Southern Africa Journal of Communication and Information Science pp 39-54 Vol[2021]

sajcis@nust.ac.zw

Internet Use and Network Disruptions on Health Information Provision and Health
Delivery Among Private Practising Physicians in the Bulawayo, Zimbabwe

Prince K Madziwaa, Mehluli Masukub, Hausitoe Narec and Solwayo Ngwenyad

a. Village Consult, Email prince@villageconsult.co.zw

b. Department of History, Sorbonne University Abu Dhabi, Email: mehluli.masuku@sorbonne.ae
c. Department of National University of Science and Technology, Zimbabwe, Email: hausitoe.nare@nust.ac.zw
d. Mpilo Central Hospital, Zimbabwe, Email: solwayo.ngwenya@nust.ac.zw

Abstract
Purpose: To explore internet uses by physicians and patients as well as the effects of internet disruptions on health
information provision health care service delivery among patients and selected Private Practising Physicians in
the Bulawayo Metropolitan Province.
Methods: A qualitative research methodology was used with a qualitative case study as the research design. The
population of the study constituted of 106 PPPs who were purposefully chosen from the Medical and Dental
Practitioners Council of Zimbabwe, (MDPCZ) (2021) register based on their Bulawayo addresses. The study
conveniently selected 200 patients bringing the population of the study to 306. Data was collected using semi-
structured questionnaires and presented as narratives and thematically in the order of the research objectives.
Findings: The results showed that patients and PPPs greatly relied on the Internet in health information exchange
between each other and PPPs relied on the Internet in the delivery health care services. Uses of the Internet
included online health information seeking by patients, communication between patients and physicians, making
online payment of medical bills, provision of telehealth services and conducting medical research.
Conclusions: Although not an everyday phenomenon, internet disruptions, no matter how brief they are, had a
negative impact on health information communication and the provision of healthcare.
Originality: The study was relied on primary data that was collected in the field by the researchers. The study
could be the first one to empirically explore internet use and network disruptions on health information and
healthcare provision in the Bulawayo Metropolitan Province in Zimbabwe.

Keywords: E-health, Healthcare, Information provisions, Internet disruptions, Private Practicing Physicians

Received: 22.09.22 Accepted: 20.12.22

Introduction

The need to promote reliable, fast, and convenient health care services has placed the Internet
at the centre of the health care system in Zimbabwe. Since the Internet has become a knowledge
hub of health information, the number of patients and physicians seeking and sharing health
information on the Internet has also increased (Chawurura, Manhibi, Van Dijk and Van Stam,
2019; Madziwa and David, 2022). Furthermore, in the wake of the Covid-19 global pandemic
there was a surge in the use of telehealth services across the country which led to the Medical
and Dental Practitioners Council of Zimbabwe (MDPCZ) reviewing its 2014 telemedicine
policy to suit the current health care needs (Ralph, 2022). Among other use cases, Internet
usage within the health care system has seen Zimbabwe having one of the fastest growing
populations of Internet users in Africa (Kemp, 2021). For example, as of January 2021, there
were an estimated 5.01 million Internet users in Zimbabwe which was an increase of 223
thousand (+1.5%) between January 2020 and January 2021 (Kemp, 2021). Kemp, (2021)
further highlights that Zimbabwe had 14.76 million mobile connections in January 2021, which
is 98.5% of the total population.
Despite the importance of the Internet within the health care system, there has been an increase
in Internet disruptions across the globe with Zimbabwe included (Ayalew, 2019; Rajagopal,
2020). According to the Shutdowns Tracker Optimisation Project (STOP) (2016-2018) an

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Internet disruptions can be described as the intentional or unintentional disruption of electronic

communications or the Internet as a whole, subsequently rendering the Internet unusable within
a defined location and time. There were 106 Internet disruptions in the year 2017 across the
globe, which was an increase from 75 Internet disruptions in 2016 (STOP, 2016-2018).
Furthermore, according to the STOP (2016-2018) data, there were at least 196 recorded Internet
disruptions in the year 2018. Despite official justifications of Internet disruptions presented by
governments, such as political instability, public safety, national security, fake news, hate
speech and third-party actions among other justifications, the effects of Internet disruptions are
often not documented, and literature tells us they likely have more disadvantages than
advantages (Wagner, 2018; Chutel, 2019; Mare, 2020). This is especially true within health
delivery systems that employ telehealth services (Mbah, Nkangu and Rogoff, 2018; De
Gregorio and Stremlau, 2020). Internet disruptions negatively impact the manner in which
health care information flows from one service provider to another or from a service provider
to patients (Mbah, Nkangu and Rogoff, 2018; De Gregorio and Stremlau, 2020).
Zimbabwe has also experienced Internet disruptions between the years 2016 and 2019 (Chutel,
2019; Marchant and Stremlau, 2019). In July 2016, the Government of Zimbabwe ordered
telecommunications companies to specifically disrupt social media platforms such as
WhatsApp and Facebook for a maximum of 4 hours (Chutel, 2019; Marchant and Stremlau,
2019; Mare, 2020). A total/blanket Internet disruption was imposed in January 2019 which saw
the country going for a maximum of seven days without the Internet (Mpofu and Mare, 2020).
The arguments presented by the Government for shutting down the Internet have been centered
on the need to promote public safety, national security, fake news mitigation and cyber bullying
control (Mare, 2020). Such disruptions have the potential of effectively blocking health
information exchange between patients and physicians, translating to interruptions of
healthcare delivery systems. Where there is no health information exchange between patients
and physicians due to internet disruptions, patients are compelled to physically travel to the
premises of their physicians for matters that would have been addressed remotely. In extreme
cases such disruptions may lead to worsened medical conditions of patients or even death.
Internet and healthcare service delivery in Zimbabwe
The Ministry of Health and Child Care (MoHCC) in partnership with the Postal and
Telecommunications Regulatory Authority of Zimbabwe (POTRAZ) and the
Telecommunications Union (ITU), under the E- health strategy, have started implementing the
TELEMEDICINE PROJECT (Gwarisa, 2018; Furusa and Coleman, 2018; Madziwa, 2022).
The TELEMEDICINE PROJECT was initiated to promote health information dissemination
for interaction and collaboration among institutions, health professionals, health providers and
patients (Gwarisa, 2018; Furusa and Coleman, 2018). This programme was considered
especially important due to the hierarchical structure of the health care delivery system in
Zimbabwe, which largely depends on a fluid uninterrupted flow of health information from
one health care institution to another and one physician to another (Khumalo and Mnjama,
2019; Masuku and Ngulube, 2019). For example, the health delivery system is divided into the
primary, secondary, tertiary, and quaternary levels (Masuku, 2013; National Health Strategy
for Zimbabwe (NHSZ), 2015). The primary health care service delivery provides basic health
care services and in case of complicated medical cases, a patient is further referred up the
hierarchy (Madziwa and David, 2022). As such it is imperative that there exists a fluid health
information communication system that promotes effective service delivery throughout those
levels of care.

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The TELEMEDICINE PROJECT has been rolled out against a background of the dilapidating
physical health infrastructure which is currently being overwhelmed by the growing population
(Ngwenya, 2017; Gwarisa, 2018). Furthermore, some studies have shown that PPPs have also
joined in the telehealth wagon by mainly adopting the use of electronic health record (EHRs)
systems, use of online communication platforms such as WhatsApp, Emails, and Websites
(Madziwa and David, 2022; Khumalo and Mnjama, 2019). Patients, likewise, use the Internet
for seeking health information tips, communication with PPPs, and even purchasing of health
supplies online (Doyle, Bandason, Dauya, McHugh, Grundy, Dringus, Chikwari and Ferrand,
2021). At the centre of it all is the availability of an uninterrupted Internet supply which is the
key vehicle on which such health care services are dependent (Doyle et al, 2021). As such, this
study was interested in exploring the effects of network disruptions on those health care service
delivery with a particular focus on PPPs in the Bulawayo Metropolitan Province. The
expansion of training capacity of medical doctors across the country has seen an increasing
number of physicians in the country (Chinyadza, 2014). Some of these physicians go on to
establish private practices specializing in different fields such as anesthesiology, gynecology,
plastic and reconstructive surgery, radiography, oncology, neurology, urological, Pediatrics,
and Orthopedic services to mention a few (Chinyadza, 2014, Mugwagwa, Chinyadza and
Banda, 2017; Madziwa and David, 2022). According the Medical and Dental Practitioners
Council Zimbabwe (MDPCZ, 2021) website, there are 2,949 registered private doctors in
Zimbabwe with only 106 registered with a Bulawayo address (MDPCZ, 2021). Some PPPs
have adopted telehealth services to serve the growing patient population across the country
(Mugwagwa, Chinyadza and Banda, 2017).
Internet governance in Zimbabwe
The Zimbabwean Government is a major shareholder in telecommunication companies such
as TelOne, and Telecel, while Econet Wireless is privately owned. Although the Government
does not have total control of some of the telecommunication companies such as Econet
Wireless which is a major shareholder in Zimbabwe Online (ZOL), and Liquid
Telecommunications, it has the power to impose such orders based on what Mpofu and Mare,
(2020) call digital authoritarianism and Internet Service Provider (ISP) Ownership within non-
democratic states. Although telecommunication services providers are morally obliged to
provide un-interrupted Internet services to their clients, they are also legally caught in the cloud
of legal obligations to their regulator which in the case of Zimbabwe is the Government
(Ayalew, 2019; Chutel, 2019; Marchant and Stremlau, 2019; Mare, 2020). Mare (2020:4248)
argues that “one of the reasons it is difficult for telecommunications to push back against
government orders is that certain licensing obligations allow regulators to invoke nebulous
justifications, such as the need to protect national security.” For example, all
telecommunication companies in Zimbabwe are governed by the Postal and
Telecommunications Act of 2000 and the Interception of Communications Act (ICA) of 2007.
Section 9 of the ICA gives authority to the Government to monitor and control communication
surveillance including the Internet (ICA, 2007). This is despite the Government not owning
some of the International Gateway Systems in Zimbabwe.
Problem statement
The use of internet in the health sector needs not be overemphasised. The internet enables
health information change between different stakeholders across the health spectrum, including

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the exchange of health information between patients and physicians, between healthcare
providers themselves, and many other health players. Electronic health records, electronic
medical records and electronic personal health records are all dependent the internet for
optimum functioning. Despite the rampant use of the internet for health information, the
qualitative impact of internet disruptions in Zimbabwe remains under researched. This comes
on the back of countless such disruptions in Zimbabwe. The hardest hit stakeholders in cases
of internet disruptions perhaps are patients and physicians. Furthermore, whilst is well
understood that patients and physicians use internet for different purposes, it remains to be
understood how these stakeholders use the internet and the main purpose for which they use it.
Thus, there is scanty literature shedding light on how internet is being used in the health sector.
The present study explores the uses of the internet by physicians and patients in the Bulawayo
Metropolitan Province.
Purpose of the study
The study sought to find out the uses of the internet by physicians and patients (for what
purpose?) in the Bulawayo Metropolitan Province as well as how internet disruptions affected
health information and service delivery.
Research objectives
The study was guided by the following objectives:
1. To explore the use of Internet in the delivery of health care services by PPPs and
patients in the Bulawayo Metropolitan Province.
2. Establish ways in which network disruptions affect health information sharing among
PPPs and patients in the Bulawayo Metropolitan Province.
3. To find out how PPPs and patients circumvent and/or ameliorate the challenges
associated with Internet disruptions in health information sharing.
Design
The study used a qualitative case study as its research design. Qualitative descriptive research
is one whose aim is “a comprehensive summarisation, in everyday terms, of specific events
experienced by individuals or groups of individuals.” (Lambert and Lambert, 2012:255).
Because this study intended to gather data about everyday experiences or uses of the internet
in health information provision and service delivery among physicians and patients in the
Bulawayo Province, a qualitative descriptive research methodology was appropriate for the
study. The population of the study constituted of 106 PPPs who were purposefully chosen from
the MDPCZ (2021) register based on their Bulawayo addresses. The study further conveniently
selected 2 patients per physicians’ rooms, therefore bringing the population of the study to 306
participants. A semi structured questionnaire was distributed to 106 PPPs. Another semi-
structured questionnaire was distributed to 200 conveniently selected patients within the PPPs’
rooms. The patients were key in validating the data given by PPPs and most importantly to
understand how, as key stakeholders in health delivery, were affected by Internet disruptions
in Zimbabwe. From the 306 distributed questionnaires the study retained a 100% response rate
as all questionnaires were returned. Data was qualitative in nature and was presented in a
thematic style following the order of the research objectives. This is in tandem with the
statement by Lambert and Lambert (2012:255) that “the presentation of data from a qualitative

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descriptive study involves a straightforward descriptive summary of the informational contents

of the data that is organised in a logical manner.”
Results
The following section presents the results of the study as obtained from the study’s participants.
Basic statistics were presented in graphs and tables. The statistics did not imply a quantitative
analysis as insignificant for the study to be quantitative. The bulk of the results were qualitative
and were presented in statements, including direct quotations from participants.
Demographic information
The data collected from the study showed that there were 117 (58.5%) males and 83 (41.5%)
females surveyed. The mode age group was 22 with 13 (6.6%) patients, followed by the age
39 with 12 (6.1%), and the third mode was the age 29 with 11 (5.6%). The collected data
showed that patients between the ages of 36 – 40 years old were more 52 (26%), followed by
33 (17%) within the age group of 31 – 35 years old and the least 3 (2%) were those above the
age of 65+. The data collected also shows that the surveyed patients were spread across various
age groups which allowed the researchers to capture varying responses from different
demographics, as such gaining insights on how different age groups utilise the Internet when
seeking health care services.
Private practicing physicians’ specialty
PPPs were profiled by area of specialization as shown by Figure 1 .

Physician speciality
N =106
Urologist 6
Orthodontist 1
Orthopaedic 11
Otorhinolaryngologist 3
Ophthalmologist 2
Allergist 5
Cardiologist 7
Gynaecologist 19
Endocrinologist 2
Psychiatrist 5
Neurologist 4
Radiologist 12
Epidemiology 4
Dentist 9
Pediatrician 14
Rehabilitation 2
0 2 4 6 8 10 12 14 16 18 20

Physician speciality

Figure 1: Private practicing physician specialization

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Physicians’ experience in years

Regarding the length of service of the study participants, 11 (10%) of the PPPs had more than
30 years working experience which was the highest number of working experiences among the
surveyed physicians. Furthermore, 24 (23%) had between 25 - and 29-years working
experience, while 44 (42%) had between 15 to 20 years working experience. At least 17 (16%)
had between 10 to 14 years’ experience, while the remaining 10 (9%) had less than 10 years
working experience. This data shows that PPP who participated in the study had extensive
experience within the medical field hence their responses could be trusted based on the
experience they had. Furthermore, the data showed that, by the time Internet disruptions started
to happen in 2016 the PPPs were already in practice hence the possibility of them having first-
hand experience on Internet disruptions.
Internet use by patients in seeking health services
The study also sought to understand the purposes of using the internet in the context of health.
The section below presents selected responses from patients.
Patients using the Internet
Data collected from the participants showed that out of 200 patients only 152 (76%) use the
Internet to seek health care services. This data validates the importance of the Internet within
the health care. The researchers further enquired on the reasons why some participants used the
Internet for seeking health care services. One of the patients highlighted that “with services
such as electronic payments I can easily pay my medical bills or purchase medication from the
comfort of my home”. This was one of the major uses of the Internet evidenced by at least 100
(66%) of the participants who used the Internet to make online medical payments. The gathered
data showed that 120 (79%) patients utilised the Internet to communicate with their physicians,
while 100 (66%) use the Internet to make online payments. The data further showed that 44
(29%) of the patients utilised the Internet to store health records online, while 90 (59%) utilised
the Internet to seek health information online.
Another response was that “The Internet makes it easy for me to check some health tips,
especially during this Covid-19 period”. Another similar response was that “I use the Internet
a lot to check on health information pertaining to any illness il be having at that particular
time”. Another participant highlighted that “I use the Internet in seeking health information
because its discrete”. Another participant noted that “I store my health records on my google
drive so that I can access them whenever needed”. Responses from other participants also
showed that patients used the Internet to follow different fitness and wellness pages on social
media platforms such as Tik-Tok, YouTube, Instagram and Facebook. Communication was
one of the major reasons why patients used the Internet. For example, some participants
acknowledged that they used the Internet to communicate with their physicians through social
platforms such as WhatsApp, Facebook Messenger, and also emails in some cases.
Why some patients were not using the internet in communicating with physicians
The study also sought to find out the reasons other patients were not utilizing the Internet in
seeking health care services. One of the patients highlighted that “I do not have a smart phone
that can access the Internet”. It is worth noting that this response was also given by other
patients especially those who were relatively older at the age of 65+. Another interesting

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response was that “I do not have interest in using the Internet to access health care services”.
The majority of the participants also noted that there didn’t have data to access the Internet.
Another interesting response from one of the participants was that “I do not have trust in the
information that is presented on the Internet, hence it is difficult for me to use the Internet”.
Another elderly participant noted that “I do not have the technical knowhow to fully utilise the
Internet”. Notable, there are a couple of responses that showed that some participants did not
only lack the motivation to use the Internet in seeking health care services, but they also had
limited knowledge on how to do so.
Online communication platforms used by patients
The researchers were further interested in understanding the communication platforms used by
patients.

Communication platforms used by patients

N = 152
200
150
100
133 140 152 147 143 130
50 96 106
19 83 69 56 12 0 46 67 85 5 9 22 65 87
0

Yes No

Figure 2: Communication platforms used by patients

Data gathered from the study showed that communication platforms that were used by patients.
The data gathered from the study showed that most patients use social media platforms such as
WhatsApp, Facebook manager, Websites and Twitter which are the very platforms that are
usually censored by the government by means of shutting down the sites. WhatsApp was the
most used communication platform to communicate with PPPs this was mainly because of the
convenience, easy to use and relative cheapness compared to other platforms.
Use of the Internet in the delivery of health services by physicians
The research also sought to establish the various uses of Internet when seeking health care
services.
Internet usage by Private Practicing Physicians
The collected from the study revealed that 87 (82%) of the PPP use the Internet within their
practices. An analysis of the study’s participants that is both the PPPs and patients, highlights
that from a total of 306 participants, 239 (78%) relied on the Internet in seeking health care
services. This baseline data shows the importance of the Internet within the health care service
delivery space. PPPs were asked some of the reasons why they use the Internet in providing
health care services, the responses centred on the convenience of the Internet in promoting
communication with their patients, easy electronic payments, medical research just but to

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mention a few. For example, Physician 3 highlighted that “With the Internet it’s easy for me to
schedule patient appointments using Calendly”, while Physician 7 noted that “I use an online
health record system, as such the Internet is a must have in my practice”. A similar response
was given by Physician 16 who highlighted that “I use proprietary software for my health
information, so I use online payment to subscribe for it monthly”. Physician 14 who was a
Gynaecologist highlighted that “I actually chat a lot with my patients on WhatsApp, as such
it is paramount that I am able to access the Internet every time”. Another Physician 32, a
specialist in Neurology noted that “Apart of my daily use of the Internet in my practice, I am
currently teaching at one of the local teaching hospitals and in most cases, we have online
sessions, hence the need for Internet services”. The results of the study also showed that
physicians use the Internet for online research. For example, Physician 26 noted that “as a
medical doctor online research is inevitable”, Physician 32 noted that “I constantly research
on different cases that I face in practice”. The above responses are clear evidence of how health
information management and sharing is affected by network disruptions.
Use cases of the Internet by PPPs

PPPs who use online EHRS

No No , 24

Yes Yes, 63

0 10 20 30 40 50 60 70

Figure 3: PPPs who use online EHRs

The data collected from the study showed that out of 87 PPPs who indicated that they use the
Internet within their practice, only 63 (72%) actually utilised EHRs. This meant that during
Internet disruptions PPPs failed to access online EHRs as such negatively affecting continued
healthcare. Furthermore, the results showed that all the PPPs utilize the Internet for
communicating with patients, medical research, communicating with other physicians, and
making online payments or purchases. What can be deduced from the presented data is that the
Internet is an essential variable within PPPs’ practices, hence the need for the Internet to be
always up.
Communication platforms used by PPPs
The researchers were also interested in understanding the communication platforms utilised by
PPPs who use the Internet within their practices. This was especially essential so as to establish
whether some of the most censored platforms such as Facebook, WhatsApp were also used by
PPPs or not.
Effects of network disruptions on patients
The results of the study showed that out of 152 patients who had indicated that they use the
Internet when seeking health care services, only 103 (68%) of the patients had been
negatively affected by Internet disruptions when seeking health care services. The
researchers further enquired that out of the 49 (32%) of patients who highlighted that they

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were not negatively affected by Internet disruptions, only 17 (35%) were not seeking health
care services during Internet disruptions periods. As such what can be deduced from this is
that Internet disruptions greatly affect the greater population of patients. When asked to
describe how Internet disruptions have affected their health seeking practices, patients gave
various descriptions with most of them centred on the failure to communicate with their
PPPs, failure to search for online health information and the failure to make medical bills
payments. It is essential to highlight that the failure for patients to perform such tasks, in
particular the failure to make medical bill payments may in some cases result in delayed
medical procedures subsequently resulting in patient conditions worsening and/ or even
casualties.
The researchers managed to capture some patient narratives pertaining to how the Internet
disruptions affected them in seeking health care services. Patient 14 noted that “During the
2016 Internet disruptions I remember I had my first pregnancy and during that time I was
doing a lot of online research and the disruptions really affected me”. It is worth noting that
just like the aforementioned participants, other participants were also hindered from
conducting their online research on various health issues. Patient 43 noted that “My uncle
was planning to book for a second opinion from a Doctor in India, but due to the Internet
blackout he had to access some email communication a week after”. According to the
participant, such a disruption was indeed a major setback to his uncle’s health condition. This
case was also similar to Patient 39 who highlighted that “I remember then, I was having
weekly check-ups with my specialist in South Africa using Skype, but we could not connect
that week”. This response was similar to patient 41 who highlighted that “some of my
communication with the doctor are done online so network failure really affects me”. The
same response was also given by patient 48 who noted that “its easier to communicate with
my doctor online other than physically coming to this office”. What was evidenced from the
participants’ responses was that the Internet disruptions were indeed negatively affecting the
way in which they were accessing health care services. Another response from patient 61
was that “there are various health forums we access on through the Internet, but due to
disruptions this becomes difficult”. A similar response was given by patient 67 who also
noted that “I always follow fitness lessons on YouTube but because of unavailable Internet
my routine was affected”.

Effects of network disruptions on private practising physicians

The researchers further enquired on the effects of Internet disruptions on PPPs, the results
showed that from the 87 out of 106 PPPs who had indicated that they use the Internet in
seeking health care services, only 80 (92%) had been negatively affected by Internet
disruptions when providing health care services. PPPs were then asked to highlight one
important area that had been negatively affected the most during Internet disruptions (see
Figure 4).

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Areas affected by Internet shutdowns

N = 80
Software upgrades of medical equipment 4
Storing medical record on the cloud 9
Online purchasing of medication/drugs 13
Telehealth consultations 23
Online learning 6
Online medical research 5
Remote monitoring of patient vitals 9
Communication with patients and physicians 11
0 5 10 15 20 25

Areas affected by Internet Shutdowns

Figure 4: Effects of Internet shutdowns on PPPs

Strategies for circumventing and/or ameliorating challenges associated with Internet
disruptions
Researchers were also interested in understanding the various strategies of circumventing
and/or ameliorating challenges associated with Internet disruptions. However, before
understanding about the circumventing strategies, the researchers had to first establish the
participants’ level of understanding of the various types of Internet disruptions. Results from
both physicians and patients are presented below. One of the interesting facts that the study
wanted to establish was the level of knowledge of different types of Internet disruptions by
both PPPs and patients. Measured in singulars, the responses gathered from PPPs showed that
they have a general understanding of the various types of Internet disruptions, with all 87
(100%) knowing about the Internet blackouts or blanket Internet blackout. Furthermore, the
results highlighted that 33 (38%) had knowledge of bandwidth throttling, while 60 (69%) knew
about broadband Internet disruptions, and 66 (76%) only knew about service specific
disruptions. The general responses from the study showed that PPPs could easily identify
Internet disruptions in whatever forms they are deployed in.
When it came to patients the data collected from the patients showed that the patients’
knowledge of types of Internet disruptions was limited. This is especially true considering that
only 56 (37%) know about bandwidth throttling, while 54 (36%) know of broadband Internet
disruptions, 47 (31%) and 29 (19%) knew of mobile Internet disruptions and service specific
disruptions, respectively. However, when it came to total Internet disruptions, all 152 (100%)
of patients knew it. Comparing to PPPs, what can be highlighted is that PPPs have a better
understanding of Internet disruptions than patients.
Familiarity with Virtual Private Networks (VPNs)
Participants were asked about their knowledge and familiarity with VPNs as a way of
circumventing internet disruptions. Findings are presented below.
Private Practicing Physician’s knowledge of VPNs
The data showed in figure shows that out of 87 PPPs who used the Internet in delivering health
care services, 65 (75%) had knowledge of VPNs. When asked of the specific VPNs that they

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have used during Internet disruptions, PPPs highlighted that they had used commonly known
VPNs such as 27 (31%) Proton VPN, 16 (18%) TunnelBear, 11 (13%) Super VPN, 10 (11%)
Hotspot shield, while the remaining 1 (1%) used Speedify VPN. What can be understood is
that PPPs mostly used these VPNs because they are freely available. The researchers further
enquired on the security, ethical, privacy and confidential issues surrounding the use of VPNs.
Most 67 (77%) did not know about how VPNs impacted on their security, ethical, privacy, and
confidentiality. As such this resulted in the PPPs personal data being vulnerable to malicious
attacks.
Patients’ knowledge of VPNs
The data collected from 152 who had highlighted that they used the Internet to access health
care services showed that only 132 (87%) knew about VPNs. When asked of the specific VPNs
that they have used during Internet disruptions, Patients highlighted that they had used VPNs
such as 69 (52%) Super VPN, 11 (8%) Fast VPN, 19 (13%) Secure VPN, 15 (10%) Hotspot
shield, 21 (14%) used Windscribe VPN, 12 (8%) used Tomatoe VPN, while the remaining 5
(3%) used Speedify VPN. Just like PPPs, patients showed that they used freely available VPNs
to circumvent Internet disruptions. However, what was key to note is that out of 152 patients,
only 143 (94%) patients did not have an appreciation of the impact of VPNs on their data
security. Just like the case of PPPs this meant that patients’ data was vulnerable to malicious
attacks.
Discussion
This section discusses the findings of the study.
Use of the Internet in the healthcare delivery in the Bulawayo Metropolitan Province
The National Research Council Committee on Enhancing the Internet for Health Applications
(2000:1) report highlighted that “many health-related processes stand to be reshaped by the
Internet”. True to their argument, the data gathered from both the patients and PPPs who
participated in this study showed that both stakeholders heavily rely on the Internet in accessing
and delivering health care services. The high usage of the Internet in the health care delivery
system may also be credited to the high Internet usage by general Zimbabweans (Kemp, 2021).
Patients highlighted that they used the Internet to communicate with their PPPs and in some
cases, they often sought online health information for the purposes of self-diagnosis. It is
essential to highlight that the use of the Internet by the studied patients can also be generalized
to other case studies (Whiddett, Hunter, Engelbrecht, and Handy, 2006; Asibey, Agyemang,
and Dankwah, 2017; Kushniruk, 2019). For example, a study by Asibey, Agyemang, and
Dankwah, (2017) on Internet use for health information among Ghanaian University Students
revealed that Ghanaian university students were active users of the Internet. From a total of
650 students, about 440 (67.7%) revealed that they used the Internet for health purposes. Asked
on the reasons for Internet usage for health, 249 (56.6%) noted that the Internet has vast amount
of valuable information available, 340 (77.3%) revealed that there is anonymity, privacy, and
confidentiality when accessing health information online than visiting a general practitioner.
An interesting finding from existing literature is that the anonymity, privacy, and
confidentiality of the Internet is what also draws many patients to utilize the Internet in seeking
health information. Kushniruk, (2019) is of the view that the Internet has allowed for the
progression of a more patient-centered care, which gives patients the freedom to search for
health information on their own. The same perspective is shared by Mutanu, Gupta, and Gohil
(2022) who note that the Internet is key in promoting communication between patients and

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physicians to establish effective relationships that lead to improved health care management.
Furthermore, similar to the study’s findings, physicians are also able to gain rapid access to
health care information which aids in how they diagnose patients (Asibey, Agyemang, and
Dankwah, 2017; Mutanu, Gupta, and Gohil, 2022). For example, through the Internet
physicians are able to research on various cases that patients present and at the same time being
able to communicate and share health related knowledge amongst each other (Mutanu, Gupta,
and Gohil, 2022). The study also showed that PPPs also utilise the Internet to store and share
patient health records. Highlights that the Internet is key in making patient health records to be
accessible whenever they are needed by physicians. As highlighted by Ngwenya, (2017) and
Madziwa and David, (2022) the health care delivery system in Zimbabwe is overburdened by
the growing population and as such, a significant number of patients and doctors now prefer
the use of the Internet to ease the pressure exerted on physical health facilities. The
aforementioned arguments explain the high Internet usage rate by both the PPPs and the
patients. Furthermore, the usage of the Internet in seeking health care services by patients may
also be a cost saving measure especially for patients who live far away from PPPs or healthcare
facilities. Madziwa, (2022) highlighted that patients who live outside of Bulawayo with minor
conditions preferred e-consultation to travelling long distances to meet their doctors. This may
also explain the high Internet usage by patients and PPPs. The study also found out that patients
and PPPs also used the Internet to make payments of medical bills and buy medication online.
This finding does not come as a surprise within the context of Zimbabwe, considering that there
has been a significant shortage of cash within the economy and as such, most people are now
using wireless transactions (Mazorodze, 2018). Therefore, it can be summarized that the high
Internet usage by both patients and PPPs as revealed by the study is not a surprise based on the
issues discussed.
Effects of Internet disruptions on health care services in Bulawayo Metropolitan
The study established that Internet disruptions (Internet disruptions in particular) negatively
affected the way in which PPPs delivered health care services and the way in which patients
access health care services. A significant number of patients highlighted that Internet
disruptions negatively affected their communication with PPPs and their endeavour to seek
health information online was also compromised by such disruptions. Despite a dearth of
studies on the effects of Internet disruptions in health care delivery, a few studies have shown
that blacking out the Internet negatively affects the manner in which patients access online
health information (Mbah, Nkangu and Rogoff, 2018). A study carried out in India showed that
since the COVID-19 global pandemic started, people in India have not been able to “access
websites that provide information about the pandemic” due to Internet disruptions. Such a
situation has left people failing to take some of the best care in dealing with the effects of
COVID-19 and as such, most of them are succumbing to the virus (United Nations, 2021). In
Ethiopia, millions of people in the Western Oromia are missing key information about COVID-
19 because of government induced Internet disruptions (United Nations, 2021). In Bangladesh,
Internet disruptions have jeopardized the lives of about 900 000 refugees who fail to access
health care information (United Nations, 2021). Findings of the present study showed that
patients failed to communicate with their PPPs and this negatively affected the way in which
they dealt with their ailments. This is especially true for those patients who highlighted that
they had chronic conditions as they had to constantly check with their PPPs.

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Circumventing and/or ameliorating the challenges associated with Internet disruptions

Findings of the study highlighted that patients and PPPs used tools such as VPNs to ameliorate
the effects of Internet disruptions. The study findings also showed that some patients and PPPs
resorted to the use of making direct phone calls to patients which was costly to the PPPs.
Furthermore, some PPPs resorted to the use of VPNs. As much as VPNs play a crucial role in
dealing with Internet disruptions in which key social media and communication platforms are
blocked or restricted, (Mbah, Nkangu and Rogoff, 2018), it is worrying that a significant
number of PPPs and patients had no adequate knowledge on key issues related to the use of
such tools. This exposed their private and confidential data to unauthorised access by third
parties. Constantin, (2017) notes that VPNs pose serious risks to users because attackers siting
on the same networks can use various techniques to hack their information. As such, as much
as patient and PPPs used this technique, it was not wise because they lacked ample
understanding of privacy risks that are associated with VPN usage. Therefore, what can be
summarized from this discussion is that Internet disruptions forced patients and PPPs to
unknowingly expose their private and confidential information to unauthorised third parties
and also strained their budgets since they had to resort to financially uncomfortable methods
of communication.
Conclusions
It can be concluded that a lot of patients and PPPs in the Bulawayo Metropolitan Province
utilised the Internet in seeking and delivering health care services, respectively. The effects of
Internet disruptions have serious negative implications on how patients and PPPs access and
delivery health services, respectively. Internet disruptions negatively affected the
communication processes of both patients and PPPs. Furthermore, PPPs and patients fail to
make online payments and fail to access online health information
Recommendations
• The Government of Zimbabwe should effectively consider the effects of Internet
disruptions on health care service delivery and as such avoid the shutting down of the
Internet.
• There is need for patients and PPPs to invest more time in learning about the
implications of using VPNs in order to avoid jeopardizing and compromising their
privacy in the event of them using VPNs.

Acknowledgements
The authors would like to thank PPPs and patients in the Bulawayo Province who participated
in the study. The authors would also like to thank Bunake Kaitse, Brilliant Ndlovu and Eniah
Muruviwa for their assistance with data gathering.

Declaration of conflict of interest

There is no conflict of interest with regards to the authorship and publication of this article.

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Funding
The study was not funded.
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