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Background. In KwaZulu-Natal (KZ-N), South Africa, recent reports have indicated that spontaneous use of smartphones has occurred, providing access to specialist dermatological care to remote areas. This informal use has raised a number of practical, legal, regulatory, and ethical concerns. Aim. To assess the nature and content of WhatsApp messages sent to dermatologists, to determine the referring doctors' reasons for, and satisfaction with, their interactions, as well as their knowledge of legal, regulatory, and ethical requirements. Methods. A retrospective study of WhatsApp messages between referring doctors and dermatologists, as well as a cross-sectional survey of doctors working at district hospitals in KZ-N who used IM for teledermatology. Results. Use of IM (primarily WhatsApp) for teledermatology was almost universal, but often not considered 'telemedicine'. Few referring doctors were aware of South Africa's ethical guidelines and their requirements, and few of those who did followed them, e.g., the stipulated and onerous consent process and existing privacy and security legislations. No secure methods for record keeping or data storage of WhatsApp content were used. A desire to formalize the service existed. Conclusions. Based upon these findings, it was proposed that a number of described steps be followed in order to formalize the use of IM for teledermatology.

Background: While e-health readiness assessment is vital to the successful implementation of e-health innovations, there is little published guidance (i.e. e-health readiness assessment frameworks (eHRAFs)) for institutions and countries. Objective: To develop an evidence-based and locally relevant eHRAF for Uganda. Method: A list of possible e-health readiness domains and constructs was developed through a structured review of the e-health literature. This list was first refined using author experience, insight and reflection. Based on this refined list, an eHRAF questionnaire was developed, which was initially pilot tested for face and content validity. Thereafter, it was distributed to 13 purposively selected study participants who were Ugandan e-health experts from the fields of health, information and communications technology (ICT) and academia. The questionnaire was discussed in a focus group setting for consensus input, where study participants confirmed, rejected or revised proposed domains and constructs suitable to guide e-health readiness assessment at either the national or site-specific level within Uganda. Results: Of 148 identified literature resources, 13 met inclusion criteria. A subjective review highlighted 11 frequently used e-health domains. Further reflection reduced these to nine domains, which were shared with study participants by means of the questionnaire. Based upon prior use of, and familiarity with, a management tool (PESTEL), participants' consensus on factors essential for readiness assessment in Uganda was aligned with PESTEL's six domains: political, economic, sociocultural, technological, environmental, and legal and regulatory. The participants considered engagement, and core and societal readiness as optional domains. Based on this input, the authors developed a proposed eHRAF suitable for Uganda, comprised of domains, sub-domains and constructs. Conclusion: The eHRAF developed in this research is an evidence-based framework (literature and cross-sectoral expert opinion) and consists of primary domains, sub-domains and constructs suitable for assessing e-health readiness in Uganda, either nationally or locally, prior to implementation of any e-health system. The process and principles may have utility in other countries. Implications: A national, culturally relevant, context-specific Ugandan eHRAF could facilitate efficient and effective planning and implementation of new e-health programmes across the country and assist policymakers and legislators to develop consistent and reliable guidelines and regulations.

Background: There are few telemedicine projects in Africa that have reached scale. One of the reasons proposed for this has been failure to assess health provider readiness for telemedicine prior to implementation. Objective: To assess health provider readiness for implementation and integration of telemedicine services at three levels of Uganda's health facilities, namely, a national referral hospital (NRH), regional referral hospitals (RRHs) and level 4 health centres (HC-IVs) and to investigate factors associated with readiness for telemedicine. Method: A cross-sectional descriptive study was conducted at public healthcare facilities in Uganda. One RRH and HC-IV was identified from each of the Western, Eastern and Northern regions using a multistage random sampling technique. Mulago Hospital, which doubles as an RRH and HC-IV in the central region, was purposively identified for the study. After validation, a questionnaire was distributed for self-administration to senior administrators and doctors selected at the NRH, RRHs and HC-IVs. Data were analysed using bivariate associations between the outcome and the potential independent variables. Results: In total, 114 healthcare workers completed the questionnaire. Of the respondents, 24 (21%) were from HC-IVs, 44 (39%) were from RRHs, and 46 (40%) from NRH. Doctors made up 45.8% (11) of respondents at HC-IVs, 59% (26) at RRHs, and 30.4% (14) at NRH. Administrators across all health facility levels were more likely to integrate telemedicine into the healthcare system than doctors (odd ratio = 1.39 [95% confidence interval = 0.38–4.95]). A significant association existed between the state of readiness and type of health facility, p < 0.001. The NRH and RRHs are more likely to integrate telemedicine into their systems than the HC-IVs. Among the factors investigated (job title, health facility, technology type, reason for referral and frequency of electronic communication), the level of health facility and title or role of healthcare worker were found to have a significant statistical association with being ready to integrate telemedicine into the healthcare system. Conclusion: Health provider readiness to integrate telemedicine services varies at the different levels of the health facility and job title or role. However, referral hospitals and administrators were more likely to integrate telemedicine than HC-IVs and doctors, respectively. While this study shows physicians and administrators are ready, other sectors (nurses, allied healthcare workers, public) will also need to be assessed.

Behavioral contracting was used with moderate success as a primary intervention strategy in an urban clinic-based health promotion program designed to reduce serum cholesterol. Of the 223 adults screened, 144 had high serum cholesterol. One hundred and eighteen attended an interpretation/education session, and 51 participants agreed to sign a behavioral contract. Among those who signed contracts, adherence to American Heart Association dietary guidelines was significantly related to serum cholesterol changes. Eleven of the 46 adults who returned for the six-month clinical assessment reduced their cholesterol levels to recommended levels.