Testing Integrative Technology Telemedicine Acceptance Models Among Ethiopian Physicians

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Testing Integrative Technology (Telemedicine)
Acceptance Models Among Ethiopian Physicians

• Mengistu Kifle
• Stockholm University, Sweden
• Victor Mbarika
• Southern University, Baton Rouge
• Fay Cobb-Payton
• North-Carolina State University

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SSA in Context

• Accounting for over ten percent (approximately
  633 million) of the worlds population, the 49
  countries that comprise sub-Saharan Africa are
  demarcated by their geographical location, and
  representing 33 of the 48 poorest nations of the
  world
• Sub-Saharan Africa begins immediately south of
  the Sahara Desert below the Tropic of Cancer
  (latitude 23½º N) through the Equator up until
  35º South, just north of South Africa.
• The region we call Sub-Saharan Africa in this
  paper consists of typically low-income countries
  suffering from long-term constraints against
  growth.
• low levels of human resource development
• severe structural weaknesses economic, social,
  and political.

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SSA Healthcare Status

• Healthcare is unarguably one of the most
  fundamental needs for sub-Saharan Africa
  considering the regions multiple medical
  problems.
• The SSA region represents the least developed
  regions of the world in terms of most dimensions
  and indications of healthcare provisions (WHO
  2001 Mbarika 2004).
• The World Health Organization (WHO) reported that
  at the end of 2003 an estimated 40 million people
  worldwide are infected with HIV/AIDS. More than
  70 percent of these people (28.1 million) live in
  sub-Saharan Africa about 60 of those with HIV
  are women.

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SSA Healthcare Status (Contd)

• Another killer, malaria, is responsible for as
  many as half the deaths of African children under
  the age of five.
• Kills more than one million children (2,800 per
  day) each year in Africa. In regions of intense
  transmission, 40 of toddlers may die of acute
  malaria.
• In most malaria cases, however, there is a good
  chance of survival if appropriate medical
  attention is provided in a timely manner
• Another problem is the shortage of medical
  personnel (See Table 1 below). Sub-Saharan Africa
  has, on average, fewer than 10 doctors per
  100,000 people, and 14 countries within the
  region do not have a single radiologist (Fraser
  and McGrath 2000).
• Ethiopia has a population of over 67 million
  people, but less than 31 radiologists in the
  entire country.

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Disparity of Medical Personnel and Resources in
Sub-Saharan Africa and other Regions of the
World
Sources World Bank 2001 World Development
Indicators World Health Organization 1998 WHO
Estimates of Health Personnel Note These are
the most recently available statistics we could
obtain from the WHO
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TeleMedicine A Possible Answer?

• Telemedicine has been identified as one of
  several possible solutions to sub-Saharan
  Africas serious medical problems (Huston and
  Huston 2000 Mbarika 2004).
• Telemedicine involves delivering health care
  using telecommunications equipment as simple as
  telephones and fax machines or as complex as
  Internet-connected personal computers with
  full-motion interactive multimedia (Huston and
  Huston 2000).

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TeleMedicine Instances in SSA

• In Senegal, three hospitals in Dakar Fann, St.
  Louis, and Djourbel are connected by ISDN, which
  allows transmission of medical images and other
  medical information. The store and forward
  method for transmitting patient data reduces
  costs.
• Ethiopian physicians use telemedicine
  technologies to schedule consultations and
  referrals, preventing long trips by ill patients
  with no guarantee of being seen and or treated by
  a physician.
• In response to a cholera epidemic in Zambia, the
  medical librarian at the University Zambia
  obtained literature from her partner library at
  the University of Florida, and then disseminated
  the information to doctors in the region. Medical
  libraries have been resourceful to many doctors
  and medical practitioners in Africa who do not
  subscribe to medical journals that discuss
  current issues which can and do help them in
  their practices.
• Malaria researchers at a remote site in northern
  Ghana used telemedicine technologies to
  communicate daily with the London School of
  Hygiene and Tropical Medicine and the Tropical
  Disease Research Center in Geneva. The same
  approach can be used to educate African-based
  doctors on many other contemporary medical
  issues, such as HIV/AIDS diagnosis, prevention,
  and treatment.

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Why Research TeleMedicine in SSA?

• Despite growth in the adoption and use of
  Telemedicne (and other IT applications) in the
  SSA region, IS research with a focus in this
  region is very rare.
• We searched the following key information systems
  journals for publications concerning sub-Saharan
  Africa MIS Quarterly (MISQ), Information Systems
  Research (ISR), Decision Sciences (DS), Journal
  of MIS (JMIS), Journal of the AIS, and
  Communications of the AIS.
• Out of over 1,800 research articles published in
  these six journals, as of April 2004, we found
  only one article (in JMIS) related to IS issues
  in the sub-Saharan African region (de Vreede,
  Jones, and Mgaya, 1999).
• Therefore, researching Telemedicine using well
  established theory bases, in the African context,
  is both relevant and interesting.

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Research Question and Hypotheses

• In this study we seek to address the question
• What salient factors would impact the adoption of
  telemedicine among sub-Saharan African physicians
  based in Ethiopia?
• Previous health care research has been keen on
  utilizing telemedicine as a technological
  innovation.
• Hu, et al. (1999) stated that telemedicine
  development can result in diverse clinical
  applications that result in desirable financial
  impacts among its user organizations.

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Research Question and Hypotheses (Contd)

• However, the issue of technology acceptance is
  not only about a technology, but also a human
  behavior.
• Bashshur (1997) stated that physicians rejection
  of this novel technology is one of the reasons
  that telemedicine implementations have failed,
  and physicians have been shown to play a critical
  role in the implementation of health care
  applications and networks (Payton and Ginzberg,
  2001).
• Perednia and Allen (1995) suggested that the
  success of telemedicine should account for
  technological advancements as well as user
  technology acceptance.
• Hence, information system (IS) research focusing
  on technological acceptance has been widely
  studied (Taylor and Todd 1995a Venkatesh and
  Davis, 1996 Jackson et al., 1997, Agarwal and
  Prasad, 1999 Venkatesh et al., 2003)
• However, few models explain technology acceptance
  in the health care domain (Wooton, 1997 Succi,
  1999 Hu, et al., 2002 Chau and Hu, 2002)

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Research Question and Hypotheses (Contd)

• The few existing IT and healthcare studies have
  typically focused on developed countries.
• Further, studies of technology in healthcare that
  focus on telemedicine are almost nonexistent
• Even more acute is that no known study has
  examined telemedicine within the sub-Saharan
  African context.
• Hence, applying technology acceptance models,
  such as TAM, which have been widely studied in
  the developed world context, to the sub-Saharan
  African context is both relevant and interesting.
  
• We, therefore, combined a modified TAM (Davis,
  1989), IDT (Rogers, 1995) and TPB (Ajzen, 1985,
  1988, 1991) theories, to address our research
  question

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Research Question and Hypotheses (Contd)

• Our proposed model combines well-validated
  constructs used in a previous study that focused
  on telemedicine adoption (Croteau and Vieru,
  2002).
• Croteau and Vieru (2002) combined constructs from
  TAM and IDT (Venkatesh and Davis, 2000 Rogers,
  1976 Davis, 1989 Moore and Benbasat, 1991).
• In addition, we also borrow from the Hu et al.
  (1999) study which is based on the TPB (Ajzen
  1991 Taylor and Todd, 1995a and1995b) and from
  the Raestone et al. (2000) study
• These studies are based on the integrated TAM and
  TPB models.
• In our study, technology acceptance is defined as
  a physicians psychological state with regard to
  her/his intention to adopt telemedicine. Because
  telemedicine in Ethiopia is still in the early
  adoption stage, we targeted both image-based
  telemedicine practices (such as in radiology) and
  patient contact-based telemedicine practices
  (such as in internal medicine).

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Integrated Technology Adoption Model
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Methodology

• We used well validated instruments from three
  previous studies (Raestone et al., 2000 Hu et
  al. 1999 Croteau and Vieru 2002) to develop our
  survey instrument, using a seven point Likert
  scale with values ranging from 1-strongly
  disagree to 7 strongly agree.
• The previously validated instruments were adapted
  to the Ethiopian (sub-Saharan African) context of
  telemedicine technology.
• Our instrument included the constructs of
• ease of use (4 items), perceived usefulness (6
  items), compatibility (3 items), image (2 items),
  self efficiency (8 items), voluntariness of use
  (2 items) and behavioral intention to adopt (4).
• These constructs were adapted from the Raestone
  et al. (2000)
• as well as the Croteau and Vieru (2002) studies.
  The anxiety (5 items), social influences (4
  items), and facilitating conditions (4 items)
  constructs were based on the Hu et al. (1999)
  study.

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Root Constructs, Definitions, and Scales
Root Constructs, Definitions, and Scales
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Root Constructs, Definitions, and Scales (Contd)
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Survey Administration

• Prior to administering the survey, we ran a pilot
  of the questionnaire among some Ethiopian
  Physicians
• Proposed revisions from the pilot test were
  integrated into the survey instrument.
• Our survey was administrated at several hospitals
  that were scheduled to implement telemedicine
  applications in the near future (6 to 9 months).
  
• We targeted subjects (physicians) from (i) a
  teaching hospital, (ii) a non-teaching hospital
  (iii) a military hospital, and (iv) a health
  post.
• We administered the surveys to 260 physicians.
• Although this number may arguably seem low by
  some accounts, it is important to note that there
  is a major limitation on the total number of
  physicians in Ethiopia.
• Further, the number of physicians in the country
  working in health centers or health institutions
  that use or plan to use telemedicine is limited.
• Out of the 260 surveys distributed, 144 were
  returned with complete responses. This accounts
  for a 55.3 response rate.

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Results
Model Path Coefficients and Significance n144
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Results of Hypotheses Testing
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• Computer self-efficacy among Ethiopian physicians
  was positively related to their perception of
  ease of use of telemedicine.
• Although computers are still very limited in most
  African countries (still at a dismal 1 per 10,000
  people), it is interesting to see that these
  African doctors prior computing knowledge
  impacts their perception of ease of use of
  telemedicine technologies. This further makes
  sense given that computers are heavily used for
  telemedicine practices (specially in visual based
  application such as radiology, dermatology,
  pathology) to view images that they receive
  mostly through store-and-forward networks.

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• Facilitating conditions among Ethiopian
  physicians was NOT positively related to their
  behavioral intention to adopt telemedicine.
• Existence of widely inadequate and scarce
  information technologies in most African
  countries explains why these African physicians
  do not really rely entirely on such technologies
  to do their jobs. Essentially, it does not matter
  to these physicians that these technologies are
  inadequate because they are willing and able to
  adjust or shift their adoption behaviors to use
  these scarce resources to accomplish the most for
  their patients. Given that African physicians
  have been used to less than par resources to
  perform their jobs, advanced or adequate
  technologies to facilitate what they do is not
  a priority hence, the saying half a pie is
  better than none. The African doctors know that
  there exist adequate technologies, but given that
  they also know their limitations to obtain to
  these technologies, they are prepared and willing
  to work with what they have.

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• Perceived compatibility among Ethiopian
  physicians was positively related to their
  perception of the ease of use of telemedicine.
• Here, the Ethiopian physicians do realize that
  telemedicine can assist them in their practices
  in many ways. This is consistent with their
  needs to reach patients especially in rural parts
  of the country. This is also consistent with
  their perceptions of telemedicine being
  well-suited with health care delivery and
  technology value. This, consequently, results in
  a high degree of significant of perceived
  usefulness of telemedicine. Hence, this results
  in behaviors demonstrating intentions to adopt
  telemedicine innovations.

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• Perceived ease of use of telemedicine among
  Ethiopian physicians was positively related to
  their perception of its usefulness.
• This finding reveals that Ethiopian doctors
  believe that if it is easy to learn and use
  telemedicine technology, then there is some
  utility to it. Hence, such a belief in ease of
  use impacts their intention to adopt
  telemedicine. These African doctors have
  developed such a belief because the telemedicine
  providers (typically from Europe and the US) have
  historically offered exceptional training and
  technical support. Further, these doctors are
  aware of the widespread use of telemedicine
  technologies in more advanced African countries,
  such as South Africa and some of the richer
  Northern African countries.

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• Image among Ethiopian physicians was weakly
  related to their behavioral intention to adopt
  telemedicine.
• In this case, the Ethiopian physicians place
  somewhat of a high value on social status that
  comes with the use of sophisticated information
  technologiestelemedicine. However, the way
  society (as well as their cohorts) views medical
  innovations is more significant to the African
  than how the individual views him/herself. This
  is deeply rooted in most African cultures which
  place a high value on individuals social status.
  Physicians and university professors are held in
  high regard as noble professions in African
  countries, and in fact it becomes a crime not
  to refer to them with their professional
  titlesDr or Professor. Hence, while practicing
  telemedicine could further place a physician at a
  higher social and professional status than
  their colleagues that do not practice using such
  technologies

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• Voluntary use of telemedicine among Ethiopian
  physicians was negatively supported.
• This finding contradicts those from pervious IS
  literature that found a positive relation between
  voluntariness of use and intention to adopt (for
  example Moore and Benbasat, 1991). Most of these
  previous studies, however, were performed in
  developed countries context. In Africa, however,
  most of the cultures dictate a high respect for
  hierarchy (bosses, immediate supervisor, persons
  older in age, etc). Thus, an individual must
  obey without question, especially if such
  hierarchy consist of a male in authority
  (although there have been recent progress in
  having females authorities in a few African
  countries). Therefore, even in the case where it
  is mandatory that these doctors use
  telemedicinesay from the Minister of Health in
  Ethiopiasuch an order will not necessarily lead
  to resistance to adopt the technology. This
  explanation is based on prevailing African
  cultures and traditions. Another explanation of
  this finding is based on prevailing
  infrastructures in Ethiopia (and other African
  countries). The acute shortage of adequate
  technology infrastructures does not provide the
  doctors too many options and so they have to work
  within their limitations. In the developed
  world, physicians have numerous choices which
  engender free will to support the voluntarily
  use of telemedicine and/or other medical
  information technologies. African doctors do not
  have this luxury of choice.

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• Social influences among Ethiopian physicians was
  weakly related to their behavioral intention to
  adopt telemedicine.
• The crux of this finding indicates that it is not
  only important to the Ethiopian doctors what
  their peers think about them, but also what the
  broader society thinks about them. This is very
  typical of most African cultures that have
  collectivism-base as opposed to an
  individualistic-based culture where it matters
  what other people think of them and their
  practice when using telemedicine technologies
  (Straub et al., 2001 Straub et al., 2002 Okoli
  and Mbarika, 2003).

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• Anxiety in the use of telemedicine among
  Ethiopian physicians was positively related to
  their behavioral intention to adopt.
• The Ethiopian doctors reported that their ability
  to be liable for mistakes/medical malpractice
  with the use of telemedicine creates anxiety in
  their use of the technology. This was in fact
  surprising given that most African countries have
  historically had very weak or almost nonexistent
  legal systems that were upheld. As opposed to the
  phenomenon in most Western countries, Africans
  rarely sue or go to court for medical or other
  damages. In fact, most Africans have historically
  not even considered lawsuits as an option. It
  could be that with the penetration of European
  and American TV via satellites, these Western
  practices are beginning to infiltrate Ethiopia
  and other African countries. The result is the
  recent growth in lawsuits among African
  countries. Such recent developments are making
  Ethiopian doctors anxious about medical
  malpractice through the use of telemedicine. It
  is important that Ethiopian telemedicine
  practices follow the DICOM and other standards
  enacted by the American Radiology Association
  that sets most internationally recognized
  telemedicine standards. Thus, Ethiopian patients
  now have several opportunities to sue physicians
  for damages.

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• Perceived ease of use of telemedicine among
  Ethiopian physicians was weakly related to their
  behavioral intention to adopt.
• In the Western context, current research suggests
  (and assumes) that existing IT infrastructures
  facilitate computer self-efficacy, which in turn
  impacts behavioral intentions to adopt. However,
  in the African context where there exist
  inadequate IT infrastructures, the physicians are
  aware of such limitations such that perceived
  ease of use is really one of the least of their
  concerns given that these basic prerequisites are
  nonexistent. This finding ties in with the famous
  psychology theory, Maslows hierarchy of needs.
  We suggest that the African doctors are mainly
  concerned with having the most basic technology
  to maintain and sustain their current practices
  that is, perceived ease of use becomes a luxury
  and not a basic need or desire.

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• Perceived usefulness of telemedicine among
  Ethiopian physicians was positively related to
  their behavioral intention to adopt.
• Ethiopian physicians believe that the way they
  view telemedicine as beneficial to their medical
  practices will impact their intentions and
  willingness to adopt the technology. It is
  important to note here that they could view
  telemedicine as important in radiology
  (teleradiology) but may not necessarily view
  telemedicine as important cardiolology
  (telecardiology) or less tele-intensive forms of
  care delivery, hence negatively impacting their
  intentions to adopt the latter.

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Concluding Remarks

• Our study does not claim that telemedicine can
  solve all of Africas medical problems. However,
  we do contend that it is a starting point to
  developing a strategy to reach populations that
  live in areas with limited medical facilities and
  personnel. Hence, our study could have far
  reaching consequences as the world looks to
  positively impact this regions medical nightmare
  by saving lives and providing more opportunities
  for SSA citizens to enjoy better health, actively
  participate in the information society, and
  provide a platform for sustainable socio-economic
  development.

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THANK YOU!!!QUESTIONS???