Background: The established aim of the Saudi Health Electronic Surveillance Network (HESN) is to support the prevention and control of different health events, and to facilitate the delivery of other public health programs. This study aims to evaluate the perceptions of active HESN users regarding its general performance through five major components: practicability, design, data and communication, technical support, and general impression. Methods: A cross-sectional study was conducted in 2016 using a sample of active HESN users. Out of 1535 active users, 700 were randomly selected. A predesigned electronic questionnaire was sent to each participant via email which was completed by 485 participants. Different composite scores were calculated and compared to the sociodemographic and other technical variables. Results: The mean age of the participants was 36.92 ± 9.12 (24–65 years), and 57.8% of the sample were male. Riyadh and the KSA’s eastern province represented the highest two regions of participation, at (18.4%) and (14.2%) participants, respectively. About 70.8% were generally satisfied with HESN, while 86.6%% believed that it is better than the traditional paper-work system. Participants who used to work more frequently expressed more level of satisfaction compared to those with minimal use per week or month (P ≤ 0.001). Internet speed displayed a significant association with the general level of satisfaction with HESN (P < 0.001). Additionally, users who accessed HESN with the Google Chrome browser displayed higher levels of satisfaction when compared to users who relied on other browsers (P = 0.003). Conclusion: Presently, the level of user satisfaction with HESN is reasonable. However, to achieve optimal outcomes for HESN usage, improvements should be considered. 1 Introduction Over the last two decades, this international concern In recent years, countries around the world have started has primarily arisen in response to the increasing preva- to recognize the essential role played by effective elec- lence of emerging and re-emerging diseases. Many of tronic health surveillance and reporting systems for pub- these conditions have the potential to cross borders rap- lic health. Hence, practitioners, policymakers, and other idly, with prominent examples including severe acute re- relevant stakeholders are becoming fully aware of the ur- spiratory syndrome (SARS), the Ebola virus disease gent need for the implementation of such systems . (EVD), Middle East respiratory syndrome (MERS), Chol- era, and the Zika virus disease [2–5]. In addition to the fact that the traditional surveillance systems are out-of-date, fragmented, non-standardized, * Correspondence: firstname.lastname@example.org and ineffectively integrated into epidemiologic functions, Field Epidemiology Training Program, Ministry of Health, Riyadh, Saudi the limited resources and infrastructures of many coun- Arabia P.O. Box 543, P.C 329 Rustaq, South Batinah, Oman tries have meant that improvements to novel electronic Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Almayahi et al. Journal of the Egyptian Public Health Association (2021) 96:17 Page 2 of 10 health surveillance systems are slow, and the literature is user chooses one of the six components to use; investi- still deficient [1, 6]. However, such systems are antici- gation, outbreak, notification, immunization, work man- pated to become one of the major and necessary compo- agement, and reporting. nents of public health in the near future. The Health Electronic Surveillance Network (HESN) 2.1 The flow of information of HESN was introduced into the Kingdom of Saudi Arabia’s The governmental, nongovernmental, and military (KSA) public health services to fortify its ability to cope health care facilities, either primary, secondary, or ter- with ongoing global health challenges, and alongside tiary are obliged at this stage to use HESN to notify for this, to support national health security. It has achieved the communicable diseases, and also to complete the this by aiding in monitoring disease trends over ex- data for immunization. The data are validated by the tended periods of time, generating hypotheses, and de- health sector (the preventive medicine office serving a tecting clusters and outbreaks in a timely manner. In specified catchment area within each region), and then addition, HESN is expected to aid the country’s public the public health department on the respective region, health services in combating biological terrorism, health before it reaches to the headquarter in the MOH as threats, and facilitating other health programs (e.g., demonstrated in Fig. 1. Public health officers working in immunization and general health research). the health sectors and public health departments are also HESN relies on strong and immediate communica- able to modify, add, or delete the data especially during tions among frontline users in designated health facil- the cases investigation of the communicable disease. The ities, headquarters specialists and health officers, and the staff working as the end users in the health care facilities central leadership in the Riyadh-based Ministry of could have medical or paramedical background, and Health (MOH) under the Deputy Ministry for Public could also be qualified as public health professionals; Health. As an initial stage, HESN has been implemented however, those working in the health sector and public in the KSA to manage individual cases, outbreaks, im- health department are mainly public health oriented. munizations, and vaccine inventories. Many useful tools HESN implementation was started in selected health are integrated into HESN to assist health professionals directorates (Makkah, Qunfudha, Taif, and Jeddah) dur- in monitoring, managing, and reporting on public health ing the second half of the year 2012, whereas Al-Ahsa issues . and Najran were included in the next year. However, the At the global level, HESN continues to evolve and re- entire rollout for the remaining 14 health directorates main innovative. Noteworthily, relatively few countries was finished on June 2014. Each implementation stage have yet to make this significant and rewarding step . was preceded by conducting a full infrastructure assess- Establishing a solid and successful electronic health sys- ment and enhancement specifically for the availability of tem does not simply mean adding or upgrading to a new computers and internet connection, and also by con- technical function; rather, it is preceded by a long series ducting a full customized training to the staff. Selected of preparatory stages . This involves the availability of staff from each health directorate were trained by ex- sufficient and advanced infrastructure, trained human perts of HESN from the central unit in MOH, as well as capital in the field of public health, the ability to devise by staff from other regions who were qualified as sensitive and specific algorithms, and the ability to se- trainers. Each training course took about 1 month, and cure sustainable resources and funds [9, 10]. This study was performed in three stages. First stage was to train aims to evaluate the perceptions of active users of HESN the staff about all components and the full usage of in regards to its general performance through five major HESN, whereas the second stage was to let the trainees components: practicability, design, data and communica- use HESN practically under the supervision. The quali- tion, technical support and general impression. fied trainees from each health directorate were then pro- viding the training to the end users from all health 2 Methods facilities in the same region as a third stage. This newly developed surveillance system was initially developed by the International Business Machines Cor- 2.2 Research setting poration (IBM) and used in Canada for the first time A list of all HESN users was obtained from the Deputy under the name of “Panorama.” Saudi Arabia was Ministry for Public Health’s HESN unit. Users were from granted the license to operate it under the name of different areas in the health sector, both governmental HESN in 2012 [11, 12]. and private. These included the MOH’s HESN unit, des- HESN is a web-based surveillance system connected to ignated health directorates, and hospitals and primary all health facilities, where every user has login data. The health care centres (PHCCs) around the KSA. Addition- user is given an authority level based on his or her pos- ally, the study took place between June 2016 and July ition. It has bilingual interfaces; Arabic and English. The 2016. Almayahi et al. Journal of the Egyptian Public Health Association (2021) 96:17 Page 3 of 10 Fig. 1 Flowchart for information through the Health Electronic Surveillance Network (HESN) with regards to the authority level and the feedback process 2.3 Target population Atlanta, GA, USA). A list of all users with valid emails Target population were all registered HESN users affili- (n = 1535) was generated, and in turn, a simple random ated to governmental or nongovernmental institutions sampling technique was applied to identify the required (N = 11,324). number. Upon the trial done to ensure good understanding of 2.4 Study population the questionnaires, and also to estimate the response, we The study population was comprised of all HESN users found errors in some of the emails. Therefore, to ensure with valid email contacts, and who had previously used the required response rate and in order to compensate their HESN account at least once for either for the invalid emails and incomplete answers, the deci- immunization or investigation purposes. The total num- sion was made to distribute the questionnaire to 700 ber of users who met the inclusion criteria were 1535 randomly selected HESN users. (14%). This means that there was a significant number of users whose emails were missing, in addition to others 2.7 Data collection where the role was only limited to supervision and ana- The predesigned questionnaire was developed by the re- lysis, and not actively entering the data as the case of the searcher and reviewed by the central unit department in end users who are the most important keys of HESN. MOH, after careful understanding to all the different Other people may have changed their duties and works, components of HESN including the type of information and thus their accounts were dormant. needed to be entered and analyzed, the way of input and output of the data, and the different setup required for 2.5 Design successful use. The questionnaire was created using the The research design utilized for this study was a cross- “Survey Monkey” website, and in turn, emailed to all sectional design. participants. The questionnaire included two categories: firstly, a 2.6 Sample size category collecting data pertaining to the participants’ Assuming 50% satisfaction with HESN functionality and demographic characteristics, technical knowledge, and performance at 95% confidence interval, the required surveillance experiences. Secondly, a category collecting sample size was 384, using Epi Info™ version 7 (CDC, data pertaining to the users’ perceptions regarding the Almayahi et al. Journal of the Egyptian Public Health Association (2021) 96:17 Page 4 of 10 overall use and design of HESN through 40 questions, present categorical data. Normality assumption was eval- which were used to generate five different composite uated with Kolmogorov-Smirnov test. Mann-Whitney U scores. Each composite score was computed for each test and Kruskal-Wallis test were used, as appropriate, participant by taking the mean of a number of questions. to compare groups in terms of different composite The mean and standard deviation (SD) were then calcu- scores, while the P value was considered statistically sig- lated for each composite score independently. nificant if < 0.05 Scores of 11 questions on performance and daily prac- tice were used to obtain a composite practicability score 2.9 Ethical considerations and similarly, a composite score for perceptions to This research was revised by the Saudi Field Epidemi- HESN design was calculated by using 5 questions (user ology Training Program (FETP; Centers for Disease interface, and data output). The third, fourth, and fifth Control and Prevention [CDC]; Atlanta, Georgia USA) composite scores on communication and completeness scientific board, as was accepted technically and ethic- of data, technical support, and general impression were ally. In order to contribute to the research by completing calculated using 11 (communications/updates, laboratory the questionnaire, all participants were asked to information, accuracy of data, and search), 7 (technical complete a written consent form. In addition, data were support and logistic support), and 6 questions (impres- collected anonymously and used only for the purposes sion and satisfaction), respectively. of the study. Finally, data confidentiality was assured Specifically, a 5-point Likert scale was used to gauge throughout the whole study. participants’ opinions which utilized a spectrum of re- sponses as follows: “Strongly Disagree,”“Disagree,” 3 Results “Neutral,”“Agree,” and “Strongly Agree.” They were Table 1 describes the demographic characteristics of the coded as 1, 2, 3, 4, and 5 respectively. study participants in relation to the composites scores of All five sections of the questionnaire obtained a Cron- practicability, design, data and communication, technical bach’s alpha (α) above the acceptable standard value of support, and general impression. The mean and SD for 0.7; practicability 0.899, design 0.844, data completeness the age variable was 36.92 ± 9.12, with a range from 24 to and communication 0.91, technical support 0.774, and 65 years. Approximately, two-thirds of the participants general impression 0.836. The total Cronbach’s alpha co- (68%) were aged 30–50 years, and males represented efficient for internal consistency was 0.961. higher proportion than females (57.3%). The participants The questionnaire was emailed to 700 participants on 2 were mainly Saudis (43.9%), and the remainder were di- June 2016, and subsequent reminders were sent periodic- vided into two groups: firstly, Arabs (27.2%); and secondly, ally. The questionnaire was designed bilingually using non-Arabs (28.9%). Almost 77% of participants had a Arabic and English, and the choice as to which language graduate degree, compared to 23% with post graduate de- to use in completing the questionnaire was left to each gree such as master, PhD, or residency programs. participant’s preferences. The questionnaire was first de- Riyadh and the KSA’s eastern province represented the veloped in English by reviewing available surveys and ex- two highest regions of participation (18.4%) and (14.2%) periences in the literature [1, 12], but it was tailored for participants, respectively. Regarding the work specialty, the HESN setting, and the study objectives. For the trans- approximately half of the participants were working in lation into Arabic, a native Arabic speaker and Arabic bi- public health activities (49.1%), while participants in- lingual expert in public health and epidemiology carried volved in clinical works comprised about (29.1%). Al- out the translation from English into Arabic. The ques- most two-thirds of participants (66.6%) had already tionnaire’s content was then reviewed by two public health experienced working in the public health surveillance experts with HESN experience and face-validated by pilot- system, whereas only (23.7%) had previously worked ing it among 10 public health professionals before the with electronic medical records. study for doubtful or confusing items. The total number Notably, the estimated composite scores of HESN users of responses was 607 (response rate = 87%), and since a were significantly associated with gender, nationality, edu- form was only considered complete if the participant val- cational level, and use frequency. The level of satisfaction idly answered at least 90% of the questions, the completed among female users were greater than male users regard- forms amounted to 80% (n =485). ing most of studied aspects particularly for the composite design score (P = 0.002), and likewise among Non-Arab 2.8 Statistical analysis users who were more satisfied than both Arabs and Saudis IBM SPSS 21.0 (IBM, Armonk, NY, USA) was used to (P = 0.001). Surprisingly, users with post graduate degree organize, tabulate, and statistically analyze the data. Nu- showed less agreement to the different aspects of HESN merical data were presented as means and standard de- functionality in comparison to those with graduate degree viations, whereas numbers and percentages were used to and likewise for the general impression composite score Almayahi et al. Journal of the Egyptian Public Health Association (2021) 96:17 Page 5 of 10 Table 1 Characteristics of the study participants in relation to the composites scores of practicability, design, data and communication, technical support, and general impression, KSA, 2016 Socio- n Composite Composite Composite data and Composite technical Composite demographic practicability score design score communication score support scale impression scale Age < 30 107 3.71 ± 0.69 3.74 ± 0.77 3.63 ± 0.67 3.34 ± 0.74 4.00 ± 0.69 30–50 330 3.62 ± 0.69 3.58 ± 0.74 3.55 ± 0.69 3.28 ± 0.72 3.96 ± 0.71 > 50 48 3.65 ± 0.60 3.34 ± 0.74 3.60 ± 0.54 3.25 ± 0.57 3.98 ± 0.65 p value† 0.792 0.045* 0.909 0.642 0.726 Gender Male 278 3.57 ± 0.73 3.54 ± 0.78 3.50 ± 0.71 3.23 ± 0.74 3.95 ± 0.73 Female 207 3.74 ± 0.61 3.76 ± 0.65 3.68 ± 0.60 3.37 ± 0.66 3.99 ± 0.66 p value! 0.031* 0.002* 0.003* 0.045* 0.173 Nationality Saudi 213 3.56 ± 0.75 3.50 ± 0.84 3.49 ± 0.75 3.11 ± 0.77 3.93 ± 0.79 Arab 132 3.60 ± 0.60 3.63 ± 0.65 3.53 ± 0.60 3.34 ± 0.63 4.00 ± 0.65 Non-Arab 140 3.81 ± 0.62 3.84 ± 0.56 3.74 ± 0.57 3.52 ± 0.62 4.00 ± 0.59 p value† 0.006* 0.001* < 0.001* < 0.001* 0.587 Education Graduate degree 372 3.68 ± 0.70 3.66 ± 0.75 3.62 ± 0.68 3.29 ± 0.73 3.99 ± 0.71 Post graduate 113 3.51 ± 0.63 3.53 ± 0.67 3.44 ± 0.60 3.29 ± 0.67 3.90 ± 0.65 p value! 0.014* 0.038* 0.006* 0.984 0.015 Current work specialty Administration 106 3.70 ± 0.67 3.68 ± 0.64 3.59 ± 0.61 3.37 ± 0.66 3.96 ± 0.73 Clinical 141 3.66 ± 0.65 3.73 ± 0.64 3.65 ± 0.58 3.35 ± 0.67 3.92 ± 0.61 Public health 238 3.60 ± 0.71 3.55 ± 0.81 3.52 ± 0.74 3.21 ± 0.76 4.00 ± 0.73 p value† 0.662 0.118 0.227 0.133 0.516 Surveillance experience Yes 323 3.66 ± 0.68 3.64 ± 0.75 3.58 ± 0.68 3.30 ± 0.70 3.98 ± 0.71 No 162 3.61 ± 0.69 3.62 ± 0.70 3.56 ± 0.65 3.26 ± ± 0.73 3.95 ± 0.68 p value! 0.359 0.642 0.457 0.449 0.458 Electronic surveillance Yes 115 3.59 ± 0.77 3.53 ± 0.83 3.51 ± 0.77 3.35 ± 0.65 3.88 ± 0.76 No 370 3.66 ± 0.65 3.66 ± 0.70 3.60 ± 0.63 3.27 ± 0.73 4.00 ± 0.68 p value! 0.68 0.195 0.375 0.291 0.134 Use frequency More frequently per 396 3.72 ± 0.64 3.68 ± 0.71 3.63 ± 0.66 3.33 ± 0.7 3.86 ± .68 day/week Once a week or 89 3.3 ± 0.76 3.4 ± 0.78 3.35 ± 0.66 3.1 ± 0.72 3.57 ± 0.71 month p value! < 0.001* 0.003* < 0.001* 0.015* < 0.001* P < 0.05.! Mann-Whitney, †Kruskal-Wallis tests, * statistically significant (P = 0.015). Participants who used to work on HESN more Table 2 describes the different technical and func- frequently expressed more level of satisfaction compared tional aspects of HESN in respect to the composites to those with minimal use per week or month (P ≤ 0.001). scores of practicability, design, data and communica- Unexpectedly, the surveillance work experience and the tion,technicalsupport,and generalimpression. Most current work specialty had no significant relationship. of the participants (85.8%) underwent training, while Almayahi et al. Journal of the Egyptian Public Health Association (2021) 96:17 Page 6 of 10 Table 2 Functional and operational aspects of HESN in respect to the composites scores of practicability, design, data and communication, technical support, and general impression, KSA, 2016 Technical aspects n Composite Composite Composite data and Composite technical Composite practicability score design score communication score support scale impression scale Training Once 225 3.62 ± 0.70 3.65 ± 0.72 3.56 ± 0.66 3.24 ± 0.71 3.96 ± 0.71 More than once 191 3.67 ± 0.70 3.61 ± 0.77 3.60 ± 0.69 3.34 ± 0.71 3.99 ± 0.69 No training 69 3.64 ± 0.59 3.62 ± 0.68 3.58 ± 0.62 3.30 ± 0.74 3.93 ± 0.70 p-value† 0.702 0.909 0.573 0.307 0.855 Internet speed Fast 94 3.98 ± 0.62 3.87 ± 0.65 3.80 ± 0.58 3.65 ± 0.61 4.22 ± 0.56 Moderate 239 3.74 ± 0.59 3.71 ± 0.66 3.64 ± 0.61 3.38 ± 0.64 4.03 ± 0.66 Slow 152 3.28 ± 0.70 3.36 ± 0.80 3.33 ± 0.74 2.91 ± 0.72 3.72 ± 0.76 p value† < 0.001* < 0.001* < 0.001* < 0.001* < 0.001* Internet connection Home net 30 3.75 ± 0.79 3.76 ± 0.86 3.72 ± 0.78 3.21 ± 0.90 4.00 ± 0.87 Work and home 169 3.74 ± 0.63 3.72 ± 0.67 3.64 ± 0.62 3.30 ± 0.74 4.09 ± 0.64 net Work net 286 3.58 ± 0.70 3.56 ± 0.75 3.52 ± 0.68 3.29 ± 0.67 3.89 ± 0.70 p value† 0.133 0.074 0.294 0.744 0.088 Authority Entering and 209 3.60 ± 0.66 3.58 ± 0.73 3.55 ± 0.66 3.18 ± 0.69 3.96 ± 0.68 presenting data Full use 103 3.68 ± 0.70 3.7 ± 0.70 3.60 ± 0.71 3.31 ± 0.78 4.08 ± 0.72 Only entering data 173 3.67 ± 0.71 3.66 ± 0.74 3.60 ± 0.65 3.41 ± 0.69 3.92 ± 0.70 p value† 0.397 0.352 0.732 0.009* 0.223 Function Immunization 79 3.67 ± 0.70 3.72 ± 0.78 3.51 ± 0.66 3.10 ± 0.78 3.91 ± 0.89 Investigation 101 3.68 ± 0.66 3.64 ± 0.66 3.63 ± 0.64 3.38 ± 0.64 4.06 ± 0.66 Notifications 53 3.64 ± 0.74 3.61 ± 0.75 3.67 ± 0.63 3.33 ± 0.80 4.01 ± 0.66 management Outbreak 141 3.56 ± 0.75 3.53 ± 0.82 3.52 ± 0.75 3.17 ± 0.74 3.91 ± 0.73 investigation Reporting 100 3.72 ± 0.59 3.73 ± 0.62 3.62 ± 0.59 3.50 ± 0.54 3.98 ± 0.55 Work management 11 3.55 ± 0.55 3.47 ± 0.57 3.42 ± 0.62 3.14 ± 0.81 4.05 ± 0.53 p value† 0.840 0.178 0.429 <0.001* 0.684 Internet browser Firefox 235 3.62 ± 0.69 3.60 ± 0.76 3.53 ± 0.65 3.24 ± 0.72 3.97 ± 0.71 Google chrome 222 3.72 ± 0.65 3.72 ± 0.66 3.66 ± 0.67 3.36 ± 0.70 4.01 ± 0.67 Internet explorer 28 3.25 ± 0.75 3.25 ± 0.86 3.29 ± 0.67 3.12 ± 0.69 3.57 ± 0.73 p value† 0.003* 0.011* 0.005* 0.08 0.003* Interface language Arabic 159 3.59 ± 0.68 3.56 ± 0.74 3.51 ± 0.65 3.16 ± 0.74 3.93 ± 0.77 English 209 3.71 ± 0.66 3.71 ± 0.67 3.65 ± 0.64 3.44 ± 0.66 3.97 ± 0.61 Both Arabic and 117 3.6 ± 0.72 3.59 ± 0.81 3.54 ± 0.73 3.6 ± 0.72 4.01 ± 0.74 English p value 0.355 0.183 0.063 <0.001* 0.568 P< 0.05, †Kruskal Wallis tests, * statistically significant Almayahi et al. Journal of the Egyptian Public Health Association (2021) 96:17 Page 7 of 10 the remainder (14.2%) did not. Of the participants who the composite score of technical support (P = 0.009, underwent training, less than half (46.4%) received 0.001, < 0.001) respectively. However, the type of inter- training once only. net connection, and the training frequency did not show Firefox and Google Chrome were the most commonly any significant differences with any of the calculated used Internet browsers (48.5% and 45.8%, respectively). composite scores. Internet speed was classified as “Moderate” by nearly Figure 2a–e shows the data related to users’ percep- half of the participants (49.3%), compared to 19.4% who tions and experience regarding the different functionality classified this variable as “Fast.” Majority (59%) used the of HESN. Approximately 41.7% of the participants internet connection of work to open HESN, (6.2%) used agreed that HESN rarely freezes or stops working sud- home connection while the remaining (34.8%) used work denly. Almost (58.3%) of participants agreed that HESN and home connections too. The English interface was is a flexible and user-friendly application, compared to used by (43.1%) participants, and Arabic interface by (19.6%) who disagreed and (22.1%) who responded neu- (32.8%), while (24.1%) used both the Arabic and English trally. Approximately two-thirds (65.9%) believed that it interfaces. has a well-organized design, and furthermore, that its Remarkably, users with a fast Internet speed were key functions or buttons have a clear format and specific more satisfied than those with a moderate and slow order. The majority (68.0%) agreed that HESN is Internet speed for all composite scores (P < 0.001). Simi- equipped with an easy and fast search system, while larly, participants who used HESN with the Google 61.4% stated that they had not encountered any dupli- Chrome browser were more satisfied, compared to users cates. Only 57.3% showed satisfaction on laboratory data of Firefox and Internet Explorer. The authority level of completeness and quality, compared to 11.4% who were the users, the interface language used, and the different not, while 31.3% remained neutral. Finally, more than functions of HESN only showed significant relation with two-thirds (70.8%) were generally satisfied with HESN, Fig. 2 User’s perception and experience regarding the functionality of HESN. A Practicability, B Design, C Communication and completeness of data, D Technical support, and E General impression Almayahi et al. Journal of the Egyptian Public Health Association (2021) 96:17 Page 8 of 10 and 86.6%% believed that HESN is better than the trad- surveillance systems in China, where the evidence indi- itional paper work system. cates that professionals have employed their mobile phones to overcome the unavailability of computers and 4 Discussion the Internet [15–17]. In the case of HESN users with a There is a limited number of papers in the literature reasonable internet speed, they tended to be more satis- which have described the use or the advantages of using fied and recommend more improvements. Generally, the electronic health records for public health surveil- therefore, it is possible to conclude that the unstable lance. However, the several experiences in the clinical Internet connections are one of the major difficulties settings in some countries suggest that the electronic professionals encounter when working with electronic health surveillance systems have great promise to im- systems, especially in rural areas where infrastructure prove the public health surveillance and the outcome. continues to be deficient . Accordingly, it is critical to assess health surveillance At the same time, it is important to gain insight into the systems periodically, and this is even more critical in the type of the Internet browser employed by HESN users, case of electronic health surveillance systems. Further- since certain key functions or software extensions may more, user perceptions are crucial to consider in order only be compatible with one browser but not others. No- to ensure the success of public health systems. ticeably, the results indicated that the most satisfying The implementation of HESN was started in the mid browser for the present study’ssamplewas Google of 2012, before few months of the official announcement Chrome, followed by Firefox and Internet Explorer. of the emergence of a novel coronavirus (MERS-CoV) in Multi-purpose system: the KSA . Intuitively, the several outbreaks of HESN is a multi-functional system which serves differ- MERS-CoV in the kingdom provided opportunity to ent objectives. The results indicated that investigation pur- practically use and assess HESN as an early notifying poses form the core function of the system, which do surveillance system. Moreover, until the full implemen- require extensive data and communications to be com- tation which was accomplished in the mid of 2014, other pleted quickly. Users involved in the outbreak investiga- unpredicted infectious diseases had re-emerged globally tion function showed less satisfaction with regards to the such as Ebola. This indicates that the current time is technical support provided, which somehow reflect the crucial to develop intelligent surveillance systems where complexity of work in such cases. It can also be explained the periodic assessment, evaluation, and updating are by inadequacy of staff and or limit of the time; only 42.7% continuously needed. The randomly selected sample of and 53.8% of respondents agreed that staff and time were HESN users represented a fairly unbiased assortment of adequate respectively. This goes in consistence with previ- individuals with varying backgrounds and characteristics. ous studies that have identified different challenges with Notably, all regions and cities of the KSA were repre- electronic public health surveillance systems in Peru. sented in the sample. Other factors which affect outbreak investigations using In general, the results showed a reasonable level of sat- electronic surveillance systems are potentially related to isfaction (70.8%) among HESN users. However, their sat- the unnecessary time delay, inadequate sensitivity, poor isfaction was remarkably associated with the following positive predictive value, the significant turnover of factors: Internet browser, Internet speed, use frequency, trained personnel, and poor data quality . gender, nationality, and education. Other factors had Authority level and the software’s used language: minimal significant association including; age, interface HESN users had different levels of authority, but this language, different functions of HESN, authority level, variable was insignificantly related to their perceptions and the type Internet connection used. of the system, except for the technical support aspect. The role of internet speed and internet browser: Noteworthily, as indicated by the existing literature, this The successful adoption of any electronic health sys- was not the case with other electronic systems, with the tem relies mainly on the degree to which the infrastruc- results suggesting that perceptional differences exist be- ture setup has been prepared effectively . In the tween basic and advanced users . present study, users who rated their Internet speed as The majority of respondents considered HESN a user- fast represented less than 20% of the sample. It is note- friendly software. However, the results showed that users worthy, then, that a significant number of users of the English interface showed more satisfaction of the employed HESN at home because the speed of their system compared to Arabic interface users, though this Internet connection at work was slow. This indicates only showed significance with technical support aspect. that the infrastructure has yet to be improved, particu- Likewise, non-Arab users showed more noteworthy sat- larly with respect to the variable of the stability of the isfaction compared to Saudis and Arabs. This is indica- Internet connection. The same challenges have been en- tive of the fact that the Arabic coding of different countered after establishing electronic health software and systems may be troublesome or perhaps Almayahi et al. Journal of the Egyptian Public Health Association (2021) 96:17 Page 9 of 10 that Arabic translation of the functions may not be ap- Human errors may also occur, for instance, the tran- propriate. Indeed, HESN is a developed version of the scription of paper-based data to the system. Notably, the Canadian “Panorama” software, which was built primar- incidence of such errors can be limited by using elec- ily using the English language [11, 12]. The high satisfac- tronic systems for data collection and data entry, pro- tion level toward HESN among the non-Arab users may vided with logic check programs [18, 24]. also be attributed to the use of the English interface. Finally, it is critical to recognize that issues such as se- Notably, one of the major reasons why the electronic curing a fast Internet speed are as important as provid- surveillance system for malaria in Thailand succeeded is ing an adequate number of working staff. This is due to the functional design of the system, which pro- because all these factors ensure that the work is being vided malaria staff with close-to-real-time case manage- updated and conducted in a suitable manner. Therefore, ment data quality . it is worth emphasizing that a significant proportion of The role of usage: this study’s participants believed that their workplaces Clear differences were observed in the frequencies were neglecting to draw on adequate levels of human HESN usage, and furthermore, the results indicated that capital. these differences significantly affected the participants’ This study recommends the need for public health impressions of the system. One way in which to account electronic surveillance systems especially during this for this result is by stating that when users interacted time of frequent epidemics and pandemics. It is essential with HESN more frequently, they were exposed to dif- to ensure the readiness and availability of all aspects of ferent technical issues, they learned to manage them, infrastructure setup before anything else, including the and they started to locate the correct keys and buttons accessibility and speed of the internet, while developing rapidly. Subsequently, they saved time due to their ac- the best and friendly design, and interface, and selecting quired competency, thus entering a position where they the appropriate browser when applicable. Surveillance could recommend further improvements to the system. users get more satisfaction when they spend more time It is always fundamental to study and understand the on using the system which undoubtedly becomes more setting and context carefully before designing any new effective and successful. system. This is because the findings from such inquiries can ensure effective model processes, with which obsta- 4.1 Limitations cles can be overcome when using electronic health data Minimizing the collection of certain types of demo- . Many users agreed that freezing is not an uncom- graphic data (e.g., age and gender) may help to improve mon issue, and so the encountered errors may be the re- the quality of data and reduce bias. It is possible that sult of technical defects within the system rather than certain participants were not comfortable sharing their misuse. Therefore, a thorough technical evaluation to opinions freely as a consequence of the focus on demo- the system may be needed. graphic variables. Also, this study did not consider per- A significant proportion of HESN users also found forming multivariate analysis to adjust for potential that tabulation and graphing of data is not a straightfor- confounders. The use of both Arabic and English ques- ward task. Improving this would certainly help users tionnaires during the data collection complicated and understand their important role, thus ensuring that they lengthened the process of logging and analyzing the participate intellectually. The literature also indicates data. One language would have saved more time. The that even non-specialists can benefit from the availability survey was purposefully developed for HESN with the of automated analysis (specifically, those which generate respect of and based on other literature experiences, graphics and tables easily), particularly when performing though they were few and mostly unvalidated. complex assessments in short periods of time . Although many of the present study’s participants agreed that data conflict and data duplication issues are 5 Conclusion not common issues with HESN, it is critical to ensure A reasonable level of satisfaction was observed among that data are consolidated and not repeated. This is a HESN users in this study. However, to ensure that the particularly crucial point with respect to laboratory data, HESN’s public health goals are achieved, various import- which must be accurate and updated instantly. Notewor- ant improvements should be considered. As indicated by thily, conflict or discord issues within data sets have the results, user satisfaction was significantly affected by been identified in other studies of electronic surveillance the frequency of use, Internet speed, and the type of programs . Indeed, the development of electronic Internet browser used to access HESN. Therefore, it is health systems should have the advantage of preventing clear that the basic infrastructure requirements must be any medical errors, or as an alternative, it should aid in established adequately, particularly regarding the issues reducing health care disparities . of Internet connection, computers, and staff. Further Almayahi et al. Journal of the Egyptian Public Health Association (2021) 96:17 Page 10 of 10 studies to explore the effectiveness of HESN as a public 5. Mayahi ZKA, Al-Shaqsi N, Elmutashi HA, Al-Dhoyani A, Hattali AA, Salim K, et al. Two cases of cholera O1 in South Batinah, Oman, April 2019: lessons health surveillance are unquestionably required. learned. Epidemiol Health [Internet]. 2019;12:41. http://www.e-epih.org/ journal/view.php?number=1048. Abbreviations 6. Al Mayahi ZK, AlAufi I, Al Ghufaili B, Al Balushi Z, Al Mughazwi Z, HESN: Health Electronic Surveillance Network; KSA: Kingdom of Saudi Arabia; Mohammed E, et al. Epidemiological profile and surveillance activity of SARS: Severe acute respiratory syndrome; EVD: Ebola virus disease; tuberculosis in South Batinah, Oman, 2017 and 2018. Int J Mycobacteriol. 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British Colombia; 2015. https://www.bcauditor.com/pubs/201 facilitated the project. Z.A. performed computations. F.A verified the 5/auditpanorama-public-health-it-system. analytical methods. All authors have read and approved the manuscript. 13. Zaki AM, van Boheemen S, Bestebroer TM, Osterhaus ADME, Fouchier RAM. Isolation of a novel coronavirus from a man with pneumonia in Saudi Funding Arabia. New Eng J Med. 2012;367(19):1814–20. No funding was received for this research. 14. Qureshi QA, Shah B, Najeebullah D, Kundi GM, Nawaz A, Miankhel AK, et al. Infrastructural barriers to e-Health implementation in developing countries. Declarations EJSD. 2013;2(1):163. 15. Yan W, Nie S, Xu B, Dong H, Palm L, Diwan VK. Establishing a web-based Ethics approval and consent to participate integrated surveillance system for early detection of infectious disease This research was revised by the Saudi Field Epidemiology Training Program epidemic in rural China: a field experimental study. 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Journal of the Egyptian Public Health Association – Springer Journals
Published: Jun 16, 2021