BUILDING CAPACITY FOR E-LEARNING FOR NURSE TRAINING IN ZAMBIA AND GHANA: APPROPRIATE COMPUTER TECHNOLOGIES? J.M. Vallis¹; A.C. Mason²*; K. Afari-Dekyi; E. Ansotinge; J. Antwi; L. Chifwaila; F.Fraser; P. Moyo; C. Mudenda; C. Turner; G. Urquhart; G. Van Stam; A.Wales† ¹*NHS Education for Scotland (NES), Scotland, [email protected] ²*The Tropical Health Education Trust (THET), England, [email protected]

Keywords: e-learning, workforce, capacity

technologies,

nurse

training,

Abstract Zambia and Ghana share similar health workforce challenges, including acute shortages of trained nurses and tutors in remote and rural areas, hindering achievement of Millennium Development Goals (MDG). E-learning technologies present a potential solution, with shared teaching and learning resources contributing to reduced tutor workloads; more evidence-based, student-centred education; and potential for increased student intakes. E-learning for nurse training has been successfully implemented in other African countries but not yet in Zambia or Ghana. There are many challenges and this paper describes a 10-month THET-funded Multilink project to address these. A mini-conference and field visits, in Zambia, enabled consultation on e-learning needs and 3 ICT Champions were trained to support an e-learning system developed by project partners, incorporating complementary ICT knowledge systems (one of them internet-free); a Dropbox file-share; Skype for synchronous clinical supervision (CS) of mental health nurses; 2 email networks on Maternal and Child Health (MCH) and Mental Health (MH); portable DVD players for piloting of health-related films; and a range of hard and software to support e-learning. Lessons learned from attempts to embed these technologies, and their appropriateness for the contexts concerned, are discussed.

technological era, e-learning presents one potential solution [5]. Africa is embracing e-learning, which has been successfully implemented for nurse training in other African countries [6]. However, there is no equivalent yet in Zambia or Ghana [2] and there are many technical and other challenges as well as opportunities [5]. A THET-funded Multilink project has been addressing these through development and piloting of a range of complementary elearning technologies and knowledge sharing systems. 1 This paper describes the project, including the information and computer technologies (ICT) utilised and presents lessons learned from attempts to embed these for nurse training. It reflects on the lessons learned, including appropriateness of the technologies for the rural African contexts concerned.

2 THET-funded Multi-link Project 2.1 Background In early 2011, 2 THET links (Ghana, Upper West Region/Inverness, Scotland; and Chitambo Nurse Training School, Zambia/Penicuik for Africa (PfA), Scotland) united in a bid for Multi-link funding to take forward work on building capacity for e-learning for nurse training. The purpose of multi-link working is ' to improve global health outcomes for people living in poverty through more coordinated link activities'. A successful bid resulted in an intensive 10 month Multi-link project from June 2011. 2.2 Aims and objectives

1 Introduction Zambia must double its nursing workforce to meet basic health needs [1,2] and Ghana faces similar workforce challenges [3]. In both countries nurse tutors are particularly scarce and recruitment and retention is problematic, especially in remote, rural areas. Limited training resources create heavy tutor workloads and can result in rote learning styles [2]. Increased reliance on inexperienced tutors (new graduates) has implications for training quality, and constraints on regulatory resources could be an added factor [2]. There is an urgent need for better support (supervision and mentoring). However, this is limited by distances and costs, with implications for meeting Millennium Development Goals for health by 2015 [4]. In this

The overall objective was to build on the capacity of nurse training schools (NTS) to deliver nurse education and continuing professional development (CPD), improving 'evidence-based' nursing practice in 2 priority areas: maternal and child health (MCH) and mental health (MH). It was anticipated that development of national and international elearning networks, by and for participating NTS, would enhance usage of 'evidence-based' educational resources and improved standards of MCH and MH care. 1

http://www.thet.org/healthlinks/zambiaghananhs-educationfor-scotland-nes-health-multi-link/

2.3 Partners The Multi-link project brought together 6 diverse organisations in Zambia, Ghana, Scotland and the Netherlands.2 The 4 participating NTS, in Zambia and Ghana, were government-funded and trained registered and /or enrolled nurses and midwives. The project grant was administered by NHS Education for Scotland (NES) which provided overall co-ordination and financial management. Operational and steering groups were established and incountry co-ordinators identified to facilitate the work on the ground. The Ghana/Inverness co-applicant was taking up a THET post as Volunteer Nurse Tutor (VNT) at Chipata NTS, eastern Zambia. As an experienced nurse lecturer with a knowledge of Africa, she was ideally placed to both coordinate the project in Africa and act as education lead. Other operational partners took charge of specific aspects such as ICT, training, monitoring and evaluation. 2.4 Activities Given the short project duration, there was a need to act quickly. The timeline prepared for the grant application included: project initiation and administration: project processes (e.g. consultation and training); technical and elearning requirement; and evaluation. 2.4.1

Project initiation and administration

There was considerable, initial work to establish the project, including procuring computer equipment (laptop computers, modems; routers; e-learning development software; USB pens etc); arranging an e-learning mini-conference to be held in southern Zambia; and organising travel to this conference for partners from Zambia for Ghana and Scotland. 2.4.2 Project processes Consultation was a key project process and the miniconference on e-learning, hosted by Macha Works3 (a grassroots internet providing co-operative based in southern Zambia), was the first main activity. Twenty eight delegates including project partners and associates from Zambia, Ghana, Scotland, the Netherlands, and Kenya, attended actually or virtually, with direct, face to face contact between 23 participants in Zambia, and 5 more connecting by Skype 2

Zambia • Chipata NTS, Eastern Province • Kasama NTS, Northern Province • Chitambo NTS, Central Province • Macha Works Zambia, Southern Province Ghana • Jirapa Midwifery College, Upper West Region • Europe • NHS Education for Scotland (NES), Scotland • Macha Works, Netherlands (fundraising arm) 3 www.machaworks.org/en

from Zambia, Kenya and Scotland. This was an example of e-learning in action, involving communications between two continents, 5 countries, and 4 time zones. Feedback was positive: “(it was) an opportunity to meet a lot of people, project partners from Ghana...within the country (other) nursing schools. It was brilliant just to come together with all those partners... I actually learned a lot...(and) we’ve created that link and friendship.”(Nurse Tutor, central Zambia) As well as sharing information, the conference provided an opportunity for some formative evaluation of e-learning needs. Recorded interviews with conference delegates were followed up by exchange visits to partner NTS in central, northern and eastern Zambia, where further observational and focus group data provided a clearer picture of the challenges involved in integrating e-learning into nursing curricula. Inadequate internet access was identified as the main obstacle. However, the prescribed curricula left little spare capacity for innovation and resistance to change, especially amongst older, established tutors, could be an added factor. Macha Works technical arm (LinkNet) visited partner NTS in Zambia to ascertain their existing ICT provision and 'readiness' for community-driven internet solutions. Macha Works has a track record in provision of the internet to underresourced rural communities and operates through a Zambian cultural, 'relational' or 'ubuntu' perspective [7]. This involves whole community dialogue (from the Chief down) to engender internet 'ownership' and cost-sharing between local organisations. Only in this way can the crippling costs of low bandwidth, typical of low and middle income countries (LIMIC), be sustained [8]. Once such commitment is obtained, Macha Works then aims to provide the necessary ICT infrastructure (computers and satellite-driven internet access, within sea containers to form internet hubs). They have linked several remote, rural NTS to the internet, in this way, including providing whole computer labs in some cases [9]. The hope was that that they would do the same for some of our partner NTS and/or at least supply some basic ICT infrastructure. Macha's ICT assessment report confirmed that there was a pressing need at all 3 NTS visited. At Chipata and Kasama, computer provision was inadequate (around 8 desktops each for upwards of 200 students and very precarious internet access). At the newly re-opened Chitambo NTS, in central Zambia, computing facilities were, at the time, entirely absent and the promise of a computer lab was attractive. Training is a crucial aspect of sustaining e-learning developments at NTS is having skilled ICT personnel to support them. Our project, therefore, funded 3 partners to undertake ICT Champion (Local Hero) training at Macha's LinkNet Information Technology Academy. Two undertook the short, advanced A+ training for ICT literate persons, one the 6-month International Computer Driver Licence (ICDL) training, for ICT novices. Training took place at Macha Works immediately after the conference. The project’s education lead, based at Chipata NTS, in eastern Zambia, initiated two e-learning networks, one on

MCH, the other on MH. Once established, 21 members (11 MCH; 10 MH) received fortnightly email updates on relevant topics. Some also received training on use of the internet and Skype as forms of communication, as well as other skills such as report writing, budgeting, peer training via Skype etc. In particular, a small group of under-supported Mental Health nurses at Chipata Regional Hospital, eastern Zambia, engaged in synchronous Clinical Supervision (CS), discussing issues of clinical interest, by Skype, with an experienced Mental Health Nurse Consultant in NHS Highlands (Scotland). Towards the end of the project, 6 key partners and contacts attended a 2-day workshop and were trained in use of eGranary digital library, and Moodle Learning Management System.4 This on-site, internet-free system, otherwise known as 'the internet in a box', was donated to the project by the University of Alabama at Birmingham Sparkman Center for Global Health, USA. It complements the interactive Africa Knowledge Network (AKN) ICT portal developed for the project, providing access to relevant knowledge resources even where the internet is unavailable. 5

2.5 E-learning system components We developed an e-learning system incorporating various technical components.6 Some aspects (AKN, Dropbox, Skype CS) were developed internally, by project partners. Others, like eGranary and Medical Aid Films (MAF), were included through external collaborations facilitated by global health networks such as Health Information for All (HIFA)7 and the Zambia UK Health Workforce Alliance (ZUKHWA). 20% of THET grant awards can be spent on capital and this enabled purchase of some hard and software. As regards hardware, 4 laptop computers were donated, 3 to Jirapa Midwifery College in Upper West Region, Ghana; one to Chitambo NTS, central Zambia. These are both remote and rural institutions with very limited internet access and their only means of project participation was by laptop with modem or router. Two laptops, purchased in Scotland, were delivered direct to African partners at the e-learning conference in Zambia. Eight desktop computers were also provided, via MachaWorks Zambia, to Kasama, Chitambo and Chipata NTS in Zambia. These were re-constituted

4

http://www.widernet.org/egranary/; http://moodle.org/ http://www.africaknowledge.org/ 6 E-learning system components: • Complementary ICT portals and platforms: o The Africa Knowledge Network (AKN) o eGranary Digital Library (internet-free) and Moodle Learning Management System • Dropbox (project file store) • Portable DVD players and health-related films • 2 email learning networks on MCH and MH • Skype for distance Clinical Supervision (CS) 7 http://hifa2015.org/ 5

machines obtained from Computer Aid International 8 and shipped to Macha for distribution in Zambia. LinkNet delivered the computers by air to the nearest collection points. Routers, modems and, in one case, a hard disk drive (HDD) were also provided to some NTS, for better internet, email and Skype access. In addition, two Articulate e-learning development software licences were provided to key project partners, to enable future development of e-learning tools and worklshops. Finally, a range of e-learning resources, obtained from Teaching Aids at Low Cost (TALC) 9 and/or gleaned from the HIFA networks, were supplied to e-learning conference delegates, some on USB stick.

2.6 Implementation The components of the above system are at different stages of development and implementation. 2.6.1

The Africa Knowledge Network (AKN)

This pilot prototype of The NES Knowledge Network, a sophisticated, ICT platform for healthcare workers in Scotland10, has potential for re-customisation as a ‘one-stopshop’ for African healthcare workers to search, store and share relevant health resources. The AKN internet portal currently offers quick links to relevant data bases (e.g. the Africa Index Medicus); education and training resources (e.g. Medical Aid Films); and global health networks (e.g. HIFA2015). Further funding is needed to complete the development including, for example, consulting on information needs; prioritising the Africa Index Medicus; developing MCH and MH Communities of Practice (CoP); preparing local partners to administer the system; and ultimately creating a sophisticated sister platform to The Knowledge Network, founded on African information needs. Although low bandwidth and high 'airtime' costs can currently hinder internet access in rural Africa [8], it is hoped that, in time, this valuable resource will become readily available in these areas. 2.6.2

eGranary (eG)

Meantime, this on-site digital library provides an internetfree alternative. Although it closely mimics the internet, it is not dependent on it, using a local disk drive instead. It incorporates the Moodle Learning Management System for teaching and learning developments. Although eG has tended to focus on primary and secondary school education, it has potential for health professional training and piloting of donated units at 4 partner NTS, in Zambia, is innovative, with many anticipated benefits: “The most beneficial aspect of the project was eGranary...(it) will offer the students and teachers an invaluable resource.” (Volunteer Nurse Tutor, northern Zambia) 8

http://www.computeraid.org/ http://www.talcuk.org/ 10 http://www.knowledge.scot.nhs.uk 9

“..(eG is) a fantastic knowledge exchange platform because we have a data base within our vicinity and students can access the knowledge, the information they need, before the internet is installed.” (Nurse Tutor, central Zambia) 2.6.3

Skype15

Skype has been useful throughout the project, facilitating meetings, discussions, conference presentations, course applications, synchronous Clinical Supervision (CS) etc.

Dropbox11

Until full implementation of the above platforms, this versatile file store provides an interim solution, with advantages over other similar options.12 Wikis file-sharing systems can be cumbersome [10]. Google Distribution Lists can be similarly limited and, whilst showing promise, the bespoke system initiated by MOH Ghana, needed further development. Dropbox is versatile and, although not without its own challenges (e.g. security; and synchronisation cost to users), it represented the best available way of sharing open source resources. Journal articles, reports, video clips, websites, Powerpoint slides etc., gleaned from global health networks such as HIFA, were roughly catalogued. Partners were invited to join the Dropbox, in order to access these, and 20 have done so. 2.6.4

2.6.5

Project communications: We were lucky to have had access to the e-learning suite at the University of Edinburgh's Medical School which has e-learning links with Malawi.16 Two formal project meetings, were co-ordinated, by Skype, from this venue (Image 1).

Portable DVD players and health-related films:

Medical Aid Films (MAF)13 is piloting films, on the subject of maternal and infant health, at Chitambo NTS in central Zambia. The aim of this 12-month pilot is to demonstrate the impact of these films on reducing maternal and infant mortality in this rural area through (1) improving health worker and patient education; and (2) increasing community awareness and uptake of relevant health services. Films will be screened weekly at the hospital antenatal clinics and monthly at routine rural health clinics, using portable DVD players donated by MAF. These will be transported to clinics in the local ambulance and can be charged on the vehicle battery. Data captured by local health staff, using impact questionnaires and attendance records, will form the basis of the evaluation. The NES Remote and Rural Healthcare Educational Alliance (RRHEAL)14 has, in collaboration with the Scottish Multiprofessional Maternity Development Programme (SMMDP), also launched new teaching tools on Pregnancy Induced Hypertension (PHI) and Post Partum Haemorrhage (PPH), for use in rural healthcare contexts. Their suitability for international settings is being explored, with potential for collaboration with MAF and others.

Image 1. Edinburgh University's e-learning suite: Ghana and Scotland Skype Zambia Technical and other project discussions were also facilitated by Skype enabling, for example, choice of project website, evaluation planning, and even synchronous completion of an online application for a Masters in International Child Heath, by a nurse tutor in rural Zambia, and the UK project coordinator. Apart from a longer delay in uploading the online application form at the Zambian end, both partners were able to see and discuss the form simultaneously. Conference presentations: There were several remote presentations to the Macha e-learning conference. The keynote speaker, from the African Medical and Research Foundation (AMREF), connected by Skype from Kenya as did the project’s education lead and colleagues, from Chipata NTS, eastern Zambia (around 700 miles from Macha). In addition, an e-learning developer from the University of Edinburgh presented on use of Articulate e-learning software17 and demonstrated examples of e-learning tools developed by lecturers at the University of Malawi. The education lead also delivered an e-learning update to the mid-project meeting, by Skype from Zambia, by powerpoint presentation.

11

https://www.dropbox.com/ File-sharing systems considered for the project: • Macha Works Wiki • Google Distribution List • MOH Ghana file-share (developed by project partner/ICT expert at MOH Ghana) • Dropbox 13 http://www.medicalaidfilms.org/ 14 www.rrheal.scot.nhs.uk/ 12

Synchronous Clinical Supervision (CS): One of the most successful uses of Skype, within this project, has been for synchronous clinical supervision (CS) between mental health nurses at Chipata Regional Hospital, eastern Zambia, and a 15

http://www.skype.com/intl/en/home http://malawi.mvm.ed.ac.uk/ 17 http://www.articulate.com/ 16

Mental Health Nurse Consultant in Scotland. This small-scale but innovative pilot, initiated by the project’s education lead, has so far, involved 3 group sessions with 3 mental health nurses in Zambia discussing a range of topics relevant to them.18 Participants, all trained mental health nurses with 4 to 10 years of service, rated the sessions as useful: “I think the patient was helped with the ideas or interventions which were discussed as she has since been discharged home.” (Deputy Charge Nurse, eastern Zambia) 2.6.6 Computer hard and software Implementation of the above developments has been facilitated by computer hard and software purchased for the project. For example, a laptop and router are enabling distribution of eGranary to desktop PCs, at Chitambo NTS, providing a complete digital library for this remote, rural school. Similarly, desktop PCs, a router and a hard disk drive (HDD), provided to the MH unit at Chipata Regional Hospital, are enabling ongoing development of the Skype CS sessions, in collaboration with Ghana and Scotland.

3 Appropriate Technologies? We have made headway on developing an e-learning system for nurse training in Zambia and Ghana. Yet, how appropriate are its component technologies for the rural contexts concerned? Overlapping challenges have included technical, financial, capacity-related, and cultural factors.

barrier….(and) internet connectivity sometimes” (Nurse Tutor, central Zambia) eGranary provides a partial solution, but how suitable is it for nurse training as opposed to primary and secondary education? And how acceptable are such static knowledge resources compared with interactive ones like AKN? Interactive systems like Facebook are certainly popular in rural Africa [13]. However, they are often inaccessible. eGranary offers greater certainty, but even it needs electricity and lack of this could be another technical barrier: “There was one time we had a problem with electricity and that was a barrier to the project.” (Nurse Tutor, central Zambia) Internet problems also affected use of Skype. Internal African links were less stable than inter-continental ones and conference presenters from Naorobi (Kenya), and Chipata (Zambia), could connect only briefly. Fortunately, some presentations could be delivered ‘actually’ by on-site delegates or by later circulation of slides. The Skype clinical supervision (CS) sessions could be similarly affected: “Yes we indeed had challenges, technical, where the line would suddenly be cut off.” (Deputy Charge Nurse ,Mental Health, eastern Zambia) Skype video links were generally prohibitive. Voice links worked better but could also be unpredictable. Instant Skype messaging worked well in one formal project meeting but its use in more complex, sensitive communications, such as CS, merits further investigation. Other formats, such as Webex, might be generally more stable and cost-effective. 3.2 Financial factors

3.1 Technical factors Lack of adequate ICT infrastructure has been a main obstacle, particularly to implementing those aspects of the system which are internet-dependent (AKN, Dropbox, Skype, email etc). Zambia and Ghana are embracing e-health and striving to improve internet access [11,12], distribution and uptake remains patchy. Low bandwidth is a major drawback [8]. All our partner NTS in Zambia and Ghana had at least some computers e.g. small computer labs with around 8-10 desktops. These could sometimes serve several hundred students and, in most cases, internet access was limited: “The major barrier is the internet….Without it we cannot participate.” (Principal, Midwifery College, North West Ghana) “The main barriers were, basically, the materials….for internet we need a lot of computers. That was a

The high internet costs typical of low and medium income countries (LIMIC) [8] were reflected in partner feedback: “Internet (access) is very, very expensive.. that is a barrier” (Nurse Tutor, central Zambia). ‘Airtime’ and mobile phone ‘top-ups’ are expensive. This may have affected uptake and utilisation of Dropbox files, and it is not yet clear to what extent these global health resources have been utilised by members. A main drawback of Dropbox is that, with every addition to the file-store, the system synchronises, transferring airtime costs to users. Accessing it from the website rather desktop is a partial solution. However, although the project donated a certain amount of ‘airtime’, this is not sustainable and it seems that, until such technicalities are resolved, there is no ideal knowledge-sharing system available to the project. 3.3 Capacity factors

18

Synchronous (Skype) CS: Topics discussed • Patient conditions and sharing ideas about how best the patient could be assisted in getting better • Alcohol and drug dependency issues • Nursing care for individuals who live independently with some psychosis

E-learning technologies could, theoretically, help to free up tutor time. In reality, however, implementing innovations takes time and effort and heavy staff workloads could help to explain low uptake of aspects such as the e-learning networks and Skype CS. For example, an MH nurse identified “shortage of manpower” as a main obstacle to participation in

the CS: “You are on duty alone and had to attend.” (Nursing Sister, Psychiatry, eastern Zambia) 3.4 Cultural factors Despite these practical aspects, the most crucial tests of technical appropriateness may be cultural [14]. To what extent did the technologies meet African expectations? Who demanded them and did they fulfil local needs? What, anyway, constitutes ‘evidence-based’ information in rural Africa? Is western ‘evidence’ always best? Does it take account of Africa’s own innovative knowledge contributions and potential for informing higher income countries (HIC) about, for example, ‘doing more with less’ [7]? These questions need answers. Ubuntu African culture prioritises relationship and reciprocity. Consultation precedes decisionmaking and everyone has a say. Yet western donors often remain blind to these African values, prioritising actions and commodities (things) instead [7]. Funded projects rarely allow adequate time for dialogue. Recipients may collude for cultural or pragmatic reasons, such as politeness, or access to ‘things’, without actually having full commitment, or capacity to engage. Many external projects fail as a result, or are not sustained. Misunderstandings can arise from, for example, differing perspectives on project remunerations. Deeper dialogue, and recognition of Africa’s unique contributions, could help to resolve these issues and create better understandings. If anything, our project’s main achievement has been in building relationships: “We’ve created a link and friendship… set a platform for knowledge exchange… so whatever project we may have in the future….we will just build on that foundation.” (Nurse Tutor, central Zambia)

4. Lessons learned We used a range of ICT to build an e-learning system for nurse training in Zambia and Ghana. Components are at different stages of development and implementation. Early evaluation is promising. However, although technical challenges are a major factor in uptake and utilisation of the system, issues of workforce capacity and culture are equal determinants. Further dialogue in needed to build crosscultural bridges and confirm the appropriateness of the technologies for the contexts concerned. On this, we have only just begun and the sustainability of our mutual endeavours depends on it.

Acknowledgements Sincere thanks to: The Tropical Health Education Trust (THET) for the opportunities which this grant award has afforded; NHS Education for Scotland (NES) for hosting and managing the grant; NES Knowledge Services Group (KSG) for developing the AKN; NES Remote and Rural Healthcare Educational Alliance (RRHEAL) for advice and support and, in collaboration with Scottish Multiprofessional Maternity Development Programme (SMMDP), DVD resources; the University of Edinburgh for use of facilities and e-learning development advice; Dr. Craig M. Wilson, Director, the

University of Alabama at Birmingham Sparkman Center for Global Health, for donation of eGranary units; Medical Aid Films for collaboration on piloting films; Dr. Neville Sutle, Chair, Penicuik for Africa, for steering group guidance and editorial assistance; and to everyone else who contributed.

References [1] Government of Zambia Ministry of Health. Ministry of Health Annual Training and Development Plan 2008. MOH, Lusaka, Zambia, (2008). [2] A. Tjoa, M. Kapihya, M. Libetwa, J. Lee, C. Pattinson, E. McCarthy1,K. Schroder. “Doubling the number of health graduates in Zambia: estimating feasibility and costs”, Human Resources for Health, 8, http://www.human-resourceshealth.com/content/8/1/22, (2010). [3] World Health Organisation. “Country Case Study, Ghana: Implementing a National Human Resources for Health Plan.” Geneva, Switzerland (2008). [4] J.D. Sachs. “From Millennium Development Goals to sustainable development”, The Lancet. 379, pp 2206 2211, (2012). [5] J. Schurgers, G. Van Stam, S. Banda, M. Labib. “Opportunities and challenges of E-learning in Zambia: Experiences and Reflections”, Medical Journal of Zambia, 36 (3), 119-124, 2009. [6] Accenture (for AMREF). “Working Together to Lunch an Unprecedented E-learning Initiative to a Address a Critical Nursing Shortage in Kenya. New York, USA, (2007). [7] K. Sheneberger K., G. van Stam. G. “Relatio: An Examination of the Relational Dimension of Resource Allocation”, Economics and Finance Review, 1 (4), pp 26 – 33, (2011). [8] ICWE. The e-learning Africa 2012 Report. ICWE. 21012 [9]MachaWorks. “Latest news Mukinge”, http://wiki.machaworks.org/Communities/Mukinge/Latest_ne ws_Mukinge, (2011). [10] C. Wei, B. Maust, J. Barrick, E. Cuddihy, J.H. Spyridakis. “Wikis for supporting distributed collaborative writing”, Tools and Technology, http://depts.washington.edu/ibuxl/docs/STC_Wiki_2005_STC _Attribution.pdf (2005). [11] Ghana Ministry of Health. E-health Strategy, MOH, Accra, (2010). [12] D.L. Mulozi. “Rural Access: Options and Challenges for Connectivity and Energy in Zambia,” IICD, The Hague, (2008). [13] D.L. Johnson., Belding, E. M., & Van Stam, G. “Network traffic locality in a rural African village”, Information and Communication Technologies for Development (ICTD) (Conference proceedings), (2012). [14] G. Van Stam. “Information and Knowledge Transfer in the rural community of Macha, Zambia,” The Journal of Community Informatics, 2012 (In press).