mediterranean journal of medical sciences (mjms)

8/10/2019 Mediterranean Journal of Medical Sciences (MJMS)

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Mediterranean Journal of Medical Sciences Volume 1, Issue 1, October 2014: 1-5

Original Paper

Screening Program for Proteinuria in Rural AdultPopulation:Kirsehir, Turkey

Mehmet ZDEMIR*, Glay AKGL*

*Ahi Evran UniversityTraining and Research Hospital, Kirsehir, Turkey

Background objectives: The burden of kidney disease is disproportionately high in central Anatolia, and the conditions often remain undiagnosed until late-stage disease. In order toreduce this burden, strategies must be implemented to improve the detection of kidney disease,and preventative measures must be targeted at those at greatest risk of disease. Importantrisk factors among include hypertension, diabetes, and obesity. As the exact prevalence ofproteinuria is not known in the general population, we undertook this study to estimate thesame in a rural adult population in Kirsehir district.Methods: A survey of health and health related issues was conducted on 2524 volunteers,average age 52.19 years, selected randomly from the Kirsehir District, Turkey. A dipstickurinalysis and test for Proteinuria was performed on a clean void, untimed urine sample as apart of a 4-hour interview/examination. Ultrasound of the abdomen was done in patients

with renal failure and renal biopsy was performed in selected patients.Results: Of the total 2524 individuals screened, 61.3 per cent were females. Mean age of thestudy population was 51.19 11.2 yr. First dipstick test identified 289 individuals positive foralbuminuria. Repeat dipstick could be done in only 263, of whom 117 showed persistentalbuminuria. Significant proteinuria was detected in 14 individuals of the 208 who had 24 hurine protein measured. Of these 14 patients, 3 were found to have chronic renal failure, 6were presumed to have diabetic nephropathy clinically, one each had focal segmental glomerulosclerosis and biopsy proven diabetic nephropathy, and 4 patients had proteinuria ofunknown aetiology.Interpretation conclusion: The prevalence of proteinuria in this adult rural population was

0.47 per cent (0.30-0.67%) and Males were more affected than females. The detection andtreatment of chronic kidney disease in 14 individuals is bound to reduce the rate of decline ofrenal functions.

Key words Albuminuria - dipstick - endstage renal disease - proteinuria

1. Introduction

Proteinuria is defined as urinaryprotein excretion of greater than150 mg per day. Urinary proteinexcretion in healthy persons

varies considerably and may reachproteinuric levels under severalcircumstances. Most dipstick tests(e.g., Albustin, Multistix) that are


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Mediterranean Journal of Medical Sciences V1, I1 October 2014: 1-5 2

2014 Mediterranean Center of Medical Sciences

positive for protein are a result ofbenign proteinuria, which has noassociated morbidity ormortality[5]

. Among the various

predictors of progression ofchronic kidney disease to endstage renal disease (ESRD),proteinuria is the most potentpredictor[6]. Angiotensinconverting enzyme (ACE)inhibitors (ACEi) and angiotensinII receptor blockers (ARB) have

been given to persons withproteinuria and chronic kidneydisease to decrease the progressionto end stage renal disease[4,7-11],treatment of proteinuric patientswith ACEi and ARB has beenshown to decrease the rate ofprogression of chronic kidneydisease.Since the exact prevalence andcause of proteinuria as a marker ofkidney disease is not known inour population, we undertook thisstudy to estimate the same in arural population inKirsehir.

2. Material & Methods

A convenient sample of 2524adults (aged 40 yr and above)from rural area ofKirsehir, Turkeywas included in the study. Thestudy was carried out for a periodof 24 months between April 2011and April 2013. Individuals wereselected under an ongoingcommunity health programme bythe Department of Urology, Ahi

Evran University Training andResearch Hospital, Kirsehir,Turkey.After explaining about theobjective of the study, individualswere tested for albuminuria bydipstick examination (MultistixSG, Bayer Diagnostics) in anuntimed urine sample. Individualswho had acute illness, nonambulatory persons andmenstruating women were

excluded. Individuals testedpositive for albuminuriaunderwent a second dipstickexamination after a gap of oneweek. Repeat dipstick wasperformed to rule out transientproteinuria.Individuals with persistentalbuminuria on the seconddipstick examination underwentfurther evaluation at the whichincluded medical history, physicalexamination, 24 h urine proteinestimation, total serum proteinand albumin estimation. Thosewho had proteinuria (proteinexcretion >150 mg/day on 24 h

urine protein estimation)underwent urine microscopicexamination, blood urea andserum creatinine, fasting andpostprandial blood sugar levelestimations. Ultrasound of theabdomen was done in patientswith renal failure (serumcreatinine >1.4 mg/dl). Renalbiopsy was performed in patientswith proteinuria >1 g/day or


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were away from home at workduring the time of samplecollection. Among the variousaetiological factors, diabeticnephropathy was found in 7 of 14patients (50%) with proteinuria.Seven patients with significantproteinuria not meeting thecriteria for a renal biopsy arebeing followed up. Patients withdiabetic nephropathy wereadvised euglycaemic measures and

are on follow up with the healthdepartment. One individual withfocal segmentalglomerulosclerosis was treated

with ACEi and has stable renalfunction. The risk of renal failure

is greater in younger patients.In conclusion, although theprevalence of proteinuria in thisrural population was low,detection and treatment of chronickidney disease in 14 individualswith proteinuria is likely to reducethe rate of decline of renalfunction. Similar screening

programmes for proteinuria withproper study design in different

parts of the country may prove tobe an effective measure inreducing the burden of chronickidney disease.

AcknowledgmentThe authors thank trained healthcare workers at Ahi EvranUniversity Training and ResearchHospital, Kirsehir, Turkey fortheir assistance in performing

urine dipstick examination.

References

1. Nakopoulou L, Stefananki K, Papadakis J,Boletis J, Zeis PM, Kostakis A etal. Expression of bcl-2 oncoproteinin various types ofglomerulonephritis and renalallografts. Nephrol Dial Transplant1996; 11: 9971002

2. Gerstein HC, Mann JF, Yi Q, et al.Albuminuria and risk ofcardiovascular events, death, andheart failure in diabetic andnondiabetic individuals. JAMA 2001; 286 : 421-6.

Table 2. Prevalence rate of proteinuria ( ) according to age and gender Age Males Females(yr) (N) Prevalence (N) Prevalence

40-59 621 0.60 (0.58 - 0.62) 1050 0.62 (0.61 - 0.64)60-79 319 0.32 (0.30 - 0.34) 441 0.35 (0.347 -0.349)>80 36 0.07 (0.06 - 0.09) 57 0.03 (0.027 -0.029)Total 976 1548Values in parentheses indicate range


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M. ZDEMIR, G. AKGL 5

http://www.mcmscience.org

3. James PA, Oparil S, Carter BL, et al. 2014evidence-based guideline for themanagement of high blood pressurein adultsreport from the panelmembers appointed to the Eighth Joint National Committee (JNC 8).The Journal of the American Medical Association. Published onlineDecember 18, 2013.

4. Anastasio, P, Spitali, L, Frangiosa, A,Molino, D, Stellato, D, Cirillo, E,Pollastro, RM, Capodicasa, L, Sepe, J, Federico, P, Gaspare De Santo, N(2000) Glomerular filtration rate inseverely overweight normotensivehumans. Am J Kidney Dis 35 (6)

1144-1148.5. Lindholm LH, Ibsen H, Dahlof B,et al.Cardiovascular morbidity andmortality in patients with diabetesin the Losartan Intervention ForEndpoint Reduction inHypertension Study (LIFE): arandomised trial against atenolol.Lancet 2002; 359 : 1004-10.

6. Jafar TH, Schmid CH, Landa M, et al.Angiotensin-converting enzymeinhibitors and progression ofnondiabetic renal disease: a meta-analysis of patient-level data. AnnIntern Med 2001;135 : 73-87.

7. Uluhan A, Payda S, Sal ker Y, Demirta M, Bozdemir H, Sar ca Y: Lowblood pressure and amyloidosis.Nephron 1995; 69: 118-119

8. Agodoa LY, Appel L, Bakris GL,et al.Effect of ramipril vs amlodipine onrenal outcomes in hypertensivenephrosclerosis: a randomizedcontrolled trial. JAMA 2001; 285 :2719-28.

9. Lewis EJ, Hunsicker LG, Clarke WR,et al.Renoprotective effect of theangiotensin-receptor antagonistirbesartan in patients withnephropathy due to type 2 diabetes.N Engl J Med 2001; 345 : 851-60.

10. Brenner BM, Cooper ME, de Zeeuw D,etal. Effects of losartan on renal andcardiovascular outcomes in patientswith type 2 diabetes and

nephropathy. N Engl J Med2001; 345 : 861-9.11. Saati , zdemir S, zen S, Bakkalolu

A: Serum concentration and urinaryexcretion of beta 2 microglobulinand microalbuminuria infamilialMediterranean fever. Arch DisChild 1994; 70: 27-29

12. Aktu H, etinta VB, Kosova B, OltuluF, Demiray B, avuolu T et al.Dysregulation of nitric oxidesynthase activity and Bcl-2 andcaspase-3 gene expressions in renaltissue of streptozotocin-induceddiabetic rats. Turk J Med Sci 2012;42: 8308


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Original Paper

Urinary Tract Infections (UTI) Among Patients at theUniversity Hospital Center Mother Theresa , Tirana,Albania.

Selam Shkurti*

*Department of Emergency, University Hospital Center "Mother Theresa", Tirana, Albania.

AbstractBackground objectives: The resistance of bacteria causing urinary tract infection (UTI) tocommonly prescribed antibiotics is increasing both in developing as well as in developedcountries. Resistance has emerged even to more potent antimicrobial agents. The primaryobjective of the study was 1) to detect the prevalence rate of bacterial infection among urinaryisolates from patients having UTI and 2)to detect prevalence rate of drug resistance amongpathogen isolate from patients having UTI.Methods: Early morning mid-stream urine samples were collected using sterile, widemouthed container with screw cap tops. On the urine sample bottles were indicated name, age,sex, and time of collection along with requisition forms. Results:. Significant association (P


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least 59% of cases. Other lesscommon pathogens includeKlebsiella, Proteus, Enterobacterspp, etc. To be mentioned that thedistribution of pathogens thatcause UTI is changing. There areseveral factors and abnormalitiesof UTI that interfere with itsnatural resistance to infections.These factors include sex and agedisease, hospitalization and

obstruction in urinary tract.The treatment of UTIs variesaccording to the age of the patient,sex, underlying disease, infectingagent and whether there is loweror upper urinary tractinvolvement. Diagnosis of UTIoften requires laboratoryexamination of a urine sample inaddition to clinical evaluation.Although many guidelinesindicate that the culture of urine isnot required in most cases ofuncomplicated cystitis[1], thelaboratory in UHC MotherTeresa, accepts all such requestsfrom patients to send samples on

all suspected UTI.With the increasing trend ofantibiotic-resistance in E. coli, themanagement of urinary tractinfections is likely to becomecomplicated with limitedtherapeutic options.

2. Material & Methods

Study site: The study was carriedout in the Department ofEmergency, University HospitalCenter "Mother Theresa", Tirana,Albania from November 2006 toSeptember 2007.This was an analysis of datagenerated from the records ofconsecutive urine samplesreceived in the laboratory during

the study period.Analysis of the data was carriedout focusing on the age, gender,whether admitted or not, whetherreceived prior antibiotic therapy,any surgical or gynaecologicalintervention performed in therecent past, and any history ofurinary tract infection in the past.The antibiotic susceptibility dataof all isolates were also reviewedand analyzed. Samples receivedincluded mid-stream clean catchurine, suprapubic aspirate, urinecollected from Foleys catheterand from the nephrostomy tubeunder sterile precautions, in

patients who had undergonepercutaneous nephrostomy.Samples were processed andisolates were identified as perstandard methods 14. All urinesamples were inoculated ontocysteine lactose electrolytedeficient (CLED) medium using acalibrated loop (volume-0.005 ml)

and were incubated for 18-24 h at37 C. Wet mount preparations


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S. Shkurti 9


were also made from all urinesamples to look for pus cells andepithelial cells. Depending uponthe number of the colonies grownon the CLED medium, theinterpretations of urine culturewere made as insignificant (50 -


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males) had positive culture resultand there was a statisticallysignificant relation betweengender and UTI (p=0.005).Wet mount microscopy forpresence of bacteria or pus cells insignificant amount per field hadsensitivity, specificity, positivepredictive value (PPV) andnegative predictive value (NPV)of 83, 58, 44 and 89 per cent,respectively in detecting

infections.Of the 2876 culture positives, E.coli was the most common (59%)isolate. (Table I).

4. Discussion

Ciprofloxacin and ofloxacin arethe most extensively usedfluoroquinolones for thetreatment of UTIs. This studyshowed that E. coli was thecommonest pathogen causingcomplicated and uncomplicatedUTI as described previously[1][3]. There are several organismsknown to cause UTIs, including

P. aeruginosa, S. saprophyticus,S.epidermidis, Enterococcusspp,P. mirabilis, Klebsiella spp.,Citrobacter spp, etc. as reported byearlier workers[4] . This study alsodemonstrates the emergence of E. faecalis and the non-fermenters Acinetobacterspp and Pseudomonasspp as major uropathogens

especially in the patients admittedin the hospitals, more so in the

intensive care units. Such findingshave been documentedelsewhere[5-16]. The percentage ofisolates of E.coli resistant toampicillin was found to be asmuch as 80 per cent in our set up.Such high levels of resistance toampicillin have been quoted bymany other studies from differentparts of Albania[5]. Our MICresults showed thatfluoroquinolone resistance

increased significantly withpatients age. An MIC of 256 g/ml was noted in the age groupof >60 yr of age. There could betwo explanations for this. Firstly,as a consequence of frequentexposure to fluoroquinolonesresulting from the treatment ofrepeated infections in elderlyleads to increase in MIC offluoroquinolone19. Secondly,unlike urinary tract infections(UTIs) in females, UTIs in malesare frequently complicated and aremore likely to require prolongedantimicrobial therapy, especiallyin the elderly, potentially

explaining the fluoroquinolonethe higher MIC[25].


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S. Shkurti 11


References

1. Vellinga A, Cormican M, HanahoeB, Murphy AW: Predictivevalue of antimicrobialsusceptibility from previousurinary tract infection in thetreatment of re-infection. Br JGen Pract 2010, 60:511-513.

2. Gatermann SG. Bacterial infections ofthe urinary 1. tract. In: BorrielloP, Murray PR, Funke G. editors.Topley & Wilsons microbiology &microbial infections,10th ed. vol.

III. London: Hodder ArnoldPublishers; 2007. p. 671-83.3. Karlowsky JA, Jones ME, Thornsberry

C, Critchley I, Kelly LJ, SahmDF. Prevalence of anti microbialresistance among urinary tractpathogens isolated from femaleoutpatients across the US in1999.Int J Antimicrob Agents2001;18: 121-7.

4. Gorbach SL, Bartlett JG, BalcklowNR. Urinary tract. In: GorbachSL, Bartlett JG, Balcklow NR,editors. Infectious diseases.Philadelphia: LippincottWilliams & Wilkins Publishers;2004. p. 861-81.

5. Idrizi, Alma, et al. "Urinary tractinfections in polycystic kidneydisease." Med Arh 65.4 (2011): 213-5.

6. Zervos MJ, Hershberger E, NicolauDP, Ritchie DJ, Blackner LK,Coyle EA, et al. Relationshipbetween fluoroquinolone useand changes in susceptibility tofluoroquinolones of selectedpathogens in 10 United Statesteaching hospitals, 1991-2000.Clin Infect Dis2003; 37: 1643-8.

7. Arslan H, Azap OK, Ergnl

O,Timurkaynak F. Risk factorsfor ciprofloxacin resistanceamong Escherichia coli strains

isolated from community-acquired urinary tract infectionsin Turkey. J AntimicrobChemother2005;56: 914-8.

8. Karlowsky JA, Kelly LJ, ThornsberryC,Jones ME, Sahm DF. Trendsin antimicrobial resistanceamong urinary tract

9. Kahlmeter G. An international surveyof 8. the antimicrobialsusceptibility of pathogens fromuncomplicated urinary tract

infections: the ECOSENSProject. J Antimicrob Chemother2003;51: 69-76.

10. Anjum F, Kadri SM, Ahmad I,Ahmad S. A study of recurrenturinary tract infection in womenattending the outpatientdepartment of SMHS hospital,Srinagar, Kashmir, India. JK -Practitioner2004;11: 272-3.

11. Kauser Y, Chunchanur SK, NadagirSD, Halesh LH,Chandrashekhar MR. Virulencefactors, serotypes andantimicrobial susceptibilitypatterns of Escherichia coli inurinary tract infections. AJMS2009; 2 : 47-51.

12. Pais P, Khurana R, George J. Urinarytract infections: A retrospectivesurvey of causative organisms

and antibiotics prescribed in atertiary setting. Indian JPharmacol2002; 34: 278-80.

13. Ena J, Amador C, Martinez C, Ortizde la Tabla V. Risk factors foracquisition of urinary tractinfections caused byciprofloxacin-resistantEscherichia coli. J Urol 1995; 153:117-20.

14. Tabibian JH, Gornbein J, Heidari A,Dien SL, Lau VH, Chahal P, etal. Uropathogens and host


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characteristics. J Clin Microbiol2008; 46 : 3980-6.

15. Collee JG, Duguid JP, Fraser AG,Marmion BP, Simmons A.

Laboratory strategy in thediagnosis of infectivesyndromes. In: Collee JG, FraserAG, Marmion BP, Simmons A,editors. Mackie & McCartneypractical medical microbiology, 14thed. New York: ChurchillLivingstone; 1999. p. 84-90.

16. James HJ, John DT. SusceptibilityTest Methods: Dilution andDisk Diffusion methods. In:Murray PR, Baron EJ, Jorensen JH, Landry ML, Michael AP,editors. Manual of clinicalmicrobiology, 10th ed.Washington, D.C.: AmericanSociety for Microbiology Press;2007. p. 1152-72.

17. Clinical Laboratories StandardsInstitute (CLSI). Performance ofstandards for antimicrobial disk

susceptibility tests;approvedstandards. 10th ed. M02-A10. vol.29. Wayne, PA: CLSI; 2009.

18. Hooper DC. Emerging mechanismsof fluoroquinolone resistance.Emerg Infect Dis2001; 2 : 338-41.

19. Canbaz S, Peksen Y, Tevfik SA,Leblebicioglu H, Sunbul M.Antibiotic prescribing andurinary tract infection. Int

JAntimicrob Agents2002; 20 : 407-11.20. Boyd LB, Atmar RL, Randall GL,

Hamill RJ, Steffen D,Zechiedrich L. Increasedfluoroquinolone resistance withtime in Escherichia coli from>17,000 patients at a large countyhospital as a function of culturesite, age, sex, and location. BMCInfect Dis 2008;8 : 4-10.

21. Hooton TM. Fluoroquinolones andresistance in the treatment of

uncomplicated urinary tractinfection. Int J Antimicrob Agents2003; 22: S65-S72.

22. Arjunan M, Al-Salamah AA,

Amuthan M. Prevalence andantibiotics susceptibility ofuropathogens in patients from arural environment, Tamil Nadu. Am J Infect Dis2010;6 : 29-33.

23. Bhargavi PS, Gopala Rao TV,Mukkanti K, Dinesh Kumar B,Krishna TP. Increasingemergence of antibacterialresistance mainly inuropathogens:southeast part ofIndia. Intl J Microbiol Res2010; 2 :1-6.

24. Gupta N, Kundra S, Sharma A,Gautam V,Arora DR.Antimicrobial susceptibility ofuropathogens in India. J InfectDis Antimicrob Agents2007; 24 :13-8.

25. Manjunath GN, Prakash R, AnnamV, Shetty K. Changing trends in

the spectrum of antimicrobialdrug resistance pattern ofuropathogens isolated fromhospitals and communitypatients with urinary tractinfections in Tumkur andBangalore. Int J Biol Med Res2011; 2 : 504-7.

25. Hummers-Pradier E, Koc M, OhseAM, Heizman WR, Kochen

MM. Antibiotic resistance ofurinary pathogens in femalegeneral practice patients. Scand JInfect Dis 2005; 37: 256-61.


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Original Paper

Factors affecting the introduction of ICTs forhealthcare decision-making in hospitals ofdeveloping countriesNajam Afaq Qureshi 1 Qamar Afaq Qureshi 2 Dr. Muhammad ZubairKhan 2 Dr. Bahadar Shah 3 Irfan Marwart 2

1Sarhad University, Pakistan, 2Gomal University, Pakistan, 3Hazara University, Pakistan

AbstractBackground objectives: Several studies have evaluated the impacts of ICTs on decision-making process in both public and private health organizations but there is a dearth of suchstudies that integrate ICTs and effective decision making in Pakistan. Since the Pakistani governments continue to provide huge IT investment for its designated e-governmentagencies, the need to comprehend the impacts of ICTs on effective decision making becomesmore important.Methods: This study strives to ameliorate the comprehension of the impacts of ICTs fordecision-making process at all management levels of both public and private healthorganizations in Pakistan. Research on the information and communication technologies fordecision-making is tabling new tools and techniques in the marketplace.Results: This study attempts to unearth literature review-based definition of the localdecision-situations to help private and public sector organizations in Pakistan.Interpretation conclusion: In the emerging ICTs environment, IT elements such as e-mailand group support facilities improve the coordination among the members of an organizationin decision making. The use of these ICTs improves the organizational communication, whichultimately leads to effective decision-making

Key words: ICTs; adoption factors; decision-making; healthcare; developing countries.

1. Introduction

The concept of global-villageindicates high levels of interactionbetween nations of the world. Italso reflects impacts ofglobalization with global cultureon the organizational life of publicand private organizations workingin both developed and developingsocieties (Luthans, 2002: 47).

Modern organizational life ischaracterized with complexenvironments demanding theprocessing of huge data to analyzeand diagnose complex situations(Robbins, 1998:6). It is the fast-paced, global, highly competitiveand information-intensiveenvironment, due to whichmanagers are facing new decision-


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making challenges (Boiney,2000:33).

Despite these environmentalpressures, the decision-making isunanimously considered as themost important and uniquefunction of every manager(Drucker, 1974:465; Loomba,1978:3). In this modern agetraditional decision-makingapproach has been replaced by a

systematic decision makingprocess (Weihrich and Koontz,1999:199), which is a key factordriving the quest for informationand development of supportingtechnologies (Boiney, 2000:32;Turban et al., 2004:544). Digitaltechnology has influenced allsectors like business, governmentutility services and personal life.

1.1 ICTs in health sectorOne of the most significantimpacts of the ongoinginformation revolution has beenon the health sector. In the field ofhealth care, ICTs have emerged as

key instruments in solving manyof the most pressing problems.ICT has helped to bridge the gapbetween the provider and seekerthrough telemedicine and remoteconsultations, enabled healthknowledge management byinstitutions and agencies, andfacilitated in the creation of

networks between providers forexchange of information and

experiences. In fact, globally, thee-Health or health telematicssector is fast emerging as the thirdindustrial pillar of the healthsector after the pharmaceuticaland the medical (imaging) devicesindustries(Macleod,2007).From adevelopment perspective, ICTsare key instruments towardsmeeting the MillenniumDevelopment Goals (MDGs)related to health. In this respect,

the increasing adoption of ICT inhealth care services of developingcountries, by both public andprivate sectors, has been awelcome trend. All across theworld, governments are pledgingand pooling more and more oftheir resources towardsdeveloping ICT tools and systemswith the ultimate aim offacilitating management,streamlining surveillance andimproving health care throughbetter delivery of preventive andcurative services (Turban et al.,2004). In line with this trend thegovernment of Pakistan in August

2000, announced an integratedpolicy of InformationTechnology, which has beenwelcomed as step towardsmodernization and globalization.

2. Factors affecting adoptionand use of ICTs in hospitals

The increasing pressure ofbusiness environment of the


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information age is forcing theorganizations of the entire worldto adopt and use Information andcommunication technologies(ICTs) in decision making. It iswell reported that private sectororganizations are usinginformation system for achievingstrategic advantages and gainingfinancial and business benefitsmore than its public counterpart.The influence of some factors on

the information system (IS)success is well documented (seefor example, Ahlan, 2005; Michel& Betty, 2003); Andrew Georgiouet al., 2002). Various studies havepointed out Users, executives,Proper Organization, and externalenvironment as the key crucialfactors that influenceimplementation of ICTs in anyorganization.

2.1 UsersHuman relations movement(behavioral approach tomanagement) stresses that humanelement in an organization must

be given importance in order toincrease the organizationalefficiency (Certo, 2001:37-38). Italso emphasizes that effectivehuman relations generatecommitment of workers and highproductivity in organizations.Thus management must buildappropriate relationships with its

people, as ability to work withpeople enhance organizational

success. A manager underinterpersonal role motivates,directs people and performs dutiesof social nature i.e. generatesrespect for each other, trusts theworkers. likewise the success ofICTs is not possible in theorganizations whereby the humanelement is not given importanceand where exists a lack ofparticipation of end users in IS(Information system)

development proceedings asasserted by Macleod (2007) thatdesign and implementation of thehardware/software have greatersuccess rates in the organizationswhereby end users and IT-staff/professionals jointly developan information system and asBradly (2006) says that it is thehuman element which is relatedwith the adoption and success ofnew technologies.

The literature reveals that privatehealth organizations in Pakistanare more inclined to e-governmentinitiatives and whereby the

executives of these hospitals aremore interested in the adoptionand use of IT in their decisionmaking process than themanagement of public sectorhospitals. Furthermore, privatehealth organizations are involvingthe doctors, physicians and otherhealthcare workers in information

system (IS) development.Literature also highlights that to


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date the private sectors use ofinformation systems for achievingstrategic advantages and gainingfinancial and business benefits ismuch greater than its publiccounterparts (Ahlan, 2005).According to Macleod et al. (2007)people have no participation inthe IS development due toconcept prevailing in public healthorganizations that theirsuggestions for IS development

and implementations are neitherwelcomed nor entertained andalso increases the time duration ofIS development. Similarly Certo(2001: 37-38) argues thatorganizational success can beenhanced by building appropriaterelationships with the people.

2.2 ExecutivesLiterature reveals that in privateorganizations managementarranges and provides propertraining to the people, theenvironment is friendlier,management has trust in theiremployees and people have

respect for each other.Furthermore, results of thedifferent studies validate theassertion that human force inprivate health organizations ishighly qualified, professional,trained and well experienced aswell as more committed to theadoption and use of IT in decision

making process than themanagerial staff of public health

organization ( see for example,Keri, 2007; Michel & Betty,2003);Avital, 2003).

Executives are responsible foroverall management of theorganization. They establishoperating policies and guide theorganizations interaction with itsenvironment (Stoner andWankle, 1986:15) and playdifferent roles such as

interpersonal, informational anddecisional. Thus underinformation role they areresponsible for transmitting theinformation received from outsideor from other subordinates to themembers of the organization andtransmits information to outsiderson organizations plans, policies,actions and results (Robins andDecenzo, 2006: 37). To play aninformational role successfully,executives require and make theuse of ICTs but our study revealsthat executives of publicorganizations do not take interestin the adoption and use of ICTs as

pinpointed by Ahlan (2005) thatthe executives in public healthorganizations do not take muchinterest in the adoption and use ofICTs, they do not possessawareness about ICTs and haveno experience of using the samefor solving their unstructuredproblems.


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2.3 Proper OrganizationProper organization helps thesmooth running ofadministration. It provides anopportunity to direct employeesand coordinate their efforts. Itfacilitates the distribution of workamong different units. It provideschannels of communication,command and coordination. Itfixes authority andresponsibilities for each individual

of an organization. All thisindicates that organization hasmany roles to play inadministrative processes. Despiteall such theoretical claimsliterature study reveals that thereis poor organization mechanismin the public health organizations,however, reasons to which aremultifarious and playing differentroles such as highly centralizedsystem, limited participation,unclear role and responsibilities,lack of cooperation andcoordination, absence of timework, lack of interest andcommitment. This highly

centralized system ofadministration with non-participatory approach of thepublic sector organizations is themain obstacle in the ICTs success(Hage & Aiken, 1969).

2.4 External environmentThe environment of an

organization contains bothsupportive and antagonistic

forces. An organization systemderives support from clients orcustomers who need its productsand services and from societysprotection of property and otherrights. But the organization is alsosubject to the constraints of publicregulations, demands for socialresponsibility, and meetingmultiplicity of demand that areoften conflicting (McFarland,1979: 290). It is part of every

managers responsibility to bealert about the forces of externalenvironment that affect anorganization and its goal.However, findings of the studyindicate that the management ofprivate health organization ismore capable to fight with bothexternal and internal environmentto meet their desired objectivesthan to its counterparts.

3. Discussions

ICTs refer to how an organizationtransfers its inputs into outputs.Every organization has

information technology thatconverts financial, human andphysical resources into productsor services ( Robbins,1998). ButICTs in private healthorganizations are fully compatiblewith the organizational systemsbecause they are designed,developed and implemented

according to an existing workpatterns and requirements of an


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13. Keri, K. S. (2007). The Successive Useof Information andCommunication Technologiesat Work, CommunicationTheory, Volume 17 (4): 486507.

14. Loomba, N.P. (1978). Management, Aquantitative perspective.Macmillan.

15. Luthans, F. (2002). OrganizationalBehavior, McGraw-Hill.

16. MacFarland, D.E. (1979).Management: foundations andpractices. Mac Millan publishingco., INC, New York.

17. Matthew, I. E (2005). ExecutiveInformation Systems and thetop-officers roles: Anexploratory study of user-

behavior model and lessonstaught, Australasian Journal ofInformation Systems, Volume13 (1).

18. McLeod, L. Stephen, G. MacDonnelland Bill, D. (2007). Userparticipation in contemporaryIS development: An ISmanagement perspective,Australasian Journal ofInformation Systems, Volume15 (1).

19.


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20. Michel, A. and Betty, V. (2003)Ownership Interaction: A KeyIngredient of Information

21. Technology Performance Sprouts:

working papers on informationEnvironments, Systems andorganizations Volume 2 (1).

22. Robbins, S. P. (1998) Organizationalbehavior: Concepts,controversies and applications.Prentice-Hall.

23. Rockart, J.F. and Short, J.E. (1989). ITin the 1990s: Managinginterdependence. SloanManagement Review, Volume30 (3): 7- 17.

24. Stephen P., Robins and David. D.(2006). Fundamentals ofmanagement, PearsonEducation.

25. Stoner, J. A. and Charles, W., 1986,Management, prentice hall.

26. Turban, E., Ephraim, M. and James,W. (2004). Informationtechnology for management:Transforming organizations inthe digital economy. 4 th Edition. John Wiley & sons, Inc.

27. Weihrich, H. and Harold, K., 1999,Management: A globalperspective. 10th ed. McGraw-Hill. Inc.


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Original Paper

Assessment Of Nutritionnal Status Of HivInfected And Hiv Negative Pregnant Women InNgaoundere, Cameroon

M Dangwe 1, 2, C M Mbofung 1

1Laboratory of Biophysics, food biochemistry and Nutrition 2Laboratory of Protestant hospital of Ngaoundere

Background objectives: Malnutrition (underfeeding) can affect the treatment of AIDS inthat it reduces the ability of the intestine to absorb drugs, organic substances andmicronutrients. Underfeeding could also increase the chances of transmission of the disease from an infected mother to the baby during pregnancy. The objective of this study is tocompare the energy intake, weigh rate and nutritional status between the HIV and non HIVpregnant women attending two referrals hospitals in Ngaoundere (Cameroon).Methods: A cross sectional study using 24-hour dietary recall was applied to a sample of 109women, randomly selected from a population-based and anthropometric data were done.Results: Result show that HIV negative pregnant women consumed less energy intake perday than the HIV infected pregnant women at all age groups with no significant difference(Fcal=1.19, p=0.317). Gain in weight between the HIV infected and HIV negative pregnantwomen in relation to their various age groups was no significant (F= 1.23, p=0.27). There was no significant influence of HIV status in pregnant women BMI (F=2 29, p=0.133).Interpretation conclusion:In this study, the higher consumption of energy by HIV infectedpregnant women than HIV negative women could be because HIV infected pregnant womenwere at the beginning of the infection which has not yet affected the immune system. In thetwo referral hospital of Ngaoundere besides HIV screening tests, should be also nutritionalservices to advice these women on their nutritional habits.

Keywords: Malnutrition, Body mass Index, HIV/AIDS, energy consumption

1. Introduction

Acquired Immune DeficiencySyndrome (AIDS) is aninfectious disease caused by theHuman Immunodeficiency Virus(HIV) which appeared for thefirst time in the mid 1980 (BICE,

1993). The HumanImmunodeficiency Virus (HIV)reproduces in certain blood cellsand more specifically in the whiteblood cells (WBC). The HIVthus attacks and weakens theimmune system rendering thevictim vulnerable to infections. It


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has ravaged sub-Sahara Africa fordecades and is still a major causeof adult morbidity and mortality(Masanjala, 2007). Recentestimates by the World HealthOrganization (WHO) show thatabout 33.3 million people are livingwith HIV/AIDS worldwide with22.5 million living in sub-SaharanAfrica (Global Report, 2010). Theprevalence in Cameroon stands at5.5 % with the Adamawa region

occupying the 5th

position with 6.9% (Comit National de Luttecontre le Sida, 2004).

Studies outlined that thereis a relationship betweenmalnutrition and AIDS (AIDSinstitute, 1995). Research showsthat, the chance of infection withthe HIV virus might be reducedin individuals who have goodnutritional status withmicronutrients and especially,vitamin A playing significantroles (ACC, 1998). Malnutrition(underfeeding) can affect thetreatment of AIDS in that itreduces the ability of the

intestines to absorb drugs, organicsubstances and micronutrients.Underfeeding could also increasethe chances of transmission of thedisease from an infected motherto the baby during pregnancy(Semba, 1997). This affirmation thus necessitatescertain questions on the

increasing rate of HIV positivesin this region of the world, which

is one of the most affected(CNLS, 2004). One wouldtherefore be tempted to believethat underfeeding plays animportant role in increasing thedamaging effects of theHIV/AIDS. In the town ofNgaoundere, there is a dearth ofinformations on the relationshipbetween underfeeding andHIV/AIDS. Thus, this study wasundertaken to compare the energy

intake, weight rate and nutritionalstatus between the HIV and non-HIV pregnant women attendingtwo referrals hospitals inNgaoundere, Cameroon.

2. Materials And Methods Study Area

Ngaoundere is the capital city ofthe Adamawa Region, Cameroon.The city is located at latitude70.19N and longitude 13034E. Itspopulation was estimated atabout 230,000 inhabitants in 2001(Tchotsoua, 2006).The Adamaouaregion is high in altitude; its

whether is between 22 and 250

.This plateau contains 2 types ofclimates: the Sudanese type oftropical climate and theCameroon type of equatorialclimate. The Sudanese type oftropical climate has a dry seasoncovering the period of Novemberto March; then comes the moist

season with down falls rangingfrom 900 mm to 1500mm. The


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Cameroon type of equatorialclimate has a long dry seasonfollowed by a long rainy season.The down falls here range1500mm to 2000mm per year(Okouba and al., 2010).

Study population and DesignThe study was cross-sectional indesign. Pregnant women thatattended antenatal services of thetwo referral hospitals in

Ngaoundere (Protestant andRegional) were enrolled for thestudy. The study was conductedfrom May 2003 to January 2005. Atotal of 109 pregnant women attheir third trimester wererandomly selected and enrolledfor the study. They were groupedinto HIV infected (13) and non-HIV infected (96).Four age groups were ranged forthe evaluation of age influence asa factor studied ( 27 years).

Questionnaire Administration Questionnaires were administered

to the women to collect data on:Age, level of education, number ofchildren, gravidity, preferredmeals, family inherited illnesses,certain disease frequency in thefamily and pre-natal treatments.Nutritional feeding habits wereobtained through interviews onthe diets. A 24-hour dietary recall

was applied to a sample ofwomen, randomly selected from a

random population-based studysample. Most of the women hadcommon feeding habits and theircommon meals were reported tobe cereals (maize), tubers(cassava) and vegetables. Theconversion of quantity consumedinto calories was done with thehelp of a chart on food andnutritive value (FAO, 1968;Yadang, 2000).

Assessment of nutritional statusof the pregnant womenAnthropometry is themeasurement of human body. It isa quantitative method and ishighly sensitive to nutritionalstatus (Amuta and Houmsou,2009). The anthropometricfactors: Weight (Kg) and Height(m) were used to calculate theBody Mass Index (BMI) as:BMI = ( )

( )

As the aforementioned formulareflects the human body withoutpregnancy, we subtracted thefoetal weight from the totalweight of the pregnant woman toget the exact BMI.We generally assume that a bodymass index less than 18.5 impliesthat the woman is thin andbetween 18.5 and 25, we say thewoman has a normal weightmeanwhile values superior than 25indicates over weight (Gallagher

and al.,2000).


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Statistical analysisCollected data were analyzedusing Statgraphics 3.0. The oneway ANOVA test was used tofind significant differencebetween the means. Thesignificance level was at p 0.05level.

3. ResultsComparison of energy intakebetween HIV infected and HIV

negative pregnantwomen in Ngaoundere,Cameroon

The quantity of energy consumedby HIV negative pregnant womenand HIV infected pregnantwomen is shown in Figure 1. Theresult shows that HIV negativepregnant women consumed lessenergy intake per day than theHIV infected pregnant women atall age groups with no significantdifference (F cal=1.19, p=0.317).

Variation in weight gain of HIVinfected and HIV negative

pregnant women .Studies and analysis of the weightparameter of HIV infected andHIV negative pregnant womenshowed that the daily weight gainby HIV negative pregnant womenis 0,041 0,029 kg/day , 0.042 0,033 kg/day; 0,054 0,047 kg/day;0,057 0.06 kg/day for group I, II,

III and IV respectively,

meanwhile for HIV infectedwomen it is 0.038 0.023kg/day;0.039 0.014kg/day; 0,044 0,012kg/day; 0,017 0.037 kg/dayfor group I, II, III and IVrespectively (Figure 2). Nosignificance difference wasobserved in weight gain betweenthe HIV infected and HIVnegative pregnant women inrelation to their various agegroups (F= 1.23, p=0.27).

Body Mass Index BMI) of HIVinfected and HIV negativepregnant womenThe body mass index of HIVinfected and HIV negativepregnant women is shown inFigure 3. It is observed that HIVstatus does not influence pregnantwomen BMI (F=2 29, p=0.133).Pregnant women were groupedinto 3 depending on their BodyMass Index (Table 1). Resultsshowed that 0,92% of the HIVinfected pregnant women areunderweight , 7,34% are ofnormal size, and 3,67% areoverweight, while 0.92% of the

negative were of underweight46,79%are of normal size, and40,36% are overweight. Althoughaccording to the body mass indexof women at the start ofpregnancy, 18.34% are thin and81.65% normal.


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Table 1: Percentages on the Body Mass Index of HIV infected and HIV negative pregnantwomen in relation to their age group.

NumberBMI (Kg/m 2) HIV positive (%) HIV Negative (%)

Underweight (< 18.5) 1 (0,92) 1 (0,92)Normal weight (18.5-25) 8 (7,34) 51 (46,79)Overweight ( 25) 4 (3,67) 44 (40,36)

Fig1: Comparison of energy intake between HIV infected and HIV negativepregnant women in relation to age.

0

500

1000

1500

2000

2500

3000

3500

4000

< 19

19-22

23-26

27-35

E

g K

/ HIV negative pregnant women

HIV infected pregnant women

(Years)


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(Years)

Fig 2: Variation in weight gain among HIV infected and HIV negative pregnant womenin relation to age groups

Fig 3: Variation in Body Mass Index among HIV infected and HIV negative pregnantwomen in relation to age group

0

5

10

15

20

25

30

35


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4. Discussion

Generally, the energy intake byHIV infected pregnant womenappears to be higher than that ofHIV negative pregnant women.This could be because HIVinfected pregnant women were atthe beginning of the infectionwhich has not yet affected theimmune system. It could be also

due to the fact that there were notaware of their HIV status whichcould have affected their mindtherefore influencing them to loseweight through their thoughts. Astudy reported that the quantityof energy necessary for pregnantwomen of the third trimester is2,250 kcal per day. However, acomparison of the energy taken bythe HIV negative and HIVinfected pregnant women in thisstudy revealed that the energylevels were higher than valuesreported by Dupin and al (1992).This could be justified bythe fact that these pregnant

women were in the third trimesterof pregnancy when they have thetendency of eating a lotirrespective of their HIV status.In our study group, we noticedthat infected pregnant women andnon infected pregnant womengain weight during pregnancy.We observe that the biggest mean

rates of gain for 3rd

trimester ofpregnancy in our population

group is 0,399kg/wk for HIVnegative pregnant women and0,308 kg/wk for HIV infectedpregnant women. The presumablygain weight from HIV-uninfectedadult women from the UnitedStates and Europe are 0,30 to 0,54kg/wk during the 3 rd trimester.However, people on whom weworked have weight ranges thesevalues. This result is similar to

those reported by Strauss and al.(1999) and Ladner and al (1998),but contrasts that of Kim and al.(1996) who observed HIVinfected subjects to be sufferingfrom underfeeding and weightlost at the onset of the infection.The difference between our studyand that observed by Kim et al.(1996) is that the subjects enrolledin our study were found to havemore energy intake than therecommended energyconsumption. The energy surplusconsumed by these pregnantwomen would have compensatedthe expected weight. We did not

find further evidence in theliterature that suggesteddifferences in the pattern ofweight gain by HIV status. Butwe know that lean body mass losscan be improved when nutritioncounseling is combined withnutritional interventions (Stackand al.,1996). The body mass index

observed in our study show thatHIV status does not influence the


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weight gain by pregnant women.This result is similar with studiesreported in Tanzania who findthat there is not significantdifference between body massindex infected and HIV-negativewomen (Villamor and al., 2004).This could be justified by the factthat these infected women are atthe beginning of their illness.

5. Conclusion

Our study report that, nosignificant difference wasobserved between HIV infectedand HIV negative pregnantwomen with regards to energyintake and weight gain. Ourresults also showed that agegroups and HIV status had nosignificant influence on thepregnant womens Body MassIndex. Besides HIV screeningstest, were done to the womenattending their antenatal servicesin there should be also nutritionalservices to advice these women ontheir nutritional habits.

Acknowledgements The authors thank the

pregnant women that attended theregional and protestant hospitalsof the Adamaoua region for theirkindness and collaboration whichallowed successful data collection.The nurses of antenatal services

both hospitals are alsoacknowledged.

References

1. ACC/SCN. 1998. Overview to feature:Nutrition and HIV/AIDS.

SCN News, 17:3-4.2. AIDS INSTITUTE.,1995. Nutrition inHIV/AIDS infections.Available at Http://aidsinfonye.Org/ai/nutrit.hlnl. AccessedApril 12, 2001.

3. Amuta, E.U.and Houmsou, RS. (2009).Assessment of NutritionistStatus of school children inMakurdi, Benue State. Pakistan Journal of Nutrition, 8 (5):691-694.

4. BICE (Bureau InternationalCatholique de lenfance)., 1993.SIDA les enfants aussi.Lenfance dans le Monde.vol.20,N 2-3/93.

5. CNLS (Comit National de Luttecontre le SIDA au Cameroun) .,2004. SIDA! Ce que vous devezsavoir Manuel destin auxprofessionnels de la sant.

6. Dupin H; Cuq jean louis; M-IMalewiak, C.leynaud-Rouaud,A-M. (1992).Alimentation et Nutritionhumaines. Berthier ESF EditeurISBN 2.7101.0892.5

7. FAO (Food and AgricultureOrganization of the UnitedNations)., 1968. Food

composition table for use inAfrica. Department of Health,Education and welfare publichealth service, Rome, Italy.

8. Gallagher D, Heymsfield SB, Heo M Jebb SA, Murgatroyyd PR,Sakamoto Y. (2000). Healthypercentage body fat ranges: anapproch for developingguidelines based on body mass

index. American Journal ofclinical Nutrition; 72 (3): 694-701.


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Original Paper

Issues and Prospects of e-health in Pakistan

Qamar Afaq Qureshi 1, Najam Afaq Qureshi 2, , Dr. Muhammad ZubairKhan 2, Dr. Allah Nawaz 1 Dr. Bahadar Shah 3,

1Gomal University, Pakistan 2Sarhad University, Pakistan, , 3Hazara University, Pakistan

AbstractBackground objectives: In connection with access to information in developing countries,information flows through existing networks of communication is a main theme in the currentIS literature .Methods:Information-intensive infrastructure is a requirement for information disseminationdue to the shortage of network infrastructure in the majority of developing states. It isverified by many researchers that information managing technologies with their main purposeof handling information have the advantage to enhance already existing technologies bymaking better information-communication a priori to new ICT innovations .Presently healthinformation system infrastructure is deficient in resources to meet the demands and needs ofincreasing population in developing countries. Health care systems of developing countries

have major barriers like poverty and lack of technological sophistication.Results:The basic difficulties or barriers in using information technologies include poor orinadequate infrastructure, insufficient access to the hardware and inadequate or poorresources allocation. By eliminating these barriers population health status can be improved indeveloping countries.Interpretation conclusion: This study aims to determine the main issues and prospects for e-health in the current situation of developing countries like Pakistan and the way forward forpolicy makers to manage all issues in future for more effective and rational decision-makingin healthcare organizations.

Key words: e-health; challenges; prospects; developing countries; Pakistan

1. Introduction

Ehealth is a latest platform forhandling many healthcare issues.E-health systems have presentedso many gadgets which are beingused by both developed and

developing states. Healthcarerelated IS and hardware is now

inexpensively obtainable all overthe world. On the other handsuccessful adoption and use of e-health systems depends on thesuitable infrastructure (Khoja etal., 2012). The readiness andawareness of doctors and

physicians about the usage of IT-applications in hospitals can be


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developed and maintained byproviding proper tools and devicesand proper training on regularintervals for more rapid access toinformation on internet. Forhandling users- related issues andmaintaining regular use of ICTsin health organizations, healthcareproviders must be givenopportunity to take part ininformation systems developmentprocess and include the IS-

contents according to theirrequirements (Rezai-Rad et al.,2012).

Concentrating on information-centered ICT applications indeveloping countries iscomparatively a new sphere andsubject in the domain of healthinformatics (Kimaro & Titlestad,2008). Sound evidence-basedliterature extracted on influenceassessments or outcomemeasurements is still lackingregarding ICTs-applications inthe healthcare sector (Rezai-Radet al., 2012). Published evidences

are presently available on thistopic and are at pilot or the proof-of-concept stage. In many cases,the statements are not individualanalyses, rather are based oncollective skills and practices,consensus statements, and policies(Soar et al., 2012).

The significance of the conceptsof information, information

first has been advocated by manyIS researchers for the successfuladoption and use of the IT-applications in any organizationand involvement towards theinformation-centered ICTconcept is a major example(Nyella & Mndeme, 2010).Furthermore the ICT-applicationsmay only bring small directbenefits for poverty alleviationand the possibility for ICT-

applications depends on bothfinancial and access to cultural,political and educationalresources. And finally, the accessto social assets and increasingconfidence and support throughlocally contextualized socialnetworks built throughcommunity-based initiatives ismore crucial than looking foraccess to new information fromdigital ICTs (Khoja et al.,2012).

Many studies reveal that doctorsand physicians in developingcountries are not given anopportunity to be take part in

information system developmentprocess, consequently IS/ICTs donot possess the features which areaccording to the needs ofhealthcare providers (Rezai-Rad etal., 2012).Although e-healthsystems in developing countries isnot a new concept any longer butthere is sluggish usage of internet

among healthcare providers due tolack of the capability to read, be


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emergency situations (Ansari etal.,2012).

There has been an explosion inknowledge and informationmanagement activity, mainly inhealthcare sector over theprevious few years. By and large,hospitals and medical schoolshave started using the services ofdoctors who possess computer andcomputerization skills. These

organizations have also obtainedcomplicated information systemsto collect and retrieveaccumulated knowledge. Ehealthsystem includes many elementssuch as telemedicine, tele-education, telematics for bettermanagement of healthcare andresearch (Kijsanayotin ,Kasitipradith & Pannarunothai,2010). There are four areas wherehealth informatics is performingan escalating role in healthcaredevelopment: a) administrative,b) education and training, c)quality improvement and d) therecovery of efficiency of health

care services (Bhutto et al., 2010).In Pakistan 72% of populationlives in rural areas and 28% ofpopulation lives in urban areas.Condition of health can bedetermined effortlessly from thereality that there are 74 physiciansper 100,000 persons in early 2000s.

There are several rural areaswhere people have not seen a

capable and skilled healthprofessional in their entire life(Bhutto et al., 2010). Themunicipal areas of Sindh are wellequipped with health facilities;which are not enough for hugepopulation but facilities are there,whereas rural Sindh does not havewell equipped health facilities.Available possessions at urbanareas can be shared as well asexpanded to the rural areas with

the help of digital connectivity.Particularly, Karachi capital cityof Sindh holds very latesthealthcare facilities (Durrani etal., 2012).

In urgent cases where instantmedical treatment is very vital,current studies reveal that beforetime and particular pre-hospitalpatient management leads to thepatients survival. Especially incases of serious head injuries,spinal cord or internal organsdamage and pain, the way theevents are treated and transportedis critical for the forthcoming

well-being of the patients.Bringing improvements inhealthcare services and remain fitand healthy is one of the mostdiscussed and key issues in oursociety. The acceptance of IT-applications in healthcare sectorhave very solid and successfulattempt for the provision of

improved healthcare services(Malik et al., 2008). But constant


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Q. A. Qureshi et al. 35


guidelines must be developed andagreed across the board inconnection with the processing ofhealth-related data, withparticular explanations regardingdiagnostic notes, which stress andassure its protection andconfidentiality, as well as free andopen access, by the patients totheir own data. Furthermore thepotential technical knowledgedifficulties can be neutralized by

making sure that the IT-application is both technicallypossible and clinically suitable. Inaddition to that all citizens,doctors & physicians and policymakers must acknowledge andappreciate the adoption and use ofeHealth systems (Bhutto et al.,2010).

The significance of a healthinformation system (HMIS)cannot be neglected in a countrylike Pakistan because healthpolicies and planning in anycountry generally depend on theaccurate and well-timed

information on various healthissues (Ali & Horikoshi, 2002). InPakistan, before the 1990s, anumber of vertical programs withcategorical disease-specificinformation systems ended indisorganized data transmission,which made evaluation ofprogram usefulness difficult for

managers. In 1991-92, the Ministryof Health (MoH) started an

assessment study of existing HISand transformed the reportingsystems into a comprehensiveNational HMIS through aconsultative procedure (Qazi &Ali, 2004). However, there is needto develop integrated disease closewatch infrastructure and technicalcompetence in tropical countrieson the reporting and scientificevidence necessities of thesanitary agreement under the

WTO (Singer & deCastro, 2007).

Health information isinformation about peoples healthand what they, government, andothers are doing about it. Itexplains the occurrence,frequency, and reasons of majordiseases, as well as accessibilityand efficiency of curativeactivities (Ali & Horikoshi, 2002;Khalid et al.,2008). Under thetransfer of power initiative,Pakistan's MoH has advocatedstrengthening of healthinformation systems for moreinformed decision-making in

planning, managing, checking andcontrol of healthcare services forimproved service delivery in thedistricts. However, the efforts atincreasing information systemshave generally provedunproductive and sometimescounterproductive. Analyses ofthe malfunctioning often fail to

notice the perceptions of


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stakeholders as an importantfactor (Ansari et al., 2012).

Given the large healthinfrastructure in Pakistan bothpublic and private, supplying to apopulation of 137 million people,there had been a need to build upand start a national healthmanagement information systemwhich is able to collect, process,analyze and provide criticism on

all health related data includinginformation on input, process andoutput indicators (Gururajan etal.,2008). The national feedbackreports on the new HMIS admit aslow development in scope andreporting reliability, but also notethe continued need forimprovement in the quality andusage of information at variouslevels. A study carried out in 2000pointed out that the informationproduced via HMIS was unrelatedand the data did not helpmanagers to make decisions(Bhutto et al., 2010).

Ministries of Health areapproving Computer Software inorder to get better health datacollection, stretch, storage,analysis and distribution in theirHealth Information Systems(Khoja et al., 2008). Computersoftware are obtained throughvarious means including buying

on-shelf software, indenture basedsoftware, and donated software.

Most of the Software acquiredthrough these means is notdistributed with their source codesin that they are proprietarysoftware. However, the dataelements of Health InformationSystems are changing regularlydue to changing disease patterns;incoming and outdated drugs, andchanging health policies (Ishtiaqet al., 2012).

As software requires to be re-designed from time to time to takeon changing requirements arisesthere is a need to think aboutefforts on open source software.With Open Source Softwaredevelopment method, thesoftware is distributed with theirsource code which means that aMinistry of Health can uphold itssoftware with no uniquedevelopers (Mostafa et al., 2011).The characteristics of OpenSource Software developmentapproaches seems to beappropriate in developingsoftware for Health Information

System in that health informationsystems institutions has fullaccess to their software sourcecodes and thus can bring in anychanges according to theirrequirements instantly. In thecase, the Ministry has no ICTcapacity (say human resources) tobe able to change the software; the

software can be restructured byany computer expert and not


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necessarily the ones who havedeveloped that software (Durraniet al., 2012).

3. Issues Prospects

Pakistan health services andhealth signs are usually poorespecially in the far flung andrural areas. Out of 1000 infants76.6 persons of them die and thedeath rate under age 5 is 10.1 %.

Malaria occurrence is 0.75 per 1000persons, whereas, TB incidence is181 persons per 100,000. The healthexpenses have been very low andnot adequate to give good healthto people. For example thedevelopment spending was Rs.14.272 billion for the year 2007-08,and the recent expenditure was.Rs. 3.791 billion. Improved healthenhances the output of the laborforce, strengthens their economicconditions and eventually enablesthem to lead a superior life. Toachieve better, competent,effective and industriousworkforce, governments promote

the healthcare services. Moreoverthe present state of affairs of thehuman resource, a smalladjustment in public sectorexpenses on healthcare servicescan have a strong influence on theworkforce and thus the economicdevelopment.

E-Health is slowly but surelybecoming popular throughout the

world. This is ordinary and theroutine in the developed countriesbut developing nations are so farinitializing to implement and useeHealth systems for betterhealthcare services (Sarkar, 2008).The appearance and advent ofIS/ICTs have opened new viewsfor the countries to handle theirproblems consequently thedeveloping countries are alsomaking efforts to implement these

tools and gadgets. On the otherhand, there are several difficultiesand barriers which needs to beremoved away prior to taking fullbenefits of IT-applications forhealthcare (Chanda & Shaw,2010).

E-Health is the adoption and useof ICTs that includes the internetfor more improved and betterdelivery of healthcare services(Eng, 2001). Another writerremarks that e-Health is a newand very potential subject andfield of medical informatics,referring to the organization and

delivery of healthcare services andinformation using the Internetand interrelated technologies(Pagliari et al., 2005). It is alsonoteworthy that the majority ofthe studies about eHealth and itssuccessful adoption and use havebeen carried-out in both developed(Eysenbach, 2001; Alvarez, 2004;

Pagliari et al., 2005) anddeveloping states (Mosse & Sahay


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2003; Braa et al.2004; Chanda&Shaw, 2010).

A number of aspects and featureshave been exposed as the crucialfactors in creating or destroyingthe functions and tasks of e-Health system everywhere.Though, the research indicatesthat top-management-supportand government-ePolicies playleading role in all the matters

concerning to the planning,development, adoption and use ofnew ehealth systems along withtheir maintenance on continualbasis(Scott et al., 2002). Thisbecomes extremely important incase of the developing countrieslike Pakistan. The developingnations have extra issues ofdigital-literacy of all thegovernment authorities,developers of the systems anddefinitely the future users ofehealth applications (Lang &Mertes, 2011).

It is not just the willingness and

acceptability of the all theexpected users in an organizationwhich controls and decides thesuccess and failure of the e-Healthinitiatives rather it also containsthe approach and stance ofgovernment (external authority)as well as the top management ofthe organization (internal

executives) (Kimaro &Nhampossa,2007). Keeping in

view the specified responsibilityand function of top management,it is not unexpected that theinterest and support of theexecutives in an organization hasbeen one of the most generallytalked-about organizationalfactors for the successfulimplementation of eHealthprojects (Hussein et al., 2007).Alot of studies on the role of topmanagement support for the

success of e-health systems havebeen conducted (Sajjad et al., 2009;Qaisar & Khan, 2010).

E-Health policy is fastened withthe availability of resources alongwith the professionalism is neededfor the proper utilization of theresources, implementing plansand receiving the results. Lack ofprofessional frame of mind andthe attitude is apparently thebigger concern and matter forthose developing states whichhave the resources (Scott et al.,2005).Government eHealthpolicies make an environment

where the likelihood of usingresources effectively is increased,the professionals find theirsuitable places and exercisefaithfully and the future of IT-application in healthcare becomesclearly identifiable (Shaqrah,2010).

In spite of the abilities andbenefits of e-Health and


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Telemedicine for sustainability ofeHealth systems, some barriers, atdifferent levels, are required to beovercome for health systems totake full advantage of theseopportunities. These barriers arenot uni-dimensional,concentrating on technicalknowledge as assumed in the past,but somewhat a multidimensionalconcept, surrounding technicalknowledge, economic feasibility,

organizational support andbehavior adaptation. TheTelemedicine Alliance, acollaboration between the WorldHealth Organization, theEuropean Space Agency and theInternationalTelecommunications Unionstudied e-Health andTelemedicine adoption trendsthrough personal interviews with54 European telecommunicationsexperts, health policy makers, andhealthcare providers (Rhidian, &Hughes 2003).

3.1 Specific Issues of Developing

States like PakistanThese Issues of Developing Statesare divided into following groups:

1. National Policies towardsHIT: Efficient, effective andsecure national policy can addressthe local health needs according tothe changing environment is

needed. These policies can bedevised by policy makers and

practitioners to assess andimplement research evidences.Enforcing the legislation isdifficult in developing countriesand acceptance by the communityfor the transformation of anysystem is hard.2. Poor eHealthcare design:Many e-healthcare systems aredeveloped by InformationTechnology (IT) solutioncompanies which operate for the

purpose of getting profit. Thesecompanies are interested with thefinancial gain from e-healthcareproducts that they produce. Theyconcentrate much in producingusable products for healthcareinstitutions and hence causingprivacy, security andconfidentiality to suffer. In orderto resolve this, efforts to secure e-healthcare systems need to betaken from design of the systemsto implementation in order for thedevelopments that have beenachieved so far to be rolled to thereal world.3. Organizational Barriers:

Organizations and people play avery critical role in implementingand transformation of aninformation system. First of allthere are no documented studiesavailable regarding level and use,benefits, cost, risk analysis andother aspects of health technologyin health sector of underdeveloped

countries and if they are availablefor the developing countries they


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and the available information isnot according to the localsituation. This availableinformation cannot be used forevidence based decisions. Withouthaving a proper local area networkand internet facility inter-organizational and intra-organizational communication isnot possible. This is a backbonefor any information system.8. Lack of Professionals &

their Trainings: A computerizedinformation system requiresskilled personnel for its effectiveoperation. Training is one of theaspects for use of any newtechnology. Deficiency of skilledworkforce can be overcome byproviding appropriate training inthe required area. A propertraining module in constructingarchitecture of a reliable databaseshould be available. If it is notimplemented then outcomes orresults gained by such type ofdatabases gives unauthenticresults which can neither be usedfor decision making process nor

for evidence based practice.Training requires cost as well astime.9. Cost and TimeConstraints: Major problem inorganizing workshops andtrainings for establishment andimplementation of HIT in underdeveloped countries is financial

and time constraint.Transformation of any system is a

difficult task and cannot completein short time period. Barriers likelack of skilled workforce,infrastructure, and cost along withother effects like initial decreaseof productivity due to adjustmentwith new technologicalenvironment and system itselfimpose strong limits to theintroduction and adoption of newhealth technologies. It requiresyears and years for transformation

process to complete.10. Educational Barriers:Professional education in healthinformatics is badly ignored andmissing in curriculum of medicalinstitutes for undergraduates.Although module of educationrelated to IT use in research isincluded in postgraduatecurriculum but it is the need ofthe hour to include this area inmedical professional education atgraduate level. Transformation ofour existing paper based healthsystem into computerizedinformation system is not possiblewithout providing the basic IT

knowledge to health professionals.11. Fear of losing Control overData: The shift from traditionalhealthcare to e-healthcareinvolves the transformation ofrecords from paper-based todigital format. These records arereferred to as ElectronicHealthcare Record (EHR).

Grimson (2001) defines andcharacterizes the next generation


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EHR as the longitudinal cradle-to-grave records readily accessibleand available over the Internet.These records will be linked toclinical protocols and guidelines todrive the delivery of healthcare tothe individual. The presence ofthese records over the Internetfacilitates record sharing betweenphysicians. However, patientsusually feel that they are losingcontrol of their data hence

resisting e-healthcare adoption.

3.2 Prospects of e-Health inPakistanThe healthcare facilities inPakistan has got better andincreased in figure each year butthis increase is not proportionateto the population growth.Therefore; the healthcarefacilities are not that enoughwhich can fulfill the needs andnecessities of a large population.Persons particularly in rural areasface more difficulties of poorhealth than the people living inurban areas. Likewise, there has

been a rise in expenses onhealthcare planning andimplementation but theseexpenditures on more andexpanded healthcare setups arenot enough for the populationwhich is growing faster than theincrease in the expenditure(Saleem, 2009). Moreover, there is

also an increase in the number ofdoctors, dentists and physicians

every year .The increase indoctors and dentists number ismore than the population growthwhich has decreased the numberof patients/people for each doctorand dentist for treatment.

In the present times ofmanagement, a practical andstructured information system ismore or less a need and mainconcern of many organizations

especially the healthcareinstitutions. In Pakistan, the oldtechniques and methods for datacollection and analysis must bechanged if the information inhealthcare sector is to be usedcorrectly for more effectivehealthcare-related activities anddecisions. The Ministry ofHealth, Government of Pakistan,in alliance with the provincialhealth departments andinternational agencies developed aNational HMIS during 1990-93(Ali & Horikoshi, 2002). Thefacility based HMIS is one of themost influential tool for the

planning and management ofhealthcare services. In view of theexisting huge healthinfrastructure, stretched all overthe country in terms of healthfacilities, services, staff, drugs andsupplies etc. there has been arequirement to start a well-organized information system

responding to the informationneeds of various decision making


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levels of the healthcareorganizations(Durrani &Khoja, 2009).

The relationship between theICTs and better healthcareservice delivery has beendiscussed significantly(Ferraro, 2008; Nowak, 2008).The present studies havefocused on the introduction ofparticular technologies, such as

the cell phone or the Internet,but few have examinedempirically the relationship indetail (Fraser et al.,2007;Kollmann et al., 2007). Oneprobable method of tacklingthis dispute is appraisal andevaluation of user needs beforeadoption and use of eHealthsystems. However, user studieswhich can be very helpful andproductive for adoption of IT-applications in healthcaresector but unfortunately thesestudies are not always carriedout at the right time in designand development cycle

(Saleem, 2010).A lot of healthcareorganizations implementtelemedicine technology for thedevelopment of healthcareservices and increase usefulness& effectiveness. Thewillingness of healthcare

organizations and theavailability of the suitable

conditions are driving forces forthe implementation and use oftelemedicine. Earlier studiesshowed that a telemedicineprogram can be disobeyed byorganizational culture and workprocesses (Wootton, 2008)

One main obstruction in e-Healthcare implementation, eitherin developed or developing statesis privacy, secrecy and security

concerns of e-Health systems.The American government, forexample, for the year 2009reserved 19 billion dollars for IT-applications in healthcare sector.However, in spite of this massiveinvestment, e-healthcare adoptionin the USA is still hesitant. Itsexpected users for instancedoctors and physicians are notconvinced about the securityissues and concerns ofinformation systems in healthcareorganizations therefore they resistthe implementation and use of thesame. Furthermore, patients arealso worried about the privacy of

their medical records. This hasbeen influenced by a number ofexisting cases involving violationsin e-healthcare informationsystems. However, we disagreethat adoption of eHealth systemsis not a financial problem as such.It goes beyond, to include humanfaith and belief. Therefore, in

spite of concentrating on securingfunds for e-healthcare


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implementation, developing stateshave to think about the humanfactor as well (Durrani & Khoja,2009).

Though we suggest the use of Freeand Open Source Software(FOSS) (from operating systemto EHR software) but due toshortage of money, these productsare linked with many challenges.As these products are free, its

users do not have any support andmaintenance from developmentteams. The government ofdeveloping countries needs to setaside sufficient finances for stafftraining in the healthcare sector.If e-health is to succeed indeveloping nations it needs to betake care of. We need to developour own local abilities andinfrastructure, based on localdemand.

The shared understanding andcollaboration is a coordinated,synchronous activity that is theoutcome of a continued effort to

construct and uphold a sharedconception of a problem.Cooperation is working jointly toachieve shared goals surroundedby joint and supportive activitiesindividuals look for results whichare advantageous to themselvesand helpful to all other groupmembers. Methodically and

thoroughly structuring those basicelements into group learning

circumstances helps ensure jointefforts and makes possible theclosely controlled implementationof joint learning for lastingsuccess (Kaplan, 2000). Theadvantages of collaborativelearning are that persons bringdifferent ideas in a collaborativeenvironment and work on theway to the growth of a sharedunderstanding and building usualknowledge (Tan , 2005). At

present, the existingunderstanding seems to be thatcollaboration is a synonym forhigh-quality learning and goodeducational technology; more orless any web-based application islabeled as collaboration(Heinzelmann et al., 2003).

Ever increasing charges forhealthcare services and fastincrease and development of theknowledge have led the doctorsand physicians to work in acollaborative way and shareknowledge and skills. It is usuallyunderstood that healthcare

professionals working in acollaborative style, can deliverhealthcare services in a successfuland well-organized manner.Collaborative learning process canexchange of ideas within littlegroups not only enhances interestbetween the participants but alsogenerates and encourages critical

thinking. Collaboration inhealthcare organizations requires


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There is limited research availableon determinants and factors thatare critical to understanding userperceptions of technologiesspecific to healthcare on a largerscale. Therefore, any knowledgeof these factors of adoption ofnew technology will help thehealthcare administrators todevelop suitable policies in orderto handle the ever-increasingdemands of healthcare services.

This is more valid in the case ofPakistan because of the demandsplaced on the healthcare servicesand rising interest in wirelesstechnologies in the health domain.

The culture of Pakistanienvironment has alwaysencouraged the use of technology.This is high on the programs andplans at country and federal levelgovernment. The healthcaresector in Pakistan is operating inan environment of strongregulatory framework, costreduction, high competition, andexpectation of high quality of

services, high demand on thehealthcare sector, limitedresources, and the demand forproviding high quality of care -anytime anywhere. Factors suchas familiarity, infrastructure, cost,clinical process, quality of care,management support, policies andprocedures, security, availability

of appropriate wirelessapplication, trust and knowledge

of the technology will facilitatethe adoption and hence the use ofwireless handheld devices inPakistani healthcare environment.

4. Discussions

The process of developing andimplementing IS in the context ofdeveloping countries is achallenging endeavor. Thischallenge mainly emanates from

existing adverse situation of theinstalled base that is characterizedby uneven infrastructuraldevelopment across regions,inadequate skilled manpower, lackof integration of exitingstandards, work practices, andvarying political commitment andorganizational support at differentlevels (Raghupathi & Wu, 2011).Simply acquiring andimplementing e-Healthtechnology alone would beinsufficient to accomplish clinicalperformance and, subsequently,drive adoption and diffusion. E-Health technology should be

integrated effectively with theorganizational change andimprovement (Asangansi et al.,2008). The improvement inprocesses requires theoptimization of clinical functionsand processes which should besupported by the technology andnot driven by it. By doing this it is

likely to generate significantpatient outcomes and financial


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improvements with healthorganizations. This is estimated interms of attracting more patients,saving effort and time (Bhutto etal., 2010).Furthermore, in thecontext of developing states likePakistan, the cost constitutes animportant factor which will affectthe integration and, subsequently,the success of eHealth systems ina particular setting. Although costaspects are not directly explored,

however, efforts to save time,reduction in inaccuracies and highquality information are realcomponents of the cost (Somu &Bhaskar,2011). While existingresearch suggests that wirelesstechnology has the power todecrease scheduling time andmedical errors thereby enhancingthe quality in patient care, there isbleak evidence on thecomparisons of costs before andafter the implementation ofwireless technologies. It entailsthat there is a big space for furtherresearch to assess the hypothesisthat costs have the potential to

affect clinical usefulness andthreaten widespread adoption(Juma et al., 2012). Use of e-healthsystems in developing countriesholds many threats, along withthe expected advantages. Themain risk of using ICTs is theunintentional broadening of thegap in health status and

knowledge between varioussegments of the population, thus

escalating rather than addressinghealthcare inequalities. Onemethod to stay away from thisdivide is for governmentauthorities and hospitals indeveloping countries to evaluateand make them ready for changebefore adoption and use of IT-applications. This process ofpreparation for eHealth relatedchange is also termed as eHealthreadiness (Durrani et al., 2012).

eHealth readiness is determinedby assessing the comparativestatus of governments, healthcareorganizations, or expected users inthose areas most critical foracceptance and success ofprograms using ICT (Rezai-Radet al., 2012).

5. Conclusions

Literature reveals that e-Healthsystems are the future of everyhealt

mediterranean journal of medical sciences (mjms)

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