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ICT Influence on the healthcare sector in the Niger Delta region: ICT policy at an organizational level

ABSTRACT Organizational ineﬃciency, infrastructural decay and the challenge of untrained ICT personnel in the health sector have all contributed to the erratic development in healthcare delivery in the Niger Delta region. The region generates the nation's crude-oil, yet is marginalized, resulting in the neglect of infrastructural development and the collapse of functional health systems. Humans now suﬀer from various kinds of diseases resulting from the eﬀects of oil exploitation and exploration, and gas ﬂaring. This study is focused on growth within the health sector, identifying the extent of ICT application, the application of appropriate ICT policy in the sector, and the inﬂuence of related policy. Critical data were obtained from key-players by way of interviews and questionnaires. A quantitative analysis was carried out on the data obtained at an organizational level. Several tests were performed on the parameters; descriptive statistics, and where necessary, the Pearson correlation coeﬃcient were introduced to check relationships between variables. Results obtained indicated low-level adoption rates of ICT application in healthcare delivery and a need for an enabling policy. This study conﬁrmed the low levels of healthcare delivery in the region and the importance of an ICT policy in the healthcare sector to improve eﬃciency.


Introduction
The use of Information communication technology (ICT) in socio-economic development is evident in various sectors of Western nations. However, healthcare is one of two key concerns in any developing country. While the health and education sectors have received substantial breakthroughs because of enabling ICT policies, intrinsic problem within the healthcare sector, specifically in Nigeria, have affected organizations and people. An appropriate assessment of the impact of an ICT policy in the health sector is likely to assist in the improvement of ICT policy and its implementation thereof.
This study set out to examine the critical issues linked to healthcare delivery within the Niger Delta of Nigeria, in relation to the application of ICT within a health-ICT policy. Among the issues examined are staffing, personnel attitude and training, ICT infrastructure and policy management, funding, e-health solution policy, and policy acceptance. The study was guided by the following research questions: 1. What are the core areas of the health sector that require ICT tools for effective healthcare delivery?
2. How does the current ICT applications influence technological/ infrastructural growth and knowledge transfer?
The paper is organized as follows. A brief overview of the related literature of ICT in the healthcare sector is presented in section 2. Next, the research methodology is described in section 3, followed by the presentation of the data and the analysis in section 4. Thereafter, the summary of results and concluding remarks are presented in section 5.

Related literature
The use of ICT has marked a turnaround in the health sector. According to Adeleke et al. (2014), ICT has become the cornerstone upon which efficient and effective healthcare delivery thrives. Evidently, computer technology has a critical role in the transformation of healthcare services. ICT is useful in data gathering, as well as the administration of healthcare services, and has the potential of improving the quality and reliability of healthcare data and services. Links with other healthcare providers have become possible through dedicated communication lines enabled by ICT, and electronic medical records and knowledge-based healthcare services are achievable with the use of ICT. Clinical research, health information and related resources are made readily available through the Internet, which has become a viable means of communication, training and education. One can also purchase healthcare products using the available online stores.
Expert systems have been developed to predict health states and prescribe drugs to treat cases of health challenges. Telemedicinehealthcare at a distanceis an aspect of ICT application that has been in use in developed economies for years. With telemedicine, healthcare is delivered in real time, or asynchronously, and may involve the use of a video link. Several online applications have now evolved, making healthcare readily available and ICT penetration into the healthcare field has grown exponentially in the twenty-first century (National Health ICT Strategic Framework 2015-20202015. This growth is due to the development of new and affordable ICT tools to assist healthcare practitioners in the provision of health services. The literature is replete with materials on ICT and healthcare. Furthermore, health information managers now have databases such as the Health Information Management System (HIMS) to manage patient health information. National HIMS databases are available through reliable networks to healthcare providers on demand to assist healthcare practitioners in the treatment of patients. The importance of IT tools cannot be overemphasized in the dissemination of health information across geographically and socially isolated landscapes (Ducut and Fontelo 2008;Quy 2000;Tamrat and Kachnowski 2012). These social networks have become platforms to create awareness in cases of an epidemic. Social inclusion and civic engagement are made possible using IT tools.
ICT is in use in several areas of healthcare delivery (Asiabaka 2010;Asian 2007;Babalobi 2010;Babalobi, Westhuizen, and Croft 2006;Chiemeke and Longe 2007;Matthew and Monica 2011). Studies have been conducted to determine the use of ICT practices among all users, old and young, male and female, and the employed and unemployed. Blanchard et al. (2008) suggest that although ICT is important and necessary for improved health among young people, it is not readily available. They found that many young people who suffer from psychological illness, should be engaged with meaningful ICT tools. The implication is that the Internet can be an efficient platform to promote mental health among young people who feel marginalized but observed that many of these marginalized people have little access to technology or the skill to use it.
In their study, Heart and Kalderon (2013) stressed the important role ICT plays in assisting older people recover from memory loss and mental fatigue and they further state that older adults will readily accept health-related ICT if they are introduced to it. Kiel (2005) believes that the elderly can improve their cognitive capabilities by learning to use new technologies. If Internet facilities are made available to all, healthrelated information can be found online, reducing the time and cost of seeking medical assistance from practitioners. In fact, with ubiquitous computerized services, health information is available with the click of a button.
Travel may be avoided with the use of telemedicine. Additionally, mortality rates can be reduced if patients are attended to before embarking on a trip to the hospital. Telemedicine goes beyond mere first-aid procedures. Lives will likely be saved if ICT is adequately utilized in the health sector. In fact, if telemedicine, as well as other ICT tools, are appropriately utilized the benefits to national development can only increase.
In some regions, older persons and people with critical health challenges are being monitored using sophisticated hardware and software devices. Arai (2014) designed a rescue device with network sensors to monitor the calorie consumption, blood pressure, pulse rate, body temperature, among others, of patients, the elderly, and disabled persons. In an earlier study, Bucknall et al. (2013) proposed a way to monitor patients, whereby a call is activated when an in-patient becomes critical by making use of the Medical Emergency Team (MET). From their results, it was also determined that patients with high mortality that fulfilled the MET conditions and activated the system were higher in number than those who were end-of-life cases.
Another key system is the health monitoring system that was designed by Ahmed et al. (2015) to assist the elderly and their care providers in monitoring their glucose level, pulse rate, blood pressure, weight status and activity levels, like other healthcare applications. The ICT-based system operates on a real-time feedback generation basis. It also produces a historical summary calculation of the various results and generates recommendations. Ahmed et al. (2015) used several sensors which are interconnected to provide the needed information services, and the information generated is used to provide the necessary care to patients. All these services need to be implemented within a set of rules and regulations, which in turn can only efficiently be implemented within a policy that includes the use of ICT in the healthcare sector. The confidentiality, risks and security of patient data are of utmost importance. Ethical practices must be adhered to.
There is significant progress in the application of ICT in the health sector, however, there are noticeable obstacles evident in its comprehensive implementation from location to location, owing to a reluctance to change from old methods. According to Suomi (2000), the structure of the industry, national differences, the professional culture among healthcare personnel and education, among others, are identified as obstacles to the implementation of ICT in the healthcare sector. The application of ICT to health communication in primary health care (PHC) has increased the awareness level of practitioners and other users, according to Mahmud et al. (2013). PHC is central to any country. Therefore, in an enabling environment, healthcare delivery should entail making relevant health information readily available to minimize or prevent the spread of diseases. Employing ICT, therefore, becomes very important in assisting healthcare practitioners to pass health information down the line as may be required.
Given the important role ICT can and does play in healthcare delivery, it is imperative to examine how ICT can be harnessed efficiently in the healthcare system in Nigeria. One way of doing this, is to examine the role of ICT policy and its use in the healthcare sector. ICT policy for economic growth and development certainly impacts positive change, resulting in the achievement of its objectives. This is the case with nations that realize the importance of a reliable policy model. Therefore, if developing nations expect economic growth and sustainable development using ICT, there is the need to adopt ICT policies in relation to the healthcare sector. As is reported in the NDP vision for 2030 (2011, 171) ' … Like energy and transport, ICT is an enablerit can speed up delivery, support analysis, build intelligence and create new ways to share, learn and engage'.
In another report, on health information technology, (ICT Healthcare 2013) the acceptance of ICT in the healthcare sector was summarized as: engage users in policy by proving its benefits, 'keep it simple and evidence-based, strengthen organizational and health professionals' awareness skills and leadership in order to champion the further development of ICT use in the health sector' (p. 3).

Study site
The Niger Delta region was selected for the study because of its characteristics and the strategic nature of the region in the development of the nation.

Target population
The target population was drawn from various departments in two hospitals in the Niger area. This includes researchers, career public administrators, consultants and interest groups such as unions within the hospitals.
Other key players in the sector within the categories listed above, such as managers, CEOs of NGOs, MDs (doctors, HODs, etc.), technologists, nurses, principal officers, and secretaries were part of the target population.

Sample size
Following Krejcie and Morgan's (1970) formula for the determination of an appropriate sample size as a representative of the overall population of the organization (s) being studied, the sample size in excess of 250, was used. The total population size of the expected participants in the study was more than 800. Out of the 400 questionnaires that were sent out, 250 (62.5%) were successfully collected from participants. A sample size of 250 was therefore considered suitable as a basis for drawing conclusions.

Data collection method
Questionnaires were used to collect data from participants. The questionnaire consisted of five sections, namely, demographic data, personnel attitude (personnel views of ICT and healthcare delivery), ICT infrastructure and policy management, e-health solution policy, and ICT end-user views. The last four sections were designed to address the two research questions. Participants responded to the questions in the questionnaire based on a Likert scale ranging from one to five corresponding to 'Strongly Disagree, Disagree, Uncertain, Agree, and Strongly Agree' respectively.

Pilot study
A pilot study was conducted with a few key personnel from the target population. Based on the data obtained from the interviews conducted for the pilot study, categories of description for the questionnaire were determined. Each of the categories investigated are referenced as follows in the tables: Personnel Views (PV); ICT Infrastructure and Policy Management (ITPM); e-health Solutions (EHS); and ICT end-users (ICT). Each item within a category is referenced with the category's acronym, followed by the item number, for example, PV1 for Item One under Personnel Views.

Analysis
Descriptive statistics were calculated using various statistical measures such as: mean, standard deviation, onesample, the Pearson correlation and the binomial test, where applicable. The one-sample t-test was used in this study to test whether the average value was significantly different from the value of three (the central score); this was applied to the Likert scale questions presented in the questionnaire. A correlation analysis was performed to determine the degree of association between two or more variables, while regression analysis estimated the value of one variable for a given value of another (Rumsey 2010). The binomial test was used (where necessary) to test whether a significant proportion of the respondents selected one of a possible two responses.

Validity and reliability tests of the questionnaire
The validity of the questions in the questionnaire were tested based on the sections, and later tested for reliability based on the regrouping using the Cronbach's alpha reliability test. According to Tavakol and Dennick (2011), if Cronbach's Alpha ≥ .700, the reliability is considered high; if Cronbach's Alpha ≥ .500, the reliability is acceptable. Any value less than .500 is considered poor.
Based on reliability, the various items in the questionnaire were found to obtain a correlation significance at either .005 or .001; thus, proving the reliability of the correlations between the items. The reliability of all the items in the questionnaire (Section Two to Section Five), based on the Cronbach's alpha, was .776. This meant that all the items passed the reliability test. Upon testing the reliability of each of the sections in the questionnaire, starting with Section Two; the Cronbach's alpha values were .452, .612, .763 and .658 for each section respectively.
Factor analysis was conducted on the items in Section Three (Infrastructure and Policy Management). Hence, items 12, 13, and 14 were removed and the Cronbach's alpha became .794. Thus, combining these items; a measure for the adequacy of the infrastructure in relation to the rating of the work environment could be obtained. Further analysis on the items in Section Four (E-health Solution) were carried out, yielding single item construct measure, indicated in Table 3.

Personnel views of ICT and healthcare delivery
Each of the items used to measure personnel attitude were analysed individually. The main aim of this category was to investigate the attitudes of the personnel in healthcare delivery. Also, of interest were the attitudes of the health workers to change and the application of ICT to healthcare delivery. The statistics of the items used to measure the attitudes of staff towards ICT in healthcare are provided in Table 1. These included the frequencies of the level of agreement with the items, the mean, the standard deviation and the level of significance.
From the table, it appears that only three items are significant with corresponding mean values greater than three and large t values that are worth discussing.
Item Threethere was significant agreement that staff needed assistance in using the HIS (t(234) = 12.413, p < .0005). This result suggests that the respondents need assistance in the use of this system. A possible explanation is that the system may have been handed down without the necessary documentation or training to empower the users. The response to Item Four also seemed to support this assumptionthat staff needed motivation to use the existing system.
Item Four -11% believed that staff needed no motivation to be trained. Conversely, 11% of the respondents may have received 'adequate' computer training to be fit for their respective duties in the hospital, and so did not believe that any form of motivation was necessary in this direction. There was, however, significant agreement that staff needed motivation to learn to use the existing system (t(243) = 14.394, p < .0005). This meant that most of the respondents (83%) believed that staff should be motivated to learn or be trained in the use of computer applications (σ = 1.156, µ = 4.07). The implication was that the greater percentage of staff within the hospitals in the Niger Delta needed to be trained to be computer literate, to be able to use computers in their operations. The 5.7% that were not certain may have been among those who did not care about any of the conditions. This category of persons may not have been involved in any decision-making processes and were thus passive.
Item Ten -The discovery of new techniques, whether in ICT, health or any other field should stir up excitement when there is a willingness to work. New methods result in positive change when they are embraced by all parties concerned. Resistance to new methods arises when employees are not properly informed of the benefits that will result from the implementation of the new methods in the organization (Svensen, Neset, and Eriksen 2007). This must have influenced the responses to this item, indicated in Table 1.
There was significant agreement that staff were generally excited at the discovery of new ICT techniques (t (246) = 7.398, p < .0005). Item Ten provided a graphical representation of the responses (as in previous cases) on how excited medical professionals were with new ICT techniques within the Niger Delta region. 55% of the base value indicated excitement, with 14% being extremely excited. The 16% that showed no excitement could be categorized as 'old school'; that felt they would still be alright with the old methods. From the results (σ = 1.023; µ = 3.48) there was a strong reason to believe that the respondents were at home with new ICT techniques. Also, the skewness and kurtosis (−0.570, −0.068) pointed to higher range values meaning that there was excitement among staff when new systems were introduced.

ICT infrastructure and policy management
This section of the questionnaire was intended to investigate the extent of the growth and availability of ICT infrastructure in the health facilities within the Niger Delta. Also investigated was the existence and impact of related ICT policy within the health sector in the region. The results represented in the analysis showed the challenging state of the health sector in the Niger Delta region of Nigeria. The statistical analysis was based on the responses obtained from the participants. Following from section 3.3, items were referenced based on the item number and variable name, i.e. Item One referred to ITPM1.
Item Nine -Lopsided policy and implementation is responsible for the slow pace of growth in healthcare delivery -The descriptive statistics from the responses showed that there was, in fact, a lopsided ICT policy in terms of use of ICT with an uncoordinated implementation strategy within the healthcare sector. From the descriptive statistics and one-sample t-test results presented in Table 2, there was significant agreement that the lopsided policy and its implementation were responsible for the slow pace of growth in healthcare delivery (t (243) = 3.440, p = .001).
Item 11 -Faulty infrastructure is responsible for the inefficiency in the healthcare delivery in our heath facility -There was significant agreement that the faulty infrastructure in the hospitals in the Niger Delta was responsible for the inefficiency in healthcare delivery within the region (t(246) = 5.041, p < .0005). Responses to Item 11 suggested that the major infrastructures necessary for service delivery were faulty. Out of 247 respondents, 59% (144) believed that healthcare delivery would have thrived if not for the faulty infrastructures. The mean and standard deviation were 3.43 and 1.350 respectively, indicating that the distribution clusters gravitated towards the higher ranges. From these results, it was certain that the inefficient healthcare delivery within the region could be attributed in part to faulty infrastructures. Item 12 -Available ICT tools are relatively old/obsolete and due for recycling -A significant agreement was recorded to indicate that the ICT tools available were relatively old and obsolete and should be recycled (t (244) = 3.253, p = .001). From the previous responses (Item One to Item Eight) it was evident that there were no reliable/up-to-date ICT tools for healthcare delivery available throughout the hospitals where this study was conducted. The question then also arose that if the ICT tools available were obsolete and due for recycling, was there a recycling policy in place to deal with them? Item 14 provides the answer to this question.
Item 13 -There is poor ICT management in my healthcare facility -There was significant agreement with this statement that the ICT management in the hospitals under study was poor (t(243) = 6.404, p < 0.0005)see Table 2, as 59% (144/244) of respondents were convinced that this was the case in their health facilities. This result was very convincing (σ = 1.309; µ = 3.54).
Item 14 -There is no ICT infrastructure recycling policy in my healthcare facility -The statistical analysis of the responses to this item indicated that there was significant agreement with the statement that there was no infrastructure recycling policy in the hospitals in the study (t(245) = 6.616, p < .0005). As stated earlier in Item 12, the results indicated that there was no ICT recycling policy in any of the medical facilities visited, and the mean (3.51) supported this assertion.
From Table 2, the direction of the relationship between the availability of IT facilities to a reliable Internet connectivity (ITPM1 and ITPM2) was established. With r = .470, n = 245, p < 0.01 it was possible that an increase in or availability of IT facilities might have meant an increase in Internet usage. On the level of the relationship between Item One and Item Three, i.e. with the use of personal modems, although it had a low confidence level, it was obvious that the use of personal modems would decrease when the IT facilities were provided in the workplace. The strength of the relationship was small (Cohen 1988(Cohen , 1992a(Cohen , 1992b, but with the availability of personal modems, a reliable Internet connection was established, i.e. Item Two and Item Three (r = −.234, n = 245, p < 0.01).
Availability of IT facilities at work meant the ability to use the Internet during working hours (Item 4). Testing the direction of the relationship, the strength and the confidence level (significance) between Item One and Item Four, the following statistical results were obtained: r = .422, n = 242, p < 0.01. The availability of IT facilities would also mean that there was a functional broadband network in the health facilities (Item Five). The statistical results in Table 2 showed a high interdependence between them (Item One and Item Five). The results also showed that a reliable Internet connection might have meant the possibility of having Internet access during working hours (Item Two and Item Four)r = .558, n = 243, p < 0.01. The remaining results, except the relationship between Item Three and Item Four, were significant. Although, the result (Item Three and Item Four) was not of a high confidence level, it was necessary to observe that an increase in the usage of personal modems would decrease access to the Internet, possibly as most users would only connect when it was most needed (r = −.091, n = 242, p > 0.01).

E-health solution
As part of the assessment of the present healthcare delivery status in relation to ICT in the Niger Delta region of Nigeria, this section of the questionnaire intended to establish the extent to which the global policy on ehealth solutions (overall application of ICT in healthcare delivery (Scott 2010)) had permeated the region and by extension, the nation. Several items were presented in the questionnaire to ascertain the level of acceptance or adoption of the e-health applications within the health facilities (hospitals) in the region and nationally. Table 3, item1 indicates that a greater percentage of the 250 participants were not familiar with or were ignorant of the existence of e-health solutions. Item Two -I support the introduction of e-health solutions in healthcare delivery -On the support for the introduction of e-health solution in healthcare delivery, 203 participants (83%) willingly endorsed the idea (EHS2). The percentage of those that were not in support of the introduction of e-health solutions in healthcare delivery was insignificant.
Item Nine -I believe that there are benefits of ICT applications in rural healthcare centers -There was significant agreement that there were benefits to using ICT applications in the rural healthcare centers (t(246) = 4.980, p < .0005) - Table 3. Regarding the benefits of ICT applications in rural healthcare centers, 55.8% (138/247) agreed that it was beneficial, 21.1% disagreed that there was any benefit to it, and 23.1% were neutral on the topicthey were not sure of whether it would be of any benefit or not. The response provided assurance of how ICT had penetrated healthcare and of the awareness of it among the health workers. Although a higher percentage of affirmative responses were expected, it still proved that most health personnel in the Niger Delta were aware of the benefits of ICT in healthcare delivery. The 23.1% of respondents who were uncertain gave an indication that there were still gaps in ICT education and in the dissemination of basic knowledge of ICT applications in healthcare delivery. Item 11 -The e-health card is essential and will assist in healthcare delivery -Although the health professionals within the Niger Delta may not have been aware of the introduction of the e-health card in the health sector, they still believed that it was essential and would assist in healthcare delivery within the region. There was significant agreement that the e-health card was essential and would assist in healthcare delivery in the region (t (237) = 6.491, p < .0005) - Table 3. There thus appeared to be a willingness to embrace ICT related to healthcare. 134 of the 250 study participants (57%) believed that the e-health card was essential and should be implemented to assist healthcare delivery (Table 3 -EHS11); while 14.7% of them believed that it would not be helpful; and 29% were uncertain of the outcome.
Items EHS14 to EHS18 (Table 3) suggests the overall impact of e-health on patients and the efficiency of medical personnel with its adoption, if properly managed. In other words, they saw its usefulness. There was significant agreement that: If properly implemented, e-health would be beneficial to both patients and doctors (t(243) = 13.543, p < .0005); the Niger Delta would benefit from e-health irrespective of its peculiar nature (t(245) = 10.296, p < .0005); e-health would contribute to quality healthcare delivery (t(243) = 14.524, p < .0005); an e-health card should be made available to every citizen in Nigeria (t(240) = 13.103, p < .0005); and an enabling ICT policy would contribute to the development of the healthcare sector (t(243) = 16.042, p < .0005). It could thus be inferred that staff were willing and ready to use ICT in healthcare (and embrace e-Health) if given the opportunity.
Extrapolating this reasoning, it is likely that the participants of the study were willing to incorporate e-health and the related ICTs necessary to deliver an efficient healthcare service.
The responses indicated that most healthcare administrators and practitioners were optimistic of the effect of e-health on healthcare delivery if fully implemented.

Staff perception of ICT infrastructure and ehealth solution
This section gives an abridged conclusion of the state of the ICT infrastructure and the e-health solutions, based on further statistical results obtained by employing the t-test.
The general perception of the present state of the ICT infrastructure (including the e-health solutions) was further analysed, based on the construct measures emanating from the factor analysis conducted. This was done to gain further insight into the responses and to give credence to earlier submissions made with respect to the state of the infrastructureas part of e-health solutions.
The statistical results presented in Table 4 were pointers indicating that (1) there was inadequate infrastructure, (2) the e-health solution was not functional, (3) there was a general ignorance of the application of the e-health solution in the hospitals, (4) the e-health solution would not lead to sharper practices among the political class, and (5) the e-health solution would be of help in healthcare delivery if fully implemented.
The results in Table 4 indicated that there was agreement that e-health would be useful to the health system (t(246) = 15.951, p < .0005). There was, however, a significant disagreement that e-health was functional (t(247) = −5.386, p < .0005). There was also a significant disagreement that the health practitioners within the region were familiar with the e-health solution (t(248) = −3.212, p = .001).

Conclusion
This study set out to determine the influence ICT has in the healthcare sector from the perspective of staff at different hospitals in the Niger Delta, Nigeria. To achieve this aim, two questions were formulated to guide the study. Results revealed the level of development of the ICT infrastructure. In addition, the attitudes of the health professionals to the application of ICT in healthcare delivery, emerged. Prominent among the issues raised in the analyses was the poor infrastructural state of ICT within health facilities in the region. Reliable Internet connectivity, a functional LAN, an uninterrupted power supply (electricity), training, and e-health applications were some of the major areas that require ICT tools for effective healthcare delivery. This finding answers the first research question. The second research question was answered to some extent by the aspects of e-health solutions category, that is, current ICT applications were unknown to most staff, however, training requirements among health personnel emerged as a high priority for personnel. In effect, ICT policy would assist if implemented correctly and forcefully for the transfer of knowledge as the responses to most of the items presented in the questionnaire were significant.
Other statistical results obtained from further analysis of the data (bivariate analysis, t-test, Pearson correlations cross-tabulations) showed an unwillingness to change among the staff, resulting in the need for motivation to accept the new ICT techniques within the health sector in the region. It was possible from this point to assess the success accruing from ICT application in the growth and development of the healthcare sector within the Niger Delta region of the Federal Republic of Nigeria.
A major limitation of this study is the issue of security. Traveling to different parts of Niger, to collect data was problematic, which hindered the full depth of data collection from a broad set of participants. Hence, these results may not be applicable to the wider population. However, this study offers valuable insights into the importance of having an implementation plan for the use of ICT in the healthcare sectorwhich would be an enabling ICT policy.
It would be interesting to assess the effects of a forceful implementation of an ICT policy at the organizational level. This could be a project for further study.