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Adoption of Health Information Systems by health workers in developing

countries — Contextualizing UTAUT

Conference Paper · January 2013

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IST-Africa 2013 Conference Proceedings
Paul Cunningham and Miriam Cunningham (Eds)
IIMC International Information Management Corporation, 2013
ISBN: 978-1-905824-39-7

Adoption of Health Information Systems

by Health Workers in Developing
Countries ± Contextualizing UTAUT
Josephine KARURI1, Peter WAIGANJO1, Ayub MANYA2
1
School of Computing & Informatics, University of Nairobi, Box 30197, Nairobi, Kenya
Tel: +254-20-4447870, Email: joskaru@yahoo.co.uk, waiganjo@uonbi.ac.ke
2
Ministry of Public Health and Sanitation, P. O. Box 30016, Nairobi, Kenya
Tel: +254-20-2121250, Email: ayubmanya@yahoo.com
Abstract: Kenya recently implemented the web-based DHIS2 system as the national
Health Information System (HIS) that will facilitate effective management of health
information from health facilities in the country. For maximum benefits to be reaped
from this implementation, it is important that the DHIS2 gains acceptance from all
categories of targeted users. This paper describes a research model that has been
adapted from UTAUT to explain the factors that are hypothesized to affect adoption
of DHIS2 in Kenya, and by extension the factors that will affection adoption of HIS
in developing countries context. Among other modifications, the new model extends
UTAUT by adding Computer Anxiety and Training Adequacy as important direct
determinants of intention to use and actual use of HIS respectively. Once validated,
the model will inform health policy makers and system developers on approaches
that can enhance use of HIS in developing countries context.

Keywords: Technology Acceptance; DHIS2; UTAUT; Health Information Systems;

1. Introduction
World Health Organization (WHO) defines Health Information System (HIS) as ³a system
that integrates data-collection, processing, reporting and use of the information necessary
for improving health service effectiveness and efficiency through better management at all
OHYHOVRIKHDOWKVHUYLFHV´ [1]. However implementation of HIS in developing countries is
often fragmented and ill-managed, leading to weak systems that provide inaccurate,
incomplete and untimely information [2]. Increasingly ICT is being applied in management
of national HIS and this is expected to improve the efficiency and effectiveness of such
systems, and hence lead to availability of the quality health information necessary for
efficient monitoring, evaluating and delivery of healthcare services and programs in
developing countries [3]. For the purpose of this study the term HIS is considered
synonymous with ³computer-based HIS´. Despite increasing implementation of ICTs in
health, healthcare professionals have been reluctant to accept and utilize such systems,
causing concerns that the expected benefits may not be realized [4]. Understanding the
factors that affect user acceptance of HIS in developing countries will inform policy makers
as well as system designers and implementers in these countries on approaches that will
contribute to more successful implementation of such systems. Currently there is limited
research on user acceptance and adoption of ICT in the health sector [5].
The Kenya ministries of health and their stakeholders have, over the last five years or
so, been engaged in a rigorous process of restructuring the national HIS. This process has
resulted in the development and adoption of a national health information policy document

Copyright © 2013 The authors www.IST-Africa.org/Conference2013 Page 1 of 8

as well as the detailed Strategic Plan for Health Information Systems (2009 ± 2014). As in
other developing countries, Kenya faces many challenges in implementing ICT in health,
ranging from ICT infrastructure challenges, lack of the adequate ICT skills among health
professionals, economic challenges, as well as other social and political issues.
Nevertheless between March and December 2011 Kenya undertook the successful
implementation of a new national HIS system, the DHIS2, for use at public health facilities
throughout the country. The web-based, free and open source DHIS2 is intended to capture
health facility service delivery data and allow analysis at that level, thus promoting data use
at all levels for decision making [6]. For the country to reap the expected benefits from
DHIS2, it is important that the system gains wide acceptance from the targeted users. A
review of the literature indicates that one major factor leading to failure of systems
implementation is the inadequate understanding of the socio-technical aspects of
information technology, particularly the understanding of how people and organizations
adopt ICTs [7]. This paper presents a model that has been developed as part of a broader
study to evaluate the individual, technology and organizational factors affecting user
acceptance of DHIS2. It describes the theoretical basis against which constructs and
relationships that comprise this model have been selected, the methodology to be used in
verifying the model and the research and business contributions expected from the study
results.

2. Objectives
The overall objective of this research is to adapt UTAUT, a technology model with proven
success in predicting user acceptance, to evaluate the factors that affect acceptance and use
of a national HIS by healthcare workers in developing countries.
The specific objectives of the study will be to:
1. Establish the key factors that influence acceptance and use of HIS in Developing
Countries, and specifically for the Kenyan public health sector.
2. Design the model that will explain the acceptance and use of DHIS2 by health workers
in the public healthcare sector of Kenya ± the model will be adapted from the UTAUT
structural model.
3. Gather primary research data and use structural equation modeling (SEM) to
empirically validate the research model and the associated hypothesis.

3. Research Methodology
This study will be conducted primarily through the use of quantitative methods, but
qualitative data will be collected to provide background and contextual information with
regard to the implementation of HIS and DHIS2 in developing countries. A correlational
study design will be used to determine the existence of relationships between the dependent
and independent variables in the conceptual model. A detailed description of the study
phases is provided below.

3.1 Phase I: Model Adaptation

Phase I involves the comprehensive review of existing literature related to health

technology adoption and implementation, especially in the developing country context.
The process of implementing DHIS2 in developing countries will also be reviewed. The
model for explaining acceptance and use of HIS by health workers in developing countries
has been developed based on the knowledge acquired in this phase of the study. Twelve
hypotheses have been derived from the model and these will be empirically tested in a
separate phase of the study.

Copyright © 2013 The authors www.IST-Africa.org/Conference2013 Page 2 of 8

3.2 Phase II: Key Informant Interviews

In this phase qualitative data will be gathered through key informant interviews with 15 ±
20 informants drawn from DHIS2 implementers, users and other stakeholders. The
information gathered at this stage will be used to refine the research model and data
collection tools in order to make them more relevant to the context of health information
management in Kenya. A topic guide with open ended questions will used to guide the
discussions and collect information around key themes touching on acceptance and use of
'+,6LQ.HQ\D¶VKHDOWKFDUHVHFWRU.

3.3 Phase III: Pilot Testing, then Cross-sectional Survey

This phase will start with pilot testing of the survey instruments to identify and address
potential problems, and thus develop the final version of the tools to be used in the wider
cross-sectional survey. Subsequently the survey will be administered to four participants
associated with each of the sampled health facilities to provide cross-sectional data on
current usage, behavioural intention and acceptance of DHIS2, as well as on other factors
surrounding utilization of ICT in public healthcare setting. The resulting quantitative data
will be used to establish the statistical reliability and validity of the study tools, and
empirically test the research model and the associated hypotheses.

3.4 Phase IV: Data Analysis and Contextualizing the Research Findings

The descriptive analysis of the survey data will be performed using SPSS statistical analysis
tool for the purpose of obtaining the frequencies, means, and confidence intervals, and
medians and inter-quartile ranges for non-normally distributed data. This study will also use
Structural Equation Modeling (SEM), and specifically Partial Least Square path modeling
(PLS), for analysis of the conceptual model and testing of the hypothesis. In drawing
conclusions from the study, reference will be made to the background contextual
information earlier obtained from literature review and the qualitative data.

4. Technology Description
Research on user acceptance and use of technology has over the years generated many
competing models originating from different theoretical disciplines such as psychology,
sociology and information systems, each comprising different sets of determinants. Models
based on social psychology perspective focus on the determinants of behavioural intention,
which serves as predictors for technology usage or acceptance. Venkatesh et al [8]
developed the UTAUT model by combining items from eight prominent technology
acceptance models based on their effectiveness in predicting anticipated and actual system
use behaviour. The 8 models are: Theory of Reasoned Action (TRA) [9]; Technology
Acceptance Model (TAM) [10]; Motivation Model (MM) [11]; Theory of Planned
Behaviour (TPB) [12]; Combined TAM and TPB [13]; Model of PC Utilization (MPCU)
[14]; 5RJHU¶V,QQRYDWLRQ'LIIXsion Theory (IDT) [15]; and Social Cognitive Theory [16]
With integration of the eight models, the predictive power of the hybrid UTAUT model
was increased to 70% which is way above the value for each model separately. UTAUT
has four constructs which are considered to be the direct determinants of behavioural
intention and subsequent use of technology. These four core determinants are:
x Performance expectancy - GHILQHG DV ³WKH GHJUHH WR ZKLFK DQ LQGLYLGXDO EHOLHYHV WKDW
using the system will help him or her to attain JDLQVLQMRESHUIRUPDQFH´
x Effort expectancy - GHILQHGDV³WKHGHJUHHRIHDVHDVVRFLDWed with XVHRIWKHV\VWHP´

Copyright © 2013 The authors www.IST-Africa.org/Conference2013 Page 3 of 8

x Social influence - GHILQHGDV³WKHGHJUHHWRZKLFKDQLQGLYLGXDOSHUFHLYHVWKDWLPSRUWDQW
RWKHUVEHOLHYHKHRUVKHVKRXOGXVHWKHQHZV\VWHP´
x Facilitating conditions - GHILQHGDV³WKHGHJUHHWRZKLFKDQLQGLYLGXDOEHOLHYHVWKDWDQ
RUJDQL]DWLRQDODQGWHFKQLFDOLQIUDVWUXFWXUHH[LVWVWRVXSSRUWXVHRIWKHV\VWHP´
Venkatesh et al (2003) emphasized that most of the key relationships in UTAUT model
are moderated by gender, age, experience, and voluntariness of use.

4.1 Previous Applications of the UTAUT Model in Health

There has been limited application of UTAUT to study acceptance of technology in the
health sector with varying results, however very few of these studies have been in a
developing country setting. Nuq [17] used a model adapted from UTAUT in a study to
identify the motivational factors that would expedite the widespread use of eHealth services
in developing countries. The study provided evidence that performance expectancy,
government policy, social influence, medical education and knowledge positively impact on
behavioural intention. Chang et al. [18] examined physicians' acceptance of a decision
support system and supported the important effect of Performance and Effort Expectancy
on Usage Intention and actual use. In their study on acceptance of health ICTs among
healthcare workers in Thailand, Kijsanayotin et al. [5] demonstrated a positive impact of
facilitating conditions, experience, and intention to use health IT in a developing country
context. This study however looked at ICT in general, rather than examining acceptance of
a specific health information system.

5. 'HYHORSPHQWRIWKLV6WXG\¶V&RQFHSWXDO Model
The conceptual model illustrated in figure 1 has been developed with constructs derived
from an understanding of previous technology adoption models as well as understanding
the role of HIS in developing countries. This model shares some of the constructs of
UTAUT model; however it also includes other constructs and moderators that have been
found relevant to the developing country context. This section justifies the selection of the
model constructs and explains the derivation of the associated hypothesis.

Training
Computer Anxiety Adequacy

Performance
Expectancy

Effort Behaviour
Expectancy al Intention Use
Behavior

Social
Influence

Facilitating
Conditions

Gender Age Computer Voluntariness

Experience of Use

Figure1: Conceptual Model for User Acceptance of HIS in Kenya: (Adapted from UTAUT)

Copyright © 2013 The authors www.IST-Africa.org/Conference2013 Page 4 of 8

 Agreeing with Chau & Hu [19] that technology acceptance has individual, technological
and organizational GLPHQVLRQVWKHSURSRVHGPRGHO¶VYDULDEOHVKDVDOVREHHQJURXSHGLQWR
the 3 contexts. This section describes the model components and provides theoretical
justification for the selected hypotheses.

5.1 Individual Context

At the individual level, UTAUT suggests that computer anxiety does not exert a significant
influence on behavioural intention, due to its effect being captured by the existence of effort
expectancy [8]. However, considering that the subject of this study are health workers in a
developing country who may have had limited prior exposure to computers and ICT in
general, it is possible that many have a high level of anxiety toward use of computer
technology which will significantly influence their intention to use DHIS2. Thus the
following hypothesis is proposed:
x H1: Computer Anxiety will have a negative influence on user intention to use DHIS2
Other factors are captured in the variables of gender, age, and computer experience.

5.2 Technological Context

Technological context determinants included in the proposed model are performance

expectancy and effort expectancy. Studies on user acceptance of technology have shown
WKDW SHUFHSWLRQ SOD\V D NH\ UROH LQ DQ LQGLYLGXDO¶V HYDOXDWLRQ RI D WHFKQRORJ\ DQG
subsequently on their decision to accept it or not. Thus the user perceptions rather than
actual technology attributes contribute more to their technology acceptance decision [20].
The significance of performance expectancy to technology adoption by health
professionals has been consistently demonstrated in previous studies [5], [21] and it is thus
incorporated in the model. This study hypothesizes that:
x H2: Performance expectancy will DIIHFWWKHKHDOWKZRUNHU¶VLQWHQWLRQWRXVH'+,6
In contrast to technology acceptance studies in other environments, health sector studies
suggest that effort expectancy has no significant influence on intention behaviour in the
health professional context [22]. The focus of these studies was mostly physicians known to
operate autonomously, whereas the focus of this study includes various categories of
healthcare workers who may not possess such autonomy. This study supports UTAUT and
postulates that effort expectancy will play a significant role on user acceptance of DHIS2.
x H3: Effort expectancy will positively affect the health wRUNHU¶VLQWHQWLRQWRXVH'+,6

5.3 Organizational Context

The specific professional environment of the user as outlined in the research model includes
the determinants of social influence and the organizational facilitating conditions.
The impact of social influence on behaviour is through compliance, internalization and
identification which cause an individual to alter their belief structure or intentions [21]. A
study examining physician adoption of internet-based health applications [22] found social
influence insignificant in their adoption decisions. However the health workers targeted in
the current study may not operate as autonomously as those physicians and, as in other
African countries, the culture of communalism is quite dominant in Kenya. It is thus
plausible that social norms and pressures will be significant in determining their technology
acceptance decisions, and hence the following hypothesis:
x +6RFLDOLQIOXHQFHZLOOSRVLWLYHO\DIIHFWWKHKHDOWKZRUNHU¶VLQWHQWLRQWRXVH'+,6
Organizational facilitating conditions incorporates objective factors in the
implementation context such as infrastructural adequacy, management and system support,

Copyright © 2013 The authors www.IST-Africa.org/Conference2013 Page 5 of 8

and these have been found to be relevant in studying adoption of health information
systems [5], [23]. In the developing country setting, the availability of the pre-requisite
organizational and technical infrastructure to support use of a newly introduced technology
is not guaranteed. The degree to which these facilitating conditions are present will
influence the intensity with which a new technology can be used. Thus we postulate that:
x H5: Organizational facilitating conditions will not have a significant influence on
behavioural intention.
x H6: Organizational facilitating conditions will positively affect the intensity of
technology use behaviour.

5.4 Moderators

UTAUT identifies four key moderating variables that were found to significantly influence
intention and/or use behaviour: gender, age, experience and voluntariness of use.
Venkatesh et al. [8] found that the effect of social influence on intention to use differed
depending on voluntariness. In mandatory settings, social influence was a significant
predictor of intention to use, however in voluntary settings it was not. Also, even in
mandatory settings, the role of social influence diminished over time, becoming
insignificant with sustained usage of the system. Because the system under the proposed
study is mandatory for some (the Information Managers) while voluntary for others
(Facility and DHMT Managers) it will be interesting to find out how voluntariness
influences the proposed model.
The experience moderator in UTAUT was operationalized by converting aggregate data
from three consecutive time periods, however the proposed study is cross-sectional and the
XVHUV¶ H[SHULHQFH ZLWK XVLQJ '+,6 ZLOO EH PRUH RU OHVV WKe same. The study however
anticipates that experience in general use of computers will have a moderating effect on 3
of the key determinants of intention to use DHIS2. The following summarizes the expected
contribution of all the moderating conditions:
x H7: The influence of performance expectancy on behavioural intention of using DHIS2
will be moderated by gender and age, such that the effect will be stronger for men and
particularly for younger men.
x H8: The effect of effort expectancy on behavioural intention of using DHIS2 will be
moderated by gender; age and computer use experience, such that the effect will be
stronger for women and particularly for younger women, and particularly at early stages
of computer experience.
x H9: The influence of social influence on behavioural intention will be moderated by
gender; age, voluntariness, and computer use experience, such that the effect will be
stronger for women, particularly older women, particularly in mandatory settings in the
early stages of computer use experience.
x H10: The influence of facilitating conditions on the usage of DHIS2 will be moderated
by age and prior computer experience, such that the effect will be stronger for older
users, particularly in the early stages of computer experience.

5.5 System Usage

The UTAUT study found that behavioural intention has a significant positive influence on
actual usage, and this is supported by numerous other studies on technology adoption [22],
[24]. This relationship is also expected to hold in the model. In addition, because DHIS2 is
a relatively complex s\VWHPWRWKHLQWHQGHGXVHUVLWLVDQWLFLSDWHGWKDWWKHXVHUV¶SHUFHSWLRQ
of the adequacy of training received on DHIS2 will have a positive effect on actual use of
the system. Thus this study postulates that:

Copyright © 2013 The authors www.IST-Africa.org/Conference2013 Page 6 of 8

x H11: Perceived training adequacy will have a significant positive influence on health
ZRUNHU¶VDFWXDOXVHRI'+,6
x H12: Behavioural LQWHQWLRQZLOOKDYHDVLJQLILFDQWSRVLWLYHLQIOXHQFHRQKHDOWKZRUNHU¶V
actual use of DHIS2.

6. Research Contributions
6.1 Theoretical Contribution

To our knowledge this is the first scholarly research ever done using a technology model to
study the acceptance and use of a national HIS by healthcare workers. The research model
will test the constructs of UTAUT adapted for HIS solutions, and add some new constructs
that fit specifically within the developing country setting. This will lead to validation of
UTAUT model for application in undertaking HIS studies in developing countries.

6.2 Contribution to HIS systems Development and Implementation

Once completed, the research will enhance knowledge on adoption and use of a national
HIS by the targeted healthcare workers; and of the factors affecting their ICT acceptance in
general. This knowledge will guide HIS systems developers in coming up with more
effective and acceptable systems for implementation in developing countries. Interventions
to address any identified barriers to the HIS acceptance and use can also be formulated,
paving way for more successful future implementations.

6.3 Contribution to Health Information Policy in Kenya and the Region

Kenya identifies the need to strengthen health information systems to enable her provide
adequate information for monitoring health goals and empowering individuals and
communities with timely and understandable information on health. One of the ways in
which the Ministries of Health are attempting to bridge the HIS adequacy gap is with the
introduction of DHIS2. Results from this study will allow these Ministries to proactively
design and target interventions to increase the success of DHIS2 implementation as well as
of other new health ICTs in the country. This is particularly pertinent given the
JRYHUQPHQW¶V substantive work in developing an e-health strategy for Kenya.

7. Conclusions
Most of the existing scientific studies on acceptance and use of technology done in
developed country settings do not seek to understand acceptance of a national HIS in any
context. The model described in this paper will bridge these gaps by studying the factors
influencing acceptance and use RI+,6E\KHDOWKZRUNHUVLQ.HQ\D¶VSXEOLFKHDOWKIDFLOLWLHV
When fully developed, tested and validated, the model will both explain the current
situation in terms of HIS adoption in a developing country context, as well as provide
significant contribution to the scientific understanding of acceptance and use of technology
in healthcare setting by extending the UTAUT model. The outcomes of this study will also
provide practical suggestions to system developers and implementers on interventions that
can lead to more successful HIS deployment; and inform policy makers on strategies to
proactively design and target interventions to increase the success of new health ICTs.
Future work for this study includes collection of primary data and analyzing it through
structural equation modeling to validate the model and test the associated hypothesis. The
study can also be further extended and validated in other developing country settings as
well as in other sectors of these countries.

Copyright © 2013 The authors www.IST-Africa.org/Conference2013 Page 7 of 8

 Acknowledgement: The authors gratefully acknowledge AfyaInfo National HIS project through Dr. Martin
Osumba for their ongoing support.

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