This study has provided an insight into the experiences of e-health use among a variety of health workers from different post-conflict settings. Using Roger’s innovation-decision model as a theoretical framework for an inductive qualitative analysis allowed us to disentangle what happens at each stage of the decision-making process (that is, knowledge, persuasion, decision, implementation and contemplation), thereby making it possible to understand the process of e-health adoption in post-conflict settings. To our knowledge, this is the first study to investigate the perceptions and experiences of health-workers in post-conflict settings in regards to their adoption of e-health. We are aware of the theoretical and methodological limitations of our study (see the ‘Study limitations’ section below), including the danger of generalising from this small-scale qualitative study, however, still some trends emerged.
There was generally a lack of awareness among interviewees on the scope of e-health innovations. The most common understanding of e-health among those interviewed is in line with the definition posed by Kwankam and colleagues which describes e-health in terms of ‘the improvement of health, and the use of ICTs to do so’ . Although a wider range of e-health innovations, such as health informatics  and m-health applications  have been described in low- and middle-income countries, these were not frequently described in this study. Interviewees found it difficult to identify types of e-health other than those they used themselves, with two interviewees stating that they had not heard of the term ‘e-health’ previously. These results indicate that there is a scope for increased awareness of e-health even among current e-health users in post-conflict settings.
The predominance of e-health for communication and educational purposes found in this study appears related to the isolation that health workers in post-conflict studies experience. In addition to being in low-resource environments, participants in this study reported that the need and desire to interact with other health professionals as a driving motivation behind their adoption of e-health. It is difficult to retain health workers in areas where they are likely to feel professionally isolated and have limited access to information resources and training opportunities. These challenges to the distribution and retention of human resources for health in poor and fragile settings are well-documented [36–41]. Our study indicates that health-workers in post-conflict settings are responding to the challenge of isolation by adopting e-health innovations that connect them to an international network of health workers.
This study purposively selected health workers with some experience with e-health. Since e-health is still in its infancy in post-conflict settings, our interviewees are more likely ‘early’ than ‘late’ innovation adopters . Thus, the awareness gap is expected to be even larger among health workers not (yet) using e-health innovations. A cross-sectional survey among 186 health professionals working at a teaching hospital in Pakistan also found limited knowledge and awareness of e-health in their sample . This would suggest that more efforts are needed to diffuse e-health innovations among intended users in post-conflict contexts.
Findings from this study indicate that international partners play an important role in diffusion of e-health innovations into post-conflict states. Often these partners were from the global north (for example, UK and US). The risk here is that the global north drives e-health innovation exposure, which is likely to be less culturally appropriate and sustainable than if driven by the south [43, 44]. For this reason we believe that south-south links at individual, institutional and national levels need more promotion while the north takes a more facilitating role. Even when e-health innovations are introduced in more similar environments, local needs and barriers need to be considered.
It is imperative that e-heath innovations are compatible with local needs of intended adopters [9, 45, 46]. Rogers suggests an ‘innovation can lead to needs, as well as vice versa’ . A cross-sectional study cannot determine the direction of this relationship between innovations and needs. However, our results indicate the importance of perceived needs in decision-making on e-health use, particularly for the persuasion and decision stages. For example, a lack of up-to-date information in current working and learning environments was one of the main reasons for interviewees to consult resources available elsewhere using e-health. This information demand might be a starting point for actors involved in diffusion of e-health, bearing in mind that perceived needs are not always in line with actual needs, nor with what experts think individuals or institutions might need , and neither are they fixed .
In our study the information need was particularly severe in the area of mental health and amongst rural health workers. As a result of traumatic exposure to armed conflict and daily stressors , post-conflict populations often experience poor mental health outcomes. In addition, a lack of medical expertise in-country and stigma surrounding mental health made this an area of particular need for health workers in this study. Tele-psychiatry has seen success in improving access to mental health in rural and remote communities in high-income countries [49, 50], even for treatment of post-traumatic stress disorder such as: , and in creating a platform for transcultural psychiatry between UK and Somali medical students . However, more research is needed to determine the feasibility and effects of e-health interventions in post-conflict populations . Based on perceived needs within our sample, future e-health initiatives and evaluations in post-conflict settings might be most beneficial for education and clinical support of mental health professionals and rural health workers, which might contribute to reducing health inequities in populations they serve.
Besides perceived needs, future e-health initiatives also need to consider what is perceived as ‘new’ among intended users. In this study, newness generally involved quite basic use of e-health such as for sending emails or Internet searches. This suggests that innovations in e-health should be considered at a local level. In other words ‘what is new locally’?
Health workers in post-conflict settings would already benefit from more sustained Internet access. Current barriers need to be addressed by making the Internet more reliable, affordable and faster. Post-conflict settings are generally resource constrained, therefore increased cooperation with and investments from private and commercial sectors, including social entrepreneurs , will be needed to advance e-health infrastructure. As the Global Health Workforce Alliance noted: technological innovations to strengthen a health workforce ‘rely upon an infrastructure with hardware, software, and human component’ .
This study used purposive sampling and therefore has a selection bias towards those known to be e-health users. Future studies might benefit from a comparative design (e-health users vs. non-users) to explore differences and similarities between these groups. Due to project constraints there was bias towards post-conflict settings where contacts were readily available and towards participants that spoke English. Future research might want to explore e-health use in other post-conflict settings and among health workers who are less or have no proficiency in English. Project constraints allowed for interviews to be conducted by telephone but not face-to-face, meaning participants may have been more likely to give socially desirable responses . Snowball sampling possibly made our sample less heterogeneous (that is, interviewees tended to recommend candidates with experience with similar e-health innovations), although the final sample contained a good mixture (that is, male and female health workers from various health cadres and stages in their careers from four different post-conflict countries). Despite its shortcomings, this study adds to the knowledge on health workers using e-health innovations in challenging settings and provides direction for future research.