An evaluation of a Framework for Supporting Ehealth Service Delivery in a Ugandan rural setting (Preprint)
Authors: Ali Mwase 
Published: April 2022

BACKGROUND

In developing countries, especially where a large proportion of the population still resides in rural areas, healthcare access and delivery are often poor, and can potentially benefit from innovative service models and supporting technologies (Barjis et al,2013). Health perspectives differ between rural and urban communities. The health perceptions of rural and urban residents significantly reflect their health-promotion behaviours, health maintenance, and illness treatment (Ouma & Herselman,2009).
Health service delivery to rural communities has always been challenged with specialized services and infrastructure are usually less available (Ouma & Herselman,2009). It is argued that rural communities are confronted with the out-migration of working-age adults from rural to urban areas and the in-migration of former urban dwellers, often at retirement age. This affects the quality of life and health in rural communities (Hage et al.,2013). Nonetheless,e-Health services are seen as a solution to these concerns. This is because e-Health has diverse web portals and encompasses both core healthcare services and social innovation (Hage et al.,2013). Electronic health (e-health) is the application of ICT across a whole range of functions that affect the healthcare industry when it comes to matters relating to health through the various solutions that exist (Ouma & Herselman,2009).
Ehealth initiatives present the ability to tackle challenges that exist within the healthcare industry especially for the rural communities (Ouma & Herselman,2009). These initiatives are artifacts in form of models, frameworks, web-based and mobile-based applications or platforms. However, it is argued that a designed artifact ought to be verified for quality, effectiveness, and efficiency using well-grounded assessment approaches (Iivari & Venable,2009). Offermann et al (2007) moreover adds that a designed artifact can be evaluated in terms of completeness, accuracy, functionality, reliability, consistency, traceability, understandability, usability among others. In another related study, it is asserted that researchers rigorously evaluate designed artifacts and this should be done through evaluation methods like observational, analytical, experimental, testing, and descriptive (Hevner et al,2004). Oesterle et al (2010), further argue that artifact evaluation is done through laboratory experiments, pilot applications (i.e. instantiation of prototypes), simulation procedures, expert reviews (Delphi technique approach), and field experiments (i.e. instantiations in several user organizations). This paper, therefore, is aimed at evaluating a designed framework for supporting Ehealth Service Delivery in Iganga district, a rural setting of Uganda using the expert judgment evaluation method.
The rest of the paper is organized as follows, Section 2 presents the literature review, section 3, methodology, in section 4 results are presented and in section 5, the conclusion and recommendations are presented.

OBJECTIVE

This paper, therefore, is aimed at evaluating a designed framework for supporting Ehealth Service Delivery in Iganga district, a rural setting of Uganda using the expert judgment evaluation method.

METHODS

This study adopted the Design Science Research Methodology. Design science methodology attempts to create things that serve human purposes and it is technology-oriented (March & Smith, 1995), and is a paradigm in information system science for understanding, executing, and evaluating research that aims at designing new and novel artifacts intended to solve identified organizational problems (Hevner et al., 2004). The artefacts can be defined as constructs, models, methods, or instantiations.
A quantitative research approach was adopted and used in the evaluation exercise. Avison and Heje (2005) argue that quantitative research enables researchers to answer scholarly and practical questions about the interaction of humans and artifacts such as computer systems and applications.
According to Skulmoski et al (2007), when applying the Delphi technique, a sample of between 10 to 15 people yields sufficient results. In this study, therefore 13 ehealth experts were purposively selected from the 5 health facilities around two divisions (Central and Northern division) of Iganga District. A five-point Likert scale questionnaire was administered for data collection. Spss v20 software was used for data analysis and descriptive statistics were generated.

RESULTS

This study adopted the expert judgment (Delphi technique approach) evaluation method to evaluate the FSEHSD. This is because the expert judgment relies on a group of experienced scientists with a good understanding of environmental problems and who are the most knowledgeable and capable members of society to judge the relative significance of interventions(Virtanen et al,1999). The expert judgment further plays a vital role in risk management, uncertainty analysis, and decision-making(Beaudrie et al,2016). The results are of the study are presented throughout section 4 of this paper.
4.1 Study Participants
A total of 13 participants were purposively selected to participate in the evaluation exercise. These participants included 2 database administrators, 2 IT/ IS managers, and 2 IT/IS experts from the 5 health facilities, and 3 Ehealth experts.
Table 1: Breakdown of participants involved in the evaluation of the FSEHSD
Participants	Health facilities	No
Database administrators, IT/ IS managers, IT/IS experts	Iganga Nakavule Hospital(Database administrator 1, IT/IS expert 1)
Mercy Health Centre(Database administrator 1, IT/IS expert 1)
Iganga Municipal Council HC(Database administrator 1, IT/ IS manager 1)
PeakPoint HC(Database administrator 1, IT/ IS manager 1)
Iganga Islamic Medical Centre(Database administrator 1, IT/ IS manager 1)	2
2
2
2
2
Ehealth experts	1
1
1
Total	05
13

4.2 Framework usability (ease of use).
Table 2: Evaluation results of the FSEHSD from 5 health facilities based on the parameter of usability
SD	D	NS	A	SA
1.0 Usability (ease of use) of the framework
1.1	Is the framework easy to learn and use?	0%	9.1%	9.1%	18.2%	63.6%
1.2	The framework requires little or no training to be used.	0%	0%	9.1%	27.3%	63.6%
1.3	Is the framework easy to understand?	0%	0%	18.2%	9.1%	72.7%
The results presented in table 2 above indicate that majority (72.7%) of the respondents agreed that the framework is easy to understand. In addition, 63.6% of the respondents indicated that the framework requires little or no training to be used. It was also observed that 63.6% of the respondents reported that the framework is easy to learn and use.

4.3 Framework traceability.
Table 3: Evaluation results of the FSEHSD from 5 health facilities based on the parameter of traceability
SD	D	NS	A	SA
2.0 Traceability of the framework
2.1	Are the various components of the framework are interdependent on each other?	0%	0%	0%	18.2%	81.8%
2.2	The guidelines/principles of the framework are interrelated.	0%	0%	9.1%	18.2%	72.7%
2.3	Are the factors/variables leading to supporting Ehealth logically arranged?	9.1%	18.2%	9.1%	9.1%	54.5%

The results presented in table 3 above indicate that majority (81.8%) of the respondents indicated that the various components of the framework are interdependent. In addition, 72.7%% of the respondents indicated that guidelines/principles of the framework are interrelated. It was also observed that 54.5% of the respondents indicated that the factors/variables leading to supporting Ehealth were logically arranged.

4.4 Framework functionality.
Table 4: FSEHSD evaluation results based on the parameter of functionality
SD	D	NS	A	SA
3.0 Functionality of the framework
3.1	The framework addresses all the major challenges hindering Ehealth service delivery in the Iganga district.	18.2%	9.1%	9.1%	9.1%	54.5%
3.2	The framework simplifies the process of supporting Ehealth service delivery by providing guidelines or principles to be followed.	0%	0%	9.1%	18.2%	72.7%
3. 3	Does the framework contribute to the support of Ehealth service delivery in the Iganga district?	0%	0%	18.2%	18.2%	63.6%
Regarding the functionality evaluation parameter, the results indicate that majority (54.5%) of the respondents agreed that the framework addresses all the major challenges hindering Ehealth service delivery in the Iganga district. In addition, 72.7% of the respondents agreed that the framework simplifies the process of supporting Ehealth service delivery by providing guidelines or principles to be followed. Lastly, it was also observed that 63.6% of the respondents indicated that the framework contributes to the support of Ehealth service delivery in the Iganga district.
4.5 Results from the Ehealth experts
4.5.1 Framework Usability.
Table 5: Evaluation results from Ehealth experts based on the parameter of usability
SD	D	NS	A	SA
1.0 Usability (ease of use) of the framework
1.1	Is the framework easy to learn and use?	0%	0%	0%	0%	100%
1.2	The framework requires little or no training to be used.	0%	33.3%	0%	33.3%	33.3%
1.3	Is the framework easy to understand?	0%	33.3%	0%	0%	66.7%

The results in table 5 above indicate that all the experts indicated that the framework was easy to learn and use, and further the majority (66.7%) agreed that the framework is easy to understand. In addition, 33.3% of the experts indicated that the framework requires little or no training to be used.
4.5.2 Framework Traceability.
Table 6: Ehealth experts opinions based on the parameter of traceability
SD	D	NS	A	SA
2.0 Traceability of the framework
2.1	Are the various components of the framework are interdependent?	33.3%	0%	33.3%	33.3%	33.3%
2.2	The guidelines/principles of the framework are interrelated.	0%	0%	0%	66.7%	33.3%
2.3	Are the factors/variables leading to supporting Ehealth logically arranged?	33.3%	33.3%	0%	0%	33.3%
The results in table 6 above indicate that 33.3% of respondents reported that the various components of the framework are interdependent, 66.7% of the respondents reported that the guidelines/principles of the framework are interrelated and 33.3% of respondents disagreed that the factors/variables leading to supporting of Ehealth logically arranged.
4.5.3 Framework functionality.
Table 7: Ehealth experts opinions based on the parameter of functionality
SD	D	NS	A	SA
3.0 Functionality of the framework
3.1	The framework addresses all the major challenges hindering Ehealth service delivery in the Iganga district.	0%	33.3%	0%	0%	66.7%
3.2	The framework simplifies the process of supporting Ehealth service delivery by providing guidelines or principles to be followed.	0%	33.3%	0%	33.3%	33.3%
3.3	Does the framework contribute to the support of Ehealth service delivery in the Iganga district?	0%	33.3%	0%	0%	66.7%
Ehealth experts' evaluation opinions regarding the parameter of traceability indicate that majority (66.7%) of the experts agreed that the framework addresses all the major challenges hindering Ehealth service delivery in the Iganga district. In addition, 33.3% of the respondents indicated that the framework simplifies the process of supporting Ehealth service delivery by providing guidelines or principles to be followed. Lastly, it was also observed that 66.7% of the respondents indicated that the framework contributes to the support of Ehealth service delivery in the Iganga district.
4.5.4 General Experts recommendations for an improved FSEHSD
Through face-to-face interactions with the experts, the experts recommended government consideration as one of the constructs of the framework. Additionally, the experts suggested that the variables for the FSEHSD be rearranged to get a uniform flow such as a bottom-up approach, top-bottom, or left to right. This issue was given attention by the researchers and hence the FSEHSD variables were rearranged to the new top-bottom flow as seen in figure 1, section 4.5.5 of this paper.
Another expert suggested the need to consider integration and interoperability of information from different Ehealth systems. But with the existence of the ICT training to staff and Human resource recruitment and capacity building constructs as part of the FSEHSD, the staff shall be equipped with skills to develop interoperable Ehealth systems that integrate information from different Ehealth systems. Therefore the FSEHSD was fine-tuned and thus improved to incorporate the suggestions from the experts.

4.5.5 The Evaluated framework (FSEHSD)
In this study, the artifact is the designed Framework for Supporting Ehealth Service delivery in a rural setting of Uganda ( FSEHSD). This is presented in figure 1 below and subsequently explained in section 4.5.5.1.

Figure 1: The Framework for Supporting Ehealth Service delivery in Iganga District, Uganda. ( FSEHSD)

4.5.5.1 Explanation of the Framework for Supporting Ehealth Service delivery in a Ugandan rural setting.

A favourable government policy should provide a legal framework to support the Ehealth budget and this will lead to the availability of funds for supporting Ehealth in terms of setting up the infrastructure which includes implementations of suitable secure backing up of data in a secondary device or location and power backups like standby generators and solar power. Hence constant power supply leads to internet connectivity. In so doing Ehealth service delivery is supported.
Availability of funds will also aid capacity building that will see that there is the recruitment of qualified staff and ICT personnel, ICT trainings being conducted as well as sensitization of Ehealth to the public. Once the staff is trained, they can develop, operate and provide sustainable technical support for coordinated Ehealth systems. Ehealth systems should provide data reporting and a feedback mechanism inform of SMS alerts, emails to service recipients as well as stakeholders. Finally, appropriate monitoring and evaluation techniques should be implemented across all chains to ensure effectiveness and comprehensiveness. Hence supported Ehealth service delivery. Thus the FSEHSD can be used to support Ehealth service delivery in a Ugandan rural setting since the majority of the challenges concerning Ehealth service delivery have been addressed. Moreover, the experts opinions have also been incorporated.

CONCLUSIONS

In this digital age, the potential for effective use of Ehealth initiatives in healthcare in rural settings is promising. This study looked at the concept of evaluating a designed framework for supporting Ehealth service delivery (FSEHSD) in a rural setting to ensure that health facilities seamlessly deliver services and exchange information amongst health workers and patients. The FSEHSD was evaluated using the Delphi technique and the findings revealed that the framework was useful and the framework layout was understandable and applicable. This affirms that the FSEHSD can support Ehealth service delivery in a Ugandan rural setting.