JOURNAL OF THE INTERNATIONAL SOCIETY FOR TELEMEDICINE AND EHEALTH
TELENURSING - A POTENTIAL RESOURCE IN THE EHEALTH AGENDA OF INDIA Suman Bala Sharma MBBS1
1National Institute of Nursing Education, Postgraduate Institute of Medical Education & Research, Chandigarh, India
Abstract
In spite of wide-ranging successes that have im- proved population health, the call of ‘health for all’
across the globe remains significant. In India, mak- ing provision for basic healthcare to all people is a difficult task because of its large and diverse geo- graphical terrain, and huge ethnically and cultur- ally diverse population. Telenursing could provide better access to healthcare in communities and en- sure a more effective, comprehensive and accept- able relationship of trust within communities. The focus of this paper is on availability and utilization of healthcare service types and health human re- sources, and factors influencing healthcare seeking behaviour in marginalized communities, and to use these findings to discuss the potential of integrating telenursing into planning as a stimulus for inter- professional and system-wide change. Methods:
The availability and utilization of healthcare ser- vices through available health systems were ex- plored in urban, rural, slum, and rehabilitated communities through a cross-sectional survey in the Union Territory of Chandigarh, India. Primary data were collected through structured interviews, observation, checklists, and periodic visits, includ- ing reasons for preference of a particular care sys- tem by consumers and factors affecting their health seeking behaviour. Results and Conclusions: All health systems studied had a limited scope of ser- vices. This lack of a suitable range of health ser- vices led consumers to seek traditional (unscien- tific) care for meeting their health needs. Telenurs- ing could stem this trend by improving clinical out- comes for chronic diseases, and thereby safeguard the interests of consumers, reduce costs associated with long-term care or delayed institutionalization, and help prevent the global threat of non-treatable hospital acquired infections.
Keywords: eHealth; telehealth; telenursing; develop- ing countries; telecommunication.
Introduction
India covers 2.4% of the Earth’s surface and holds 16% of its population. Quality health-care is inacces- sible throughout much of the country, despite the pres- ence of a highly skilled and qualified medical work- force.1 Other healthcare providers also exist, including untrained providers of medical aid, herbalists, and magico-religious practitioners.2,3 None the less, the healthcare sector in India has witnessed a paradigm shift over the last few years, with a change from unor- ganized to organized structures provided by different health organisations.
Within this context, it is the individual and com- bined mix of these health services, and the relationship between the organisations, that impacts the health and well-being of patients, and collectively describes the healthcare ‘systems’ available.4 Four health service systems have been described: owner based, public, charity, or private for profit, each of which are present in India.5 Different patterns of population settlement call for different patterns of healthcare in terms of preventive, promotive, and curative care.6 The basic networked organization of health services (“basic health services”) should aim at providing primary healthcare to all inhabitants of a place, and extensive health systems have been developed and implemented to handle the needs of different populations.7,8
As India’s international status grows, it still faces the challenge of meeting the healthcare needs of its growing and diverse population. Though there are a variety of healthcare agencies belonging to the various healthcare systems, there is inadequate funding to deliver healthcare services, and a perception that each healthcare facility provides only a limited scope of health services. Public health institutions are the only hope for underprivileged people in most developing countries.9 Yet the majority of healthcare agencies are in the private sector,10 and are unable to provide ser- vices to the entire population. Anganwadi centres pro- vide basic healthcare as part of the public healthcare system, and the anganwadi worker receives four
months training in health, nutrition, and child care.
Most maternal and child health services are provided by “dais” (untrained traditional birth attendants).10 These approaches directly address the social realities of today. Nearly two million children under the age of 5-years die every year, the highest number anywhere in the world, highlighting India’s inability to ade- quately deliver healthcare services.11
The health human resource (HHR) shortage re- mains a major factor involved in imbalances of health- care demand and supply. Decisions of how to most effectively use the available resources can have major implications for national health outcomes and fulfil- ment of national health goals.12 A recent study found that auxiliary nurse midwives (ANM) in one rural area served a population of more than 20,000 each (WHO recommendation: 1:5,000),6 the pharmacist attended patients in the absence of a doctor, and all traditional dais were illiterate and mostly untrained.13 Further- more, the state of the infrastructural facilities and nec- essary supplies was woefully inadequate. Compound- ing this, the peoples’ cultural beliefs and perceptions were that the cause and cure of illnesses was linked to supernatural powers, which was one reason that con- sumers sought readily available, unscientific, unsafe, and unregistered health services. This was more com- mon in low socio-economic communities, where edu- cation levels were also lower.
In the face of such realism, eHealth (the use of in- formation and communication technologies (ICT) in health) 14 is perceived as having the potential to im- prove access to healthcare in a cost effective manner, and to allow increased health literacy and personal well-being with great societal impact. Given that nurses are the largest group of healthcare providers, they are key stakeholders.15 Nurses already act as an intermediary between doctor and patient, providing trustworthy healthcare information, and supporting patients to make informed decisions.16 Telenursing (use of ICT for nursing) could extend the reach of nurses, providing healthcare when and where patients need it, even in their homes. There is need to investi- gate the role of telenursing in India with respect to the provision of long term sustainable care at the commu- nity level.
Implementation of a holistic telenursing pro- gramme would require an assessment of the available health systems. The present study hypothesized that the existing health agencies provide limited scope of health services, and that services are not delivered
according to government policies. It explored commu- nity based care in different communities to gain an understanding intended to support debate around tele- nursing as a means to develop more effective health systems.
Methods
Health Service Categories
The type of health services were studied under the categories of preventive, promotive, curative, rehab- ilitative, special services, and other services.
Preventive services included nutrition services, immu- nization services, and health surveillances.
Promotive services included providing health educa- tion material, and providing health education.
Curative services included services related to treat- ment aspects of illnesses e.g., examination, prescrip- tion of medicines, supply of medicines, minor surger- ies (including incision and drainage of wounds, dress- ings etc.).
Rehabilitative services included follow up services subsequent to hospitalization after chronic illnesses, diseases, or surgeries etc..
Special services included physiotherapy, occupational services, de-addiction services, laboratory tests, and indoor facilities.
Other services were referral services either to private or government health agencies or according to the will of the patient.
Study Sample
Study sites were of 4 types: urban, rural, slum, and rehabilitated agglomerations, all located in the Union Territory, Chandigarh. The north-west division of Chandigarh was selected, and one ‘unit’ of each com- munity type was then selected. There were 55 units in terms of sectors in the urban area, 22 units in terms of villages in the rural area, 25 units in terms of colonies of slum dwellers, and 2 units in terms of rehabilitated colonies.
Data were collected during periodic visits to the study areas and associated healthcare agencies. Avail- able healthcare agencies were identified through a physical survey of the study areas, and informal inter- views with caretakers, caregivers, and others. Agency data were collected using observation, and formal and informal interviews.
For consumer input, systematic random sampling was used in the urban, rural and rehabilitated commu- nities. Beginning with a random start, every 20th house (urban and rehabilitated sectors), or every 3rd house (rural sector), was taken as the sample. The slum area was divided into four subareas and these were termed
‘strata’ and all houses in all of those strata were sam- pled, interacting with one person per house.
Data collection continued until 150 surveys were completed for each community type. Data were col- lected from one person per house (whoever was avail- able and could respond to the survey) during home visits. A structured survey and observation (using a checklist) were used. In total 600 people (as consum- ers) were surveyed; i.e., 150 consumers from each study area were taken as the sample for the study (Ta- ble 1).
Research Instruments
A survey and observation checklist were developed for data collection. Insight regarding content of the in- struments was gathered from the literature, theses, the Internet, and consultation with experts from the fields of Public Administration, Nursing, Psychology, and Community Medicine.
Survey tool.
The survey consisted of open ended and multiple choice questions, and was divided into four parts:
Part I. Questions focussed on identification of type and availability of healthcare agencies, and healthcare services of the identified health agencies.
Part II. Questions focussed on utilization of healthcare agencies and healthcare services by consumers. In addition to demographic questions, information was gathered about the nearest agency, its type, its dis- tance, the type of health agency most often used, and reasons for attending the most often used agency.
Part III. This was used to assess the availability of staffing, basic infrastructure, equipment and supplies like physical assessment articles, dressing articles, laboratory facilities, and basic records in formal agen- cies; i.e., government or private healthcare agencies.
Part IV. This was used to assess basic infrastructure, staffing, equipment and basic technology used in healthcare in home or indigenous healthcare agencies.
Parts III and IV had stem statements followed by dichotomous (yes or no) responses (provision for re- marks was also made).
Observation checklist.
The observation checklist addressed the availability of health agencies, their services and basic technology used in healthcare.
Ethical Considerations
Study contributors were free to participate or refuse to participate in the study; verbal consent was obtained from all those who participated. Respondents were assured of confidentiality of collected data.
Results
Health Agencies
Of the 208 health agencies, 25% were in the urban, 13% in the rural, 15% in the slum, and 47% in the rehabilitated community. These 208 health agencies included 14% government health agencies (6 types), and 86% private healthcare agencies (15 types) as seen in (Table 2).
All 30 Government health agencies were registered, while most of the 178 private health agencies (63.5%) were not registered (11, 22% in urban; 16, 73% in rural; 27, 93% in slum; and 59, 76% in rehabilitated communities).
Seventy-seven (77) formal health agencies (i.e., Table 1. Sample distribution in the different
study areas (U – Urban; R – Rural; S – Slum; Re = Rehabilitated).
Category of Sample
Study Sectors
U R S Re Total
Available Healthcare Agencies
Government 3 5 3 19 30
Private 49 22 29 78 178
Total 52 27 32 97 208
Staff Available in Healthcare Agencies
Government 14 20 3 27 64
Private 60 35 29 200 324
Total 74 55 32 227 388
Consumers
Total 150 150 150 150 600
government or private healthcare agencies) were iden- tified (excluding anganwadis and day care crèches).
Four were Government agencies (1 each in urban and rural communities, and 2 in rehabilitated communi- ties). The remaining 73 were private agencies (42 in urban, 7 in rural, 5 in slum, and 19 in rehabilitated communities).
Health human resources
The wide variety of healthcare providers that were present is shown in Table 3. They ranged from well qualified doctors (e.g., allopathy, homeopathy, ay-
urveda, registered medical practitioners) to untrained providers of medical aid (e.g., herbalists, magico- religious practitioners).
Of the 428 healthcare providers in formal health agencies, only 18% were in Government health agen- cies. Greatest availability of healthcare providers was in the urban sectors (44%), with 15% in the rural, 8%
in the slum and 33% of HHR in the rehabilitated sec- tors.
Most of the 83 physicians (80, 96%) were in the private sector, and practiced in urban (50, 62%) or rehabilitated areas (19, 24%). In contrast, of 105 in- digenous health workers 7% were present in urban Table 2. Health agencies available in the study areas (Rehab = Rehabilitated).
Type of agency Urban
n=52 (%)
Rural n=27 (%)
Slum n=32 (%)
Rehab n=97 (%)
Total n=208 (%) Government Health Agencies
Allopathic Dispensary 1 - - 1 2
Ayurvedic Dispensary - - - - -
Homeopathic Dispensary - 1 - - 1
Day Care Crèches 1 1 - 1 3
Anganwadis 1 3 3 16 23
De-addiction Centres - - - 1 1
Totals 3 (5.7) 5 (18.5) 3 (9.4) 19 (19.6) 30 (14.4)
Private Health Agencies
Allopathic Clinics 20 4 1 16 41
Ayurvedic Clinics - 2 3 - 5
Homeopathic Clinics 3 - 1 - 4
Dental Clinics 6 - - 1 7
Gynaecology Clinics 2 - - - 2
Eye Clinics 2 - - - 2
Laboratories 4 1 - 1 6
MTP Centres 2 - - - 2
Nursing Homes / Hospitals 3 - - 1 4
Traditional / Magico-Religious Centres 2 2 4 6 14
Reiki Centres 1 - - 1 2
Traditional Healing Centres 2 5 5 23 35
Meditation Centres 1 - - - 1
Magico-Religious healers 1 4 10 19 34
Traditional Dais - 4 5 10 19
Totals 49 (94.3) 22 (81.5) 29 (90.6) 78 (80.4) 178 (85.6)
Grand Totals 52 (25) 27 (13) 32 (15.4) 97 (46.6) 208
areas, with 14% in rural, 23% in slum, and 56% in the rehabilitated sector.
A high number of doctors were unregistered. A to- tal of 62% were unregistered, and included all indige- nous health providers and ~75% of private practitio- ners in rural, slum, and rehabilitated areas.
Health services
The availability of services is shown in Table 4. None of the government or private sector agencies provided physiotherapy or occupational therapy, and indoor services were provided by only 3 private sector agen- cies in urban areas.
The unorganized slum community lacked govern- ment services, except for anganwadi centres which provided some preventive, promotive, and referral services.
In contrast, the private sector provided curative services in all communities. Referral services were provided by 48% of private agencies, promotive by 17%, laboratory test facilities by 6%, and indoor facili- ties by 3%. None of the private agencies provided rehabilitation, de-addiction services, or home visits.
The data show the Government’s focus is on preven- tive, promotive, and referral services, with 90% of government agencies providing these.
Utilization of Health Services
Government health sector agencies were used by only 8% of consumers as compared to the remainder (92%) who used private sector agencies. In this study, cost was found to be an important factor in affecting the decision regarding choice of healthcare system, espe Table 3. Health Human Resource (HHR) availability by healthcare provider category and by sector. (G – Gov- ernment Agencies; P – Private Agencies; T – Total HHR).
HHR Category
Urban Rural Slum Rehabilitated
G P T G P T G P T G P T
Doctor 1 50 51 1 6 7 - 5 5 1 19 20
Nurse - 1 1 - - - 1 1
ANM 1 - 1 1 - 1 - - - 1 - 1
Pharmacist 1 8 9 1 6 7 - - - 1 2 3
MPHW 1 1 2 3 1 1 2 - - - 4 - 4
Laboratory Technician - 5 5 - 2 2 - - - - 1 1
Dai 2 1 - 1 - - - 1 - 1
Anganwadi Worker 3 1 - 1 3 - 3 3 - 3 16 - 16
Helper 3 42 45 5 14 19 3 1 4 19 7 26
Sweeper 1 42 43 1 5 6 - - - 1 4 5
Driver - 1 1 - - - 1 1 2
Receptionist - 20 20 - - -
Balsewika 4 1 - 1 1 - 1 - - - 1 - 1
Indigenous worker - 7 7 - 15 15 - 24 24 - 59 59
Total 11 178 189 14 49 63 6 30 36 46 94 140
1. Multi-Purpose Health Worker
2. Traditional dais, other than government employees, were included in indigenous workers
3. Female health worker chosen from the community and given 4 months training in health, nutrition and child- care
4. Child care support worker
cially among consumers from slum areas (Table 5). In addition, lack of 24h availability of government health sector agencies was also identified as a reason for non- utilization in all study areas.
Consumers reported that the lack of various facili- ties or services in government agencies affected their choice. Lack of 24h availability and lack of satis- faction predominated (89% and 85%, respectively).
Other factors included lack of personal attention, non-availability of staff, lack of facilities (transport, equipment, laboratory or diagnostic capabilities, medi- cines) and a lack of 24h availability of these agencies.
Further, many consumers (~30%) identified having to take leave to get health services from government agencies as a barrier. Cost was a factor for 46% of consumers, mainly those in slum areas.
Discussion
Developing countries face an imminent and dire public health crisis. The growing need for healthcare has not been matched with a commensurate increase in re- sources. In spite of a host of national health policies in India, the healthcare indices lag significantly behind those of developed countries. In developing countries
like India, there is a great disparity between the avail- ability and utilization of health services in the organ- ised and unorganised sectors.
For example; a study by Nair found that 20.2% of consumers did not utilise the government health sector because of the unfriendly attitude of the hospital staff.17 In another study of Uttar Pradesh, awareness about availability of government services was found to be high (81%), but the utilization of services of the health post was only 58.2%. Rude behaviour of staff was found to be one of the factors responsible for this.18 In the present study 288 (48%) of consumers did not utilize government health sectors because of the rude behaviour of the staff; this percentage was much higher than Nair’s study but marginally less than the Operation Research Group study.18
Healthcare costs also force the underprivileged to, in many cases, do without healthcare; to suffer delayed or incomplete treatment; to pursue self-medication; or to rely on informal - and ineffective - sources of care.
This is a common finding in studies.
When selecting a health agency cost for health ser- vices may not be a concern for those in the high socio- economic sectors of society. But for those in the lower socio-economic sectors of society, who cannot even Table 4. Health services provided by government (G) and private (P) agencies.
Type of Health Service
Urban Rural Slum Rehabilitated Total
G n=3
P n=49
G n=5
P n=22
G n=3
P n=29
G n=19
P n=78
G n=30(%)
P n=178(%)
Curative 1 49 1 22 0 29 1 78 3 (10) 178 (100)
Preventive 2 12 4 2 3 1 18 0 27 (90) 15 (8)
Promotive 2 29 4 0 3 0 18 1 27 (90) 30 (17)
Rehabilitative 1 0 1 0 0 0 2 0 4 (13) 0
Physiotherapy 0 0 0 0 0 0 0 0 0 0
Occupational Ser-
vices 0 0 0 0 0 0 0 0 0 0
De-addiction 0 0 0 0 0 0 1 0 1(3) 0
Laboratory Tests 1 9 1 1 0 0 1 0 3(10) 10 (6)
Indoor facilities 0 6 0 0 0 0 0 0 0 6 (3)
Referrals 3 42 5 12 3 2 19 29 30 (100) 85 (48)
Home Visits 0 0 0 0 0 0 2 0 2 (7) 0
afford essential commodities like food, cost can dis- proportionately affect decisions. Poverty is one reason for needs not being reflected in demand for govern- ment health services. Yet mismatches between what people need and what they want may not be resolved by simply providing more medical facilities and offer- ing servces.19
A recent working paper on healthcare financing re-
forms in India identified out of pocket spending to be four times higher than public spending on healthcare, and indicated that poor public health provision forces consumers to seek private health providers.20 Indeed, the present study showed only 8% of consumers util- ised government sector services.
This is supported by another recent study carried out in two states of North India and the Union Terri- tory, Chandigarh, where it was concluded that im- proved utilization of public health services by poorer segments of the population would be beneficial
through curtailing private sector out of pocket expen- diture.21
The tendency to use private sector health systems may not be due only to the financial status of the pa- tient,17 but also because of dissatisfaction of consumers with the existing healthcare systems.22 The physical proximity of a healthcare agency influences the treat- ment seeking behaviour of consumers, as shown by
Satesh and Gururaj for casualty services.23
Other reasons for non-utilization of government health agencies in Utter Pradesh were location outside of the village (52%) or the periphery (17%), and get- ting water logged during monsoons (15%) which made them inaccessible.17
Each of these findings is similar to those from the present study. Here it was identified that urban con- sumers identified a lack of personal attention, lack of satisfaction, non-cure of ailments, non-availability of equipment, and non-availability of medicine as factors related to their non-utilization of government health Table 5. Reasons for non-utilization of government health facilities by consumers.
Consumers’ Responses Urban n= 150
Rural n=150
Slum n=150
Rehab n=150
Total n=600 (% ‘Yes’)
Non-availability of staff 43 110 10 93 256 (42.7)
Rude behaviour of staff 15 75 98 100 288 (48.0)
Agency farther away 40 66 150 33 289 (48.2)
Non-availability of transport facilities 38 29 - 5 72 (12.0)
Costly 23 - 139 114 276 (46)
More waiting time 78 40 132 78 328 (54.7)
Lack of personal attention 121 78 109 115 423 (70.5)
Lack of satisfaction 135 130 142 104 511 (85.2)
Ailment not treated 128 122 103 50 403 (67.2)
Non-availability of equipment 140 147 - 88 375 (62.5)
Lack of seat arrangements - - - - 0
Must take leave to get health service 10 48 25 95 178 (29.7)
Not available 24 hours a day 150 132 120 130 532 (88.7)
Non-availability of laboratory or diagnostic fa-
cilities 145 150 - 108 403 (67.2)
Non-availability of medicines 139 93 43 112 387 (64.5)
sector services. In the slum and the rehabilitated sites factors like loss of wages (taking leave), distance, lack of transportation, high cost, long waiting times, rude behaviour of staff, and lack of satisfaction were com- mon factors.
Indigenous health providers were also widely ac- cepted and their use was significantly higher in low socio-economic study sectors, i.e., the rehabilitated and the slum sectors, where education levels were also lower. The wide use of these providers in the slum sector may be partially explained by their closer prox- imity.
This study has confirmed that maldistribution of health agencies (and the services they provide), exists between urban, rural, slum, and rehabilitated areas. It has also confirmed the poor utilization of government health sector services (used by only 8% of consumers, compared to the remainder who used private sector services). It has also shown a dramatic maldistribution of physicians between the government and private sectors, and the minimal availability and use of nurses.
This lack of sufficient numbers and types of quali- fied health workers, particularly nurses, in rural and remote areas is of concern. It impedes access to healthcare services, slows progress towards attaining the Millennium Development Goals, and challenges the aspirations of achieving health for all.24
Could the public health system use an alternate means of service delivery, and alter some of these findings?
Telenursing
The Government of India has planned and imple- mented various national level telemedicine projects, and extended telemedicine services to South-Asian and African countries.25 In developed countries tele- nursing applications are available in homes, home care agencies, hospital based telemedicine centres, hospices and rehabilitation centres whereas in India, the poten- tial of telenursing has not been fully investigated. Ap- propriate telenursing solutions will be different to those for developed countries. For example, even with the penetration of mobile technologies (e.g., smart- phones and tablets), it is unlikely those who need care the most (underprivileged, poor) will have access to such technology, therefore interaction will be with health centres and nursing staff, not the public.
But there is evidence that emerging economies with limited resources do find telenursing beneficial,26 in-
cluding India.27 Further, interest and awareness is growing. An international online telenursing survey of 719 nurses from 36 countries recognised the need for telenurses. Nearly 89% believed telenursing should be a part of basic nursing education, and 59% of interna- tional telenurses felt more satisfied with their telenurs- ing position than regular nursing positions.28 Impor- tantly, the type of populations expected to benefit most were those with chronic illness needs, who lived in rural areas or at a distance from services, and who were poor and under-educated.
How might telenursing help? Possible applications must be explored, but include direct and indirect pa- tient care, as well as education. For example:
Homecare. Nurses could utilise technology to monitor and record patient details and findings during home visits, aiding quality and continuity of care. These records could also be GIS tagged to facilitate locating patients in the future.
Telephone Triage. Nurses could be available through a no-charge telephone call to listen and respond to patient concerns. Patients could be provided with guidance, or directed to the nearest health agency for care.
Tele-education (or e-learning). The current short- age of nurses (and other healthcare providers) could be mitigated through ‘train at home’ initia- tives, whereby trainees stay in their home location and receive training, skills, and knowledge equivalent to their urban counterparts through remote e-learning.
Quality of care is indicated by the training, skills, knowledge, attitude, and behaviour of the person- nel.29As these improve, the capacity to treat should increase, thereby reducing the need for consumers to seek unscientific care practices or access expensive private sector systems. Such changes would lead to greater and more effective and efficient use of the public health system, to the benefit of consumer health.
Telenursing is an opportunity for social innovation, but change is not easy. Despite foreseeable benefits, non-receptivity to widespread ‘tele’ adoption may pose the biggest barrier. There is a need to ensure the readiness of providers and consumers alike, and to manage expectations to a modest but effective level.
Harmonizing education and training programmes along with reinforcing and sustaining new practice for modifying primary care behaviour tailored to a coun- try’s needs should be considered a priority agenda.
Research needs to focus on where, when, and how telenursing can improve quality and quantity of care, and how to encourage adoption in both care providers and consumers.
Conclusion
This study was an assessment of the available health system and its utilization in four different sites; urban, rural, slum, and rehabilitated, in the Chandigarh region of India. Major shortcomings have been identified, including a tendency to seek care from other than the public health system. This is partially due to the lack of availability and access to adequately trained provid- ers and public healthcare services. Telenursing could help address some of these issues. However, before comprehensive telenursing can be introduced a variety of steps must be taken. This paper encourages the fol- lowing:
1. Development of a clear national e-health strategy that encompasses telenursing.
2. Investment in the necessary physical infra- structure (e.g., rural connectivity; community- based facilities) and infostructure (e.g., trained
‘tele’nurses).
3. Staged implementation of discrete large-scale telenursing initiatives.
4. Implementation determined by sound evaluation that demonstrates value over time: improved ac- cess, acceptability, efficiency, and effectiveness.
5. Integration of successful telenursing programs and remediation or closure of unsuccessful tele- nursing programs.
...
Conflict of Interest: The author declares no conflict of interest.
Acknowledgements: The author wishes to thank Dr.
Ramanjit Kaur Johal, Professor, in the Department of Public Administration in Panjab University, Chandi- garh, India for her guidance; Dr. Meenu Singh, Profes- sor In-Charge, Department of Telemedicine, PGIMER, Chandigarh, India for encouragement to publish.
Corresponding Author:
Dr. Suman Bala Sharma
National Institute of Nursing Education
Postgraduate Institute of Medical Education and Re- search
Sector-12, Chandigarh (U.T.) India - 160012
E-mail: [email protected]
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