when determining individual health professional ICT utilization statuses.
Even though ICTs play a central role in delivering timely and evidence-based, quality healthcare services, the majority of health professionals accessed and used ICTs inadequately to manage their patients in this study. More than half of the respondents were computer illiterate and poorly initiated to ICTs. Sociodemographic (Age, educational status), skill related problems (computer literacy, refreshment training), infrastructural (poor computer access, absence/poor internet connection, setups, resource constraint) and management style were important factors in limited ICT utilization. Improving the infrastructure, management, computer access and literacy, internet connections, and training/ICTs awareness are important to improve ICT utilization among Ethiopian health professionals.
The author declared that there is no any competing interest.
Abidi, S. (2001). Knowledge management in healthcare: towards knowledge-driven decision -support services. International Journal of Medical Informatics, 63(1:2), 5-18.
Addis Ababa Health Bureau, [AAHB] (2011). Report of Human resource department. Author.
Adem, A. (2010). Knowledge sharing among health professionals: the case of Felege hiwot referral hospital, Bahir Dar. Addis Ababa University.
Ahmed, M. (2004). Electronic immunization registry and tracking system in Bangladesh. Government for Development: Health Case Study. Available at http://www.egov4dev.org/health/case/banglaimmune.shtml
Ajuwon, G.A. (2006). Use of the internet for patient care in a teaching hospital in Ibadan, Nigeria. Journal of biomedical digital libraries, 3:(12), e1-10.
Alavi, M., Leidner, D.E. (2001). Knowledge Management and Knowledge Management Systems: Conceptual Foundations and Research Issues. MIS Quarterly, 25(1), 107-136.
Aminali, P. (2007). e-Readiness assessment within the Iran’s Automotive Industry: case of Iran Khodro Industrial Group. Master’s thesis. Luleå University of Technology. Available at http://epubl.ltu.se/1653-0187/2007/045/LTU-PB-EX-07045-SE.pdf
Anwar, F., Shamim, A. & Khan, S. (2011). Barriers in adoption of health information technology in developing societies. International Journal of Advanced Computer Science Applications, (2), 8.
Asemahagn, M. (2014). Knowledge and experience sharing practices among health professionals in hospitals under the Addis Ababa health bureau, Ethiopia. BMC Health Services Research, 14(431), e1-10.
Bello, I. et al. (2004). Knowledge and utilization of information technology among healthcare professionals and students. Journal of Medical Internet Research, 6(4), e45. Available at http://www.jmir.org/2004/4/e45/
Berhane Selassie, E. (2009). Physicians’ culture of use of online medical evidence to improve clinical care of patients [MSc thesis]. Addis Ababa: Addis Ababa University.
Chandrasekhar, C.P. & Ghosh, J. (2001). Information and communication technology and health in low-income countries: The potential and constraints. Bulletin of world health organization, 79: 850-855.
Cork, R.D., Delmer, W. & Friedman, C. (1998). Development and Initial Validation of an Instrument to Measure Physicians’ use of knowledge and attitudes towards Computers. Journal of the American Medical Informatics Association, 5:164 – 176. Available at http://jamia.oxfordjournals.org/content/jaminfo/5/2/164.full.pdf
Cornia, G. (2001). Globalization and health: results and options. Bulletin of the World Health Organization, 79(9), 834-841.
Daly, J. (2003). Information and communications technology applied to the Millennium Development Goals. Washington, DC: Development Gateway Foundation.
Dubow, J. & Chetley, A. (2011). Improving the health, connecting people: the role of ICTs in the health sector of developing countries [Internet]. Available from http://www.infodev.org/infodev-files/resource/InfodevDocuments_84.pdf
Dzenowagis, J. (2005). Information technology growth in Ethiopia in Connecting for health: global vision, local insight. Geneva: World Health Organization. Available from http://www.who.int/ehealth/publications/WSISReport_Connecting_for_Health.pdf
Edejer, T. (2000). Disseminating health information in developing countries: The role of the internet. BMJ, 321 (September 30), 797–800.
Eid, M. & Nuraddeen, A. (2009). The impact of learning culture and information technology use on knowledge sharing: A case of KFUPM. 17th European conference on information systems. Available at http://aisel.aisnet.org/cgi/viewcontent.cgi?article=1146&context=ecis2009
Ethiopian ICT Development Authority [EICTDA] (2007). ICT Assisted Development Project, Monitoring and Evaluation Report On ICT Laws Enacted and ICT Business Status in Major Towns of Ethiopia. Addis Ababa.
Federal Democratic Republic of Ethiopia [FDRE] (2008). Summary and Statistical Report of the 2007 Population and Housing census. Addis Ababa: Population census Commission.
Federal Ministry of Health Planning and Programming Department, [FMoHPD] (2005). Health Sector Strategic Plan, 2005/6-2009/10. Available at http://can-mnch.ca/wp-content/uploads/2013/09/Ethiopia-Health-Sector-Development-PlanHSDP-III.pdf
Federal Ministry of Health, [FMoH] & World Health Organization, [WHO] (2007). Assessment of Ethiopian Health Information System: Final Report. Geneva: WHO. Available at http://apps.who.int/healthmetrics/library/countries/HMN_ETH_Assess_Final_2007_10_en.pdf?ua=1
Ghebre, H.A. (2005). Assessment of Health Management Information System in Addis Ababa Health Bureau [MSc thesis].Addis Ababa: Addis Ababa University.
Gibson, K. & Silverberg, M. (2000). A two -year experience teaching computer literacy to first –year medical students using skill-based cohorts. Bulletin of the Medical Library Association, 88(2), 157-164.
Hofmann, B. (2002). Is there a technological imperative in healthcare? International Journal of Technological Assessment in Health Care, 18(3), 675-89.
Hughes, K., Bellis, M. & Tocque, K. (2003). Information and communications Technologies in public health tackling health & digital qualities in the information age. Liverpool: Liverpool John Moores University.
International Telecommunication Union [ITU] (2007). E-health. Available at http://www.itu.int/ITU D/cyb/app/docs/e-Health_prefinal_15092008
Ibrahim, M., Phing, C. & Palaian, S. (2010). Evaluation of Knowledge and perception of Malaysian Health professionals about Telemedicine. Journal of Clinical and Diagnostic Research, 4(1), 2052-20.
Lemma, I. (2009). Assessment of access to health information resources among HPs working in HIV/AIDS and family health units of public health centres in Addis Ababa [MSc thesis].Addis Ababa: Addis Ababa University.
Mandruleanu, A. (2008). Knowledge dynamics. Revista Informatics Economic, 4(48), 117-121.
Ministry of Finance and economic development (MoFED) (2006). A plan for Accelerated and Development to end Poverty (PASDEP). Addis Ababa: MoFED, Volume I.
Mohamed-Arraid, A. (2011). Information needs and information seeking behaviour of Libyan doctors working in Libyan hospitals. Leicestershire, UK: Loughborough University.
Mulat, D. & Tadesse, B. (2002). A report on ICT penetration and usage in Addis Ababa, Ethiopia: Addis Ababa University.
Musoke, M.G. (2006). Information and its value to health workers in rural Uganda: a qualitative perspective. Health Information and Libraries Journal, 17:194–202.
Nonaka, I., Toyama, R. & Byosière, P. (2001). A theory of organizational knowledge creation: understanding the dynamic process of creating knowledge. Hand book of organizational learning and knowledge. New York, Oxford University Press.
Olatokun, W.M. & Adeboyejo, O.C. (2009). Information and Communication Technology use by reproductive health workers in Nigeria: State of the art, issues, and challenges. An Interdisciplinary Journal on Humans in ICT Environments, 5(2), 181–207.
Raja, E.E.J., Mahal, R. and Masih, V.B. (February 2004). An Exploratory Study to Assess the Computer Knowledge, Attitude and Skill among Nurses in Health care Setting of a Selected Hospital, Ludhiana, Punjab, India. Online Journal of Nursing Informatics (OJNI). 8(1). [Online]. Available at http://ojni.org/8_1/raja.htm
Samuel, M., Coombes, J., Miranda, J., Melvin, R., Young, E. & Azarmina, P. (2004). Assessing computer skills in Tanzanian medical students: an elective experience. BMC public health, 4(37), 1-3. Available at http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-4-37
Soar, J. Gow, J. & Caniogo, V. (2012). Sustainability of health information systems in developing countries: the case of Fiji. Health Information Management Journal, 41(3), 13-19. Available at http://him.sagepub.com/content/41/3/13.long
Wilson, T.D. (2000): Human Information Behaviour. Informing Science, 3(2). Available at http://inform.nu/Articles/Vol3/v3n2p49-56.pdf
World Health Organization, [WHO] (2006). Technical paper on regional strategy for knowledge management to support public health. Geneva: WHO. Available at http://applications.emro.who.int/docs/EM_RC53_6_en.pdf
Ye-Ebiyo, Y. et al. (2007) Study on health extension workers: Access to information continuing education and reference materials, Ethiopian Journal of Health Development 21(3), 240-245.
Zhang, J., Faerman, S. & Cresswell, A. (2006). The effect of organizational/technological factors and the nature of knowledge on knowledge sharing. The 39th Hawaii International Conference on System Sciences. Available at://www.hicss.hawaii.edu.