Assessment of Computer Literacy of Nurses in Lesotho

FEATURE ARTICLE Assessment of Computer Literacy of Nurses in Lesotho Eltony Mugomeri, MTech, Peter Chatanga, MSc, Charles Maibvise, MPhil, MPH, Matseliso Masitha, BSc Health systems worldwide are moving toward use of information technology to improve healthcare delivery. However, this requires basic computer skills. This study assessed the computer literacy of nurses in Lesotho using a crosssectional quantitative approach. A structured questionnaire with 32 standardized computer skills was distributed to 290 randomly selected nurses in Maseru District. Univariate and multivariate logistic regression analyses in Stata 13 were performed to identify factors associated with having inadequate computer skills. Overall, 177 (61%) nurses scored below 16 of the 32 skills assessed. Finding hyperlinks on Web pages (63%), use of advanced search parameters (60.2%), and downloading new software (60.1%) proved to be challenging to the highest proportions of nurses. Age, sex, year of obtaining latest qualification, computer experience, and work experience were significantly (P < .05) associated with inadequate computer skills in univariate analysis. However, in multivariate analyses, sex (P = .001), year of obtaining latest qualification (P = .011), and computer experience (P < .001) emerged as significant factors. The majority of nurses in Lesotho have inadequate computer skills, and this is significantly associated with having many years since obtaining their latest qualification, being female, and lack of exposure to computers. These factors should be considered during planning of training curriculum for nurses in Lesotho. KEY WORDS: Computer experience, Health information technology, Health management information system, Inadequate computer skills, Nurses H ealth systems worldwide are increasingly moving toward use of information technology (IT) to improve healthcare delivery.1 There is a pressing need to employ IT for healthcare in Sub-Saharan Africa.2 However, successful use of IT in healthcare systems requires basic computer skills. Basic computer skills refers to the knowledge and familiarity an individual has with computers.1 Ghazi et al1 emphasize that nurses must have basic computer skills because Author Affiliations: Departments of Pharmacy (Mr Mugomeri), Biology (Mr Chatanga), and Nursing (Ms Masitha), Faculty of Health Sciences, National University of Lesotho, Roma, Maseru, Lesotho; Department of Biology (Mr Chatanga), Faculty of Science and Technology, National University of Lesotho, Roma, Maseru, Lesotho and Department of Nursing, Faculty of Health Sciences, University of Swaziland, Mbabane, Swaziland (Mr Maibvise). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Eltony Mugomeri, MTech, Department of Pharmacy, Faculty of Health Sciences, National University of Lesotho, Roma Campus, PO Roma 180, Maseru, Lesotho ([email protected]). 528 the profession always requires processing of information. Basic computer skills are therefore essential for effective use of IT in healthcare delivery. Health IT, which can lead to higher quality healthcare delivery, is important now and for the future.1 According to McBride et al,3 health IT aims at reducing the cost and improving the efficiency and safety of healthcare systems. Asah4 reports that in Kwa-Zulu Natal, South Africa, IT is considered key in addressing challenges to healthcare delivery such as shortage of healthcare professionals, and networking. Cline and Luiz,5 also in South Africa, emphasize that IT has a substantial potential to contribute to improving access to healthcare, lowering overall cost and streamlining operational efficiency in health system. Hegney et al6 state that in Australia, the potential benefit of IT use in the healthcare industry includes those anticipated within any other industry or business such as improved efficiency and communication. Hübner et al,7 O’Mahony et al,8 as well as Kivuti and Chepchirchir9 further emphasize that IT supporting the work of nurses may help to improve patient safety, quality of care and organizational efficiency. Inadequate basic computer skills are a major barrier for the completion of required nursing tasks.1 Limited access to computers is another barrier to the use of IT by nurses.6 In addition, Kivuti and Chepchirchir9 and O’Mahony et al8 concur that although nurses’ attitudes toward computer use have become increasingly positive, negative attitudes have often been attributed to limited knowledge of computers. However, computer experience improves nurses’ attitudes toward use of IT.10 Ghazi et al1 consider computer experience as the sum of the individual’s interaction with computers, including time spent using computers and the frequency of use. One major application of computers in healthcare is the use of Health Management Information System (HMIS). The World Health Organization (WHO) defines HMIS as a data collection system specifically designed to support planning, management, and decision making in health facilities and organizations.11 The HMIS of the Government of Lesotho, launched in 2013 under the Department of Planning and Statistics, was meant to improve, among other things, the management of electronic medical records, communication of laboratory analysis results, and pharmacy information across different hospitals in the country. An important part of the HMIS is the electronic information system, which includes the use of electronic medical records.12 Use of CIN: Computers, Informatics, Nursing Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. November 2016 electronic medical records by nurses in hospitals with the HMIS in Lesotho is mandatory. The Institute of Health Measurement, working closely with the Ministry of Health, assisted with the launch of the HMIS in various ways, including provision of technical assistance, equipment, and salaries for data clerks in district hospitals. A review of the country’s health sector, conducted in preparation for the launch of the HMIS, revealed that nurses were ill-prepared to use the HMIS.13 As a result, data clerks and nurses were trained to use the HMIS. However, this training did not include basic computer skills for the nurses. Therefore, the HMIS has not been fully utilized due to many challenges that include limited computer literacy.12,13 As a result, exchanging data across hospitals and implementing automated reporting of monthly statistics remains limited despite the HMIS.12 In addition, the inclusion of data clerks with computer skills but without training in healthcare increased the costs of running the HMIS. To improve the use of HMIS and reduce the costs of running this system, nurses, who constitute about 70% of the total health workforce,14 should be enabled to run the system with minimum help from data clerks. It therefore becomes essential for nurses in Lesotho to possess the required basic computer skills to effectively use the HMIS. To maximize efficiency in their day-to-day activities including the use of HMIS, full engagement of nursing staff in Lesotho is needed. However, their basic skills in computers are not known, and hence their capacity to perform their duties may not be guaranteed. Therefore, an assessment of the basic computer skills of nurses in Lesotho is important to identify gaps in their basic computer skills. Chang et al15 emphasize that the identification of basic computer skills for nurses is important to determine the appropriate training needs for improved use of IT in healthcare in the country. These data are important for planning of educational interventions for full implementation of the HMIS and better healthcare delivery in general. This study therefore assessed the basic computer skills of nurses in Lesotho. Roma and the rural Morija area, respectively, are both run by the Christian Health Association of Lesotho. Each of these two hospitals has about 50 nurses. A diploma in general nursing or a university degree in nursing qualifies one as a general nurse in Lesotho. Entry into the diploma program, which can be completed in 3 years, requires at least six Ordinary Level passes with a credit or better, including Mathematics, English, and at least two science subjects. However, candidates who do not qualify for the diploma in general nursing can enroll for a nursing assistant program and graduate with a certificate in nursing assistance, after 18 months of training. A certificate in nursing assistance coupled with at least 2 years of working experience is also considered for admission into the diploma program. The scope of practice of assistant nurses is limited to the noninvasive nursing activities such as assisting clients with activities of daily living and routine client assessments such as monitoring and recording vital signs. They also assist qualified nurses and doctors in performing their duties. However, due to shortage of qualified nurses, assistant nurses perform most nursing duties, including documentation of client care. In this study, therefore, the term nurse refers to anyone performing nursing duties, including the assistant nurses. METHODS Sample Size and Data Collection Study Setting The study targeted the nurses working at the three hospitals in Lesotho. The study included nurses who were on duty at the time of data collection and were willing to participate in the survey. The sample size was calculated according to the survey guidelines recommended by the WHO.18 Assuming a target population of 500, an error of margin of 5% at 95% confidence interval and a minimum response rate of 50%, the minimum sample size required was 286.18 However, 300 self-administered questionnaires were distributed to cater for nonresponses and incomplete questionnaires. These nurses were selected using a stratified random sampling method. A total of 295 questionnaires were collected, The Kingdom of Lesotho is a landlocked country that is entirely surrounded by its only neighbor, the Republic of South Africa.12 The 2006 census estimated the country’s population at about 2 million.16 The study was conducted at Queen ’Mamohato Memorial Hospital (QMMH), Scott Hospital, and St Joseph’s Hospital. These three hospitals are the largest in Maseru District and were the first in the district to use the HMIS.12 Queen Mamohato Memorial Hospital is the main referral hospital in Maseru District of Lesotho, with approximately 400 nurses. St Joseph’s and Scott district hospitals, located in the semiurban area of Volume 34 | Number 11 Study Design This was a cross-sectional quantitative study that assessed the basic computer skills and availability of the computers to nurses, based on a structured questionnaire administered to nurses working in the three hospitals. The questionnaire was pretested with 10 nurses who were not included in the final data analysis. The questionnaire had three main sections, which included demographic information, access and utilization of computers, and computer skills. The study assessed nurses’ computer skills using 32 of the 37 standardized questions by Torres et al.17 However, the 11-point scale by Torres et al17 was modified to a 4-point Likert scale, which ranged from 1 to 4, representing very difficult (1), difficult (2), not difficult, (3) and easy (4). CIN: Computers, Informatics, Nursing Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. 529 of which five were spoiled or incompletely filled. Thus, 290 valid questionnaires remained and were suitable for analysis after data cleaning. Statistical Analysis Data were cleaned and checked for completeness. The internal consistency for the data collection tool was tested using the Cronbach’s α coefficient.19 Data were analyzed using Stata version 13. Descriptive statistics, including the mean and standard error of difficulty scores of computer skills, were calculated. Univariate and multivariate logistic regression analyses were performed to identify factors associated with having inadequate computer skills. Cross-tabulation of demographic characteristics was also performed to identify variables associated with inadequate computer skills. Inadequate computer skills was defined as having a score below half of the assessed skills, that is, a score lower than 16. Ethical Consideration and Clearance The study was approved by the institutional ethical review board of the Faculty of Health Sciences at the National University of Lesotho and the Ethics Committee at the Ministry of Health of Lesotho. Permission to conduct the study was also sought and granted by the relevant authorities at QMMH, Scott Hospital, and St Joseph Hospital. The respondents were provided with information on the background of the study. The respondents were also informed that their participation was voluntary and that they could decline to answer certain questions, including that they could withdraw their participation at any time. In addition, confidentiality of their information was assured. Subsequently, each respondent signed a written consent form. RESULTS Demographic Characteristics of Nurses A total of 290 nurses returned questionnaires with data acceptable for analysis. The reliability of the data collection tool as measured by Cronbach’s α coefficient was .980. Figure 1 summarizes the demographic characteristics of the nurses. The ages of the nurses ranged from 21 to 56 years, with a median of 30 years. The participants consisted of 243 (83.8%) female and 47 (16.2%) male nurses. Marital status of the nurses is also presented in Figure 1. The majority (52.8%) of the nurses had a certificate in nursing assistance, followed by 44.5% who had a diploma as their highest level of qualification. Concerning work experience, 128 (44.1%) and 115 (39.7%) had worked for 21 to 27 and 16 to 20 years, respectively, while only 22 (7.6%) had worked for 0 to 5 years. The average working experience, though, was 18.9 years, with a median of 18 years. Use of Computers and Related Applications by Nurses Figure 2 presents the availability, accessibility, and use of computers by the nurses. Regarding computer applications FIGURE 1. Demographic characteristics of nurses in Lesotho (N = 290). Figures on the bar graphs indicate frequency and percentage (%). 530 CIN: Computers, Informatics, Nursing Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. November 2016 FIGURE 2. Use of computers by nurses in Lesotho. Figures on the bar graphs indicate frequency and percentage (%). for health, 28 (23.1%) reported that they had access to diagnostic applications at their workplaces, while 38 (31.4%) had access to patient assessment applications. In addition, 19 (15.7%) and 36 (29.8%) nurses had access to monitoring and prescriptive applications, respectively. With regard to computer experience, 221 (76.2%) nurses reported to have interacted with computers, while the rest had exposure to computers. Computer experience in this study was defined as having been exposed to computers at school or during nurse training period. A total of 117 nurses (40.3%) reported computer availability at home or at the workplace. However, of those who reported computer availability, 76 (65.0%) reported unlimited access to computers, while 26 (22.2%) had no access to computers. Sixty-five (5.6%) used computers frequently, while 29 (24.8%) never used them. Computer Skills of Nurses Figure 3 illustrates specific computer skills and the proportion of nurses challenged by the skills. Overall, seven of the assessed 32 computer skills were found to be challenging to more Volume 34 | Number 11 than half of the nurses. Up to 177 (61.0%) nurses scored below 16 of the 32 skills assessed. The skills that posed challenges to the highest proportion of nurses included finding hyperlinks on Web pages (63.0%), use of advanced search parameters (60.2%), and downloading new software (60.1%). In addition, converting text extensions to other forms (59.9%), installing new software (59.5%), and compressing/ decompressing files (54.7%) were also difficult to a high proportion of nurses. Use of conference chats also proved to be challenging to 52.9% of the nurses. However, most nurses were comfortable with deleting unwanted files and using the Internet. Factors Associated With Inadequate Computer Skills of Nurses Table 1 presents the association between the computer skills and characteristics of the nurses. In univariate logistic regression analysis, age, sex, year of obtaining latest qualification, computer experience, and work experience were significant (P < .05) factors associated with inadequate computer skills. CIN: Computers, Informatics, Nursing Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. 531 FIGURE 3. The proportion (%) of nurses in Lesotho challenged by specific computer skills. However, in multivariate analyses, sex (P = .001), year of obtaining latest qualification (P = .011), and computer experience (P < .001) emerged as significant predictors of having inadequate computer skills. Nurses who obtained their latest qualification many years ago and women had significantly (P < .05) higher odds ratios of having inadequate computer skills. DISCUSSION Overall, 61% of the nurses had inadequate computer skills. This indicates that the implementation of the HMIS and the general effectiveness of nurses in Lesotho face challenges due to inadequate computer skills of the nurses. The implementation of the HMIS requires basic computer skills. Therefore, having inadequate computer skills may affect health delivery adversely because nurses constitute about 70% of the total health workforce in the country.14 According to Hegney 532 et al,6 computer skills are required for improved management and processing of information. About 59.7% of the nurses reported unavailability of computers in their lives. However, availability of computers was not significantly (P = .523) associated with inadequate computer skills. Access to computer health applications was limited in this population. All computer health applications were accessed by less than a third of the nurses. Limited access to these applications may reduce the effectiveness of the nurses in their work. Pruitt and Epping-Jordan20 report that health workforce needs access to health applications to improve patient care. Year of obtaining latest qualification (P = .011), sex (P = .001), and computer experience were the significant factors associated with inadequate computer skills in multivariate CIN: Computers, Informatics, Nursing Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. November 2016 Table 1. Factors Associated With Inadequate Computer Skills of Nurses in Lesotho Variables Age, y Sex Qualification Year of obtaining latest qualification Experience, y Computer experience Computer availability Category Inadequate Skills n (%) (n = 177) Inadequate Skills n (%) (n = 117) Unadjusted OR (95% CI) 20–30 31–40 41–50 51–60 Male Female Certificate Diploma Degree 2011–2014 2001–2010 1991–2000 1983–1990 0–1 2–5 6–10 11–15 16–20 21–27 Yes No Yes No 108 (74.8) 53 (55.4) 15 (40.0) 2 (22.2) 43 (90.9) 134 (55.1) 111 (72.7) 71 (54.9) 4 (77.8) 37 (80.2) 49 (55.5) 70 (61.5) 0 (0.0) 8 (85.7) 9 (66.7) 3 (60.0) 10 (50.0) 36 (31.3) 35 (27.3) 43 (19.5) 42 (61.5) 73 (62.7) 102 (59.0) 37 (25.2) 43 (44.6) 23 (60) 9 (77.8) 4 (9.1) 109 (44.9) 42 (27.3) 58 (45.1) 1 (22.2) 9 (19.8) 39 (44.4) 44 (38.5) 42 (100) 1 (14.3) 4 (33.3) 2 (40.0) 10 (50.0) 79 (68.8) 93 (72.7) 178 (80.5) 27 (38.5) 44 (37.3) 71 (41.0) 1 2.4 (1.4–4.2) 4.5 (2.0–9.7) 10.4 (2.1–52.4) 1 8.1 (2.8–23.4) 1 2.2 (.08–5.8) 0.8 (0.2–2.4) 1 2.7 (1.4–5.2) 9.1 (2.5–32.5) Omitted 1 3.0 (1.2–7.7) 5.0 (1.9–13.2) 6.0 (1.9–18.4) 13.2 (3.4–51.7) 16 (3.2–77.9) 1 6.5 (3.8–11.1) 1 1.2 (0.7–1.9) P .002 <.001 .005 – <.001 Adjusted OR (95% CI) 1 2.32 (1.0–5.4) 1.7 (0.4–7.2) 1.43 (0.1–39.6) 1 8.96 (2.4–33.1) Excluded P .053 .471 .831 .001 .116 .639 .003 .001 – .023 .001 .002 <.001 .001 <.001 1 3 (1.28–6.99) 2.1 (0.3–14.1) Omitted 1 1.18 (0.1–26.5) 0.29 (0.0–9.4) 0.62 (0.0–20.3) 1.15 (0.0–38.9) 0.77 (0.0–30.1) 1 4.3 (2.2–8.1) Excluded .011 .442 – .915 .490 .789 .937 .893 <.001 .523 Abbreviations: CI, confidence interval; OR, odds ratio. analysis. Nurses who obtained their latest qualification many years ago and women were the most challenged as regards computer skills. Inadequate computer skills of older nurses may be attributed to limited access to computers during their period of training. Jiang et al21 notes that older nurses may not have had as much access to computers during their training as did their younger colleagues with recent qualifications. About 26% of the nurses had unlimited access to computers in this population. Furthermore, computer experience was found to influence computer skills of nurses in this study. Exposure to computers at school or during training is essential to improve the computer skills of nurses. One way of improving exposure to computers is through encouraging nurses to have their own computers. According to Nkosi et al,10 computer experience improves nurses’ computer skills. Jiang et al21 observed that previous exposure to computers provides practice for the individual, which in turn creates adequate computer skills. Female nurses were more likely to have inadequate computer skills compared with male nurses in this study. Nursing in this population is dominated by women. The women may be lacking positive attitude to computers. Kivuti and Chepchirchir9 and O’Mahony et al8 report that negative attitude by nurses toward computers needs to be dealt with to improve computer skills. This emphasizes Volume 34 | Number 11 the need to conduct periodic in-service computer training for nurses, particularly female nurses and those who have worked many years since obtaining their latest qualification. The level of education and age were not significant factors associated with inadequate computer skills in this study. However, about 73% (Table 1) of nurses with certificate in nursing assistance had inadequate computer skills. Jiang et al21 consider level of education as one of the important factors influencing nurses’ computer skills. The high proportion (52.8%) of assistant nurses in this population is worrisome and may curtail the successful implementation of the HMIS. This proportion of assistant nurses in this population is more than double that in the neighboring South Africa, which is estimated at 25.6%.22 This implies that Lesotho has more nurses with lower level of nurse qualifications than South Africa does. Therefore, given that level of education affects nurses’ computer skills,21 Lesotho needs to scale up the training of higher-level nurses. The HMIS would have had better uptake and outcomes had it been implemented following an assessment such as the current study. The study would expose gaps in basic computer competencies of nurses prior to the HMIS training. However, the findings from the current assessment can still be used to improve the training curricula of nurses in CIN: Computers, Informatics, Nursing Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. 533 Lesotho and the subsequent implementation of the HMIS. Furthermore, the computer skills that were found lacking in this study can also be addressed through training workshops for the nurses. This study was limited to the evaluation of basic computer skills. Advanced skills that may be required to fully operate HMIS applications were not included in the study. In addition, the study did not evaluate the nurses’ attitudes toward the use of computers. According to O’Mahony et al8 and Kivuti and Chepchirchir,9 the attitude of nurses toward computers is an important factor associated with having inadequate computer skills. However, this study is the first to assess the computer skills of nurses in Lesotho. The findings of this study are invaluable in improving the implementation of HMIS and the general effectiveness of nurses in Lesotho. CONCLUSION 5. Cline GB, Luiz JM. Information technology systems in public sector health facilities in developing countries: the case of South Africa. BMC Med Inform Decis Mak. 2013;13(1): 13. 6. Hegney D, Buikstra E, Eley R, Fallon AB, Gilmore V, Soar J. Nurses and information technology. 2007. http://anmf.org.au/documents/reports/IT_ Project.pdf. Accessed June 6, 2015. 7. Hübner U, Ammenwerth E, Flemming D, Schaubmayr C, Sellemann B. IT adoption of clinical information systems in Austrian and German hospitals: results of a comparative survey with a focus on nursing. BMC Med Inform Decis Mak. 2010;10(1): 8. 8. O’Mahony D, Wright G, Yogeswaran P. Govere F. Knowledge and attitudes of nurses in community health centres about electronic medical records. 2014;37(1): 1–6. 9. Kivuti L, Chepchirchir A. Computerization readiness. Online J Nurs Inform. 2011;15(1). 10. Nkosi Z, Asah F, Pillay P. Post basic nursing students’ access to and attitudes toward the use of information technology in practice: a descriptive analysis. J Nurs Manag. 2011;19(7): 876–882. 11. Lippeveld T, Sauerborn R, Bodart C. Design and Implementation of Health Information Systems. Geneva, Switzerland: World Health Organization; 2000. About 61% of nurses in Lesotho have inadequate skills in computers. Year of obtaining latest qualification, sex, and computer experience are significant factors associated with having inadequate computer skills of nurses in this population. Having many years since obtaining latest qualification, being female, and lack of exposure to computers at school or during the training period can contribute to having inadequate computer skills among nurses. The need for in-service training in computer skills for nurses in Lesotho is recommended to improve the implementation of HMIS and healthcare delivery in general. Further studies are also recommended to assess nurses’ attitude toward computers and use of the HMIS. 12. Government of Lesotho. Health management information system strategic plan 2013-2017. 2013. http://www.nationalplanningcycles.org/sites/ default/files/country_docs/Lesotho/hmis_strategic_plan_2013-2017_ final_-_01042013.pdf. Accessed June 2, 2015. 13. Government of Lesotho. Health systems strengthening technical assistance HS-A-012-09: Health management information system review and plan. 2010. https://www.hfgproject.org/wp-content/uploads/2015/02/ Lesotho-Health-Systems-Assessment-2010.pdf. Accessed June 20, 2015. 14. WHO. Lesotho factsheets of health statistics. 2014. http://www.aho.afro. who.int/profiles_information/images/3/3a/Lesotho-Statistical_Factsheet. pdf. Accessed June 20, 2015. 15. Chang J, Poynton MR, Gassert CA, Staggers N. Nursing informatics competencies required of nurses in Taiwan. Int J Med Inform. 2011;80(5): 332–340. 16. BOS. Lesotho 2006 Census of Population and Housing Preliminary Report. Maseru, Lesotho: Government Printers; 2007. Acknowledgments The researchers thank participants and the hospital authorities for approving the study. 17. Torres AAL, Abbad G, Bousquet-Santos K. Validation of a questionnaire on ICTs (information and communication technologies) skills of undergraduate health students in Brazil. Psychol Res. 2013;3(9): 512. 18. Raosoft. Sample size calculation. 2014. http://www.raosoft.com/ samplesize.html. Accessed January 15, 2015. References 1. Ghazi N, Raikundalia G, Gogler J, Bell L. Identifying nursing computer training requirements using Web-based assessment. Int J Adv Comput Sci Appl. 2011;2(12): 49–61. 2. Friedman E. Computer-assisted medical diagnosis for rural Sub-Saharan Africa. Technol Soc Mag IEEE. 2009;28(3): 18–27. 3. McBride S, Delaney JM, Tietze M. Health information technology and nursing. Am J Nurs. 2012;112(8): 36–42. 4. Asah FN. Challenges Faced by Professional Nurses in Accessing Information Technology in Health Care Facilities for Healthcare Delivery in Northern 534 KwaZulu-Natal. KwaZulu-Natal: School of Family and Public Health Medicine, University of KwaZulu-Natal; 2010. 19. Tavakol M, Dennick R. Making sense of Cronbach’s alpha. IntJ Med Educ. 2011;2: 53. 20. Pruitt SD, Epping-Jordan JE. Preparing the 21st century global healthcare workforce. BMJ. 2005;330(7492): 637–639. 21. Jiang W, Chen W, Chen Y. Important computer competencies for the nursing profession. J Nurs Res. 2004;12(3): 213–226. 22. Health Systems Trust. Health statistics of South Africa. 2015. http:// indicators.hst.org.za/healthstats/index.php?indtype_id=004002. Accessed March 30, 2016. CIN: Computers, Informatics, Nursing Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. November 2016