text:
Because of the strong interest in the use of bio-products as alternatives to chemically derived antibiotics or antimicrobial agents, passion fruits extracts were evaluated for their antibacterial activity and chemical composition. Various solvent extracts of P. edulis were screened for their antibacterial activity by Agar well diffusion technique against an array of pathogenic bacteria (Gram positive and negative). Macro dilution technique was used to determine the Minimum inhibitory concentration of the potent extracts. Bacterial strain showing significant inhibition was further subjected to scanning electron microcopy (SEM) and the morphological changes induced by extracts were noted. Chemical composition of extracts showing strong antibacterial activity was determined by GC-MS and FTIR analysis. Extracts of Passion fruit (pulp with seeds) show significant inhibitory effects against test isolates but in a variable manner. Amongst all the test isolates Bacillus subtilis showed maximum inhibition followed by E. coli and P. aeruginosa. Ethyl acetate extracts had the least activity against the tested microorganisms. Gas chromatography-mass spectrometry of ethanol extracts showed the presence of important chemicals, such as Tetracosamethyl-cyclododecasiloxane; Dodecanoic acid, 10-methyl-, methyl ester cyclosiloxane, hexadecamethyl; 3-isopropoxy-1,1,1,7,7,7-hexamethyl-3,5,5-tris (trimethylsiloxy)tetrasil; 9-hexadecenoic acid, 9-octadecenyl ester, (Z,Z)- Fourier transform infrared studies revealed important functional groups which included phenols, esters, flavonoids, aromatic compounds, and alcohols. Significant antibacterial activity of the extracts could be attributed to phenolic compounds, esters and other chemical components identified in ethanolic extracts. Scanning electron micrographs of B. subtilis treated with ethanol extracts showed distorted shapes, rough and corrugated cell margins, and aggregations of cells. Our data depict the significant antimicrobial activity of extracts against Gram positive bacteria while the Gram negative bacteria exhibited weak inhibition by all the extracts. Based on our findings, passion fruits can be used in preparations of antimicrobial formulations against Gram positive microorganisms especially B. subtilis.
Passion fruit, pulp, Rind, scanning electron microscopy, Gas chromatography-mass spectrometry, Fourier transform infrared.
Plants serve as one the largest natural resource reservoirs. These resources have been explored for the presence of potent chemical compounds, applicable in the pharmaceutical, cosmetic, and nutraceutical industries. Yet, from a huge estimate of 250,000–500,000 plant species on Earth, only a very small fraction (1-10%) have been explored for compounds that may serve as antimicrobials1,2. In fact, medicinal plants have always occupied a vital place in our culture since time immemorial. Some Asian populations (80%) still depend on traditional medicines derived from plants 3. Moreover, recent research has discovered chemicals from plants, which possess promising antimicrobial properties that can serve as novel therapeutic compounds. The rise in antimicrobial resistance, has forced mankind to explore new alternatives with fewer irreversible side effects. The best solution to the menace of resistant microbial strains is herbal constituents that are easily available and affordable. Hence, this need has prompted us and various researchers worldwide to investigate plants and their products for their antimicrobial activity against resistant strains of pathogenic bacteria and fungi.
Passion fruit is an exotic tropical and subtropical fruit, belonging to the family Passifloraceae with an estimate of 500 species. Amongst the species, P. edulis, P. ligularis, and P. quadrangularis are chiefly cultivated for their edible fruit, economic importance, ornamental purpose, and medicinal properties4. P. edulis Sims is a perennial vine and growing at higher altitudes. It has two forms; the yellow fruit called the Passiflora edulis f. flavicarpa Deg. and the purple form referred to as Passiflora edulis f. edulis. The purple fruit is a native of Brazil, it is smaller in size with a strong aroma and is more acidic than the yellow type. Passion fruits are rich in vitamin C, A, niacin, and fiber. All the plant parts have medicinal properties and are used in various forms of herbal medicine. Dried flower and fruits are used to treat constipation, gastric ailments, as a digestive stimulant and treating gastric cancer 5 Boiled leaves are used to treat hypertension and chronic dysentery in some parts of India6.
Passion fruit and its peel have shown positive results in treating asthma, high blood pressure, menopausal symptoms, and osteoarthritis, and act as an excellent anti-inflammatory, anti-helminthic, sedative, and diuretic7-11.
For a few years, passion fruit has drawn the attention of many researchers because of its wide chemical composition. The purple fruit is not well studied for its antimicrobial properties and its chemical composition; hence, in the present research, we explore the antimicrobial efficacy of fruit pulp and peel extracts. Further, scanning electron microscopy of severely affected microbial strains will be conducted to understand the potency of extracts on cell morphology.
Plant material: Passion fruits
Fresh, disease- and injury-free fruits of Passiflora edulis f. edulis Sims (purple variety) were collected from a local market in Riyadh (Fig. 1). The fruits were washed with tap water followed by distilled water. Fruits were then cut, and the pulp was separated from the peel. Fruit pulp with the seeds and peels were freeze dried separately, and ground into fine powder with a mixer grinder. The powder was subjected to extraction.
Preparation of extracts
Pulp and powdered peels (20 g) were subjected to extraction with ethanol, methanol, acetone, and ethyl acetate (100 ml). Extracts were placed on a rotator shaker at 180 rpm for 72 h, after which they were filtered using a Whatman filter paper (No. 1). The filtrates were evaporated in a vacuum evaporator. The extracts were reconstituted in mother solvents and used for antibacterial and antifungal assays.
Microbial isolates
Passion fruit extracts were tested against selected human pathogenic microorganisms. Bacterial isolates included Gram-negative and gram-positive bacteria,namely Staphylococcus aureus ATCC 25923, Bacillus subtilis ATCC 6633, Escherichia coli ATCC 25966, Pseudomonas aeruginosa ATCC 27853, Enterococcus faecalis ATCC 29212, and Klebsiella pneumonia (hospital isolate). Fungal isolate screened was Candida albicans ATCC 60193. The tested microorganisms were provided by King Khalid Hospital, Riyadh-Saudi Arabia. Microbial isolates were pre-cultured on nutrient agar.
Antibacterial assay
Antibacterial activities of plant extracts were tested using the agar well diffusion technique12 with slight modifications. The culture plates were prepared by pouring 20 ml of Mueller Hinton (MH) agar medium into sterile Petri dishes. The inoculum suspension of 0.5 McFarland was prepared for all bacterial isolates to be tested and 200µl of this suspension was spread uniformly over the agar medium using sterile cotton swabs. With the help of a sterile cork borer of 6 mm diameter, wells were made equidistantly on the agar surface to be further loaded with 100µl of solvent extracts. Following loading of the extracts, plates were incubated for 24 h at 37°C. The inhibitory activity of these extracts was recorded by measuring the diameter of the inhibition zone (mm) formed around the well. Tetracycline (30µg) and ampicillin (10µg) discs were used for antibiotic sensitivity assays and the largest zone shown by the respective antibiotic was tabulated. Mother solvent served as a negative control, whereas the antibiotic disc was the positive control. Candida albicans was tested for its antifungal activity with Mueller Hinton agar along with bacterial isolates.
Minimum inhibitory concentration of extracts against bacteria
Minimum Inhibitory Concentration (MIC) for bacteria and yeast was determined by Broth tube dilution method with slight modification13,14. A double dilution of extracts (0.125mg/ml – 128 mg/ml) was prepared using Mueller Hinton Broth. Equal volumes of extract and broth were added to a sterile test tube followed by a fixed volume of Microbial cell suspension containing 5 × 105 CFU/ml of cells. This concoction was incubated for 24 h at 37°C . The lowest concentration that did not show any visible growth was regarded as its MIC. The experiment was performed in triplicates and their mean values were noted.
Gas chromatography-mass spectrometry (GC-MS) analysis
Ethanol extract was subjected to GC-MS analysis. GC-MS analysis was carried out on Clarus 500 Mass spectrometer and gas chromatography. Different parameters involved in the operation of the Clarus 500 MS were standardized as follows: mass spectra were taken at 70 eV; acquisition mode – scan 40-550 amu; ion source temperature 230°C; inlet line temperature 200°C; solvent delay time 5 min. Gas chromatography used in the analysis employed a fused silica column [100% dimethyl poly siloxane, 30 nm ׳ 0.25 nm ID ׳ 1µm df]. The column was packed with Elite-1. Helium was used as the carrier gas (1 ml/min). The extract (2µl) was injected into the instrument. The oven temperature program was 2 min at 45°C, 1.5°C/min to 100°C, and 2°C /min to 200°C during the GC extraction process; the split ratio was 25:1. The injector temperature was 250°C. The GC run time was 90 min. The identification of the phytocompounds and interpretation of the mass spectrum were performed with the aid of the standards database of the NIST libraries.
Fourier Transform Infrared (FTIR) Fingerprint Analysis
Fourier transform infrared (FTIR- Perkin Elmer 2000) spectrophotometer was used to identify the functional groups present in ethanol and acetone extracts. The extracts were centrifuged, filtered, diluted (1:10), and subjected to analysis in the scan range 400 to 4000 cm-1.
Bruker OPUS software was used to analyze the spectrum.
Scanning electron microscopy (SEM)
The SEM was performed as previously reported, with slight modification14 B. subtilis cell suspension at its MIC (0.25 mg/ml) treated with ethanol pulp extract was selected for the SEM analysis. The bacterial cell suspension was subjected to centrifugation (8,000 ׳ g for 10 min). Centrifuged cells were fixed by immersing in 2.5% glutaraldehyde and then washed with 0.1 mol/ L tris-acetate buffer (pH 7.2). Dehydrated samples were freeze-dried and observed by SEM (JEOL, Japan). Cells grown in an MH tube with no extract were used as a control.
The anti-microbial results of the extracts in this study are recorded in Tables 1 and 2. Pulp (with seeds) extracts were more effective than that of the peel. All the tested organisms showed variable sensitivity towards the extracts. However, we noted that the highest antibacterial activity was observed with the ethanol extract, particularly against Bacillus subtilis (24 mm), Escherichia coli (19 mm) and Pseudomonas aeruginosa (18 mm), followed by the acetone extract against P. aeruginosa (18 mm) and Bacillus subtilis (17 mm). Ethyl acetate had negligible effects on all the test organisms. On the other hand, Candida albicans was susceptible to both acetone and ethanolic extracts (18 mm and 17 mm) compared to the other organic extracts (Table 1). Peel extracts, however, did not exhibit significant antimicrobial activity, except for C. albicans which showed a maximum zone of inhibition (15 mm) with ethanol extracts.
Table (1):
Antibacterial activity of fruit pulp (with seeds) and zones of inhibition (mm).
|Ethyl acetate
|Staphylococcus aureus
|29 mm(T)
|Bacillus subtilis
|30 mm(T)
|Escherichia coli
|32 mm(T)
|Pseudomonas aeruginosa
|30 mm(A)
|Klebsiella pneumoniae
|10 mm(A)
|Candida albicans
|19 mm(F)
T-Tetracycline (30 µg), F-Fluconazole (25 µg), A- Ampicillin 40 μg/ml.
Values are means of three replicates and ± SD
Table (2):
Antibacterial activity of fruit peel and zones of inhibition (mm).
|Ethyl acetate
|Staphylococcus aureus
|29 mm(T)
|Bacillus subtilis
|30 mm(T)
|Escherichia coli
|32 mm(T)
|Pseudomonas aeruginosa
|30 mm(T)
|Klebsiella pneumoniae
|24 mm(T)
|Candida albicans
|18 mm(F)
T-Tetracycline (30 µg), F-Fluconazole (25 µg).
Values are means of three replicates and ±SD
Minimum inhibitory concentration
The MIC required to completely arrest the growth of test isolates with pulp extracts ranged between 0.25 -128 mg/ml-1, while for peel it was between 2 – 128 mg/ml-1 . Amongst all the pulp extracts, ethanol, methanol and acetone extracts inhibited Bacillus subtilis with the least MIC of 0.25 mg/ml-1, and 0.5 mg/ml-1 each . Candida albicans was inhibited at a MIC of 0.5 mg/ml. with ethanol pulp extracts. However, all the peel extracts inhibited the test isolates with a high MIC but in a variable manner. (Table 3, 4)
Table (3):
Minimum inhibitory concentration of passion fruit pulp with seeds (mg/ml-1).
|Ethyl acetate
|Staphylococcus aureus
|Bacillus subtilis
|Escherichia coli
|Pseudomonas aeruginosa
|Klebsiella pneumoniae
|Candida albicans
Each value shown in the above table is a mean of three replicates and ±SD. NI-not inhibited.
Table (4):
Minimum inhibitory concentration of passion fruit peel extracts (mg/ml-1).
|Ethyl acetate
|Staphylococcus aureus
|Bacillus subtilis
|Escherichia coli
|Pseudomonas aeruginosa
|Klebsiella pneumoniae
|Candida albicans
Each value shown in the above table is a mean of three replicates and ±SD. NI-not inhibited.
GC-MS of ethanol extracts showed important chemicals, including tetracosamethyl-cyclododecasiloxane, dodecanoic acid, 10-methyl-, methyl ester cyclosiloxane, hexadecamethyl; 3-isopropoxy-1,1,1,7,7,7-hexamethyl-3,5,5-tris (trimethylsiloxy)tetrasil; 9-hexadecenoic acid, 9-octadecenyl ester, (Z,Z)-, cyclononasiloxane, and octadecamethyl; 9,12-tetradecadien-1-ol, (Z,E). (Table 5)
Table (5):
Chemical compounds identified from the GC-MS analysis of the ethanol extract of passion fruit pulp with seeds.
|Name of the compound
|Molecular formula
|Molecular weight
|Cyclooctasiloxane, Hexadecamethyl
|Dodecanoic acid, 10-methyl-, methyl ester
|Cyclononasiloxane, Octadecamethyl
|9-Hexadecenoic acid, 9-octadecenyl ester, (Z,Z)-
|9,12-Tetradecadien-1-ol, (Z,E)
FTIR analyses
The FTIR spectra of the organic extracts ethanol and acetone, in particular, revealed the presence of the following important functional groups: alcohols, alkanes, esters, aromatic compounds, phenols, carbonyl compounds, and ketones (Tables 6, 7). Peaks at 3309, 3334, and 1370 are caused by the –OH stretch of alcohols and phenols. Similarly, the series of peaks at 2970, 2930, and 2869 were caused by the symmetric and asymmetric stretches of –CH, whereas the peaks between 2006-2211 were attributed to stretches, vibrations, and deformations of CºC and NH. The peaks at 1986, 1695, and 1647 were caused by C=C bending and stretching of aromatic. Peaks at 1043, 1085, and 1237, denoting stretching of C-O (Fig. 2 and 3). Antimicrobial activity could be attributed to the important functional groups, such as alcohols, phenols, aromatic compounds, and esters.
Table (6):
IR Spectrum for passion fruit with pulp and seeds: Acetone extracts.
|Peak values (frequency, cm-1)
|Functional group
|-OH stretch
|C≡C stretching
|C≡C stretch
|C꞊C stretch
|C꞊C stretch
|C꞊C stretch
|C꞊C stretch
|C-O stretches
|C-O stretches
Table (7):
IR Spectrum for passion fruit ethanol extract with pulp and seeds.
|Peak values (frequency, cm-1)
|Functional group
|-OH stretch
|CH2 asymmetry stretching
|CH2 symmetry stretching
|C꞊C stretch
|C꞊C stretch
|C꞊C stretch
|C꞊C stretch
|C꞊C stretch
|C꞊C bending
|C꞊C symmetric stretching
|C-H rocking stretch
|C-O stretch
|C-O stretch
Micrographs of ethanol-treated B. subtilis cells show distorted shape, rough and corrugated cell margins. Blebs, protrusions and the aggregation of cells leading to complete damage of cells was also observed. Control cells, which did not receive treatment exhibited well defined complete and regular morphology. (Fig. 4. A-D).
Fig 4. Microphotographs of Bacillus subtilis cells (treated/control) with ethanol extracts of fruit pulp with seeds
Scanning electron microscopy of B. subtilis A-control cells, non-treated cells with well-defined margins
B and C – Treated cells show clumping and aggregation of cells.
D-Leaked cells with blebs and protrusion, completely distorted and damaged cells can be seen.
The present study showed the significant antibacterial and antifungal activity of passion fruit (pulp) extracts but in a variable manner. Ethanol and acetone extracts were most effective in controlling the growth of test isolates, which could be attributed to the high polarity of solvent, which is excellent in extracting some important phenols and other bioactive compounds. Based on the inhibition zones the antibacterial activity was classified according to Okonko et al., Bacterial isolates were considered sensitive or susceptible if the inhibition zones is >18 mm; intermediate inhibition if the zone is between 13–17 mm; resistant when the zone is <13 mm15. It was interesting to note that Gram positive bacteria were more susceptible to extracts than the Gram negative isolates. The strongest inhibition was shown by ethanol (pulp with seeds) extracts against B. subtilis with a maximum zone of inhibition (24 mm) and low MIC value (0.25 mg/ml -l ).
Similar to our findings, Kanu et al., recently reported the antimicrobial activity of ethanolic extracts of P. edulis var. flavicarpa seeds. Amongst the three microbes screened, C. albicans and S. aureus were more susceptible than E. coli, their inhibition zones ranged between 5 mm-18 mm16. Therefore, as revealed by the antibacterial assay, significant inhibition was observed with gram-positive bacteria in comparison to gram-negative. Our findings are in agreement with Kanu et al.16. The differences in the sensitivity were caused by the chemical composition of their cell envelopes, which differed in permeability. The lipopolysaccharide layer present in the outer membrane of Gram negative bacteria is very tough and impermeable to bioactive antimicrobial compounds, while the peptidoglycan layer of Gram positive bacteria is easily permeable. Hence, the resistance shown by Gram negative bacteria in the present study, could be due to restricted entry of antimicrobial compounds through the complex and rigid outer membrane17. The poor antimicrobial activity shown by other extracts can be due to the weak concentration of certain bioactive antimicrobial compounds extracted by solvents due to their polarity and also the mode of extract preparation18.
In another report Ramaiya et al., screened various extracts from leaves and stems of three species of Passiflora., Passiflora quadrangularis, P. maliformis, and P. edulis. They reported antibacterial activity of various solvent extracts from all species against 10 bacterial strains, amongst them methanolic extracts were the most effective. Furthermore, gram-positive bacteria were more susceptible to extracts than gram-negative bacteria19. Yet, in another study, passion fruit co-products and albedo, were screened for their antibacterial activity The MIC for the co-products ranged between 3.125 mg/mL -50 mg/ml 20. Onuh et al., reported that aqueous extracts of the peel of Passiflora edulis showed strong inhibition of some fungi, especially Rhizopus stolonifer, Aspergillus niger and Penicillium marneffei. Peel extracts were inhibitory towards P. aeruginosa, which is not in agreement with our findings21.
The GC-MS of fruit extracts showed some important oxygenated mono and diterpenes, esters, and phenols. Similar to our findings, compounds like tetracosamethyl-cyclododecasiloxane, dodecanoic acid, 10-methyl-, methyl ester; cyclosiloxane, hexadecamethyl; 3-isopropoxy-1,1,1,7,7,7-hexamethyl-3,5,5-tris (trimethylsiloxy) tetrasil; 9-hexadecenoic acid, 9-octadecenyl ester, (Z,Z)-, 9,12-tetradecadien-1-ol, (Z,E), cyclononasiloxane, and octadecamethyl have been reported earlier from Camellia oleifera seed cake and stems of Cola nitida22,23. Compounds, such as tetracosamethyl-cyclododecasiloxane, cyclosiloxane, and hexadecamethyl have shown antibacterial, antifungal, and antioxidant properties24-27 and 9-hexadecenoic acid and 9-octadecenyl ester possess antimicrobial properties28. Yet in another study, the phytochemical screening of P. edulis seeds revealed the presence of terpenes, flavonoids, alkaloids, steroids, tannins, and glycosides. The antimicrobial activity of the extract was linked to the presence of terpenes, flavonoids, alkaloids, and other chemical components found in the extract16.
The significant antimicrobial activity shown by passion fruit pulp extracts (purple variety) in the present study could be attributed to the presence of important bioactive compounds whose presence was indicated in the IR spectrum. Similar to our findings, Wasagu et al., reported the presence of flavonoids, terpenes, phenols, aromatic compounds, and alkaloids from the fruit extracts of P. edulis var flavicarpa (yellow fruits). They further stated that these compounds, which play a crucial role in plant defense against microbes, are also responsible for antibacterial activity29. Earlier studies report high amounts of phenols, polyphenols, alkaloids, terpenes and flavonoids from fruit pulp and rind of passion fruit and related their presence to plant defense against microbes and also for antibacterial activity30. Further, polyphenols, such as isoorientin, orientin, vitexin, isoschaftoside, and luteolin-6-C-fucoside have been identified from yellow passion fruit pulp and seeds20,30,31.
In the present study, microphotographs of treated cells show the damaging effects of ethanolic (pulp with seeds) extracts on cell morphology. B. subtilis cells treated with ethanolic extracts at its MIC concentration show, cell protrusions, deformed morphology resulting in clumping of cells, while the control cells (untreated) regular cell morphology. Similar changes in morphology and cell integrity have been reported previously when bacteria were treated with fruit extracts of Punica granatum and Mesua ferrea32,33.Earlier studies have shown that terpenes, phenols, and flavonoids play an important role in damaging the cytoplasmic membrane, inhibiting cell wall and cell membrane synthesis, causing perforations by reducing membrane fluidity. They also cause inhibition of nucleic acid synthesis34,36. In addition, some flavonoids inhibit ATP synthase, which directly effects energy metabolism37. Therefore, these bioactive compounds basically destabilize cell membrane integrity by altering their permeability, causing cell disruption. However, there are no studies to my knowledge that show the effect of Passion fruit extracts on cell morphology, hence comparative study cannot be presented here.
Our data depict the significant antimicrobial activity of ethanol and acetone extracts of fruit pulp of Passiflora edulis. Our study shows, ethanol and acetone as effective solvents in extracting important bioactive compounds. The IR spectrum and GCMS showed the presence of some key functional groups. Presence of these bioactive compounds could be responsible for distorting effects seen on cell morphology of B. subtilis. Because, the purple variety of the fruit has not been explored thoroughly for its antimicrobial properties and chemical composition, further fractionation and purification will help identify the potential chemical compounds and their mode of action. Because the fruits are easily available, their formulations will be affordable and effective in treating pathogenic infections with fewer side effects.
This Research Project was supported by a grant from the financial support from the Researchers Supporting Project number (RSP-2019/114),King Saud University,Riyadh,Saudi Arabia. The authors would like to extend sincere appreciation for funding this work.
The authors declares that there is no conflict of interest.
HR designed the experimental work. NA conducted the experimental work.HR analysed the electron microscopic studies. FA assisted in GCMS and IR analysis. HR wrote the manuscript. FA reviewed the manuscript. All autrs approved the manuscript for publication.
This study received grant-in-aid from the Researchers supporting Project number (RSP2019/114),King Saud University,Riyadh,Saudi Arabia.
This article does not contain any studies with human participants or animals performed by any of the authors.
The data that support the findings of this study are available with the corresponding author.
- Borris, R.P. Natural products research: perspectives from a major pharmaceutical company. J. Ethnopharmacol., 1996; 51: 29–38.
- Osman, K., Evangelopoulos, D. Basavannacharya C et al. An antibacterial from Hypericum acmosepalum inhibits ATP dependent MurE ligase from Mycobacterium tuberculosis. Intern. J. Antimicrob Agents, 2012; 39: 124–129.
- Tagboto, S., Townson, S. Antiparasitic properties of medicinal plants and other naturally occurring products. Adv. Parasitol., 2001; 50: 199–295.
- Patil, A.S., Paikrao, H.M. Bioassay guided phytometabolites extraction for screening of potent antimicrobials in Passiflora foetida L. J. App. Pharm. Sci., 2012; 2: 137–142.
- Patel, S.S., Soni, H., Mishra, K., Singhai, A.K. Recent updates on the genus Passiflora: A review. Int. J. Res. Phytochem. Pharmacol., 2011; 1: 1–16.
- Jamir, T.T., Sharma, H.K., Dolui, A.K. Folklore medicinal plants of Nagaland, India. Fitoterapia, 1999; 70: 395–401.
- Zibadi, S., Farid, R., Moriguchi, S., et al., Oral administration of purple passion fruit peel extract attenuates blood pressure in female spontaneously hypertensive rats and humans. Nutr. Res., 2007; 27: 408-416.
- Johnson, M., Maridass, M., Irudayaraj, V. Preliminary phytochemical and anti-bacterial studies on Passiflora edulis. Ethnobotanical Leaflets., 2008; 12: 425-432.
- Watson, R.R., Zibadi, S., Rafatpanah, H. et al., Oral administration of purple passion fruit peel extract reduces wheeze and cough and improves shortness of breath in adults with asthma. Nutr. Res., 2008; 28: 166–171.
- Farrid, R., Rezaieyazdi, Z., Mirfeizi, Z. et al., Oral intake of purple passion fruit peel extract reduces pain and stiffens and improves physical function in adult patients with knee osteoarthritis. Nutr. Res., 2010; 30: 601–606.
- Akanbi, B.O., Bondunrin, O.D., Olayanju, S. Phytochemical screening and antibacterial activity of Passiflora edulis. Hygeia. J. Drugs Med., 2011; 3: 46-49.
- Valgas, C., Souza Simone, Mde., Smania, E.F.A., Smania, Jr, Artur. Screening methods to determine antibacterial activity of natural products. Braz. J. Microbiol., 2007; 38: 369-380.
- CLSI. Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria that Grow Aerobically. 9th Edn., Clinical and Laboratory Standards Institute,Wayne, PA., USA. 2012.
- Rizwana, H. In vitro antibacterial and antifungal activity of some oils, chemical analysis and their FTIR studies. Int. J. Agric. Biol., 2018; 20: 1488 1496.
- Okonko, O.I., Donbraye-Emmanuel, O.B.,Ljandipe, A., Ogun, A.A.,Adedeji, A.O., Udeze, A.O. Antibiotics sensitivity and resistance patterns of pathogens to nitrofurantoin and nalidixic acid in pregnant women with urinary tract infections in Ibadan, Nigeria. Middle-East. J. Sci. Res., 2009; 4: 105–109.
- Kanu, A.M., Agwu, C.O., Chidiebere, U., Ugochi, N.A. Phytochemical screening and antimicrobial activity of ethanoic extract of Passiflora edulis var. flavicarpa seed on selected pathogens. Uni. J. Microbiol. Res., 2017; 5: 35–39.
- Delcour A.H. Outer membrane permeability and antibiotic resistance. Biochim. Biophys. Acta., Proteins Proteomics, 2009; 1794: 808–816.
- Nazif, N.M. Phytoconstituents of Zizyphusspina-christi L. fruits and their antimicrobial activity. Food Chem., 2002; 76: 77–81.
- Ramaiya, S.D., Japar, S.B., Muta, H.Z. Assessment of total phenolic, antioxidant, and antibacterial activities of Passiflora species. Sci. World. J., 2014; 1-10.
- Lopez-Vargas, J.H., Fernandez-Lopez, J., Perez-Alvarez, J.A., Viuda-Martos, M. Chemical, physico-chemical, technological, antibacterial and antioxidant properties of dietary fiber powder obtained from yellow passion fruit (Passiflora edulis var. flavicarpa) co products. Food Res. Int., 2013; 51: 756–763.
- Onuh, J.O., Shiriki, D., Ubwa ,S.T., Shambe, T. Isolation of six microorganisms from rotten Dioscorea alata (water yam), and antimicrobial sensitivity test with nine plant extracts. Food Nutr. Sci., 2015; 6: 1381–1394.
- Olakunle, O.M., Bola, A. GC-MS Analysis of phyto components from the stem bark of Cola nitida Schott & Endl. J. Plant Sci., 2017; 5: 99 –103.
- Li, L., Xuexiang, C., Weiwei, Z., Yunhao, W., Xiang, D., Lili, C., Dangquan, Z., Wanxi, P., Systematic characterization of volatile organic components and pyrolyzates from Camellia oleifera seed cake for developing high value-added products. Arab J. Chem., 2018; 11: 802–814.
- Lalitharani, S., Ramasamy, V., Mohan, R.G.S. GC-MS analysis of ethanolic extract of Zanthoxylum rhetsa (roxb.) DC spines. J. Herb. Medi. and Toxicol., 2010; 4: 191–192.
- Musthafa, K.S., Sahu, S.K., Ravi, A.V., Kathiresan, K. Anti-quorum sensing potential of the mangrove Rhizophora annamalayana. World J. Microbiol. Biotechnol., 2013; 29: 1851–1858.
- Ahsan, T., Chen, J., Zhao, X., Irfan, M., Wu, Y. Extraction and identification of bioactive compounds (eicosane and dibutyl phthalate) produced by streptomyces strain kx852460 for the biological control of Rhizoctonia solani ag-3 strain kx852461 to control target spot disease in tobacco leaf. AMB Express, 2017; 7: 54.
- Hassan, S.R., Zaman, N.Q., Dahlan, I. Influence of seed loads on start up of modified anaerobic hybrid baffled (MAHB) reactor treating recycled paper wastewater. Eng. Heritage J., 2017; 1: 5–9.
- De Assis Lage, T.C., Montanari, R.M., Fernandes, S.A., De Oliveira Monteiro, C.M., De Oliveira Souza Senra, T., Zeringota, V., Da Silva Matos, R., Daemon, E. Chemical composition and acaricidal activity of the essential oil of Baccharis dracunculifolia De Candole (1836) and its constituents nerolidol and limonene on larvae and engorged females of Rhipicephalus microplus (Acari: Ixodidae). Exp. Parasitol., 2015; 14: 824–29.
- Wasagu, R.S.U., Lawal, M., Amedu, A.M., Sabir, A.A., Kabir, S., Tukur, U.G., Zaharadeen, A. Comparative chemical analysis, phytochemical screening and antimicrobial activities of the rinds, seeds and juice of (Passiflora edulis var. flavicarpa) passion fruit. J. Nat. Sci. Res., 2016; 6: 138-143.
- Zeraik, M.L., Yariwake, J.H. Quanti cation of isoorientin and total avonoids in Passi ora edulis fruit pulp by HPLC-UV/DAD. Microchem. J., 2010; 96: 86 –91.
- Dhawan K, Dhawan S, Sharma A. Passiflora: A review update. J. Ethnopharmacol., 2004; 94: 1–23.
- Anibal, P.C., Peixoto, I.T.A., Foglio, M.A., Hofling, J.F. Antifungal activity of the ethanolic extracts of Punica granatum L. and evaluation of the morphological and structural modifications of its compounds upon the cells of Candida spp. Braz. J. Microbiol., 2013; 44: 839–848.
- Aruldass, C.A., Marimuthu, M.M., Ramanathan, S., Mansoor, S.M., Murugaiyah, V. Effects of Mesua ferrea leaf and fruit extracts on growth and morphology of Staphylococcus aureus. Microsc. Microanal., 2013; 19: 254–260.
- Tsuchiya, H., Iinuma, M. Reduction of membrane uidity by antibacterial sophora avanone G isolated from Sophora exigua. Phytomedicine., 2000; 7: 161–165.
- Plaper, A., Golob, M., Hafner, I., Oblak, M., Solmajer, T., Jerala, R. Characterization of quercetin binding site on DNA gyrase. Biochem. Biophys. Res. Commun., 2003; 306: 530–536.
- Wu, D., Kong, Y., Han, C. et al. D-Alanine: D-alanine ligases as a new target for the flavonoids quercetin and apigenin. Int. J. Antimicrob. Agents, 2008; 32: 421–426.
- Chinnam, N., Dadi, P.K., Sabri, S.A., Ahmad, M., Kabir, M.A., Ahmad, Z. Dietary bio-flavonoids inhibit Escherichia coli ATP synthase in a differential manner. Int. J. Biol. Macromol., 2010; 46: 478–486.
© The Author(s) 2019. Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License which permits unrestricted use, sharing, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.


text:
Listings in Cladding, Flooring, Interior Design and Letters in Boca Raton and Miami
Quality Design 3D
in Architecture, Environmental/Graphic Design, Exhibit Design, Fixture Design, Interior Design, Lighting Design, Store Design, Visual Merchandising
we offer professional 3D design services to the discerning client who desires an environment with a unique style.
Miami, Florida 33156
United States
Fax: 305-280-3863
Melon Design
in Carts/RMUs, Interior Design, Visual Merchandising, Architecture, Exhibit Design, Fixture Design, Project Management, Store Design
Creative and strategic people developing Visual Merchandising, Architecture and Retail Design projects oriented by real people behavior in real purchasing situations We transform ideas into spaces & spaces into successful business.
2700 W. 3rd Ct,
2nd floor
Miami, Florida 33010
United States
Green Tile
in Cladding, Custom Metal Fixtures, Cork/Rubber, Linoleum, Marble, Stone, Tile, Stone, Natural, Other, Other
PO Box 853
Boca Raton, Florida 33429
United States
Virgin Carpet
in Graphic/Environmental Design, Carpet/Rug, Carpet/Rugs/Mats, Cork/Rubber, Other
po box 853
Boca Raton, Florida 33429
United States

subset: commoncrawl


text:
Great Phones
Yealink phones can look pretty stylish. I enjoy them more than PolyCom phones. The most annoying thing is having to provision them from the web console.
What are the pros?
Stylish. Great features. Competitive cost.
What are the cons?
It's annoying to have to provision them from the built-in web console. I'd prefer to just do it from the phone menus, like PolyCom.


text:
- Active Time : 20 Minutes
- Total Time : 20 Minutes
- Serves : 4
- 1/4 cup caramel flavored syrup
- 4 pudding cups (5.5 oz each) Super Snack Pack® Chocolate Vanilla Pudding
- 1/4 cup orange colored sugar
- 1 rainbow green fruit flavored
- 2 bananas, peeled, cut in half
- 2 chocolate sandwich cookies, crushed
Stir 1 tablespoon syrup into each pudding cup. Place sugar in shallow dish. Cut twist crosswise into 4 pieces. Cut each piece lengthwise into 3 thin pieces for carrot top.
Insert tip of small knife in flat end of each banana half to make small hole for inserting thin pieces for top. Roll each banana half in sugar until coated on all sides. Insert 3 thin pieces in each hole.
Insert a decorated banana half, pointed side down, into each pudding cup. Spoon crushed cookies evenly around each banana. Serve immediately.


text:
Discus thrower moves on
Nathan Morrell has qualified to compete in the 2016 State Track & Field Championships at Eastern Washington University this Saturday.
The Lake Roosevelt discus thrower was the only Raider who qualified out of the five that had an opportunity to move on at the district competition in Ephrata Saturday. Morrell placed fourth in the discus with a throw of 103 feet, 6 inches.
Morrell will throw at state on Saturday at 12:30 p.m. behind the Jim Thorpe Fieldhouse on EWU's campus at Cheney in the first flight of 2B Boys Discus competitors.
Nathaniel Hall ran earlier at Ephrata in the 100-meter dash. Hall placed 6th in 12.02 seconds.
Robert George was scratched out of the 110-meter high hurdles, ending his high school career. Cameron Tillman finished fifth in the pole vault by clearing the 8-foot, 6-inch standard. Tillman had to return to the pole vault for a jump-off to break a tie at fourth place. Matthew Tillman took sixth by clearing the 8-foot standard.
"Everyone competed hard," Head Coach Lori Adkins said.
Morrell will have a send-off in Gailord Nelson Gym before traveling to Cheney Thursday.


text:
During my past four years of service as an officer of your Division, and before that as a member of its Research and Executive committee, I have been very fortunate to witness and work with deeply committed and often unnamed members, session and event organizers, and sundry volunteers who have generously contributed, year after year. She is also interested in exploring the role of governments and markets in the emergence and valuation of new types of capital in an economy. Three supporting items should be attached to the e-mail:. Please do stop and thank Mary for her superb effort when you see her in Boston. E-mail required, but will not display.
Guoli received his Ph. In particular, I will continue to support rigorous and relevant research and teaching activities from multiple theoretical perspectives and methodological approaches through PDWs and co-sponsored sessions. I will aim to initiate crowdsourcing efforts to identify new needs and programming formats including interactive online formats. He has received the development reviewer of the year award from the Academy of Management Review and several outstanding editorial board member awards from the Strategic Management Journal. Having seen so many written words of authors and referees, I look forward to seeing presented in Boston the outstanding research of our members.
2019 Doctoral Consortium
Conference Track Information The STR program is organized within tracks, to create opportunities for attendees to interact across related sessions, foster the development of research communities, and minimize time conflicts across sessions. First, STR can benefit significantly by expanding our community-building efforts.
It has been humbling and gratifying to work with so many committed individuals. Michael Leiblein PhD, Purdue is an Associate Professor bpss expertise in competitive strategy and innovation management.
Strategic Management – A Division of the Academy of Management
Then, connect with colleagues at the STR Social immediately following. The Irwin Outstanding Educator Award recognizes an established strategy scholar who has demonstrated outstanding commitment to Ph. The record number of submissions allowed the assembly of a selective program that is both large and high-quality. Any doctoral dissertation may be entered that satisfies the following criteria: His mainstream contributions anticipate the entrepreneurial challenge of growth through labor advantages and reflect the new economy issues ahead.
Members who are interested in enhancing their teaching skills will find a range of PDWs on offer again this year. Please note that STR sessions, meetings, and socials will all be in the Boston Park Plaza Hotel so consider booking your accommodations there for easy access to all of our events. Therefore, please be sure to identify and register for the sessions that interest you before they are fully subscribed, by perusing the program when it becomes available and by noting those PDWs that will be announced via our listserv and other social media.
There will also be some developmental Discussion Paper sessions, and structured symposia where multiple presentations are pre-assembled by organizers. His main research interests focus on the role of diversification, product strategies, IPRs, and performance. We hope to see you at the award reception on Sunday evening 6: Candidates are judged by the relevance, academic contribution, theoretical and methodological rigor, and practical implications of their work.
A terrific panel including Jay Barney, Don Hambrick, Anita McGahan and another guest to be announced will reflect on the past, present and future of Strategic Management. We will recognize various conference best paper awards at our Monday 6: Prior to academia, Ram worked a management consultant with Deloitte in Southern California, and as a software engineer with Siemens Public Communication Networks.
Three supporting items should be attached to the e-mail:. It requires a team effort to process the conference submissions and reviews in a condensed time frame.
The social follows immediately afterward 7: This will be just the second year that the Division honors recipients of two biennial awards that were introduced in Students selected to attend the Consortium will be sent a registration code that will allow them to register online.
Doctoral programs should limit their nominations to one applicant.
The Division is preparing more opportunities than ever to indulge intellectual curiosity, contribute to our field, meet new and old friends and colleagues, engage in lively discussions, and — yes —have some fun! Designed just for OMT members, the goal of this consortium is to orient doctoral students who are broadly interested in organizations and management as they enter the final phase of their doctoral programs.
The idea behind the plenary session format is to give division members the possibility with very few other divisional sessions scheduled in parallel to gather and discuss an important theme.
I eagerly anticipate meeting the faces that match the names. Each member has made special contributions to our strategic management community during the past year and towards the annual conference.
Notify me of follow-up comments. Our Junior Faculty Teaching Consortium will also be offered again this year. Building on this solid foundation, as diszertation as our recent name change and updated Division Statement, I believe that STR is poised to move to the next level in best serving its members.


text:
The events in Odessa at 15 February 2020
Preparty "Shavua Tov" / DJ ALTE
15 February 2020, 20:00
category: party
place: Location (look in the description)
Every Saturday we are waiting for you in our bar at the preparty "Shavua Tov" bar and traditionally we offer delicious kosher cocktails from the bartender from Israel! Where? Kosher Bar, per. Tchaikovsky, 12
Available in other languages:Russian (ru)Ukrainian (uk)German (de)Spanish (es)


text: Sorry, this video has expired Video 4:11 Sculpture exhibition lights up Melbourne Updated Tue 3 Jun 2014, 9:04 AM AEST Winter may now be upon us, but a new sculpture exhibition is creating a warm glow in Melbourne. Reporter James Bennett went along to Federation Square to have a look. Share Email Facebook Twitter


text:
Back to Journals » Journal of Healthcare Leadership » Volume 11
The Moderating Role Of Top Executives' Sex, Level Of Education And Knowledge On Adoption Of Mobile Health Applications By Hospitals In Kenya
Authors Ngongo BP, Ochola P, Ndegwa J, Katuse P
Received 7 August 2019
Accepted for publication 8 October 2019
Published 7 November 2019 Volume 2019:11 Pages 115—126
DOI https://doi.org/10.2147/JHL.S226341
Checked for plagiarism Yes
Review by Single-blind
Peer reviewer comments 2
Editor who approved publication: Professor Russell Taichman
Bahati Prince Ngongo, Phares Ochola, Joyce Ndegwa, Paul Katuse
Chandaria School of Business, United States International University Africa, Nairobi, Kenya
Correspondence: Bahati Prince Ngongo
United States International University Africa, Nairobi, Kenya
Email firstname.lastname@example.com
Background: Kenya lags behind other countries in adoption of mobile health (m-health) applications. Understanding factors affecting adoption of m-health by hospitals is required to inform strategic scale up and leverage m-health for sustainable development goals. This study investigated the moderating effects of Top Executives' (TEs) traits, namely sex, level of education and knowledge of m-health, on adoption of Patient Centered (PC) and Facility-Centered (FC) m-health applications.
Methods: This study applied the Technological, Organizational and Environmental (TOE) framework and the Diffusion of Innovation (DOI) theory to test hypotheses that TEs' traits individually or combined had no statistically significant moderating effect on adoption of PC and FC m-health applications. Primary data were collected through a self-administered questionnaire from a representative sample size of 211 TEs from level 4 to 6 hospitals. The Logit Regression Model was used to determine the significance of each predictor.
Results: Most TEs of hospitals are predominantly male (75.3%). Most TEs (65%) rated their knowledge of m-health at medium level. Most TEs reported having completed undergraduate (46%) or post-graduate (38.4%) degrees. At 5% level of significance, the study found that being a male TE (p=0.041) and having higher level of knowledge of m-health (p=0.009) were statistically significant moderators of adoption of PC m-health applications by hospitals in Kenya. However, all TEs' traits combined or individually were not statistically significant moderators of FC m-health applications. The moderating effect of TEs' traits is thus affected by the focus, level of complexity of the technology, and by the required organizational change management. For PC scale-up, there is an urgent need to integrate digital health training in the medical education curricula and in the professional development programs and to develop policy incentives that remove any gender-related barriers to adoption of m-health. However, scale up of FC m-health may require other strategies such as pre-existence of systems and infrastructure and a cohesive change management strategy.
Conclusion: This study recommends a differentiated approach to introduction, scale up, and investigation of PC and FC m-health applications.
Keywords: mobile health, adoption of m-health, digital health, health innovations
The increased access to phones and smart phones in the last decade presents a golden opportunity for mobile health (m-health) revolution. Globally, there are over 6 billion mobile phone subscribers, representing 75% of the world's population, with potential for m-health business opportunities and global health impact.1 Akter and Ray2 projected that the massive penetration of low-cost high-quality smart phones will reach more than 4 billion individuals by 2017 and that the m-health market will reach US $23 billion by end of 2017. The World Health Organization3 defines m-health as the use of any wireless technology or portable device by health providers to enable communication between patients and health services, for consultation between health care professionals, for health monitoring and surveillance, and for access to information for health care professionals at point of care. It identified twelve general applications of m-health (Table 1) that could be further categorized as patient-centered (PC) and facility-centered (FC). PC m-health applications aim to facilitate communications and data between patients and health providers, while FC m-health applications mostly facilitate communications and data between health care providers and have the opportunity to provide services remotely through networked facilities.
Table 1 M-Health Applications Categories And Re-Categorization As Per WHO
While m-health adoption in hospitals is expanding in High-Income Countries (HICs), it is not realizing its promised potential in Low- and Middle-Income Countries (LMICs). Sub-Saharan Africa lags behind other regions in adoption of m-health.3–5 Kenya lags behind other Sub-Saharan countries in m-health adoption despite its earlier competitive advantage in mobile financing and in e-commerce. Despite its leadership in developing one of the first comprehensive e-health strategies in Sub-Saharan Africa, adoption of m-health remains sub-optimal and thus requires further investigation of barriers to adoption of m-health by hospitals.6 There is a gap in knowledge of factors that affect m-health adoption by hospitals in Kenya and in other Sub-Saharan countries. A review of studies as cited by Gagnon7 on m-health between 2005 and 2014 showed that more than half (54.5%) of studies were conducted in the Americas, 18.2% in Europe, 15% in Asia, and 12.1% in Africa, mainly in Ethiopia, South Africa, Botswana, and Uganda. Most of these studies focused on acceptability of m-health to consumers or health care professionals and did not investigate institutional adoption of m-health "through the lenses" of high-level decision makers of hospitals' adoption of innovations. They were also qualitative in nature and had limited geographical scope. The literature on m-health globally in general, and in Sub-Saharan Africa, does not investigate the role of top executives of hospitals in adoption of m-health applications.8 There is a need for a shift from individual adoption to organizational adoption through sound and comprehensive theoretical frameworks and through the lenses of top decision makers at the firm level or organizational level.9
There are mixed results from empirical studies by regions and sectors on the moderating role of Chief Executive Officers (CEO) or Top Executives' (TEs') sex, level of education, and knowledge of technology on adoption of Information, Communications and Technology (ICT) innovations. For instance, in Kenya, Ochola10 found that CEOs' sex, level of education, and knowledge of e-commerce significantly moderated adoption of e-commerce. The higher the level of education, the higher the knowledge of e-commerce, the higher the likelihood of adopting e-commerce. It also found that enterprises led by female CEOs had higher adoption of e-commerce. However, studies in other regions such as China11 and Bangladesh12 found contrary results suggesting that female-led SME were less-likely to adopt IT innovations. There is limited evidence in the literature of the moderating effect of TEs of hospitals on adoption of health innovations generally and on m-health specifically. Most literature on m-health focus on either consumer adoption of m-health or individual health care provider adoption of m-health. Such approaches have led to techno-optimistic results of adoption of m-health because they do not consider organization adoption and also do not include a comprehensive evaluation of technological, organizational, and environmental factors that affect adoption.8,13 Furthermore, previous studies have not integrated any differences of the moderating effect of TEs' traits based on the focus of ICT innovations, whether they are PC (patient-centered and less complex to integrate) or FC (internally and process focused, resource intensive and more technologically and organizationally complex to integrate).
This study thus hypothesized that adoption of m-health is moderated by the TEs' traits such as sex, level of education, and knowledge of m-health. It further hypothesized that this moderating effect may be different for PC and FC m-health applications. While the age bracket and tenure of the TE have been considered in the analysis, they have not been integrated in the testing of hypotheses due to potential bias related to higher variability within each bracket and higher sensitivity to annual changes to significantly associate them with the process of decision-making to adopt innovations.
As highlighted previously, adoption of innovation in the health sector is complex and requires a mix of technological, organizational, and environmental determinants. The Diffusion of Innovation (DOI) theory developed by Rogers,14 is the most used framework to analyze adoption of IT innovations. Analyzing the technological and organizational characteristics of a technology through the DOI model by itself is not sufficient when adoption requires consideration of wider industry adoption, governmental regulations, and global competition. The Technological, Organizational and Environmental [TOE]) Framework developed by Tornatzky and Fleischer in 1390 is commonly used to investigate TOE determinants of adoption of innovations in general. However, critics of the TOE models have pointed out its weakness in the constructs of technological determinants. Therefore, a mix of TOE and DOI will be used to complement the analysis of the technological determinants as done by other studies on e-health in other regions or on e-commerce in Kenya.9,19
Therefore, this study will analyze the following moderating effect of TEs' traits using the combined TOE/DOI framework. The constructs of the technological determinants are m-health relative advantage, compatibility, complexity and trialability, and m-health acquisition strategies. The constructs of the organizational determinants include the hospital's size (i.e., number of employees and number of patients), human resources and IT capabilities (e.g., availability of IT specialized staff and units); managerial structure (centralization, complexity, formalization, interconnectedness), and organizational slack (i.e., the degree to which uncommitted resources are available to a firm). The environmental constructs refer to the firm's industry characteristics such as nature of the competition, effect of government regulations and incentives; the level of competition for patients, effect of global medical tourism, government pressure or incentives, support or resistance from medical health insurance companies, support or resistance of medical professional associations, and pressure from patients. The need to include the effect of network externalities and impact of other stakeholders and professional associations have been proposed as needed additions to the TOE framework15 but due to the nascent nature of m-health and scarcity of data on m-health adoption, this study will not include network externalities in this study.
Therefore, this study investigated the moderating role of the traits of TEs of hospitals in Kenya on TOE determinants and on adoption of m-health in order to identify practical recommendations for effective scale up of m-health. It tested the following four null hypotheses:
H01 Top executives' sex has no significant statistical moderating effect on their perceptions of TOE determinants and PC and FC m-health adoption by hospitals in Kenya.
H02 Top executives' level of education has no significant statistical moderating effect on their perceptions of TOE determinants and FC and PC m-health adoption by hospitals in Kenya.
H03 Top executives' knowledge of m-health has no significant statistical moderating effect on their perceptions of TOE determinants and PC and FC m-health adoption by hospitals in Kenya.
H04 The combined effect of TEs' sex, level of education and knowledge of m-health has no significant statistical moderating effect on their perceptions of TOE determinants and PC and FC m-health adoption by hospitals.
Figure 1 summarizes the TOE/DOI conceptual framework, the constant model and the model with moderators, and hypotheses tested.
Figure 1 Conceptual framework of TOE determinants and moderators of TEs' traits.
This study is non-experimental quantitative research with correlational design as defined by Creswell.16 It used correlational statistics to describe, explain or measure the degree or relationships between one or more variables. It applied the survey design to generate numeric or quantified description of trends or association of variables.17 It used a Likert scale and self-administered questionnaire to ensure standardization and comparability of data necessary for generalizability.18
M-health applications under investigation in this study followed the WHO3 classification of 12 m-health applications and were re-categorized under PC and FC as indicated in Table 1.
The general target population of this study was the 507 (N) Top Executives (TEs) or managers of level 4, 5, and 6 hospitals as registered in the Kenya Master Health Facility database (Table 2). TEs were defined in this study as the most senior officer, manager or executive in charge of strategic leadership and management of the hospital. This study targeted one TE per hospital. The choice of TEs as respondents for this study is justified by the fact that they possess both decision-making power on adoption of health innovations and accountability for hospitals' strategic vision and performances and it follows the application of the TOE framework with CEO or TE as subject of investigation. This study targeted TEs of levels 4, 5, and 6 public, private, FBO and/or NGO hospitals because these hospitals constitute the primary mechanisms for introduction and roll-out of innovations in the Kenya health system. Levels 3 (health centers), 2 (dispensaries and clinics), and 1 (community levels) were excluded from this analysis as their relevance for m-health and other innovations are often reliant on the adoption of the higher levels of hospitals (levels 4 to 6) that they refer their patients to.
Table 2 National Distribution Of Hospitals By Categories Of Ownership And Classification Of Levels
This study used the census method for the 22 level 5 and 6 hospitals. It used the Slovin formula to select a stratified simple random sampling method for the 485 level 4 hospitals to select a sample size of 219 facilities proportionately distributed across the 47 counties and ownership to derive a total of 126 public health facilities from 278 registered hospitals; 63 private for-profit hospitals from 139 registered facilities, and 30 from FBOs/NGOs (Table 2).
The distribution of the sample size across the facilities is shown in Table 3. The random selection of level 4 hospitals in the sample size guided the random selection of TEs of the hospitals.
Table 3 Distribution Of Sample Size Across The Level 4 Hospital Facilities
The ethical approval for the study was obtained through United States International University - Africa and the research approval was given by the National Council on Science, Technology and Innovations (NACOSTI). In view of the nature and scope of the study, the Ministry of Health (MoH) at national level and the County Health Departments also provided authorizations and recommendations before data collection. A team of 15 experienced and trained local research assistants was hired to distribute and collect the self-administered questionnaire from the TEs of level 4, 5, and 6 hospitals sampled in order to ensure accuracy of respondents and higher response rate. The use of emails or e-surveys was not considered as a reliable option for this study due to the low rate of response observed in other studies that targeted CEOs or TEs of hospitals by email. Furthermore, relying on e-surveys or emails had the potential challenges of excluding rural hospitals that may have limited ICT and internet infrastructures. Participation in the study by TEs was voluntary and TEs had the option to decline participation on first contact with research assistants or later when research assistants returned for the collection of the questionnaire if applicable. Confidentiality of respondents was ensured by not collecting personal identifiers and by guaranteeing de-linkage of results to TEs or hospitals.
A pilot test was conducted in March and April 2018 with a convenience sample of 20 TEs of level 4 hospitals in Nairobi and Kiambu counties. These 20 hospitals were excluded in the sample size of level 4 hospitals included in the study. The choices of Nairobi and Kiambu counties was based on the higher presence of different levels of hospitals and different types of ownership.
The outcome of the pilot test showed a reliability test that was within the recommended range of alpha between 0.65 and 0.8.19
Because this study adapted the questionnaire used in other studies using TOE/DOI framework, content validity was used as guided by Foxcroft, Paterson, le Roux and Herbst.20 Feedback from different panels of experts, research assistants, and respondents in the pilot was summarized to guide further refinement of key terminologies in the questionnaire. Data collection was initiated from April to July 2018.
The data analysis was conducted using SPSS 21 and comprised descriptive and inferential statistics using statistical techniques, non-parametric methods. The study used the Logit Regression Analysis (LRA) to explain the theoretical and mathematical reasoning of the two outcomes Y=0 or Y=1. The Logit Regression Model (LRM) as used in this study, satisfied the characteristics of the study where the dependent variable is binary while the explanatory variables were nominal, ordinal, and interval/ratio. In addition, the LRM model was found appropriate, as its analysis was not constrained by normality requirement as well as restrictions of missing values in data. In this model, the explanatory variables were incrementally added to determine their individual and collective effect on adoption of m-health applications. The Nagelkerke R square was used to explain variance in the logistic models. The Hosmer and Lemeshow Chi-squared was used to test significance of the model and classification of respondents in their respective groups.
The model analysis collected n explanatory variables that resulted in two specific outcomes Y= 1 adoption of m-health, Y= 0 rejection of m-health. Adoption was defined as official hospital's adoption and use of PC or FC m-health at the time of the study. The inferential statistics focused on relationship and correlation between the dependent variables (Y; Y1, 0) and the explanatory variables of the constant models denoted as X (X1 to n) where X1 = =Gender of TE, X2 Education level of TE, X3= Knowledge of m-health of TE and X4 = combined effect of gender, level of education, and knowledge of m-health.
The general LRM therefore is presented as follows:
Where Pk=is the likelihood of adopting the kth (for k=1,2) m-health technological category 1= PC and 2= FC.
The total number of questionnaires that met the requirements for the study was 211 out of 241 (219 level 4 hospitals and 24 level 5 and 6 hospitals) distributed questionnaires across 24 counties. This represents 87.5% response rate which complies with recommendations by Fincham21 that a response rate of 80% and above is needed for generalizability of results of surveys. Four questionnaires were discarded because they were filled by non-top executive staff and 3 questionnaires were discarded because the hospitals self-categorized as level 3 hospitals despite being registered as level 4 in the Kenya Ministry of Health database. The overall distribution of respondents by hospital ownership was 48% for public, 36% for private, and 16% for FBOs/NGOs. The distribution by level of hospitals was 80% level 4 hospitals, 16% level 5 hospitals, and 4% level 6. The geographical distribution of hospitals was 36% urban, 38% semi-urban, and 26% rural.
Tables 4–8 show the distribution of age, sex, level of education, knowledge of m-health, and tenure of top executives. Most TEs were below 50 years old (85.2%). The age distribution of TEs represented a mix of young (18% between 21–30 years of age) and older TEs (66% between 31 and 50 years of age). The sex distribution of TEs of hospitals (levels 4–6) in Kenya is highly imbalanced with female TE in charge of hospitals representing only 24.7%. Public hospitals and FBOs have the highest imbalance of F:M (24% of female vs 76% of male), followed by private hospitals (at 26% vs 74%). Forty-six percent had completed undergraduate while 38.4% completed master's or other postgraduate levels. A few executives (2.8%) reported having obtained doctorate or PhD degrees. Most top executives (65%) rated their knowledge of m-health as medium. Only 12.9% of top executives rated their knowledge of m-health as very high, while 17.7% rated their knowledge as low. The rest (4.3%) did not have any knowledge of m-health. Private hospitals had more TEs with higher knowledge of m-health. The majority (53.1%) of TEs had held their leadership position between 1–5 years, followed by those (21.2%) who had held the leadership position between 5 to 10 years. Only 8.6% of TEs had been in their position for more than 10 years compared to 16.9% who had been in the executive leadership position for less than a year. Public hospitals had the highest number of new TEs (22.7%) and fewer long-serving TEs (2.9%).
Table 4 The Distribution Of Age Of Top Executives
Table 5 The Distribution Of Sex Of Top Executives By Category Of Hospitals
Table 6 The Distribution Of Level Of Education Attained By Top Executives
Table 7 The Distribution Of Top Executives' Knowledge Of M-Health
Table 8 The Distribution Of Tenure of Top Executives
Figure 2 shows the distribution of level of knowledge of m-health across the different age brackets. The age bracket of 31–40 years of age had the highest concentration of high and medium level of m-health knowledge. The distribution of the different levels of knowledge of m-health within each age bracket was more or less similar. The age bracket of 21–30 had 6 missing data.
Figure 2 The distribution of age and extent of knowledge of m-health.
Table 9 shows the distribution of adoption of PC and FC m-health applications.
Table 9 The Distribution Of Adoption Status By Level Of Hospital, Ownership And Geographical Location
To determine the estimated LRA of the moderating effect of TEs' traits, this study first conducted the Omnibus Tests of model coefficients to check if the new model with moderating variables of TEs' sex, level of education, and knowledge of m-health was an improvement of the constant model with TOE/DOI without integration of TEs' traits at 5% of significance level. It then used the enter method of model fitting which involves the entering of all TOE determinants or variables at the same step for each of the two categories (PC and FC) of m-health innovations and regressed them on the identified TE traits of male sex, highest educational level attained, and highest knowledge of m-health.
Table 10 presents the results of the Omnibus tests for Model Coefficients for each PC and FC m-health application.
Table 10 Omnibus Tests Of Model Coefficients
It shows that for both the PC and FC models with or without the combined moderating traits of TEs' sex, level of education and knowledge of m-health were statistically not significant as indicated by p value > 0.05 for PC m-health applications (p=0.643) with no moderator and p= 0.643 with presence of moderators. The same results apply for FC m-health applications with p= 0.604 (>0.05) with no moderator and p=0.323 (>0.05) with moderator. This implies that the predictive power of the two models did not improve over that of their respective constant only models.
However, the results of goodness of fit (Table 9) show that inclusion of the moderator variable improved the explanatory power of the variances in the two models (PC and FC). The higher values of Nagelkerke R Squared in the presence of moderators of 0.218 and 0.68 implies that 21.8% for PC and 68% for FC of the respective changes in adoption of the two interventions were explained by the moderating variables identified. Table 11 presents the output for model summary which provides information about the goodness of fit of the two models.
Table 11 Model Summary For Goodness Of Fit Test
Table 12 also demonstrates an overall goodness of fit of the two models under both the moderator and non-moderator TEs' traits variables. An overall goodness of fit of the model is indicated by p-values > 0.05. For both PC (p-value of 0.284 with no moderator and 0.615 with moderator) and FC (p-value of 0.812 with no moderator and 0.328 without a moderator) had p-values greater than 0.05. Therefore, the goodness of fit assumption was confirmed for both PC and FC models.
Table 12 Hosmer-Lemeshow Test
Tables 13 and 14 show the estimated coefficients for each moderating variable of TEs' traits on the TOEs and on adoption of PC and FC m-health. Variables with p values (Sig) less than 0.005 are statistically significant moderators of adoption of PC and FC m-health applications by hospitals in Kenya. The Wald chi-squared statistic tests the unique contribution of each moderating variable in the context of other predictor variables, to test the conventional 0.05 standard for statistical significance.
Table 13 PC Innovation Adoption And Moderating Effect Of Top Executives' Traits
Table 14 FC M-Health Applications On Adoption And Moderating Effect Of Top Executives' Traits
Table 15 Model Result Of Hypothesis Of Moderating Effect Of TEs' Traits On Adoption Of M-Health
The final LRA equation of moderating effect of TEs' sex, level of education and knowledge of m-health is as follows:
For FC m-health adoption, none of the top executive's traits variables had statistically significant moderating effect on adoption of FC model. The combined effect of TEs' sex, level of education and knowledge of m-health did not have any statistically significant moderating effect on adoption of FC m-health applications. Table 13 summarizes the outcome of the four hypotheses tested in this study.
This study uniquely shows that the moderating effects of TEs' traits are different for PC and FC m-health adoption. The sex of TE (p=0.041) and the level of TEs' knowledge of m-health (p=0.009) were statistically significant moderators of adoption of PC m-health applications but not significant for adoption of FC m-health applications.
This study concurs with findings in China by Zhang et al11 that found that being male had a higher predictability and moderating effect on adoption of m-health and found significant gender differences in adoption patterns. This study also concurs with findings of Hoque12 in Bangladesh that found significant gender differences in adoption of m-health. In Kenya, Ochola10 found that the sex of the TE significantly moderated adoption of e-commerce by small and medium enterprises. However, unlike for e-commerce (which could be categorized as PC), this study shows that male TEs as opposed to female TEs are more likely to adopt m-health. It reinforces findings by Nderitu, Kassie and Shiferaw22 in the agricultural sector in Kenya that found females less likely to adopt innovations due to socio-economic and cultural barriers. Laukkanen23 also found significant disparity on adoption of internet and mobile banking innovations due to gender related barriers.
This study also concurs with the findings by Ochola10 that TEs' knowledge of technology significantly moderated the organization's adoption of the technology. However, it differs from the findings by Ochola10 that the level of education of TE is a significant moderator of adoption of innovations. However, it is important to note that most studies reviewed did not investigate the differential effect of PC and FC m-health applications. PC m-health applications are relatively less expensive and less complex to integrate and adopt. They are relatively externally focused and may involve less complex management of changes in the hospital's processes and procedures than FC m-health applications (mobile telemedicine, information and decision support system and patient records). Adoption of PC m-health applications may also elucidate less resistance to change by staff than FC m-health.
Therefore, two possible explanations may be derived from the differences in the moderating effect of PC and FC:
- the moderating effect of TEs' traits is affected by the level of complexity of the technology. While PC m-health applications that are less complex are affected by the traits of the TE, FC are not.
- The moderating effect of TEs' traits is affected by the required organizational change and change management that the technology entails. PC m-health applications may require less organizational change, capital investment and change management than FC and therefore are highly moderated by TEs' traits.
It is also important to note the unique context of Kenya that may also explain the differences in the significance of moderating effect between PC and FC. Unlike in other HICs, Kenya's expansion of cell-phone coverage has expanded faster than ICT capacity of hospitals to support complex FC m-health innovations, which may provide a basis for confident investment in PC m-health compared to FC m-health.24 In 2016 the mobile penetration reached 88.1% with 37.8 million subscribers. Pre-paid subscriptions accounted for 97.3% (36.8 million subscribers). 99% of the internet subscribers in Kenya access the internet through their mobile phone, thus representing a good basis for PC m-health.6
The findings of this study, therefore, present significant considerations for effective scale up of m-health in Kenya and other LMICs.
In addition to developing digital or e-health policies, policy makers should integrate digital health modules in the medical education curricula and in the professional development programs of hospital managers. They should also ensure integration of policy incentives that remove any gender-related barriers to adoption of digital health innovations and reduce the gender-imbalance in the distribution of TEs of hospitals. The national and county level scale-up strategies should be differentiated for PC and FC m-health applications.
Managers and owners of hospitals should invest in capacity and professional development of the hospital's leadership in digital health innovations and establish a differentiated PC and FC introduction and change management plan. They should also ensure implementation of organizational policies that remove gender related barriers to adoption of innovations and career path.
Developers and marketers of digital health innovations should integrate TEs' knowledge of m-health and gender-related barriers in their product development and marketing strategies for PC products. However, FC products may be moderated by other factors such as pre-existence of IC infrastructure and a cohesive change management strategy. This study also recommends a differentiated approach to future investigations of adoption of digital health innovations based on the focus of the innovations. Aggregating all m-health or digital innovation without PC or FC differentiation may continue to provide a techno-optimistic bias of studies on adoption of IT innovations.8,13
Conclusion And Recommendations
This study provides evidence of effects of top executives' traits on adoption of m-health innovations by hospitals in Kenya. It shows that the sex of TE and knowledge of m-health were significant moderators of adoption or rejection of m-health applications. To increase adoption and scale up of m-health and minimize failure rates, priority should be given to increasing top executives' knowledge of m-health and establishing policies and practices that minimize gender barriers to adoption of m-health and other digital health innovations. Therefore, policy makers, developers of m-health, and marketing practitioners need to develop a differentiated approach to PC and FC scale up strategies. While PC scale up requires mainstreaming of gender-sensitive training and continuous human resources development on digital health, FC will require greater focus on system and infrastructure capacity strengthening and strategic management of change.
Limitations And Suggestions For Future Research
This study did not use a longitudinal view of adoption of innovations in view of the nascent nature of m-health adoption in Kenya. It also did not separate the different processes and stages of decision making in adoption (e.g., considering adoption or adopted then rejected) but instead chose a binary approach (adopted or not adopted) in view of the nascency of the field of m-health and in compliance with the logit regression model used. This study did also not integrate the effect of network externalities (when a hospital adopts a technology because other hospitals within the network have adopted). It also did not disaggregate the moderating effect of TEs' tenure and category of ownership of the hospitals (public, private, or faith based) and geographical locations (urban, semi-urban, rural). Future studies should integrate these analyses and evaluate their longitudinal effect on PC and FC m-health and other digital health innovations.
The authors report no conflicts of interest in this work.
1. Tomlinson M, Rotheram-Borus MJ, Swartz L, Tsai AC. Scaling up mHealth: where is the evidence? PLoS Med. 2013;10(2):e1001382. doi:10.1371/journal.pmed.1001382
2. Akter S, Ray P. mHealth-an ultimate platform to serve the unserved. Yearb Med Inform. 2010;19(1):94–100. doi:10.1055/s-0038-1638697
3. World Health Organization. Mobile Health: new Horizons for health through mobile technologies; 2011. Available from: https://www.who.int/goe/publications/goe_mhealth_web.pdf.
4. Mehl G, Labrique A. Prioritizing integrated mHealth strategies for universal health coverage. Science. 2014;345(6202):1284–1287. doi:10.1126/science.1258926
5. Mechael P, Batavia H, Kaonga N, et al. Barriers and Gaps Affecting mHealth in Low- and Middle-Income Countries: Policy White Paper. Alliance; 2010.
6. The Netherland Enterprise Agency. The Kenya health sector market survey; 2016. Available from: https://www.rvo.nl/sites/default/files/2016/10/2016_Kenyan_Healthcare_Sector_Report_Compleet.pdf.
7. Gagnon M-P, Ngangue P, Payne-Gagnon J, Desmartis M. m-health adoption by healthcare professionals: a systematic review. J Am Med Inform Assoc. 2015;23(1):212–220. doi:10.1093/jamia/ocv052
8. Chib A. The promise and peril of mHealth in developing countries. Mobile Media Commun. 2013;1(1):69–75. doi:10.1177/2050157912459502
9. Oliveira T, Martins MF. Literature review of information technology adoption models at firm level. Electron J Info Sys Eval. 2011;14(1):110.
10. Ochola P. An empirical study of determinants of E-commerce adoption amongst Micro, Small and Medium Enterprises (Msmes) in Kenya. Int J Econ Commerce Manage UK. 2015;12(12):223–240. Available from: http://ijecm.co.uk/.
11. Zhang X, Guo X, Lai K-H, Guo F, Li C. Understanding gender differences in m-health adoption: a modified theory of reasoned action model. Telemed E-Health. 2013;20(1). doi:10.1089/tmj.2013.0092
12. Hoque MR. An empirical study of mHealth adoption in a developing country: the moderating effect of gender concern. BMC Med Inform Decis Mak. 2016;16:Article number: 51. doi:10.1186/s12911-016-0289-0
13. Hoti E. The technological, organizational and environmental framework of IS innovation adaption in small and medium enterprises. Evidence from research over the last 10 years. Int J Bus Manag. 2015;III(4):1–14. doi:10.20472/BM.2015.3.4.001
14. Rogers EM. Diffusion of Innovation.
15. Baker J. The technology–organization–environment framework. In: Dwivedi Y, Wade M, Schneberger S, editors Information Systems Theory. Integrated Series in Information Systems, vol 28. New York: Springer; 2012:231–245. doi:10.1007/978-1-4419-6108-2_12
16. Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. London, UK: Sage Publications, Incorporated; 2013.
17. Cresswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research. Thousand Oaks etc. Sage; 2007.
18. Jones M, Rattray J. Essential elements of questionnaire design and development. J Clin Nurs. 2010;16(2):234–243.
19. Field A, Miles J. Discovering Statistics Using SAS. London: Sage Publications; 2010.
20. Foxcroft C, Paterson H, Le Roux N, Herbst D. Psychological assessment in South Africa: a needs analysis: the test use patterns and needs of psychological assessment practitioners; 2004. Available from: http://repository.hsrc.ac.za/handle/20.500.11910/7498.
21. Fincham JE. Response rates and responsiveness for surveys, standards, and the Journal. Am J Pharm Educ. 2008;72(2):43. doi:10.5688/aj720243
22. Ndiritu SW, Kassie M, Shiferaw B. Are there systematic gender differences in the adoption of sustainable agricultural intensification practices? Evidence from Kenya. Food Policy. 2014;49(Part 1):117–127. doi:10.1016/j.foodpol.2014.06.010
23. Laukkanen T. Consumer adoption versus rejection decisions in seemingly similar service innovations: the case of the Internet and mobile banking. J Bus Res. 2016. doi:10.1016/j.jbusres.2016.01.013
24. Wesolowski A, Eagle N, Noor AM, Snow RW, Buckee CO. Heterogeneous mobile phone ownership and usage patterns in Kenya. PLoS One. 2012;7(4):e35319. doi:10.1371/journal.pone.0035319
This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.Download Article [PDF]


text:
Derek Haines
A Cambridge qualified CELTA English teacher and author of 18 books with a life long passion for publishing in all forms. I started my working life as a lithographer and spent over 30 years in the printing and publishing business. Originally from Australia, I moved to Switzerland 20 years ago. My days are spent teaching English, writing and wrestling with technology while enjoying my glorious view of Lake Geneva and the Alps.
More Advice Articles
Add Your Comment Cancel reply
This site uses Akismet to reduce spam. Learn how your comment data is processed.


text:
GPP Episode 22: Don Moxley- Using Technology to Improve your Sports Performance Practice
October 6, 2018
On this episode of the podcast, I talk with Don Moxley. Don and I dive into the ins and outs of using technology and interpreting "big data". With all the current developments in modern wearable technology, Don breaks it down into usable information that coaches can use to improve their current practice.


text:
Issued on: Modified:
French health authorities reported 365 new deaths from coronavirus on Thursday, taking the total to 1,696.
Read more
The rise in the number of deaths represents a daily rise of 27 percent, a marked increase from the previous day with France now in its second week of lockdown.
This daily government tally only accounts for those dying in hospital, but authorities said they would soon be able to compile data on deaths in retirement homes, which is likely to result in a big increase in registered fatalities.
During a press conference, health agency director Jérôme Salomon added that the number of cases had risen to 29,155, a rise of 16 percent in 24 hours.
Salomon said 3,375 people were in a serious condition needing life support, up 19 percent compared to Wednesday and meaning that close to half of France's 8,000 beds equipped with ventilation gear are occupied.
French economy operating at 65 percent
The rise in coronavirus tolls came as the official INSEE statistical agency said French economic activity and household spending are running at about 65 percent of normal levels due to the coronavirus outbreak.
INSEE gave the first picture of the impact of the nationwide lockdown as it published its monthly business confidence index, which saw its biggest single drop since records began in 1980.
The index fell to 95 points from 105 points in February with even steeper declines seen in the services and retail sectors, INSEE said.
The French government has prepared a €45 billion pRead More – Source