Journal of Advances in Internal Medicine Editorial Underestimation of clinical importance of non-steroidal anti-inflammatory drug induced enteropathy and its exacerbation by proton pump inhibitors Umid Kumar Shrestha* Manipal College of Medical Sciences & Manipal Teaching Hospital, Pokhara, Nepal Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used over-the-counter to relieve pain and symptoms of arthritis and soft tissue inflammation. Proton pump inhibitors (PPIs) are often used simultaneously with NSAID to protect against its gastroduodenal side effects. However, the suppression of gastric acid secretion by PPIs does not seem to protect against the damage caused by NSAIDs in the more distal small intestine, often called as NSAID induced enteropathy. In fact, the small intestine seems to be more susceptible to the damaging effects of NSAIDs than the stomach1 and PPI may even exacerbate the NSAID induced enteropathy.2
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Journal of African Studies in Educational Management and Leadership
Vol: 7 No:1, August 2016, 61-81
Scholarly, Peer Reviewed
Interrogating Social Media Netiquette and Online Safety among
University Students from Assorted Disciplines
Simon Macharia Kamau, Khadiala Khamasi & Margaret Kamara Kosgey Abstract
Despite the convenient and compelling nature of social media, netiquette or good conduct in its use remains a remote practice. Being a primary agent of socialization, the social media is a popular means by which individuals exchange personal information, a situation that requires high morals, integrity and individual discipline to be exercised during such exchange. This study presents a mini review of university students' views of social media netiquette and online safety with particular focus on issues of practice relevant to university students in selected disciplines with a special focus on those in the health sciences departments at Kabianga University. An evolving emergent research design was engaged using the search strategy, Find It with keywords like Face book, Twitter, netiquette, patient privacy and social media, student behavior and internet. Students had what they referred to as favorite applications (apps) on social media where both personal and private issues as well as public debate and discourse were freely exchanged. Notably, with a great variety of clientele visiting such sites, unaware of their impact, there is always the danger of being misinterpreted or revealing confidentialities unknowingly. There is need therefore, to establish national and institutional policies regarding etiquette and privacy in the use of social media in public universities and health institutions. A less generic review addressing particular disciplines and circumstances is also recommended for more input regarding social media.
Keywords: Face book, University students, Twitter, Netiquette, client's privacy, Social
Contact author details: Simon Macharia Kamau, University of Kabianga, Kenya.
Despite their greater technological sophistication as compared to the general population, many young users of social media networks possess a limited Publisher: Kenya Association of Educational and Management (KAEAM) Corresponding author. Email:
ISSN 2078-7650 Online# 2016, http://www.kaeam.or.ke
2016 Kenya Association of Educational and Management (KAEAM)
62 Journal of African Studies in Educational Management and Leadership
understanding of harmful consequences of sharing information via social media. They tend to maintain lax privacy practices and take their postings for granted. Hardly do they read or consider private policies of web providers of the networks or applications they use before subscription to such social groups and networks. Social media on the other hand offers an efficient and convenient means by which to exchange personal information. Owing to the social need for inclusion among peers, the sites become a compelling attraction to numerous youths whose obvious access to relevant electronics and availability of time for engagement enhances the media use. In such circumstances, highly confidential content like medical information becomes public while professionalism and ethics of practice get compromised. Often, for medical students, it leads to posting of patient information, leading to serious, unintended, and irreversible consequences. Once one clicks ENTER that's it, it is no longer in one's control. There is therefore need for policies on these matters and medical educators need to inform students on the detriments of such medical information exposure. The Internet is no longer a futuristic technology trend. It is here already, for there is a likelihood of one using an element of it in one way or another. When optimized, such elements can make a real difference in living or give a competitive edge to users if only educators do effective sensitization. Simon Macharia Kamau, Khadiala Khamasi & Margaret Kamara Kosgey 63 Research Approach
This mini review; an evolving emergent design, has its foundations on grounded theory as a theory and as a research method in data collection. It is the type of study supported by Polit and Beck (2012, p. 487), who claim that an emergent design reflects on what is being learnt without hypothesizing and is not designed out of a prior theory. Furthermore, Beck (1997, p. 265) contends that at the outset, for (some) research, the state of knowledge that is known at each juncture of data collection experience is impossible to predict in terms of its trajectory. In the background of qualitative research lies volumes of individuals' opinions that are freely and unpredictably expressed; and which may contain vital data in research. In the current case, reactions to posts via Tweeter and Face book or a Chat or discussions by friends on WhatsApp may generate data that can either qualify some existing theories or produce new data that disqualifies the same. It is the voluntary comments and observations, some of which were not posted or expected by the researcher, that form the bulk of data in an emergent design. This is the very basis of grounded theory; analyzing data, getting to know the participants, generating themes, seeing questions and answers and keenly observing as old or new theories emerge. Observation was a central data collection instrument with sites like Face book, Twitter, and WhatsApp. Some of the terms critical in the research were netiquette, patient privacy, social media, student behavior +internet. The following tools were also applied in data 64 Journal of African Studies in Educational Management and Leadership
collection: observation of response to some slightly adapted coursework materials in Human Technology Interface, keeping a tab on three subscription social networking groups' sites and postings on social media: Twitter, Face book, Google+, YouTube, Instagram, Pinterest, LinkedIn and blogs. Popular social media was searched for terms and conditions for users and providers. Search on institutional policies on information technology was also done. The greatest resources were high volume platforms with possible youthful users. Regular referrals to links and hints as offered by those who got interested in posts relevant to the study were done at intervals. After visits on students' favorite sites and applications on social media, relevant data was analyzed and a draft produced. The original draft was then posted in the library notice-board in the School of Health Sciences, University of Kabianga for about four months. Substantial feedback including direct quotes was received from students in the Nursing Sciences, Environmental Health, Information Technology and Clinical Medicine disciplines. No attempt was however made to analyze for content. Concepts in social media
According to Lenhart and Madden (2007), in the Pew Internet American Life Project study on social networking and teens, a social networking site is viewed as an online location where a user can create a proﬁle and build a personal network that connects him or her to other users. It allows people with similar interests, profiles or other commonalities, to share ideas and get connected. The website knows the user's personal details like friends, likes and connections. A lot of reports have shown that social media Simon Macharia Kamau, Khadiala Khamasi & Margaret Kamara Kosgey 65 which includes message boards, blogs, microblogs and social networking sites tends to break down the walls of client-provider communication, improve access to information and provide a new channel for peer-to-peer communication among colleagues, consumers and family members. It also helps providers develop meaningful relationships that provide emotional support for people undergoing difficult situations in life, establish communities with similar interests, and empowers participants to achieve their objectives with online peer support. There are reports that have identified best practices recommendations for implementing wide-spread use of social media within the healthcare industry (Fierce Health, 2013). Currently, it is trendy that one connects with colleagues and gets updates about all their class work through a fan page. Many institutions (including most universities), organizations and interest groups make social media communities with social media links. Many provide links to a Facebook fan page to get frequently updated polls, photos and, links to news, and discussion issues and also get to view posts and answer questions, write blogs, feeds and connect with others. The Twitter facility especially, has a better utility value in getting up-to- the-minute information about a fast developing topic of interest. Netiquette is the correct way of using the internet. It governs what conduct is socially acceptable in an online or digital situation (Wikipedia). Though there might be variation between what is considered acceptable behavior in various professional environments, this review focused on the generic aspects as well as what concerns the health sciences. 66 Journal of African Studies in Educational Management and Leadership
Our take was that students were learning social etiquette from social internet use. The assumption was that they also have learnt to switch their thinking and behavior as users of the internet and as health professionals when dealing with patients' confidentiality. Face book as a social utility connects people with friends and others who work, study and live around them , enabling them to upload photos, share links and videos, and allow people to learn more about the people they connect with. In Face book, people poke each other through Wall: a forum for friends to post comments or insights about each other. Basically, tag is a special type
of link to someone's timeline on social media where anyone can add a link to a story and anyone, even potential foe, can tag another in anything while Links are paths of . By the time one manages to block such people (some people are unaware or may not bother) they might have siphoned so much of your personal information. Security while online
Basically, electronic dependency is well illustrated by widespread use of devices like Smartphone, Tablet, Thumb drive, iPad or a laptop, with each device serving a different or complementary purpose. One respondent explained it thus: Simon Macharia Kamau, Khadiala Khamasi & Margaret Kamara Kosgey 67 In case one was stolen or lost, I'm losing just the physical hardware. My data is on my office desktop and backed up to a local hard drive and to the cloud, using Carbonite or For the sake of such security, synchronizing of data becomes necessary leading to a host of security risks . Even well-meaning computer users can be their worst enemies because they fail to follow basic safety principles like; not using firewall where necessary, not updating antivirus, and not using a strong password/user's identity or user name or changing it regularly or take safety precautions like locking devices from unauthorized access while connected to a network domain or even reinforcing security by pressing a quick Windows logo key +L on the keyboard. Serious things can also happen by failing to log out because a determined hacker could access the information on your computer/mobile device if it was left unattended, or if one was negligently sharing files. One also needs to beware rogue applications (apps) on Internet. Some sites and apps that use instant personalization will have partnered with social media sites and might be able to receive your User ID and friends list when you visit them. For instance Xperia, Wordpress through Face book will receive information regarding your public profile, friends list, website, email address, groups and photos. Observing safety thus becomes individuals' responsibility though apparently majority of students hardly take such precautions or they are unaware of this fact. In keeping touch with colleagues they share information that is later distributed in such circumstances. It is clear therefore that available options are few as noted by Gitau (2013). Though Hotline gives young people the anonymity or guaranteed 68 Journal of African Studies in Educational Management and Leadership
confidentiality that most of them need (even though a referral tracking mechanism exists to follow up those linked to establish service utilization), in order to discuss otherwise embarrassing and or difficult topics, one needs to be just careful. Challenges and Issues of integrity
A major vice in social media use revolves around integrity. One Catherine Mbau, a Counselling Psychologist with Arise Counselling Services Nairobi, was quoted in EveWoman, Standard, Saturday 15th March, 2014, saying that the cyber bullies know what to say, how to say it; so that it has the right impact. In the report accompanying this, a number of Kenyan women celebrities had been targeted using the vilest of words. It usually started with a friend warning you that there is something about you that is trending online, and you go out to check the virtual environment, only to discover that you are ‘faced with a barrage of vitriol online'. Sometimes social media goes crazy over trivial or sensational issues that go viral. The term ‘go viral' is used for a rapidly spreading Internet message. More and more people go for something trending out of curiosity. The same scenario can be possible in discrediting individuals in the practice of medicine or in student relationships like during students' council elections. Though tracking can mean possibilities for identity in theft, co-locate view ‚snooping‛, view updating (even distorting) postings, block automated annotations or amended feedbacks to the subscriber, the damage is already done and blackmailers may use the same information for extortion( Gunther, 2011). More damage comes when individuals ignore warning alerts from service providers, or when hackers claim the role of service Simon Macharia Kamau, Khadiala Khamasi & Margaret Kamara Kosgey 69 providers. This warning message (details disguised for privacy reasons) was sent to an FB subscriber: We detected a login into your account from unrecognized device on Tuesday May13 at 9.25pm. Operating system; Windows 7. Browser IE, Location Nairobi, 110, KE ( IP this and that number). Note: Location is based on internet service provider…If this wasn't you please secure your account as someone may be accessing it. From the FB security They further caution against responding to requests to provide login information through email. Such are the issues that are either blushed aside by students or the students live in ignorance of them. Over-trusting technology does not therefore guarantee information being received as it was originally posted. To try and counteract challenges; the Kenya Government on 24th June, 2014 launched a Cyber-Security Coordination Centre to deal with escalating cyber-crime. The situation does not however seem to change things much for new tricks keep emerging (Gunther, 2008). Peer Pressure
In the research findings, many students admitted that they find more fulfillment in reading and sending hundreds of trivial and utterly dispensable messages; even from those they see frequently in F2F (face-to-face) situations, chatting or tweeting back an FOAF [friend-of-a-friend] or virtual friends site etc. Social networking sites worked because for them, especially, it is important to be visible, since there is a considerable social and peer pressure for youth to be present and to have a ‘positive' reputation on 70 Journal of African Studies in Educational Management and Leadership
such sites. Some students shared how they engage "war story" competitions to prove how they are this or that and to exonerate themselves from this and that allegation. One seasoned user was convinced that, ‘Battles can be won or lost on social media'. They would also share hints on how to get away with certain behaviors. How intimate these forums can actually get is another issue altogether. In a case of rating by exploring serious engagements in ‘sharing stuff', one youth poked another ‘… you got 5000 friends, how many inbox have you ever read from one of them?.is FB just for adding new friends so that you can be a celebrity, is socializing all there is to it?' Alongside such an insight there is more to the social exchange on media than the necessity to communicate constructive views, opinions and ideas. According to the students, young people regularly use social media to network, communicate or just to have fun. Social media and Internet for that matter make the knowledge of the world available to all and consequently deprives the teachers of their competitive advantage over their students; kind of eroding their authority. It has its fair share of negatives including trending hate speech as was witnessed during the post- election violence in Kenya in 2008 due to divergent political dispensation. Fun and entertainment and the cheer pursuit of hobbies were actually cited as carrying the bulk of social media focus among the students. This scenario is equivalent to what is presented in the world of soccer. For instance, 35.6 million real time Tweets were recorded during the telecast Semi-final 2014 FIFA World Cup match between Brazil and Simon Macharia Kamau, Khadiala Khamasi & Margaret Kamara Kosgey 71 Germany (results Germany 7: Brazil 1) making it the most-talked-about, most-discussed single sport ever on the social network (CBSNEWS, 07.00HRS, 9th July, 2014). Though viewed as trivial, during such seasons students may take lots of time betting, jeering the failure of opponents or cheering in jubilation on success of a team of their choice. During such moments, academics or medical practice exchange gets obscured. During academic endeavor, the same scenario is presented in medical studies. It was revealed that it was possible to share PubMed results via social media. One advertisement from Health Sciences Library ran thus: ‘<find a study you want to share on Twitter, Face book or Google+? Use PubMed's new social media sharing links! Simply search, find a result worth a share, then look for the sharing links below the abstract'. In such a case, for the entrepreneur minded, participation is meant for entrepreneurship; it's to "market" oneself. Others are for financial gains where users engage in gambling or accumulating some bonus of a Privacy Issues, Likes and Dislikes on Social Media
Some FB default settings last revised on November 15th, 2013 and available at thanks to the new ‚Graphic app‛, reveal that any person on Facebook anywhere in the world can see a profiler's ‘photos', ‚likes‛ and ‚comments‛. The policy says in part that, ‘<will be accessible to anyone who uses our APIs such as our Graph API' . Actually, API allows for unrestricted public access. Sources from Google Cloud platform indicate that even Cloud Storage can be accessed with a simple API, and one is 72 Journal of African Studies in Educational Management and Leadership
advised to add advanced features for some flexibility and power regarding what one would wish to expose or not Therefore, knowledge of such advanced features is crucial in the effective use of such For confidential information, privacy that is provided by advanced security is also not secure enough to guarantee privacy. For example, an advertisement by runs; ‘You ca n unblock popular social networking sites such as MySpace, Bebo, Face book, YouTube, Orkut, Friendster and many other sites'. Posts like‘Feel free to browse 24/7 and don't forget to tell your friends!' are common phenomena in social sites and many of the users tend to take the literal implications of such adverts with little insight into the repercussions. This was what one profiler self- updated recently. ‘My total profile views today: 132. Male Viewers 62, Female Viewers 70'. Apparently amazed, she went on to write, ‘I can't believe that you can see who viewed your Profile! One can only guess what else she might have shared in ignorance of the existing connections. However, for others, wide use and knowledge will lead them to adverts like one available atthat runs thus, ‘To See Who Visit Your Profile<'that obviously empowers the user about the openness of communication channels. Even in sites believed to be private, where profile owners may feel their audience are not public, the scenario does not change much. Given the large number of such profiler's friends/users who in-turn have other friends, this notion of privacy too is just Simon Macharia Kamau, Khadiala Khamasi & Margaret Kamara Kosgey 73 contextual. Still, there are the Page Administrators who may have access to insights data. Once someone is in a Group, anyone in that Group can add one to another subgroup (as invitee). One student confidentially expressed how it was possible to use tools like Jing, join-me which are free programs to record your screen and transmit a ‘live' screen to someone waiting for it on the other side. The effect can be exponential and fatal. This is this kind of scenario that makes medical school students vulnerable regarding ethics in medicine because they assume conversations are private while in actual facts they are shouting out to the world. For clients whom we serve in the various disciplines, their privacy in the media is not contextual; it is concrete, unyielding and unforgiving. If one posts something about a client (or about anything else) using a social media plug-in and one does not see a sharing icon, one should assume that the story is public. Positively, Clicking on like tab to a post might literally just mean anything from then onwards but generally what keeps the algorithm of social media alive and going is when you keep tab: like, comment or share. It increases the chance of it posting back (newsfeed) to you. Google+ offered a privacy tip that read as follows: Protect your info. Remove your email signature before you reply to a post on social media. As Mitrano (2006) asserts, as long as one goes on social media, it is to be assumed therefore that one chooses to represent themselves publicly and that one has absolutely no expectation of privacy. Indeed, BBC in the episode World Have Your Say has been running this agenda ‘Should people have the 74 Journal of African Studies in Educational Management and Leadership
right to delete online material about them?(Tue May 13, 2014 17.06 Health Sciences Students' Views
It was clear from the students' comments that social media is both convenient and compelling but medical educators had not informed students that posting patient's information may lead to serious, unintended, and irreversible long term consequences that may infringe on professional ethics in the medical field by posting of content that may violate a patient's privacy. This is unique to the fields of health care professionals, whose roles and their attendant responsibilities continue beyond the end of a shift or training session for that matter. Students were not aware of gross violations in their social media use and netiquette that might lead to dismissal from training, or later affect one's licensure and practice in the country or elsewhere as observed by Gunther (2008). Netiquette audit trail has become a reality among some potential employers where a human resource person on the hiring committee might decide to look you up on the Internet and find what they might consider ‘inappropriate posting' to discredit a candidate in an interview. Medical Ethics and Social media
Simon Macharia Kamau, Khadiala Khamasi & Margaret Kamara Kosgey 75 In real life situations, issues of health happen to be very personal and highly confidential in the medical practice. Certain situations leave medical staff at crossroads where a patient (or a client for that matter) might wrongly believe that a mistake had been made because they themselves misinterpreted their data, only to retract and begin clarifying the meaning and contents later. Interestingly, according to Goldman (1999) a patient has the right to control information about self, even after divulging it to others and no one should divulge protected health information. This poses challenges to potential medics because one has no control of what others do or say in instinctive response to situations. Think about this: - how can you protect a patient's privacy when they themselves posted or shared their information through social media? There is an ethical requirement to educate patients on the need to protect their own information (Freedman et al., 2009; Lucila, 2013). This is what a few students expressed: It is hard when families feel attached to you and want to keep you updated (via social media off course) on the patients progress and in turn you are curious as to how they are I worked with cancer patients for a few months and you develop such an attachment to the kids and families that it is hard to not want to stay in touch and updated'. Hospitals need to have rules against "friending" patients through social media or posting status updates with any type of identifying factors. I have issues with staff contacting patients in social media. That seems to be breaking a professional confidence. Also probably depends on who made the first contact. 76 Journal of African Studies in Educational Management and Leadership
This expresses the helplessness of students in medical practice where one has to balance between professionalism and the humane response to patients and afflicted families' distress calls that will obviously expose details of patients' illnesses. On a lighter note, one's own privacy as well as that of the patient ought to be more or less your concern too. One has to be careful about what identity they create for themselves online, how they represent others, and at the very least, be sure that they take their feelings into account. No one is too small and low profiled, to escape the attention of the ‚bad guys‛ who run cyber-attacks. They can use your posting to attack your patient, organization, institution or family. Their unfortunate victims are unaware until it is too late. Conclusion
This review article impresses upon students that online social networking sites are, in essence, broad communities with a public audience. Information that one may have posted or disclosed on the Internet often is ephemeral; enjoyed only for a short time. However, it would be good to be aware of the fact that the web is invincible, it is impossible to ignore the effects of social media on communication as identity is often permanently archived and might remain accessible long-term to others as Skiba( 2007) puts it: ‘It would be good to familiarize oneself with professional/ethical considerations as well as ethics/privacy/confidentiality laws as applied in Laws of Kenya or elsewhere like the National ICT Policy 2005, the Kenya Communications Act 1998; the Kenya Communications Regulations 2001, Kenya Communications Amendment Act (KCAA 2009), just as the US has the HITECH Act 2009. Simon Macharia Kamau, Khadiala Khamasi & Margaret Kamara Kosgey 77 The Kenya Information Communication Act 2012 criminalizes publishing of obscene information about a person. It would be good to know what constitutes sharing information in good faith and in which contexts. The rules governing the legal responsibilities of users and related policies and guidelines will demand caution to avoid bleach of confidentiality (Murungi, 2013). Even if consent was obtained by patients and clients or social media users, documentation may still not be legally defensible as practice like photo editing has been used to de-identify the patients through face blocking. Therefore, legal and ethical considerations in online portrayals ought to be prioritized (Freedman et al, 2009; Alana 2013) and protecting patients through good data security practice be a must . Penalties regarding malpractice can lead to investigation of reports of inappropriate disclosures on social media and if allegations are found to be true, victims can face reprimands, sanctions, fines, or temporary or permanent loss of their medical license (Logacho, 2014). Morals in such cases should be a guiding factor as one needs to think of the physical space in presentation and interpretation of the posts one makes as put by Mitrano (2006),'don't say anything about someone else that you would not want said about yourself'. Ones' health is private and a medic needs to understand that and limit sharing medical details of patients via the media. As many students' comments alluded, students of medicine need to be loyal, and uphold integrity as put by Shea, (1997) who also claims: ‚when someone makes a mistake, be kind about it. If it's a minor error, you may not 78 Journal of African Studies in Educational Management and Leadership
need to say anything. Even if you feel strongly about it, think twice before reacting. Moreover, having good manners yourself doesn't give you license to correct everyone else. Guidelines on internet safety are a must read to enhance practice . There is need to think of long term repercussions of social media use. There is need for review and development of national, university and institutional policies on social media to identify best practices since social media research is a vast field with a lot of emerging issues that constantly point to gaps in current knowledge. A similar review addressing other disciplines and circumstances would be interesting in order to enhance social media use. For individuals whether one is looking for a new job, or retaining a current position, it's important to take a few steps to ensure that everything out there including the social profile is in line with the image one wishes to project for viability in appointments and promotion. One should take down anything that does not show one in the best possible light. As an individual, one should be free to venture into the world of social media but make a deliberate choice to separate work and leisure; to use social media as a leisure activity if need be but not to debrief about work in the hospital.
Simon Macharia Kamau, Khadiala Khamasi & Margaret Kamara Kosgey 79 Any guidelines or advice suggested in this paper are only meant for the discussions
here in and not legal advice.
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Education Perspectives.28 Slatalla, M. (2007, June 7th). ‘omg, my mom joined Facebook'. The New York Times, Simon Macharia Kamau, Khadiala Khamasi & Margaret Kamara Kosgey 81 See Who Visit your profile' (2014, Jan 6). Retrieved: US Customs & Border Protection (USCBP). (2014, March). Retrieve Xperia. (2014, Feb). ‘To Check Who loves you'. RetrievBest (2013).Retrieved: About the authors:
Mr. Simon Macharia Kamau teaches at University of Kabianga, Kericho, Kenya. Holds an MSc Nursing Leadership and Health Systems Administration (University of Colorado Denver), BSc Nursing (Moi University). He is a doctorate student health systems option at The University of Nairobi. A member of KAEAM. Online URL link: Ms. Khadiala Khamasi is currently a Masters student at Moi University School of Public Health. She has a BA in Psychology. She is interested in Qualitative research, health promotion and studies in the area of Social Networks. Ms. Margaret Kamara Kosgey is a lecturer at the University of Eldoret, School of Education. She holds a Master of Philosophy from Moi University and is currently a PhD candidate. Previously, she served as a high school teacher and deputy principal.
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