Internet accessibility, demographic and motivational factors influencing utilization of internet health information resources among resident doctors in tertiary health institutions in southwestern nigeria




НазваниеInternet accessibility, demographic and motivational factors influencing utilization of internet health information resources among resident doctors in tertiary health institutions in southwestern nigeria
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INTERNET ACCESSIBILITY, DEMOGRAPHIC AND MOTIVATIONAL FACTORS INFLUENCING UTILIZATION OF INTERNET HEALTH INFORMATION RESOURCES AMONG RESIDENT DOCTORS IN TERTIARY HEALTH INSTITUTIONS IN SOUTHWESTERN NIGERIA


BY


AJUWON GRACE ADA (Mrs.), BA, MLS (Ibadan)

MATRICULATION NO: 50834


A Ph.D PRE-FIELD SEMINAR PRESENTED TO THE DEARTMENT OF LIBRARY, ARCHIVAL AND INFORMATON STUDIES, UNIVERSITY OF IBADAN, IBADAN


SUPERVISOR

DR S.O POPOOLA


23 February, 2011


CHAPTER ONE

INTRODUCTION

1.1 Background to the study

In the last three decades, advances in telecommunication technologies have resulted in the development of computer networks that allow access to large amount of information and services. Of the many computer networks that have been developed, the most prominent and widespread is the Internet. The Internet is a global network of networks that enables computers of all kinds to directly and transparently communicate throughout the world. This global ‘network of networks’ has been described as ‘Infobahn’ or 'Information Super-highway' (Computer Hope, 2010). Coiera (1997) defined the Internet as an open and unregulated community of people who communicate freely across an international electronic computer network. Mckenzie (1997) described it as the linking together of individual computers in a network. The Internet Society defined it as a world-wide broadcasting capability, a mechanism for information dissemination, and a medium for collaboration and interaction between individuals and their computers without regard to geographical location (Internet Society, 2010). Rosenberg (2001) described the Internet as “the most remarkable technological breakthrough of the 1990s”. The Internet is simply the network of computer networks around the globe that enable people to access information and communicate with each other. Blonde, Cook and Dey (1999) observed that few innovations in history have so profoundly changed our lives as the Internet.

The Internet was originally conceived in the 1950s by the United States of America's military as part of the Department of Defense Advanced Research Projects and as a means of ensuring a workable communication system in the event of a strike by enemy missiles or forces (December and Randall, 1994; Glowniak, 1995; Sanders, 2002). It has grown over the years from a Department of Defense Network to a vast public/private network. In the early days, access to the Internet was restricted to government departments, organizations and institutions such as universities. However, since deregulation of the Internet in the 1990s (Millman, 1995), it now includes academic, government and privately owned computers. The technology has become available to those with access to computer network in both the developed and developing countries. It is estimated that there are at least 300,000 networks, 196 million domain names attached to over 5 million computers located in over 100 countries connected to the Internet (Ukwe, 2010).

As in many other fields, the Internet has been used for medical education in diverse ways including teaching of organs, diagnosis of diseases and medical examinations. In addition, it is a popular medium for delivering educational materials for health care, training and a source of information for medical research (Jones, 1991; Odusanya, 2002; Hong, 2002). For example, the Internet is increasingly being used as a source of health information by both the general public as well as private and public health care practitioners (Eysenbach, Sa, and Diepen, 1999; Riegelman and Persily, 2001; Skinner, Biscope and Poland, 2003). Godlee and Pakenham-Walsh (2004) noted that among currently available technologies only the Internet has the potential to deliver universal access to up-to-date health care information. The Internet's increased popularity and utilization in the medical field are a result of high-speed, high-capacity personal computers and related equipment and the development of easy-to-use graphics-intensive software (Thobaben, 1999).

There has been an explosion in the volume of published health care information on the Internet during the past two decades. The amount of health information available to users now is greater than ever and keeps growing on a daily basis. It has greatly and dramatically changed the means by which information is generated, processed and retrieved. Kastin (1998) asserts that the development of the Internet as a vehicle for world-wide communication and the emergence of the World Wide Web have made instantaneous access to much of the entire body of medical information an exciting one. Accurate and up-to-date information is vital for maintaining quality of health care. Consequently, many health information resources have being increasingly developed and available on the Internet for medical decision making. The most important sources that medical practitioners could base their practice on are Evidence-Based Medicine resources.

Evidence-Based Medicine (EBM) involves the explicit, conscientious and judicious consideration of the best available evidence in making health care decisions (Sackett, 2005). The approach relies on identifying and reviewing the best and most relevant scientific literature to determine the value of diagnosis, test or treatment. As a result of these features, Grimes (1999) concluded that EBM provides a powerful tool for better patient care. Evidence-based medicine is about making informed decision, answering clinical questions and solving patient’s problems using available research evidence in the medical literature. Several EBM resources are now available online suggesting that health care decisions for individual patients and for public policy should be informed by the best available research evidence. Unfortunately, clinical decisions are seldom based on the best available evidence in the medical literature (Al-Ansary, 2002). This is due to lack of awareness (Nwagwu, 2008), lack of time, (Barghouti, Halaseh, Said and Mousa, 2009; Vlveness, Aasland, Nylenna and Kristiansen, 2009) and lack of searching skills (Vlveness, Aasland, Nylenna and Kristiansen, 2009).

Evidence based medicine resources on the Internet include among others The Cochrane Library, Clinical Evidence, PubMed Clinical Queries, ACP Journal Club, Best Evidence and DynaMed. Other sources of health information available on the Internet are digital databases such as MEDLINE via PubMed, Scopus, Web of Knowledge, EMBASE, African Index Medicus (AIM) as well as Websites of academic/health institutions, professional associations, governmental and non-governmental organizations. In addition, there are digital repositories, digital archives for full-text articles, gateways, repositories and portals owned by institutions, governmental or not-for-profit organizations. According to McKibbon (2007), many of these resources and systems that provide accurate and reliable health care information for medical doctors have been brought about by the increase pace of health care research.

Bibliographies, drug information sources, medical and health statistics sources, reference and consumer health information resources, online journals, as well as abstracting and indexing sources have also become more accessible on the Internet. Thereby, allowing the academic scientific community, medical professionals, students and consumers to be up to date in a previously unthinkable manner regarding the speed and efficiency of accessing and obtaining information (Cuenca, 2005). Anderson (1997) asserts that the availability of this (Internet) new and potentially vast source of information has improved strategies for medical decision-making. Bereczki (2002), observed that the introduction of computers and especially the Internet has provided the possibility of immediate access to the most recent and reliable results of clinical research in everyday medical practice in developed countries. The situation is however different in developing countries such as Nigeria where the Internet and its resources could be accessed only by health care professionals who work in major cities or towns and often it is not available at the point of care (Ajuwon, 2006).

Despite the availability of health information resources on the Internet access to suitable Information and Communication Technologies (ICTs) and reliable connections to the Internet is a challenge for many health professionals and researchers in Nigeria and other countries in sub-Saharan Africa, due to limited telecommunication infrastructure (Godlee, 2004; Royall, Schayk, Bennett, Casebeer, Kristofco and Collins, 2005; Watts and Ibegbulam, 2005; Akpan-Obong, 2007). At an estimated rate of 11%, Internet penetration is very low in Africa while Internet users are only 5.6% of the population compared to 85.2% users in the rest of the world (Internet Word Stats, 2010b; Internet World Stats, 2010c). Whereas almost everyone in industrialized countries now has virtually immediate access to ICT facilities, the situation is different in sub-Saharan Africa (excluding South Africa), where only a few people can afford to pay Internet subscription fees to an Internet Service Provider (Bukachi and Pakenham-Walsh, 2007). Similarly, with the exception of South Africa, only a very small percentage of health professionals in sub-Saharan Africa have routine access to broadband connections (Jensen, 2007). Most have slow and unreliable connectivity which makes Web browsing expensive and frustrating. Of the over 140,000,000 million people living in Nigeria, only 23,982,200 (16.1%) are Internet users (Internet World Stats, 2010d); many of these users reside in urban areas even though the majority of the population live in towns and rural communities where access is either limited or unavailable.

Access to the priced literature has been a challenge to researchers, academics, health care providers, scientists, students and policy makers in resource poor settings including Nigeria. For many years, Nigerian doctors especially those working in rural communities face the challenge of lack of up-to-date, relevant and reliable information from the published literature due to lack of access to ICTs. The concept of unequal access to ICTs is termed “digital divide” or “information gap”. The ‘digital divide’ is used to describe the division between those who have access to ICTs and those who do not (Bridges.org, 2002). Norris (2001) described the “digital divide” as the inequity that exists in access to ICTs between countries, within regions and among different social groupings within a country or between citizens of a country. Dimaggio, Hargittai, Neuman and Robinson, (2001) defined it as “inequalities in access to the Internet, extent of use, knowledge of search strategies, quality of technical connections and social support, ability to evaluate the quality of information and diversity of uses”.

The information gap that exists between the developing countries and the rich nations of the world has been one of the most significant development challenges that have generated series of discussions during the past decade. Edejer (2000) stated that the rich countries of the world have access to health information than those in developing countries and that the digital divide is more dramatic than any other inequity in health or income. While developed countries such as the United States of America (USA) and Australia have extensive technological resources and wealth to support future developments in ICTs and make the facilities available to majority of their citizens. On the contrary, developing countries including Nigeria often lack financial resources to establish and maintain Internet connectivity and computers for majority of the citizens. As a result, most of the citizens including health workers lack access to essential information resources available on the Internet. However, Godlee, Horton and Smith, (2000) reported that the inequity in access to health information in developing countries is narrowing as a result of the electronic revolution especially the Internet; that is providing unprecedented access to information.

Concerns about the problem of access to health information have been raised at several fora. The United Nations General Assembly in June 2000 stated that the “digital divide threatens to further marginalize the economies and peoples of many developing countries”. The United Nations Millennium Assembly in 2000 emphasized on the right of access to information and communication stated that:

“access to information is essential for describing and understanding the

deficiencies of the present, building visions of a better future, developing

practical ways to achieve those visions, education and inspiring those who

must make the future” (Godlee, Horton and Smith, 2000).

The Group of Eight at Okinawa, Japan, declared in 2000 that “everyone should be able to enjoy access to information and communications networks" (Kenny, 2003). Access to essential heath information for health care has been a priority for the development of health systems and for the care of patients in areas with limited resources, prompting recent efforts by international organizations, academic institutions, governmental as well as non-governmental agencies (Godlee, 2004; McConnell, 2004). Access to essential health information is said to be strategic in the achievement of the Millennium Development Goals (MDGs) targeted at 2015.

There have been several initiatives aimed at bridging the digital divide in access to health information in resource poor settings during the past decade. Among the most successful is the Health InternetNetwork Access to Research Initiative (HINARI) launched in 2002 by the World Health Organization (WHO) (Katikireddi, 2004; Aronson, 2004). The HINARI is an initiative between the WHO and many of the worlds biomedical publishers aimed at making published research information accessible to researchers in developing countries. Of this initiative, the former Director-General of the WHO Dr Glo Harlem Brundtland said:

“We are living in a world in which only a privileged few have access to the

fruits of the information society, our challenge is to create opportunities for

more people to participate” (Brundtland, 2001).

She described HINARI as “perhaps the first step ever taken to bridge the health information gap between rich and poor countries”. Brundtland concluded that the launch of HINARI sees the beginning of a new way to bridge the digital divide in health, and an important move by publishers in facilitating the flow of health information using the Internet (Brundtland, 2002). The availability of these resources free-of-charge on the Internet, have brought huge benefits to tertiary health care institutions and libraries in developing countries especially those in Nigeria and other countries in sub-Saharan Africa.

The avalanche of information resources on the Internet have necessitated libraries and librarians to play important roles in helping clients have better access to the resources. Medical libraries now provide useful links to relevant, reliable and up-to-date health information resources on their Website for easy access by their patrons. Rees (1982) summarized the essential role of libraries as coordinators of access to health information thus:

“the library (public and hospital) is called on to coordinate health information access

at a local level, utilizing the many information and educational resources available

locally, regionally, and nationally”.

Ruffin, Cogdill, Kutty and Hudson-Ochillo (2005) observed that libraries now develop a wide range of online resources, collections and services. Libraries are playing significant roles in providing users with access to information resources including those that require subscription. Lyon (1998) noted that Internet connections have become a highly visible service in libraries of all types while librarians and patrons alike have embraced it in their daily work. Forsman, (1998) observed that the Internet and its applications have exploded into every library, both in the developed and developing countries changing user expectations, forcing librarians to rethink the services that they provide and altering the work they do. He reiterated further that:

“the incredible impact of the Internet and the World Wide Web is likened to

the development of the printing press and movable type, the creation of the

world’s largest vanity press, and a basic platform for re-creating the process by

which scholarly communication occurs” (Forsman, 1998:1).


The involvement of librarians and libraries in facilitating access to Internet information resources has resulted in the conduct of several surveys. Rehman and Ramzy (2004) in their study of health professionals at the Health Sciences Centre (HSC) in Kuwait University found that 28.3% of the respondents used the HSC Library for accessing information on the Internet. Similarly, a study of Internet use by physicians in Ibadan, Nigeria, revealed that 11% of the respondents access information on the Internet from the Library (Ajuwon, 2006). Libraries now organize information literacy courses to teach medical doctors and other categories of health workers how to access, retrieve evaluate and use Internet health information resources.

Information is worthless if it is not used. The fact that information is available or accessible on the Internet does not mean it is being used. Studies that dwell on availability, accessibility and use of the Internet have received considerable attention by researchers. Odutola (2003) opines that the availability of information is one thing, access to and use of the available information is another. Dervin (2003) stated that information use is a process whereby the user tries to make sense of discontinuous reality in a series of information use behaviour. Agarwal and Prasad (1999) argued that systems that are not utilized do not result in expected efficiency and effectiveness gains. The use of information varies among individuals, and professionals depending on their information needs and status. An important consideration in the process of health information gathering is accessibility and use of such information.

Prior (1988) is of the opinion that information sources accessible now and at the spot are more useful than those at a distance. This view was collaborated by Abels, Liebscher and Denma, (1996). The authors noted that the probability of use of an information source or channel was found to decline as distance increases. Aiyepeku (1982) submitted that ease of access to information sources is the most important criterion determining whether an important information sources is utilized. Access to information is said to be one of the determinants of system usage. Lee and Pow (1996), in their study of factors affecting use of clinical information systems concluded that information accessibility and delivery affect usage. The decision to use clinical information sources for decision making by doctors could be determined by factors such as physical availability of the information, timeliness, accuracy and expected benefits (Janes, Arroll, Buetow, Coster, et al, 2005).

Demographic variables such as age, gender, Internet experience and income have been found to influence Internet usage among medical doctors (Teo, 2001; Casebeer, Bennett, Kristofco, Carillo et al, 2002; Cullen, 2002; Bennett, 2005; Chew, 2004; Lorence and Parkt, 2007; Callen, 2008; Masters, 2008). Age is one of the individual characteristics that have been found to play a substantial role in influencing Internet usage. It has been observed that youths tend to be more comfortable with using computer and the Internet than adults. This trend has also been observed among medical doctors. Younger physicians were more likely to consider and use the Internet as a valuable source of medical information than their older colleagues (Clayton and colleagues, 1993; Eitel, Yankowitz and Ely, 1998). In a survey of computing skills, students, junior residents, and faculty were more confident than senior residents in performing Internet tasks such as retrieving patient information or conducting a MEDLINE query (Jerant, Matian, and Lasslo, 2003).

With respect to gender, males are more Internet savvy than females. Male physicians have more experience and greater confidence in using the Internet than female physicians (Casebeer, Bennett, Kristofco et al, 2002; Eitel, Yankowitz and Ely, 1998). Lorence and Parkt (2007) found that though males use the Internet more than females but females are dominant users of online health information.

Training recency has also been found to influence Internet usage among medical doctors. It has been observed that doctors who recently graduated from medical school or completed the residency training use the Internet more than those who graduated several years ago. A study among obstetricians and family physicians showed that recent medical graduates (younger physicians) were more likely to consider the Internet a valuable resource for medical information (Eitel, Yankowitz and Ely, 1998).

Motivational variables (perceived ease of use, perceived usefulness and perceived enjoyment) have been found to influence use of the Internet. Ramayah, Muhamad and Noraini, (2003) stated that Internet usage is influenced by intrinsic and extrinsic motivation. Intrinsic motivation refers to the performance of an activity for no apparent reward except the activity itself (Deci, 1975; Deci and Ryan, 1985; Ji-Won and Young-Gul, 2001; Rao, 2007). Perceived Ease of Use (PEU) is a form of intrinsic motivation (Deci, 1975; Rao, 2007). Supporting this view, Teo (2001) citing Atkinson and Kydd, (1997) noted that PEU and Perceived Enjoyment (PEJ) are forms of intrinsic motivation. According to Davis (1989), PEU is the degree to which a person believes that using a particular system will be free of effort. Extrinsic motivation is defined as the performance of an activity because it is perceived to be instrumental in achieving valued outcomes that are distinct from the activity itself (Deci, 1975; Deci and Ryan, 1985; Ji-Won and Young-Gul, 2001). Davis (1989) defined perceived usefulness as “the degree to which a person believes that using a particular system would enhance his or her job performance”. Perceived usefulness is a form of extrinsic motivation and has been found to be directly related to system usage. Resident doctors would most likely use Internet health information resources if they perceive it to be useful to their work and also easy to use.

Studies of Internet adoption and usage among medical doctors have been on the increase during the past decade in various specialties in different parts of the world. In the United States and United Kingdom (Parekh, Nazarian and Lim, 2004; D’Alessandro, 2004; Chew, Grant and Tote, 2004; Bennett, Casebeer, Kristofco and Bellman et al, 2005; Doney, Barlow and West, 2005; Boissin, 2005; Podichetty, Booher, Whitfield and Biscup, 2006; Lorence and Park, 2007; Davis, 2011); in South Africa (Masters, 2008; Masters, 2008) and Nigeria (Bello, Arogundade, and Sanusi et al, 2004; Ajuwon, 2006; Asangansi, Adejoro,Farri and Makinde, 2008; Okoro and Okoro, 2009 Omolase, Balarabe and Omolase, 2010). However, the uptake of the Internet among resident doctors has not been fully explored by researchers. Few studies exist in Nigeria that investigates utilization of Internet health information resources among resident doctors. Previous studies of Internet usage among resident physicians were conducted in developed countries (USA, United Kingdom and New Zealand). There is the need to carry out related studies in a developing country context. This study is therefore meant to fill this gap. The study will investigate the influence of Internet accessibility, demographic and motivational factors on utilization of Internet health information resources among resident doctors in tertiary health institutions in Southwestern Nigeria.

1.2 Statement of the problem

In Nigeria, resident doctors play important roles in providing secondary and tertiary health care services. They therefore need access to health information resources to improve their capacity to diagnose, prevent and manage both communicable and non-communicable diseases. Resident doctors also need information from the Internet for research and publication of findings in their specialty.

The Internet has a large volume of health information resources that could be utilized by resident doctors for research as well as for efficient and effective management of patients. Although Internet facilities are available in most health institutions located in urban centers and especially capital cities in Nigeria however, there are challenges in accessing information resources on the Internet due to infrastructural problems such as power outages, low bandwidth, and low Internet penetration. Also, poor perceived benefits of Internet use, low information literacy skills as well as inadequate motivational factors for Internet usage such as computer training, use of online search engines and databases to access health information resources militate against its optimal use in Nigeria. In addition, personal characteristics of the users have been found to play significant role in the use of Internet health information resources among medical practitioners.

Few empirical studies exist in Nigeria on the extent to which resident doctors use the Internet for accessing health information resources, the purpose(s) for which they use the Internet and factors that motivate them to use Internet health information resources. This study is therefore designed to fill this gap in knowledge.

1.3 Objectives of the study

The main objective of the study is to ascertain the extent to which resident doctors use Internet health information resources and the factors that influence their use of these resources in tertiary health institutions in Southwestern Nigeria.

The specific objectives are to:

  1. determine the proportion of resident doctors who have access to the Internet

  2. determine the frequency of use of Internet health information resources among resident doctors

  3. investigate the purpose (s ) for using Internet health information resources by resident doctors

  4. determine the motivational factors that influence utilization of Internet health information resources among resident doctors

  5. determine the relationship between Internet accessibility and utilization of Internet health information resources by resident doctors

  6. ascertain the relationship between motivational factors and utilization of Internet health information resources by resident doctors

  7. determine the relationship between demographic variables (age, gender, income/grade level, residency status, institutional affiliation) and utilization of Internet information resources by resident doctors

  8. ascertain the influence of Internet accessibility, demographic and motivational variables factors on utilization of Internet health information resources among resident doctors

  9. identify constraints to use of Internet health information resources among resident

doctors in tertiary health institutions in Southwestern Nigeria

1.4 Research Questions

The study sought to provide answers to the following research questions:

  1. What proportions of resident doctors have access to the Internet?

  2. How frequently do resident doctors use Internet health information resources?

  3. What are the main purposes for which resident doctors use Internet health information resources?

  4. What motivational factors influence utilization of Internet health information resources by resident doctors?

1.5 Hypotheses

In order to achieve the study objectives and answer the research questions stated above, the following hypothesis will guide the conduct of this study and they will be tested at P = 0.05 level of significance.

  1. There is no significant relationship between demographic variables and utilization of Internet health information resources by resident doctors.

  2. There is no significant relationship between Internet accessibility and utilization of Internet health information resources by resident doctors.

  3. There is no significant relationship between motivational factors (perceived ease of use, perceived enjoyment and perceived usefulness) and utilization of Internet information resources by resident doctors.

  4. Internet accessibility, demographic variables and motivational factors (perceived ease of use, perceived usefulness and perceived enjoyment) will not significantly determine utilization of Internet health information resources by resident doctors in Southwestern Nigeria.

1.6 Scope of the study

This study will cover all 1,532 resident doctors who are undergoing training to become specialists in different medical disciplines in thirteen tertiary health institutions in Southwestern Nigeria. The tertiary health institutions include Federal and State University teaching hospitals, Federal Medical Centres (FMCs), and Specialist hospitals that have residency training programs. It will focus on Internet accessibility, demographic and motivational factors that influence utilization of Internet health information resources among resident doctors.

1.7 Significance of the study

This study is significant for four reasons. First, it will provide baseline data on utilization of health information on the Internet by resident doctors which will serve as advocacy tool for appropriate intervention. Secondly, it will serve as a pointer to how resident doctors use available Internet information resources, for what purposes Internet information resources are used and also the extent to which their practice is based on available research evidence in the medical literature. Thirdly, the findings of this study will be useful in identifying Internet health information resources utilized by resident doctors. It will enhance the abilities of medical librarians’ to develop, select and promote Internet health information resources that will be accepted and used by resident doctors. Such understanding will be beneficial to medical librarians in terms of advocacy for more funds from the institutions for subscription to Internet resources relevant to resident doctors. Finally, the outcome of this study will add more to the body of knowledge in the field of medical librarianship. It will also assist the health administrators and medical librarians to consider Internet accessibility, personal and motivational factors when planning to improve Internet information resources use by resident doctors.

1.8 Justification for conducting the study in Southwestern Nigeria

The main justification for conducting this study in South-west geopolitical zone of Nigeria is because there are many tertiary health institutions in this region that have residency training programmes with a high population of resident doctors. Also, in the Southwestern region, are first, second and third generation health institutions and a mixture of University teaching hospitals, specialist hospitals and Federal Medical Centers.

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