Background: In developing countries like Uganda, there are shortages of health workers especially medical specialists. The referral process is frustrating to both patients and health workers (HWs). This is due to delays in accessing laboratory results/tests, costs of travel with resultant delay in consulting specialists. Telemedicine can help reduce these problems. To facilitate successful and sustainable telemedicine implementation the eHealth readiness of different stakeholders should be undertaken. This study was conducted at public health facilities (HFs) in Uganda to assess eHealth readiness across four domains; core, e-learning, clinical and technology, that might hamper adoption and integration of telemedicine. Methods: A cross-sectional study using mixed methods for data collection was conducted at health center IVs, regional and national referral hospitals. The study was conducted in three parts. Quantitative data on core, e-learning and clinical readiness domains were collected from doctors and other healthcare providers (nurses/midwives, public health officers and allied healthcare workers). Respondents were categorised into 'aware and used telemedicine', 'aware and not used', 'unaware of telemedicine'. Focus Group Discussions were conducted with patients to further assess core readiness. Technology readiness was assessed using a questionnaire with purposively selected respondents; directors, heads of medical sections, and hospital managers/superintendents. Descriptive statistics and correlations were performed using Spearman's rank order test for relationship between technology readiness variables at the HFs. Results: 70% of health professionals surveyed across three levels of HF were aware of telemedicine and 41% had used telemedicine. However, over 40% of HWs at HC-IV and RRH were unaware of telemedicine. All doctors who had used telemedicine were impressed with it. Telemedicine users and non-users who were aware of telemedicine showed core, clinical, and learning readiness. Patients were aware of telemedicine but identified barriers to its use. A weak but positive correlation existed between the different variables in technology readiness. Conclusion: Respondents who were aware of and used telemedicine across all HF levels indicated core, learning and clinical readiness for adoption and integration of telemedicine at the public HFs in Uganda, although patients noted potential barriers that might need attention. In terms of technology readiness, gaps still exit at the various HF levels.
Keywords: Telemedicine; Uganda; E-readiness; Health facilities
All authors contributed equally to this work.
Telemedicine is the remote delivery of clinical and other healthcare services using information and communications technologies (ICT). Health professionals in developed countries use telemedicine to broaden communication with patients and fellow professionals. Indeed, the American Telemedicine Association states "Telehealth has advanced from a curious form of clinical communication to a mainstay in the way providers and consumers interact" [[
The World Health Organization (WHO) estimates the world will be short of 12.9 million healthcare workers (HWs) by 2035; today, that figure stands at 7.2 million. There is an extreme shortage of HWs in 57 countries, 63% of which are in sub-Saharan Africa [[
eHealth readiness is defined as the "preparedness of healthcare institutions or communities for the anticipated change brought by programs related to information and communications technology" [[
Core readiness has been defined as the extent to which members of a community are dissatisfied with the current status of their healthcare service provision, see eHealth as a solution, and express their need and preparedness for eHealth services [[
Finally, regarding technology readiness, Rezai-Rad et al. [[
In Uganda, the National Healthcare System is a combination of the public and private sectors. The public sector is made up of all health facilities (HFs) owned by the government of Uganda, and supervised and regulated by the Ministry of Health. Other HFs include the health services of the Ministries of Defence, Education, Internal Affairs (the Police and Prisons), and Ministry of Local Government. The private health sector consists of private not-for-profit providers, private health practitioners, as well as traditional and complementary medicine practitioners. Provision of healthcare services by public HFs is decentralized at district and sub-district levels, each with a role in delivery and management of health services. The public healthcare system is structured into National Referral Hospitals (NRHs), Regional Referral Hospitals (RRHs), General Hospitals (GHs), and four levels of Health Centres (HC); HC-IV, HC-III, HC–II and Village Health Teams or HC-I.
There have been several initiatives by the Ugandan government to improve physical structure at district, regional and national referral HFs. However the healthcare system in Uganda still faces enormous challenges including insufficient technology resources, limited use of these resources (i.e. computers and Internet), and regular power blackouts. In addition, there are limited human resources (IT professionals) to provide technical support due to high staff turn-over and redeployment, a common occurrence in Uganda's health sector [[
This study evaluated four eHealth readiness domains (core, clinical, e-learning and technology) that might hamper adoption and integration of telemedicine services at HFs in Uganda. Prior review of the literature on eHealth readiness assessment frameworks had revealed these four domains were critical in assessing eHealth readiness in developing countries. Study results will help mitigate any future barriers when implementing telemedicine technologies at HFs in Uganda, and potentially elsewhere.
This was a cross sectional study using mixed methods for data collection. Two semi-structured questionnaires were developed to collect quantitative data; first, for core, e-learning, and clinical readiness (Additional file 1), and second for technology readiness (Additional file 2). One health facility at the RRH and HC-IV levels was selected from each of three regions (Western, Northern and Eastern) using multi-stage random sampling. Mulago hospital, which functions as an HC-IV, GH and referral hospital for the Central region, was purposively identified for the study.
The technology readiness questionnaire was distributed to managers and physicians in-charge who were purposively selected. The core, e-learning, and clinical questionnaire was pre-tested for validity/consistency with 10 HWs at a HC-IV in Mukono district in the Central region of Uganda. It was then distributed to doctors, nurses/midwives, public health officers (PHOs), and allied healthcare workers at the different facilities who were purposively selected. The first part of the questionnaire addressed awareness and / or use of telemedicine. Respondents were divided into three groups. The 'telemedicine user' group was further categorised into two sub-groups, doctors, and other health professionals and administrators. The other two groups included those who were not aware of telemedicine ('telemedicine naïve' group) and those who were aware of telemedicine but had not used it ('telemedicine aware' group). Each group was analysed to assess core, e-learning and clinical readiness to integration of telemedicine.
The four eHealth readiness domains were assessed in 17 questions, core (
To further assess core readiness, Focus Group Discussions (FGDs) were conducted with patients at Out-Patient Departments (OPD) at the identified HFs (Additional file 3). Convenience sampling was used to select the OPD patients, with patients invited by word of mouth to participate in the study. Each FGD comprised six to eight participants with seven FGDs conducted. Written notes were made of the discussions because participants had reservations about audio recording. Contemporaneous notes from the moderator and an assistant were used to ensure key points of the discussion and quotes were correctly and accurately documented. The discussions were summarised and data coded according to major themes, and sub-themes identified.
The technology readiness questionnaire was used to collect quantitative data on technology readiness from purposively selected participants (Additional file 4). These included directors, heads of medical sections, and hospital managers/superintendents. Descriptive statistics and correlations using Spearman's rank order test were performed. Alpha was set at 5%.
In total, 406 HWs responded to the core, clinical and e-learning readiness questionnaire (Table 1). The sample included more nurses and allied health workers than doctors.
Demographic data of respondents by: health facility level, job category
Nurses/ Midwives n (%) Allied Health Workers n (%) Public Health Officers n (%) Doctors n (%) Missing n (%) Total N HC-IV 39 (43.8) 24 (27.0) 22 (24.7) 4 (4.5) 0 89 RRH 55 (31.6) 45 (25.9) 29 (16.7) 44 (25.3) 1 (0.6) 174 NRH 22 (15.3) 46 (32.2) 26 (18.2) 49 (34.3) 0 143 Total 116 (28.5) 115 (28.3) 77 (19.0) 97 (23.9) 1 (0.3) 406
Respondents' awareness of telemedicine and their use of telemedicine is shown in Table 2. Only 30.3% of people had not heard of telemedicine (telemedicine naïve group), while 41.1% were 'telemedicine users', of whom significantly more doctors 74 (76.3%) had used telemedicine than other health professionals (p < 0.0001). The remainder (28.6%) constituted the 'telemedicine aware' group.
Awareness and use of telemedicine services
Health Facility Telemedicine Naïve Group n (%) Aware of Telemedicine but not used it n (%) Aware of and used Telemedicine n (%) Doctors Others HC IV ( 42 (47.1) 32 (36) 3 (3.4) 12 (13.5) RRH ( 71 (40.8) 32 (18.4) 29 (16.7) 42 (24.1) NRH ( 10 (7.0) 52 (36.4) 42 (29.3) 39 (27.3) Total ( 123 (30.3) 116 (28.6) 74 (18.2) 93 (22.9)
The responses of doctors and other health professionals who have used telemedicine were further analysed according to several themes and subthemes identified in Table 3. A more detailed breakdown of these results by health facility is presented in Additional file 1.
Analysis of doctors and others who have used telemedicine (TM)
Characteristics TM Users Non-users Doctors ( Others ( Total ( TM aware non-users ( Unaware of TM ( Core Readiness - Awareness of Telemedicine TM used for Diagnosis 16 (34.0) 9 (9.7) 25 (15.3)a – – Treatment 23 (31.1) 14 (15.2) 37 (22.7)a – – Prevention 25 (33.8) 15 (16.1) 40 (24.5)b – – e-Learning 30 (40.5) 40 (43.0) 70 (42.9) – – Knowledge sharing 21 (28.4) 31 (33.3) 52 (31.9) – – e-consultation 47 (63.5) 46 (49.5) 93 (57.1) – – e-prescription 60 (81.1) 1 (1.1) 61 (37.4)c – – Impressed with TM 74 (100) 81 (87.1) 155 (95.1)c – – Core Readiness - Integrating Telemedicine TM reduces referrals 65 (87.8) 73 (78.5) 138 (84.7) 89 (76.7) 30 (24.4)c TM reduces hospital visits 65 (87.8) 60 (64.5) 125 (76.7)c 99 (85.3)a 52 (42.3)c Use TM over traditional methods 67 (90.5) 69 (74.2) 136 (83.4)b 102 (87.9) 67 (54.5)c Required before TM Licensing 43 (58.1) 64 (68.8) 107 (65.6) 85 (73.3) 48 (39.0)c Remuneration 33 (44.6) 52 (55.9) 85 (52.1) 61 (52.6) 20 (16.3)c Policy 74 (100) 80 (86.0) 154 (94.5)c 97 (83.6)a 58 (47.2)c Training 68 (91.9) 79 (84.9) 147 (90.2) 63 (54.3)c 66 (53.7)c Ethical Guideline 69 (93.2) 61 (65.6) 130 (79.8)c 66 (56.9)c 45 (36.6)c TM solves HWs crisis 70 (94.6) 74 (79.6) 144 (88.3)b 106 (91.4) 81 (65.9)c Core Readiness - Comfort with Telemedicine TM is cost effective 59 (79.7) 93 (100) 152 (93.3)c 98 (84.5) 85 (69.1)c Worth investing in TM infrastructure? 73 (98.6) 76 (81.7) 149 (91.4)c 83 (71.6)c 81 (65.9)c TM is effective for emergencies 66 (89.2) 86 (92.5) 152 (93.3) 111 (95.7) 96 (78.0)b Core Readiness – Process Workflow TM affects normal process workflow 5 (6.8) 23 (24.7) 28 (17.2)b 5 (4.3)c 24 (19.5) TM would alter work practices 24 (32.4) 47 (50.5) 71 (43.6)a 54 (46.6) 44 (35.8) TM would change referral process 63 (85.1) 66 (71.0) 129 (79.1)a 113 (97.4)c 53 (43.1)c Learning Readiness – Enhancing Provider Skill How do you access Continuing Medical Education? Conference 71 (95.9) 65 (69.9) 136 (83.4)c 91 (78.4) 70 (60.3)c Internet 70 (94.6) 56 (60.2) 126 (77.3)c 83 (71.6) 45 (38.8)c Workshop 74 (100) 63 (67.7) 137 (84.0)c 93 (80.2) 86 (74.1)a Attend course 26 (35.1) 22 (23.7) 48 (29.4) 42 (36.2) 60 (51.7)c Consult colleagues 8 (10.8) 11 (11.8) 19 (11.7) 9 (7.8) 17 (14.7) Could TM enhance e-learning? 62 (83.8) 62 (66.7) 124 (76.1)a 114 (98.3)c 113 (91.9)c Are HW ready to adopt e-learning? 68 (91.9) 81 (87.1) 149 (91.4) 107 (92.2) 113 (91.9) Would TM use bridge skills gap? 49 (66.2) 78 (83.9) 127 (77.9)b 104 (89.7)b 119 (96.7)c Clinical Readiness - Factors Use of TM for clinical gaps 67 (90.5) 84 (90.3) 151 (92.6) 109 (94.0) 104 (84.6) Agree with treatment outcome 70 (94.6) 85 (91.4) 155 (95.1) 111 (95.7) 99 (80.5)b TM will improve clinical outcome 70 (94.6) 85 (91.4) 156 (95.1) 100 (86.2) 100 (81.3)b Overall Readiness HW ready to integrate TM 65 (87.8) 60 (64.5) 125 (76.7)b 68 (58.6)b 64 (52.0)c
Attitudes of those who had used telemedicine were positive. Over 90% of telemedicine users felt that it was cost effective, improved clinical outcomes and considered it was worth investing in telemedicine infrastructure. Over 75% felt telemedicine reduced referrals, changed the referral process, reduced hospital visits, addressed the shortage of health workers, and were happy to use it in place of traditional methods. It was also seen as a means of facilitating education with 91% feeling that health workers were ready to adopt e-learning. Significantly fewer doctors felt that it adversely affected the normal workflow (p < 0.01) and altered work practices (p < 0.05) than other telemedicine users. The need for eHealth policy, guidelines and training was identified by more than 90% of doctors.
Significant differences were noted between doctors and other users with respect to their overall impression of telemedicine, in terms of cost effectiveness, reducing hospital visits, solving the health worker shortage, its impact on normal workflow and work processes, and the worth of investment in telemedicine infrastructure.
Significantly, more 'telemedicine aware' respondents felt that it would reduce hospital visits, change the referral process, bridge the skills gap, and enhance e-learning than telemedicine users. Fewer felt that it adversely affected the normal process workflow, was worth investing in telemedicine infrastructure, and that health workers were ready for telemedicine. The 'telemedicine naïve' group were generally sceptical about the value of telemedicine, its use, and investing in it, although they were positive about e-learning and its use in bridging the skills gap.
The percentage of positive responses for each readiness domain was averaged for telemedicine users, telemedicine aware, and telemedicine naïve groups. Overall readiness was based on the single question about health workers' readiness to integrate telemedicine into practice (Fig. 1).
Graph: Fig. 1The average scores for core, clinical, e-learning and overall readiness of telemedicine users, telemedicine aware, and telemedicine naïve groups
The user and aware groups averaged over 80% positive responses for all but process workflow, a domain in which low scores for changes to work flow and practice indicated a positive attitude to telemedicine. However, they expressed less overall readiness. Over 80% of both telemedicine users and aware groups were positive about core readiness, and over 80% of all respondents were positive about clinical and e-learning readiness. As expected, telemedicine users expressed the most overall readiness for telemedicine.
Participants from most of the FGDs, especially those at RRHs and NRHs, were aware of the concept of telemedicine. Some, particularly those at HC-IVs, said they had heard and were aware of the term 'telemedicine' but were not sure if they used it (telemedicine) at health facilities within their locale. In contrast those at higher health facility levels (RRH & NRH) were generally aware of telemedicine services (email and telephone) and had used them to communicate with medical workers/specialists:
"We are aware about telemedicine where a doctor treats a patient at a far distance using technology. Not sure though if this can work in our health centres because in most cases you need to see the doctor/ nurse and properly explain your sickness." (HC-IV patient).
"In most cases you call and/or email your doctor to consult him/her about your health condition and s/he responds with certain prescriptions, advice .....we believe that's telemedicine! We have used it though at times don't realize it's actually the telemedicine." (RRH patient).
"We know what telemedicine is all about but different telemedicine services like mobile phone for calling, WhatsApp and email may work well in our hospital setting. Services like video conferencing can be used with hospitals in developed countries."(NRH patient).
Participants explained shortcomings they had experienced while using telemedicine to seek and/or receive healthcare within their hospital settings.
"Often times when you're feeling unwell, you just walk to the health centre to see the doctor/nurse for treatment. Although some cases you can always call to make an appointment with a specific clinician/doctor but in all you need to have physical interaction before you can receive treatment."(HC-IV patient).
"We have found it comforting and cost effective consulting and/or securing an appointment with the doctor. Experience has shown, what the doctor/clinician does, is to recommend First Aid treatment but also advise you to visit the nearest health centre. But if it's a follow-up treatment the doctor may provide you with medical advice without necessarily asking you to come to the health centre." (RRH patient).
"There [are] those emergencies when you can't easily reach the health centre but only to call the doctor for the quickest solution. Such cases are possible if there's prior physical interaction with the doctor otherwise you will always be referred to the nearby health centre. It's not easy to explain your health details to a stranger unless if there is a formal arrangement with a health centre." (NRH patient).
Patients at all health facility levels were concerned about barriers to the integration of telemedicine within the public health sector in Uganda. Issues raised related to laboratory tests, prescriptions, records, and the cost of telemedicine.
"When we use telemedicine to seek healthcare how then do we receive the drugs? How about if there's need for a blood test and to keep my patient's form? Those things (Telemedicine) can work well in developed countries." (HC-IV patient).
"This might work for absentee/scarce health workers ... maybe reducing congestions at hospitals ... although challenges [exist] such as; heavy investment by government to train health workers, providing extra incentives, building the infrastructure, and subscribing to data and voice networks." (RRH patient).
Overall, 128 respondents completed the technology readiness questionnaire. Respondents were from one HC-IV and RRH from each of the three regions, plus the NRH. Only the District Health Office in one district responded to the questionnaire. The distribution of the respondents is shown in Table 4, and responses to the questionnaire in Table 5.
Demographic Data of the 128 Respondents by Health Facility level/Office, Job Title
Job Title HCIV RRH NRH DHO District Health Officials 0 0 0 6 (4.7%) Consultants 0 20 (42.6%) 15 (26.8%) 0 Heads of Section/ Units / Directors 16 (12.5%) 27 (57.4%) 41 (73.2%) 0 Hospital - In charge 3 (2.3%) 0 0 0 Total 19 (14.8%) 47 (36.7%) 56 (43.8%) 6 (4.7%)
Summary statistics for the 128 respondents on technology readiness assessment
General Theme Characteristics Response District 1 District 2 District 3 NRH ( HC-IV ( RRH ( HC-IV ( RRH ( HC-IV ( DHO's ( RRH ( – General Question Knowledge about TM No 3 (42.9) 0 0 0 1 (25) 0 0 0 Yes 4 (57.1) 20 (100) 8 (100) 15 (100) 3 (75) 6 (100) 12 (100) 56 (100) Missing 0 0 0 0 0 0 0 0 ICT Technical Personnel Existence of ICT section at the HF. No 6 (85.7) 0 8 (100) 0 0 0 0 0 Yes 0 16 (80) 0 15 (100) 4 (100) 0 11 (91.7) 56 (100) Missing 1 (14.3) 4 (20) 0 0 0 6 (100) 1 (8.3) 0 Access to ICT Expert? No 0 14 (70) 8 (100) 0 4 (100) 0 8 (66.7) 0 Yes 3 (42.9) 0 0 15 (100) 0 0 0 56 (100) Missing 4 (57.1) 6 (30) 0 0 0 6 (100) 4 (33.3) 0 Access to ICT consultancy services No 0 14 (70) 8 (100) 0 4 (100) 0 8 (66.7) 0 Yes 3 (42.9) 0 0 15 (100) 0 0 0 56 (100) Missing 4 (57.1) 6 (30) 0 0 0 6 (100) 4 (33.3) 0 Existing ICT Equipment & Budget Existence of ICT Budget No 7 (100) 0 0 0 4 (100) 0 0 0 Yes 0 16 (80) 8 (100) 15 (100) 0 6 (100) 12 (100) 42 (75) Missing 0 4 (20) 0 0 0 0 0 14 (25) Access to Network Connectivity Access to Internet Services No 7 (100) 0 8 (100) 0 4 (100) 0 0 0 Yes 0 18 (90) 0 15 (100) 0 6 (100) 12 (100) 47 (83.9) Missing 0 2 (10) 0 0 0 0 0 9 (16.1) Type of Internet service Wireless 0 7 (25) 0 6 (40) 0 1 (16.7) 3 (25) 5 (8.9) Access to Network Connectivity Wireless, Modem 0 8 (40) 0 9 (60) 0 0 1 (8.3) 17 (30.4) Portable Modem 0 5 (25) 0 0 0 5 (83.3) 2 (16.7) 2 (3.6) Wireless, LAN, Modem 0 0 0 0 0 0 0 17 (30.4) Missing 0 0 0 0 0 0 6 (50) 15 (26.8) Does HF have a web-portal No 7 (100) 18 (90) 8 (100) 0 0 5 (83.3) 12 (100) 0 Yes 0 0 0 15 (100) 0 0 0 56 (100) Missing 0 2 (10) 0 0 4 (100) 1 (16.7) 0 0 Is there use of official e-Mail for internal or external communication? No 6 (87.5) 19 (95) 8 (100) 0 4 (100) 5 (83.3) 12 (100) 0 Yes 0 0 0 15 (100) 0 0 0 56 (100) Missing 1 (14.3) 1 (05) 0 0 0 1 (16.7) 0 0 Is the local network enabled for both voice and data? No 6 (87.5) 17 (85) 6 (75) 0 4 (100) 6 (100) 12 (100) 0 Yes 0 0 0 15 (100) 0 0 0 41 (73.2) Missing 1 (14.3) 1 (15) 2 (25) 0 0 0 0 15 (26.8) Is licensed anti-virus installed of the computer? No 6 (87.5) 15 (75) 6 (75) 0 2 (50) 5 (83.3) 11 (91.6) 13 (23.2) Yes 0 0 0 14 (93.3) 0 0 0 36 (64.3) Missing 1 (14.3) 5 (25) 2 (25) 1 (6.7) 2 (50) 1 (16.7) 1 (8.3) 6 (10.7) Is there dedicated IT personnel? No 5 (71.4) 18 (90) 8 (100) 0 4 (100) 5 (83.3) 12 (100) 32 (57.1) Yes 0 0 0 15 (100) 0 0 0 0 Missing 2 (28.6) 2 (10) 0 0 0 1 (16.7) 0 24 (42.9)
Despite moderate to high telemedicine knowledge, Technology Readiness at HC IVs was poor, and at some individual HC-IVs having an ICT budget, an ICT section, or access to ICT consultancy services did not equate to provision of any Internet related access and services. All RRHs were reported to have ICT budgets, an ICT section, and Internet access. Only one RRH in Western Region, had access to a web-portal, official email services, a network enabled for voice and data, anti-virus protection, and ICT security and therefore could be considered technology ready. The NRH was well provisioned with budget staff, services and security (Table 5).
Significant positive correlations were found between ICT equipment and budget, quality of service (p = 0.003), access to Internet connectivity (p < 0.001) and between ICT quality of service and access to network connectivity (p < 0.001).
The key findings of this study were that 70% of health professionals surveyed across three levels of HF were either aware of or had used (41%) telemedicine. However, over 40% of HWs at HC-IV and RRH were telemedicine naïve. All doctors who had used telemedicine were impressed with it. 'Telemedicine user' and 'telemedicine aware' respondents showed core, clinical, and e-learning readiness for telemedicine. Patients were also generally aware of telemedicine but identified barriers to its use. For technology readiness, although all respondents reported knowledge about telemedicine, only the RRH in District 3 and the national referral hospital appeared to be technology ready for telemedicine. The quality of service, equipment and budget for ICT is still a challenge, especially at the lower HF levels.
Relatively few eHealth or telemedicine readiness studies have been conducted in the developing world. Whilst every country is different, with different health systems, burdens of disease, health needs, infrastructure and political agendas, the key findings of such studies are quite similar. For example, in Palestine mHealth approaches were regarded a promising strategy for mental health treatment interventions [[
It is generally acknowledged that eHealth readiness assessment should be undertaken before implementing an eHealth solution [[
In part, this study addressed some of these issues. The readiness of three sectors of stakeholders was assessed each using specific tools and methods: health workers at different levels of health facility; management, IT and technical experts; and patients. The large sample size of health workers surveyed (406 participants) provided unusual insight of readiness for telemedicine, primarily because three groups were identified based on their use and / or awareness of telemedicine (telemedicine user, telemedicine aware, and telemedicine naïve), and compared. The responses of those who were unaware of telemedicine prior to the survey (telemedicine naïve) are based solely on their perception, and can be likened to the opinions of participants in a Technology Acceptance Model (TAM) study; TAM refers to an information systems theory that models how users come to accept and use technology, based on their perception of its usefulness and ease of use [[
Patient readiness for telemedicine was unclear, since patients in this study seemingly equated telehealth to use of the mobile phone. Attempting to understand patient readiness is uncommon but important, because as availability increases it is likely patients, even the general population, will be primary users. Certainly in developed countries the importance of a citizen-centric focus, and empowering citizens as change agents, has been embraced (
A recent eHealth readiness study in Mauritius found that 80% of respondents were aware of eHealth or had used telemedicine [[
All groups (users, aware and naïve) showed a positive attitude for core readiness and integration of telemedicine. Process workflow has been defined as all activities related to patient care and can refer to clinical and administrative workflows and integrated IT solutions are considered critical to optimizing workflows in healthcare [[
Both telemedicine users and non-users showed clinical readiness for telemedicine integration at the public health facilities. Health workers see the potential benefits of telemedicine but do not yet have access to the infrastructure necessary to take advantage of it. The willingness to use ICT for health may reflect growing use of social media platforms and comfort with using computers and mobile phones.
This study has further demonstrated that e-learning is being used, and that the majority feel it would be of benefit and are ready to use it. These findings also align with the literature, which provides many examples of the use of e-learning to educate, train, or maintain the skills of the health and social care workforce in both developed (NHS eLearning; https://
While this study did not comprehensively survey all HF sites, the likelihood is that most facilities will not have adequate infrastructure. While many HWs were either aware of and / or using telemedicine, the HC-IVs lacked infrastructure and the RRH's lacked secure Internet and Web access for communication, prerequisites for both asynchronous (store and forward) and synchronous (real time) telemedicine. If the necessary technology and user training is not available, successful telemedicine cannot ensue. The introduction of 3G/4G networks offering unlimited Internet data packages [[
The study also supported the literature which shows not only the need for eHealth readiness assessment, but the need for consistent terminology and description of a limited number of discrete readiness types, and the need for standardised tools for readiness assessment of different user groups (e.g., managers, funders, technical staff, doctors, nurses, patients, policy makers). Future research should focus on the latter two requirements.
Overall, the study findings can guide policy- and decision- makers in the health sector when designing, implementing, and scaling-up telemedicine services in Uganda and similar developing countries. It is recommended that eHealth readiness assessment be conducted for a specific intervention, and for specific groups in a particular healthcare setting using appropriate group specific readiness assessment tools, and not be generalised across all levels of HF. This will ensure evidence-based implementation and integration of telemedicine solutions relevant to the beneficiaries.
A major strength for this paper is that eHealth readiness was addressed using the critical domains and sub-domains identified from the literature as relevant to the Ugandan and developing country context. In addition, this is believed to be the largest and most disparate sample surveyed regarding readiness. Thus the total sample size was 534 participants, and study participants were diverse (ranging from patients, nurses/midwives, district health teams, public health professionals, consultants, doctors and physicians in-charge). Also, both users and non-users of telemedicine services were included in the analysis to ascertain core, clinical and e-learning readiness to integration of telemedicine. Limitations of the study were that the readiness of the private healthcare sector has not been investigated and that respondents' perceptions of, and understanding of, telemedicine varied.
With regards to core, clinical and e-learning readiness for integration of telemedicine into public health facilities in Uganda, doctors across all health facility levels are typically more ready than other health professionals. This is particularly so for those who are aware of and have used telemedicine, highlighting the importance of knowledge of and exposure to telemedicine services. Unsurprisingly patients at the varying HF levels, especially the lower level HC-IVs, were sceptical and non-committal to integration of telemedicine, also perhaps because of lack of knowledge and exposure. Of practical concern is the fundamental technology gap in terms of necessary ICT equipment, which requires immediate attention prior to on-going attempts to integrate telemedicine services. This work provides a foundation for further studies on readiness in Uganda and other developing countries concerning implementation of other aspects of eHealth.
Not applicable.
Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under Award Number D43TW007004. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
In addition, the funder did not have any attachment to the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.
The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.
Participants gave consent for direct quotes from their interviews/questionnaires to be used in this manuscript.
VMK, MM and RES conceptualized the need to conduct this study. VMK collected data and VMK and MM analysed the data. VMK, MM & RES conducted further data analysis and revised the paper. All authors read through and approved the paper for final submission.
This study was approved by the Humanities and Social Science Ethics Committee of the University of KwaZulu-Natal and all participants gave written informed consent prior to responding to a questionnaire or participating in a focus group. In addition, further permission was granted by the Uganda's Ministry of Health and the respective District Health offices to conduct this study at the respective health units.
Not applicable.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Graph: Appendix 1. Core, Clinical and eLearning Readiness Assessment Questionnaire. (DOC 66 kb)
Graph: Appendix 2. Technology Readiness Assessment Questionnaire. (DOC 69 kb)
Graph: Appendix 3. Focus Group Discussion Guide with patients. (DOC 30 kb)
Graph: Appendix 4. Detailed breakdown of results by health facility. (DOC 91 kb)
• FGD
- Focus Group Discussion
• HC-IVs
- Health Center Fours
• HFs
- Health Facilities
• HWs
- Health Workers
• ICT
- Information and Communications Technology
• IT
- Information Technology
• NRH
- National Referral Hospital
• OPD
- Out-Patient Department
• RRH
- Regional Referral Hospital
• WHO
- World Health Organization
By Vincent Micheal Kiberu; Richard E. Scott and Maurice Mars
Reported by Author; Author; Author