Socio - cultural, Technical & Institutional Challenges to...

Socio - cultural, Technical & Institutional Challenges to Digital Health Literacy in Pakistan and Rest of the World: A Systematic Literature Review Adnan Adil

Lubna Zaheer

Abstract Objectives

The objectives of the present study were to investigate the institutional, socio-cultural and technical challenges to digital health literacy among different members of society, especially college and university students in Pakistan and all over the world. Level of usage of different technologies by the people belonging to different segments of life was also observed. Data Sources

Data was borrowed from Wikipedia, Google Scholar, peer reviewed journals and articles, MEDLINE, Educational Resources Information Centre (ERIC) and other online resources while using variety of terms relating digital health literacy. Review Methods

Abstracts, full texts, summaries, conclusions and recommendations of different studies were evaluated at the beginning. Both qualitative and quantitative researches were included.

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Results Twenty seven studies were included which showed different

kinds of socio cultural challenges to digital health literacy i.e. lack of education, category of gender, and level of age and so on so forth. Ten different studies revealed considerable technical barriers to digital health literacy such as lack of technical knowledge and lack of access to ICT resources. Institutional barriers were also pointed out by 13 different studies. Likewise, eleven studies concentrated on the usage of digital health literacy among students, whereas nine studies highlighted the ground realities regarding digital health literacy in Pakistan. Introduction

Digital health literacy refers to the ability of a person to use electronic resources like computers, T.V, multimedia, mobile phones and other electronic resources to search and find out health related information like health tips, different diseases, variety of physical exercises and information about diets etc. (Norman et. al., 2006).

Pakistan falls under the definition of lower middle class country according to the analysis of World Bank income groups. In Pakistan life expectancy at birth is 63 years (“Demographics”, 2016). According to World Health Organization (WHO, 2009) Pakistan spends 2.9 percent of Gross Domestic Product (GDP) on health every year. The number of Pakistan is at 128 in the ranking of ICT Development Index. In Pakistan 11.30 individuals are using internet from every 100 individuals of the total population.

Like many other nations in the world, Pakistan had also made struggle to introduce technology in health literacy but is facing huge problems in its successful implementation because of diverse cultural patterns and low literacy rate (Mumtaz et al. 2014). The constitution of Pakistan directs that health is the basic right of every citizen of Pakistan, but lack of health budget, limited access to technology and gap of technology in rural and urban areas are some main hurdles in technology implementation in this sector. Country policy makers have come to conclusion that to address

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some major health issues, e-Health resources utilization is dire needed. (Khoja et al. 2008). The major work done relating to e-Health in Pakistan was the creation of digital health association of Pakistan (e-HAP) in 2009, established by one of the proposal from the Rock Feller Conference in Bellagio (Ali 2013). Creation of this association was a joint effort of different officials of government, faculty members of different universities in Pakistan, different NGOs and other institutions working mainly in telemedicine. The major aim of e-HAP was to co-ordinate between different stake holder of eHealth, and to create general awareness among mass population regarding the advantages of digital health usage and literacy (Ali, 2013).

The advantages of digital health literacy can be categorized in terms of easy to access, low in cost, quick results and security of patients privacy (DeMonte et al. 2015). Because of the easy access of the digital resources relating to health literacy, 81 percent of the adults of United States of America (USA) use the internet, from these 59 percent have gone to search health related webs or tools (Pew internet and American life project). The usage of mobile phones is also increasing throughout the world at a larger speed, and is also being used to get health related information in different countries, as according to the report of pew internet, 52% percent smart mobile phone owner have searched for health information through their mobiles for more than one time. Another report of pew internet shows that 10 out 100 individuals are using internet, and from these 10 individuals, seven belong to the category of youth while according to the ministry of youth affairs, Pakistan (2013), 35 percent of the total population of Pakistan belongs to youth segment. So, among youth segment it is dire need to improve the health seeking behavior of youngsters.

Literature Review

The literature review tried to search out the previous researches relating to digital health literacy. Using of internet, electronic resources and online sources is becoming a favorite way of enhancing knowledge in different aspects of life. Health related


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information is also being searched out through these sources (Tustin 2010). Students, patients and general public of society can be categorized as the beneficiaries of the online health resources (Sorensen 2005). Usage of these online health resources is effected by gender (Atkinson et al. 2009), education, availability of internet resources, speed of access of electronic resources and technical support (Wangberg et al. 2008). Strategy to Deal

The present literature was dealt in the following manner.

1.1 Rationale for the literature review

1.2 Objectives of the review

1.3 Searching review strategy.

1.1 Rationale for the Literature Review

The review of the previous researches relating digital health literacy will result into a greater significance like:

I. Indicate the gap in methodologies of different researches.

II. It will create knowledge about the researches relating digital health literacy till now

III. This will guide the health policy makers and practitioners for logical decision making

IV. Compare and contrast the views and reviews of different authors relating health information

V. It will help the researchers to avoid themselves from duplication of researchers on the same topic.


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1.2 Objectives of the Review The present literature tried to fulfill the following objectives:

i. Socio cultural challenges to digital health literacy.

ii. Institutional challenges to digital health literacy

iii. Technical challenges to digital health literacy

iv. Challenges faced by students in successful implementation of digital health literacy

1.3 Searching Review Strategy Following sources were used for literature review.

i. Peer reviewed journals and articles

ii. Local journals

iii. Presentations in conferences

iv. Online sources

Literature Review

The literature review of the present study was categorized in socio cultural, institutional and technical challenges. Then challenges faced by students at different level in different countries were also included. Socio Cultural Challenges

The term socio cultural includes a wider range of meanings and aspects in it. For example it includes population, age, gender, education, language, ethnicity, caste, class and so many other aspects. In this part of literature review, the studies showing relationship between socio cultural variables and digital health literacy were included.


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Brenner (2003) pointed out the association between level of age and level of searching digital information relating gynecological problems. The research was quantitative in nature, which included 235 respondents. There was a significant difference between the perception of people who were in their fifties and those who were in their twenties. The respondents belonging to fifties responded that the technology usage in health information was less friendly. The researcher also challenged the Technology Acceptance Model (TAM), and stated that the gap between usages was not due to Perceived Ease of Use (PEOU); rather it was the result of small skills of older adults in technology.

Another study by Mancini et al. (2010) pointed out the same results. The research was conducted in France. The respondents were the patients of breast cancer. The researcher concluded that there was an inverse relationship between age and level of usage of electronic resources in searching health information.

Then another socio-cultural characteristic ‘education’ also had association with digital health literacy. Dickerson et al. (2004) pointed out the relationship of education and ethnicity of patients with health seeking behavior on internet. He divided the patients in two categories, those who attended the college and those who did not attend the college at all. He made the conclusion that the patients who attended college in their life had higher use of technology in seeking health as compared to those who did not attended the college, which meant that level of education determines the level of technology usage in health. Same kind of result may be seen in Fogel et al. (2002) research who pointed out that level of education and level of annual income were associated with use of computer and internet at home. Flynn et al. (2006) made a longitudinal study in USA to find out the association between education and health seeking behavior via internet. This was a phone and mail self report study. Only those graduates were included who were having age between 63-67 years. It was concluded that the respondents with internet access and higher years of education had a positive association with searching health


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related information online. James et al. (2007) also reported same kind of relationship between education and health literacy.

Like education, literacy level also affects digital health literacy. Birru et al. (2004) took a study which included 8 low literate subjects, which were defined as the subjects having literacy level between 3rd to 5th grades of USA grade. The subjects were given with self directed searches of health information. It was observed that the subjects were not good at understanding the health information, which was present on different websites. Gustafson et al. (2002) made review of 10 years reports, published relating Comprehensive Health Enhancement Support System (CHESS) in USA. They concluded that a higher level of literacy was required to get benefit from such kind of reports. So level of literacy determines the level of understanding health information.

Gray et al. (2005) made a qualitative research on 157 respondents to answer the relationship between level of age and education with the implementation of health information after having knowledge of it. For this purpose 26 Focus Group Discussions (FGDs) were conducted. To cover the heterogeneity, the study was conducted on the diverse geographical area including different areas of USA and UK. The research population was the students having age from 11 to 19 years. The researchers pointed out three main problems. Students were less likely to collect relevant health information. They were not good to apply such health related knowledge to solve their specific health issue. And they were less brilliant in functional skills like answering different question and asking different questions relating health. Greenhalgh et al. (2008) also pointed out same kind of association between level of literacy and level of understanding information relating health through technological resources.

Motivation of the patients to search out health information was also another great factor which can affect the level of usage of health literacy via electronic resources. Such kind of motivation was difficult to measure but researchers used many indicators to measure such kind of motivations. These indicators may include


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level of interest of a person relating his own or his family health, his experience of searching relevant information and its implementation and successful outcomes in past etc. Such kind of study was undertaken by Williams et al. (2003) at a hospital in Mussel burgh in Scotland. The patients were attending the GP surgery. The participants of the study were females having the age between 55-74 years. Thirteen in-depth interviews were conducted. The researchers pointed out that the patients had less interest in using touch screen health information kiosks. The majority of the respondents were thinking that kiosks were only for practitioners and they had no curiosity to use them. Lack of interest was also a motivational issue. This lack of interest was pointed out by Peterson et al. (2003) in a study at USA. Structured interviews were conducted on 200 cancer patients. The results showed that majority of the respondents think the information invalid, which was present on the internet relating health. Helft et al. (2005) conducted the research on the non user of internet in seeking health information.

Such respondent were cancer patients but were not using internet to get knowledge about their diseases. From the total respondent 44 percent told that they would like to use internet in seeking health if they had access to internet. While 49 percent of the respondents were not willing to use internet, having the belief that cancer information was not present on the internet. Rogers et al (2004) told in their study that motivating factor in patients can be enhanced by creating knowledge among patients that health knowledge can deal with disease in a better manner. They conducted semi structured interviews of 17 people, who were enjoying free internet clinic. It was observed that respondents managed their diseases in a better manner after having its knowledge. Flynn et al. (2006) also documented that health information was a facilitating factor in healing and recovery of diseases. Greenhalgh (2008) noted that interest in one’s own health can affect the motivational level in patient to get information access relating health, while careless attitude toward


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one’s own health decreases the motivational level of the patient to search health.

Having the prior knowledge and skills of using ICTs, also have an association with the digital health literacy. Skinner et al. (2003) pointed out that lack of searching skills resulted into lack of eHealth literacy. The research included 210 people of Ontario in Canada. Twenty seven FGDs were conducted. The researchers pointed out that searching music, pornography and sports was easy as compare to searching health. Health related information requires advanced searching skills. Bowen et al. (2003) made a research to point out the relationship between searching skills and collection of online health information among women having the age from 18 to 74 years in Washington State, USA. Telephonic survey was done for the collection of data. Number of respondents was 431. The research concluded that majority of respondent inhibit eHealth literacy due to lack of searching experience.

There was also a gap between healthier and sicker patients regarding the level of searching online health. Houston et al. (2002) made a telephonic survey on American respondents to find out the gap of believes between the healthier and sicker patients. The number of respondents was 500. It was concluded that the sicker patients’ attitude was more positively associated with the increased level of e-Health information usage. Bowen et al. (2003) also concluded same results pointing out that people with higher diseases especially mental diseases were more attracted to get online health information.

Then expectations of different users vary. Most of the respondents wish the availability of information on internet of their own will. Anhoj (2004) made a comparison of two groups of asthma patients who frequently used Link media. Link media is online asthma diary from which the asthma patients can calculate their level of disease. From the view point of expectations, the results of 85 individuals indicated two groups. Both kinds of groups had different kinds of expectation from Link media. The first group which was named as ‘outside in perspective’, expected


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concise information, relevant advice and monitoring to their disease. They did not expect scientific articles and experts opinions from Link media. The second group which was named as ‘inside out perspective’ expected fast access to their relevant problem. The researcher concluded that satisfaction of expectation may result into the increased level of technology usage in health seeking behavior. Trust in getting help from online resources was another factor which changes the level of eHealth literacy among patients, practitioners and general members of society. Dickerson (2005) pointed out his results while having 13 members FGD and eight respondents on email discussion. The research concluded that people consider internet as a goldmine of knowledge and they trust the information. However the results of different studies made different analysis. Mancini et al. (2006) categorized the respondents from the view point of their opinion regarding searching health through internet. From the total respondent, 11.1 percent respondents were those who expressed both positive and negative aspects of using internet in health. And 23.8 percent of the respondents expressed positive view, while 31.7 percent negative and 33.3 percent respondents made no comments.

The respondents who made negative comments were of the view that searching health via internet was a stressful activity. khechine et al. (2008) made a research on 121 English speaking Canadians, from which 79 percent respondents used to visit science, medical and government websites relating chronic illnesses. The respondents were of the view that this usage was based upon their trust on the validity and authenticity of information available on internet. But this trust was not universal. Glenton et al. (2006) took four FGDs with the patients of back pain in Norway. This study not only included the patients but care givers and family members of the patients were also included. The purpose of the study was to estimate the use of health related information. The respondents had access to online resources. The respondents were of the view that research material relating health available on websites, was not easy to implement to solve a


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health problem. Khoo et al. (2008) made interview survey of 360 parents about their attitude toward searching health information for their children. The objective of the study was to estimate the perception of parents about the authenticity of the health information on the websites. Out of 360 respondents, 65 percent respondents were of the view that the online information was less reliable while 53 percent respondents expressed different concerns about health information. Greenbalgh (2008) reported in his study that negative experience of past also had effect on the level of usage of digital health information seeking. Chung et al. (2008) made a quantitative research, including 113 respondents. Survey method was adopted as the data collection technique, while self administered questionnaire was used as data collection tool. The results indicated that the respondents considered the health related blogs credible and full of fruitful information. Technological Barriers

There were also some technological barriers which were being faced by patients, practitioners and general members of society, relating search of health information from the internet. These included lack of access, lack of training, lack of technical knowledge, limited knowledge to implement and lack of ICT equipments etc.

Pennbridge et al. (1999) made a quantitative research to evaluate the attitude of the respondent, who had internet access. In this study 1007 respondents from California were included. It was a questionnaire based survey research which concluded that access of internet had a positive association with level of technology usage in seeking health. Helft et al. (2005) made a research which indicated that only 10 percent of the total respondent were using internet for health information. From the total number of respondent, 44 percent were those who assured to use internet in seeking health if they would have access to internet. Same kind of conclusion was drawn by Blackburn et al. (2005), who noted that non users of digital health literacy had limited or no access to computers at home. These results were


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also supported by the research of Ibrahim et al. (2006), who made a difference between users and non users of electronic resourced in health. They pointed out that main difference was due to the availability of internet resources. Dart (2008) also believed that accessibility and availability were the main reasons for using or not using e-Health knowledge. Wangberg et al. (2008) made a telephonic interview based survey over a large geographical area, including seven European countries. From the respondent, 71 percent of the respondents were internet user. They responded that they had gone for health information on internet for more than one time. Boukhors et al. (2003) conducted a research on diabetes patients. The purpose of the study was to observe the effects of computer assisted insulin management program on the improvement of quality of life and knowledge about the disease. The study was based on pre and post treatment questions. The subjects responded that because of this computer assisted program, there was no change occurred to the quality of life but the subjects get good knowledge about their disease and its treatment. Anhoj et al. (2004) made a research on Asthma patients. The purpose was to assess the level of usage of tele-health services relating to the disease of Asthma, it was concluded that the main obstacle which abstained from tele health service was the speed of connection of internet. Bruwer et al. (2005) made a survey on the supporters of two internet groups. The respondents were sufferer of hair pulling. The questionnaire was emailed to the respondents. The sample size of the research was 1010. The purpose of the research was to measure the perceived effectiveness of each internet group by its supporters. Supporters from both sides were satisfied with their internet group, but certain barriers were pointed out by them. For example majority of the respondents did not like vast illustrations, deviation from the topic and complex terminology.

Accuracy of available information is another obstacle which hinders the users to implement health information. Esquivel et al. (2006) made a research to assess the accuracy of the health information, on the internet. For this purpose they evaluated


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4600 postings relating health information on different websites by different bloggers or opinion makers and authors. They identified that 10 out of 4600 positing were misleading or completely false. However, 7 out of these 10 mistakes were identified, amended or changed by other participants. Using internet for health knowledge sometimes results into threat for privacy. Certain kinds of diseases are of private concern. People especially, VIPs don’t want to share information about their private diseases to others. But online searching health may be a threat to privacy. Pennbride et al. (1999) made a research on the respondents who had easy access to internet. The conclusion was drawn that sharing of health information on different blogs was felt as threat for privacy by different respondents. Institutional /Organizational Barriers

It is much difficult to implement technology in health seeking behavior with the help of one individual or some groups of individuals. Organizational and institutional level efforts are required in this regard. While observing the phenomena it becomes evident that there were different kinds of institutional and organizational level barriers which were creating obstacles in the successful implementation of online technologies into health literacy. Such kinds of obstacles may include less expertise of seniors in hierarchy, absence of team work and co-operation, non-friendly policies relating technologies and lack of training and support from the organization etc. Yee et al. (2oo8) explained the factors behind unsuccessful digital health literacy. They were of the view that the fault was with the seniority of hierarchy of the institution. They consider ‘Y’ generation can change the attitude towards e-Health literacy. ‘Y’ generation includes those people who born after 1978. They had good exposure towards using technologies, so in the same manner they could do something to implement technology into heath. In contradiction, in hierarchy, seniors were those who born before 1978, who had less exposure towards using latest and new ICT technologies. Therefore, there was dire need to re-engineer the hierarchy of institutions. Ash et


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al. (2004) Pointed out that shift of power from the seniority may result as a barrier to e-Health literacy. There should be a powerful clinician control over health related organizations, so that health friendly and health facilitating policies could be introduced. Ludwick (2009) introduced that team efforts and mutual co-ordination between different organizations, health departments, primary health care, hospitals, doctors and paramedical staff was needed for the successful implementation of ICT into health seeking behavior. Mostashari et al. (2009) also agreed upon the mutual co-ordination among different segments for introducing the concept of digital health literacy.

Al-Qirim (2007) also suggested different structural and organizational aspects of e-Health literacy for further investigation. He elaborated that primary, secondary, tertiary and community level care providers were liable to perform two kinds of duties. First of all they should improve health by working independently. Then they should also co-operate with each other to improve health. Both kinds of efforts can enhance the e-Health literacy rate of patients, doctors and other society members. The RAND study (Fonkych 2005) explained that digital health literacy can ultimately affects positively on health, so health care structures should be redesigned accordingly. Ahem et al. (2006) agreed with the point that there should be greater co-ordinate efforts among the component of health department to implement ICT into health. While Winthereik et al. (2005) elaborated their point in a different manner. They were of the view that technology adaptation into health had created gap between the co-ordinations of different health practitioners at different levels. Levenson et al. (2008) was of the view that the concept of health information technology (HIT) had decreased the co-ordination between health practitioners and resulted into the autonomy of different practitioners. He was not in the favor of HIT until it was institutionalized.

Shortliffe (2005) pointed out that HIT was much functional, but doctors may not like the flourishing of such concept, as because of it there will be a decreased number of face to face


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interactions between doctors and patients. So there will be depersonalization in health care system which may results into the disadvantage to the doctors. So, doctors and different stake holders in health may become a hurdle in the successful implementation of ICT into health literacy. Shekelle (2006) suggested that to implement technology in health, there is dire need to train the end user of health field. The end user meant here, the patients. Patients with training of using HIT can perform well in searching health and level of HIT will increase rapidly. The research of Flynn et al. (2006) showed that training of the patient had positive relationship with level of usage of technology in health literacy. They were also of the view that it can result into financial savings. Meade et al. (2009) indicated in their study at Ireland that barriers to health literacy can be categorized. They ranked the “Lack of time” as top of the list barrier, while “lack of training” was the second more influencing barrier to HIT. Macfarlane et al. (2006) also made a study at Ireland and also ranked categories of the different barriers to the implementation of HIT. At first they put lack of trainings and skill development workshops for lack of e-Health literacy.

Lack of support from colleagues and institutions also result as a barrier to HIT. Such kind of support is also required at policy making stage. Digital Health Literacy in Pakistan

Pakistan is a country which is facing many kinds of social issues and problems in almost every field of life. The major concentration of the country is to fight the war against terrorism. The overall economic situation is very bad. Economic situation is also related with health situation. There is not a good situation of health in Pakistan, especially in rural areas. Rural areas are facing bundle of problems relating health. There is no availability of proper dispensaries, hospitals and pharmacies. Doctors, physicians and paramedical staff are least interested to go to rural areas. People belonging to rural areas could not access to doctors because of transportation and economic issues. (Saleem, 2010).


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Elaborating the telecommunication facilities, Ansari et al. (2012) explained that broadband connection was available in more than 1800 cities of Pakistan, while optical fiber was used by 400 cities in Pakistan. The researchers were of the view that Pakistan was also facing problems of technological integration.

In Pakistan majority of the population was living in rural areas. Approximately 28 percent population in the country was living in urban areas, while 72 percent were living in rural areas. In 2000s the situation of the availability of doctors was very alarming, where there were only 74 physicians for one hundred thousand populations. In rural areas majority of the population, were of the view that they had never attended any capable physician during their life (Bhutto et al. 2010).

Such kind of situation was also elaborated by Durrani et al. (2012) in rural Sindh, the province of Pakistan. According to them urban areas were well equipped with medical facilities while there was alarming situation of health in rural Sindh. They were of the view that Karachi, the city of Sindh province, was well equipped with digital health technologies. They recommend that such kind of medical facilities should be shared with rural areas through online connectivity. In their study Malik et al. (2008) recommended that there should be technological integration into health services for dealing with the cases of emergency. In situation of accidents, heart attacks, organ damage and pain, there should be quick availability of information to handle the problem. For this purpose there should be provision of health related information through online resources, so that the patients could inform themselves. Bhutto et al. (2010) further explained that only availability of health information on the internet could not solve the problem. As Pakistani population was also facing problem to the access of online facilities, so how could they search for health? Then people were not much trained to use the health related information available on the internet. So first of all, there should be policies to assure access of technology to the people, especially in rural areas.


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Then there should be trainings relating digital health literacy which should guide people to use the information relating health. And they should also be introduced with the benefits of using digital health literacy. According to Ali et al. (2002) significance of health information technology could not be falsified in a country like Pakistan, because all kind of treatments depends upon the well timed and accurate information. And if people could get this information through online resources, they could make their treatment successful. Qazi et al. (2004) elaborated the historical dimensions of the topic and elaborated that in Pakistan, health information related programs ended before 1990. The reason behind this was the mixture of fake and false information in the date. In 1992 Ministry of Health, Pakistan took action to pure this information through consultative procedures.

Ansari et al. (2012), while pointing out the efforts of Ministry of Health Pakistan, elaborated that bundle of efforts were made to improve the health information system. For this purpose, new managing policies, new check and balance strategies and improved service delivery services were introduced in every district of each province. But the desired out comes could not be achieved. The main hurdle was that different stake holder like practitioners, physicians and surgeons were not consulted to know about the grass root level obstacles in health information system. Bhutto et al. (2010) made a review of previous reports of Health Management Information System (HMIS) and noted that there was issue of reliability and authenticity in the results of reports. The information was un-related. Because of this it could not guide the policy makers to further make beneficial policies relating health information system. The researchers recommended that there should be improved system to make the reports of HMIS reliable. Ishtiaq et al. (2012) further continued the argument and stated that the issue was not with the authenticity of the reports of HMIS. The data present in the reports was good to greater extent. The problem was that health and disease statistics were changing every day. Then new policies relating health were also there. Because of which the data of HMIS looked as irrelevant. To


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improve the reliability level of HMIS, Mostafa et al. (2011) suggested that with every new day, technology was improving itself. So the Ministry of Health (MOH) should also improve its technological requirement. While using new kinds of software relating health information system, could improve the reliability and advantages of HMIS. The researcher advised the Ministry of Health to use open access software development method, which had the characteristics that it could be used and changed by some other operator while having the knowledge of codes. Durrani et al. (2012) further continued the discussion while elaborating that MOH had no ICT capacity to change or modify the software. The researchers also advised to use open access software design. They elaborated the advantages of using this design. This could be redesigned and restructured by any computer experts, who had not developed it. Because of this software MOH could update and change the varying statistics relating health and diseases, which will further give benefit to policy makers and health practitioners.

There were certain kinds of socio-cultural factors which became a hurdle for the integration of technology into health information system. Durrani et al. (2012) pointed out different kinds of socio-cultural barriers. Lack of interest of the stake holders was the major reason. Then lack of motivation, lack of new ideas, lack of acceptance of new technologies, anxiety in leaving the traditional methods and less readiness to change the system etc. were some of the barriers to health information system. In a broader perspective Qureshi et al. (2014) pointed out the major issues and barriers in Pakistan relating the health information system and its integration with ICT. They categorized the barriers as socio-cultural barriers, structural barriers and technological barriers. Socio-cultural barriers included: lack of education, less motivation to adapt latest technologies and attachment with traditional methods, while structural barriers included: less efficient policies of government regarding health information system, lack of efforts made by different organizations, no availability of infra-structural equipments and lack of professionalism and provision of trainings from the


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organizations relating health and technology. Then, there were also some technological constraints pointed out by the researchers which included: lack of access, lack of availability, lack of skills and lack of guidance and training in technology. Cost was also elaborated as a major barrier, as the technological equipments are much costly.

Recommendations for Further Studies

While keenly observing into literature review, it was observed that previous researches had small sample sizes. Small sample size may have small representative characteristics. So there is need of researches with larger sample sizes.

Previous researches were also lacking the relative analysis of difference of effects of different variables. Most of the researchers elaborated the effect of different variables on the dependent variables. But, to what extent each variable was causing change to dependent variable was not mentioned.

In the same manner studies were also lacking to answer, which category in a group was much affecting the dependent variable. The previous studies were also lacking the comparative analysis among different institutes and organizations regarding digital health literacy. The studies were conducted on colleges, hospitals and schools. These had not tried to make comparison among the respondents of different type of colleges i.e. medical colleges, engineering colleges, and commerce colleges etc. and these had not mentioned the difference of views of doctors, health professional and other respondents from public and private sectors. So these gaps should be filled upon. Notes and References

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Ali, Sajid. "Formulation of a National e-Health Strategy Development Framework for Pakistan." Ph.D. diss., University of Calgary, 2013.

Al-Qirim, Nabeel. "Championing telemedicine adoption and utilization in healthcare organizations in New Zealand." International journal of medical informatics 76, no. 1 (2007): 42-54.

Anhoj, Jacob, and Lene Nielsen. "Quantitative and qualitative usage data of an Internet-based asthma monitoring tool." J Med Internet Res 6, no. 3 (2004): e23.

Ansari, B., A. Shaikh, R. Khan, and N. Hamirani. "Telemedicine enlightenment: A smart heath care system for rural areas." Journal of Emerging Trends in Computing and Information Systems 3, no. 2 (2012): 145-149.

Ash, Joan S., Marc Berg, and Enrico Coiera. "Some unintended consequences of information technology in health care: the nature of patient care information system-related errors." Journal of the American Medical Informatics Association 11, no. 2 (2004): 104-112.

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Birru, Mehret S., Valerie M. Monaco, Lonelyss Charles, Hadiya Drew, Valerie Njie, Timothy Bierria, Ellen Detlefsen, and Richard A. Steinman. "Internet usage by low-literacy adults seeking health information: an observational analysis." Journal of Medical Internet Research 6, no. 3 (2004): e25.

Birru, Mehret S., Valerie M. Monaco, Lonelyss Charles, Hadiya Drew, Valerie Njie, Timothy Bierria, Ellen Detlefsen, and Richard A. Steinman. "Internet usage by low-literacy adults seeking health information: an observational analysis." Journal of Medical Internet Research 6, no. 3 (2004): e25.

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