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journal homepage: www.ijmijournal.com

A model for the adoption of ICT by health workers in Africa

Lanrewaju Jimoh a,b , Muhammad A. Pate c,d , Li Lin e , Kevin A. Schulman b,c,e,
a

Duke University School of Medicine, Durham, NC, USA

The Fuqua School of Business, Duke University, Durham, NC, USA
c Duke Global Health Institute, Duke University, Durham, NC, USA
d National Primary Health Care Development Agency, Abuja, Nigeria
e Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
b

a r t i c l e

i n f o

a b s t r a c t

Article history:

Purpose: To investigate the potential of information and communication technology (ICT)

Received 21 October 2011

adoption among maternal and child health workers in rural Nigeria.

Received in revised form

Methods: A prospective, quantitative survey design was used to collect data from quasi-

7 August 2012

randomly selected clusters of 25 rural health facilities in 5 of the 36 states in Nigeria over a

Accepted 19 August 2012

2-month period from June to July 2010. A total of 200 maternal and child health workers were
included in the survey, and the data were analyzed using a modied theory of acceptance
model (TAM).

Keywords:

Results: There was no signicant difference between ICT knowledge and attitude scores

Africa South of the Sahara

across states. There were signicant differences in perceived ease of use (P < .001) and per-

Child health services

ceived usefulness scores (P = .001) across states. Midwives reported higher scores on all

Community health aides

the constructs but a lower score on endemic barriers (which is a more positive outcome).

Maternal health services

However, the differences were only statistically signicant for perceived usefulness (P = .05)

Medical informatics applications

and endemic barriers (P < .001). Regression analysis revealed that there was no interaction

Midwifery

between worker group and age. Older workers were likely to have lower scores on knowledge

Nigeria

and attitude but higher scores on perceived ease of use and perceived usefulness. Lastly, we
found that worker preference for ICT application in health varied across worker groups and
conicted with government/employer priorities.
Conclusions: Although the objective of this study was exploratory, the results provide insight
into the intricacies involved in the deployment of ICT in low-resource settings. Use of an
expanded TAM should be considered as a mandatory part of any pre-implementation study
of ICT among health workers in sub-Saharan Africa.
2012 Elsevier Ireland Ltd. All rights reserved.

1.

Introduction

In the developing world, there has been an upsurge in Internet penetration and the use of mobile technology. Particularly
in the health sector, experts believe mobile phones can revolutionize the health system in the developing world [1]. This

premise has led to the launch of several information and communication technology (ICT) projects in developing countries,
such as MoTech in Ghana [2], Medic Mobile in Malawi [3], and
RapidSMS in India [4].
In Nigeria, the National Primary Health Care Development Agency (NPHCDA) is charged with championing primary
health care in the country. Nigeria is the most populous

Corresponding author at: Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA.
E-mail address: kevin.schulman@duke.edu (K.A. Schulman).
1386-5056/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijmedinf.2012.08.005

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African nation, with an estimated population of more than 160

million. The country is approximately 923,000 km2 (about the
size of California), and the literacy rate is 3951% [5]. Nigeria
has 6 geopolitical zones, and maternal and child health care
delivery in the public sector is typically organized into clusters
of access points (1 general hospital and 4 primary health care
centers). Maternal mortality is a serious problem in Nigeria. In
2009, the number of women dying from childbirth was an estimated 50,000 per year [6]. According to UNICEF, the maternal
mortality rate is 840 per 100,000 live births [7]. This statistic
spurred the creation of the Midwifery Services Scheme (MSS)
in 2009 to address the shortage of skilled birth attendants [8].
The MSS also supplied computers, solar panels, and mobile
phones to 200 health facilities out of more than 10,000 health
facilities in the country.
Although ICT infrastructure in Nigeria is poor overall,
including Internet penetration of less than 16% [9] and average broadband download speed of 1.38 Mbps (compared with
10.1 Mbps in the United States) [10], the Global System for
Mobile Communication (GSM) has experienced a boom in
Nigeria and much of sub-Saharan Africa. Within 10 years of
GSM availability in Nigeria, more than 90 million Nigerians
had mobile phones [11]. Given this success, health sector leaders have sought to complement efforts to reinforce frontline
maternal and child health workers with technological tools.
This led to the partnership between the NPHCDA and Duke
University to explore the possibility of an ICT intervention
in Nigerias public health sector, particularly in maternal and
child health care. Frontline workers in maternity-related care
in Nigeria are mostly midwives and community health extension workers, because of a shortage and maldistribution of
doctors.
Because many technology projects fail at the implementation stage as a result of human factors [12], as evidenced by
a similar project in Uganda [13], the need arose for an enduser assessment study to understand the prevailing human
environment in working out a customized solution that would
meet the ICT needs of the primary health sector in Nigeria. The
primary goal of the study was to investigate the base level of
ICT knowledge and attitudes, perceived usefulness, and perceived ease of use of the 2 main maternal and child health
worker groups.
Ours is the rst study to propose a model for predicting ICT
adoption in health in sub-Saharan Africa. Generally, a review
of the literature suggests that studies like this are limited even
in developed countries [14]; the closest example in a developing country was conducted in India by Chattopadhyay [15].
Therefore, we sought to access end users and predict their
adoption potential, patterns, and practice, and to understand
and address end-user needs appropriately before implementation, so as to increase chances of success in implementation,
and ultimately the chances of better patient care.

2.

Methods

Our goal was to investigate the adoption potential of midwives

and community health extension workers using the technology acceptance model (TAM) as a framework. The TAM is the
most widely accepted model of behavioral intention in the

information systems literature [16]. The original TAM suggests

that an intention to accept technology is determined by 3 constructs: attitude, perceived usefulness, and perceived ease of
use [17]. Despite a 3040% predictive power [18], a major limitation of the TAM is its failure to consider the inuence of
external variables and barriers to technology, such as access
[19]. We expanded the framework to account for this peculiar environment by including knowledge as a separate factor
from attitude, because we could not safely assume that knowledge would be adequately reected in attitude. We also added
a group of questions about endemic barriers to technology,
an important consideration in low-resource settings such as
Nigeria, and ICT use-case preferences of different workers
across geopolitical zones. We believed such a modied TAM
would be more appropriate, given the end users and the local
context [20].

2.1.

Questionnaire design

The questionnaire was designed primarily to assess 5 constructs: knowledge, attitude, perceived ease of use, perceived
usefulness, and endemic barriers. Each construct was represented on the survey by multiple question items. Survey
questions were written in English and designed with guidance
from Fink [21]. Some of the questions were adapted from a
previous computer knowledge survey [22], but most were original. The questionnaire was structured and in multiple parts.
Questions within the same construct were grouped in some
cases and not in others. Likert scales were employed wherever possible, depending on the complexity of the information
desired and the level of understanding of the respondents.
There were a total of 60 items in the survey (6 items on knowledge, 4 on attitude, 2 on perceived ease of use, 3 on perceived
usefulness, and 4 on endemic barrier). Lastly, we asked a rankorder question on individual worker preference on the type
of technology application they would like to incorporate into
their daily work activities. After all question items were generated, the instrument was revised with expert opinion. The
institutional review board of the Duke University Health System reviewed the study and classied it as exempted from
consent.
We pretested the questions in 2 locations in Kwara State
with 10 health workers who were not from the 6 states
included in the study (Fig. 1) to assess the clarity, content
validity, wording, and understanding of the questions. The
feedback was helpful, and a few modications were made
after the pretest. The changes were nalized before the commencement of the study. There were no changes made to the
questionnaires during the course of the study.

2.2.

Data collection

Data collection was conducted mostly by the rst author, a

physician, and 6 volunteers (often indigenous senior community health professionals). Surveys were handed out to the
health workers to complete individually. (In 3 of the 25 facilities, investigators assisted in local language translation for
some of the community health extension workers). The investigators were available to the health workers for clarication
of questions as they completed the surveys. All respondents

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775

question items were missing within a construct, the construct

composite score was set to missing for that participant. We
used t tests and analysis of variance to compare composite scores of worker groups and states, respectively. We also
performed a general linear regression analysis to investigate
associations between certain predicting factors (i.e., age and
worker group) and how they scored on the 5 constructs and
included an interaction term.
Data collected on end user ICT preference was simply collated and summed. Since the ranked list was ordered from 1
to 5, with 1 indicating the most desired application type and
5 indicating the least desired application type, the lower the
number, the more popular the application type.
We used SPSS 15.0 statistical software (SPSS Inc, Chicago,
IL) and SAS version 9.2 (SAS Institute, Inc, Cary, NC) for all
analyses.

Fig. 1 Nigerian states participating in the mMCHIT survey.

1 = Sokoto; 2 = Bauchi; 3 = Niger; 4 = Ekiti; 5 = Anambra;
6 = Bayelsa. Data from Bayelsa were lost during transit and
were not included in the analysis.

were literate; the lowest level of education among the community health extension workers was primary school grade
6; all of the midwives had associates or bachelors degree
equivalents. Midwives who were too busy during the day were
allowed to complete the questionnaire from home, but most
respondents completed the surveys privately at their work stations. The study was conducted between June 1 and July 30,
2010. All of the facilities visited were among the 200 facilities
that were supplied with computers and mobile phones as part
of the MSS.
To have a truly national study, we randomly selected a cluster of care delivery sites in each of the states representing
each geopolitical zone. Data from Bayelsa state representing
the south-south zone, which was to be the sixth participating geopolitical zone, was lost in transit within the country.
Each site was equipped with the same ICT hardware (i.e.,
Internet-ready computer with satellite antenna and solar
power backup). In addition, all sites had been certied as rural
areas in line with MSS policy.
Workers were eligible to participate by virtue of their active
service at the birthing facilities. An agent from the employer
(i.e., the NPHCDA) accompanied the investigating team during
the visits, and verbal consent of the respondents was obtained.
No incentives were offered for completing the questionnaire.

2.3.

Data analysis

The 5 survey constructs were investigated using multiple

questions in the survey instrument. Response categories
included both 3- and 5-point Likert scales. Each item score
was transformed to a 0100 scale for all constructs, and the
total score for each construct was a summation of the question
scores.
Higher scores reect more positive responses, except in
the endemic barrier category, in which a higher score reects
a greater barrier to technology use. If more than half of the

3.

Results

A total of 210 questionnaires were distributed to all health

workers whom the investigators met on duty at each site,
and 200 were returned completed, for a response rate of 95%.
Of these, 109 respondents were community health extension
workers and 91 were midwives. Midwives in the southern states (i.e., Anambra and Ekiti) were noticeably older
than those in the northern states (i.e., Bauchi, Niger, and
Sokoto) (Table 1). This difference stems from the fact that the
National Primary Health Care Development Agency (NPHCDA)
introduced the MSS in 2009 to reduce the current high rate
of maternal mortality in Nigeria. Under this scheme, newly
graduated midwives from around the county were deployed
to rural areas with severe health worker shortages (mostly in
the north). We did not observe the same trend among community health extension workers, because these workers are
mostly indigenous to their local communities and have lled
the worker gap caused by the shortage of midwives in northern Nigeria for decades. Some northern states, such as Sokoto,
encourage these workers to acquire further training after high
school to qualify for certication.
In comparing the mean scores of all respondents for each
construct, we found signicant differences in perceived ease
of use, perceived usefulness, and endemic barriers to technology across the 5 states (Table 2). We also found that
ICT knowledge and attitude did not vary signicantly across
states.
There were signicant differences in composite scores
across the worker groups on perceived usefulness and
endemic barriers to technology (Table 3). This analysis did not
control for age or other demographic characteristics. Because
there was a slightly higher percentage of community health
extension workers older than 35 years, we thought age might
be a factor in the differences in the scores across groups. Other
possible factors were level of education, years of experience
or exposure to ICT, or other qualities intrinsic to the worker
groups. Most of these factors were similar within each group.
Years of experience varied for midwives in the southern states
(Anambra and Ekiti), because most of the newly graduated
MSS midwives were dispatched to the areas of greatest need

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Characteristic

State
Anambra (n = 23)

Midwives (n = 91)
Age, mean (SD), y
Time spent at facility, mode, mo
Marital status
Single
Married
Divorced
No. of children, median (interquartile range)
Highest level of education, mode
Years since graduation or certication, mode

Bauchi (n = 14)

Ekiti (n = 21)

Sokoto (n = 17)

40.26 (9.9)
612

30.14 (10.1)
<6

44.4 (11.9)
612

37.5 (9.3)
612

29.6 (7.3)
612

8
15
0
3 (03)
Nurse-midwifery degree
1115

11
3
0
0 (01)
Midwifery degree
13

5
15
1
4 (24)
Nurse-midwifery degree
16

4
12
0
2 (04)
Nurse-midwifery degree
13

9
8
0
0 (01)
Midwifery degree
13

State

Characteristic
Anambra (n = 18)
Community health extension workers (n = 109)
Age, mean (SD), y
Time spent at facility, mode, mo
Marital status
Single
Married
Divorced
No. of children, median (interquartile range)
Highest level of education, mode
Years since graduation, mode

Niger (n = 16)

Bauchi (n = 34)

Ekiti (n = 25)

Niger (n = 14)

Sokoto (n = 18)

37.7 (7.8)
612 months

34 (10.1)
612 months

33.6 (7.8)
24 yrs

33.5 (8.8)
>4yrs

41.1 (12.6)
>4yrs

2
16
0
3 (15)
Secondary school
1115

8
25
1
2 (05)
Secondary school
710

9
16
0
1 (03)
Primary school
1115

1
13
0
4 (16)
Secondary school
710

2
14
2
3 (16)
Post-secondary school
710

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Table 1 Demographic characteristics of the midwives and community health extension workers surveyed.

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Table 2 Composite mean scores for each question category by state.a

Category

Knowledge
Attitude
Perceived ease of use
Perceived usefulness
Endemic barriers to technology
a

State

P value

Anambra
(n = 41)

Bauchi
(n = 48)

Ekiti
(n = 46)

Niger
(n = 30)

Sokoto
(n = 35)

50.47
74.59
81.71
94.72
57.42

45.30
69.70
48.44
80.62
48.26

43.73
73.80
73.30
88.52
33.76

52.69
75.00
53.33
90.83
46.60

45.66
70.27
64.03
86.52
62.50

.27
.59
<.001
.001
<.001

Possible range of responses, 0-100. P values from analysis of variance.

Table 3 Scores for each question category by worker group.a

Category

Knowledge
Attitude
Perceived ease of use
Perceived usefulness
Endemic barriers to technology
a
b
c

Midwives (n = 91)b

48.76
73.86
65.91
90.40
36.56

45.95
71.53
62.38
85.94
58.39

P value

.34
.37
.38
.05
<.001

Possible range of responses, 0100. P values from 2-tailed t tests.

Missing items varied from 2 to 9 out of 91 respondents.
Missing items varied from 2 to 9 out of 109 respondents.

(predominantly northern Nigeria). Also, there was no sufcient variation in education level within each worker group.
In a general linear regression model using age and worker
group as predicting factors (Table 4), midwives scored higher
on all constructs except endemic barriers (indicating better
access to technology). We found no interaction between the 2
independent variables. A closer look at the regression results
reveals that younger workers were more likely to have higher
knowledge and attitude scores but a lower perceived ease of
use score.
End-user preferences are shown in Table 5. ICT tools
often are imposed on end users without consideration of the
types of solutions the users would prefer. Our ndings shows
that application-type preferences varied between the worker
groups and varied signicantly from government priorities.
Since the rank list is from 1 to 5 (with 1 being the most important to the respondent), the option with the lowest score in
Table 5 is the most popular.

4.

Community health
extension workers
(n = 109)c

Discussion

Our study has 3 main ndings. First, there were signicant

differences on 3 constructs (perceived ease of use, perceived
usefulness, and endemic barriers to technology) across the
5 states, despite government efforts to provide uniform ICT
hardware in all states, the similar educational requirements
of the worker groups, and the certication of the sites as rural
areas under the MSS. Further research is warranted to identify
what local factors in these states are responsible for the differences in composite scores. Second, we found a somewhat
unexpected relationship between worker age and composite scores. Older workers who seemed to score worse on

knowledge and attitude scored better on perceived ease of use

and perceived usefulness (though the P value for perceived
usefulness was not statistically signicant). Third, ICT application preferences by end users varied by worker group and
often did not agree with the preferences of the employer. Failure to acknowledge these issues will make implementation
difcult and sustainability less likely.
Despite the heterogeneity among the workers within and
across states, we observed no signicant differences on 2
constructs, knowledge and attitude. Knowledge level was
moderate (ranging from 43.73 in Ekiti to 52.69 in Niger) and
attitude was generally high (from 69.70 in Bauchi to 74.59
in Anambra). In a 2008 survey of Nigerian medical students,
50.6% had knowledge about the use of computer technology. None owned a computer, and ICT is not part of clinical
education in Nigeria [23]. Therefore, knowledge and attitude
scores of midwives and community health extension workers
in our study reect progress despite the lack of institutional
training. Although the midwives, who are more highly educated, scored higher than the community health extension
workers on knowledge and attitude, the difference was not
signicant across states. However, the composite score difference between the worker groups in perceived ease of use
and perceived usefulness was signicant across the 5 states.
This nding suggests that an entirely different factor, such as
previous hands-on computer experience, could have a greater
effect on the latter 2 constructs than the former.
Using a general linear regression model, we found that the
interaction between worker group and age was not signicant.
Therefore, the estimates reported in Table 5 assume there is
no interaction between worker group and age. Table 4 illustrates how age varied with scores across worker groups. On
ICT knowledge and attitude, the variation was predictable,

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<.001
.93
.55
48.57
0.34
0.11
<.001
<.001
.70
93.00
9.43
0.04
a

78.42
9.53
0.51
<.001
<.001
.004
54.19
11.94
0.39
Intercept
Group
Age

Estimates are centered around midwives aged 35 years (median age for all respondents).

<.001
.001
.002
70.01
12.69
0.56
<.001
<.001
<.001

P value
Parameter
estimate
P value
Parameter
estimate
P value
Parameter
estimate
P value
Parameter
estimate

P value

Parameter
estimate

Attitude
Knowledge
Variable

Table 4 General linear regression analysis of survey responses.a

Perceived ease of use

Perceived usefulness

Endemic barriers

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with the midwives scoring higher because of their higher

level of education and younger age. However, there was an
unexpected pattern for perceived ease of use and usefulness. We observed that the younger the workers, the less
easy they think computers are to use and the less usefulness they ascribed to computer technology. Therefore, if we
assume younger workers know more about ICT and have a
more favorable attitude toward technology, it is not clear why
they think it is not easy to use and not useful to their work. Previous studies on TAM have shown that perceived usefulness
and perceived ease of use are the most important predictors of
technology adaption by individuals [24,25]. Therefore, it would
be important in future studies to discern whether perceived
ease of use negatively inuences perceived usefulness directly,
as suggested by Mathiesons extended TAM model, or whether
an independent construct such as accessibility of technology to individual negatively inuences both constructs, as
suggested by Musas revised TAM model [26].
The most plausible explanation to this counterintuitive
observation is that the younger health workers, who have
probably had more exposure to ICT, might have a more realistic
view or more reasonable expectation regarding the issues surrounding adoption of ICT into regular operational workow.
Introduction of technology into regular workow could be difcult at rst, because the learning period could be tedious;
but with proper training, orientation, and support, it gets easier as time goes on. This phenomenon might cause younger
and more exposed health workers to respond the way they
do. Another simpler explanation could be that exposure to
technology in the Nigerian context (plagued with infrastructural deciencies) may have left some workers skeptical of the
ability to adopt new technologies. A study by Van der Meijden found computer experience to be the major predictor
of acceptance [27]. Therefore, further studies focused on the
perception of ease of use, perceived usefulness, and perhaps
prior computer experience or exposure are recommended. A
more parsimonious tool would be needed to get to the reservations or misconceptions health workers with a high level
of ICT knowledge and attitude might harbor consciously or
subconsciously. We suggest that this model include a construct for prior ICT experience, because this might reveal
which of the other well-established constructs (perceived usefulness or perceived ease of use) is being inuenced and
how.
Analysis of end-user ICT application responses represented in Table 5 is a new contribution to the health ICT
literature. Given the variety of ICT projects in health systems
in developing countries (mostly donor-driven), these results
are eye-opening. Decision support ICT applications were most
desirable to midwives, whereas the community health extension workers preferred an application that collects individual
patient history for easy access and fewer multiple entries.
Overall, the least desired application was an electronic health
record system that would allow easy external data reporting
to government (which is usually the top priority of the government). These choices reect the need for a dynamic approach
to ICT solutions design, especially when targeting a variety of
end users. It also reects a potential disconnect between government/employer priorities and end-user priorities in terms
of what types of applications should be deployed.

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Table 5 End-user preference for ICT applications in the health system.

ICT applicationa

State
Anambrab (n = 23)

A
B
C
D
E

86
64
63
59
73

Bauchic (n = 14)
53
36
32
44
47

ICT applicationa

Ekitid (n = 20)
64
46
49
69
57

Nigere (n = 14)
46
43
29
46
61

Sokotof (n = 9)
43
45
37
46
54

State
Anambrab (n = 18)

A
B
C
D
E

Total

42
51
48
60
65

Bauchic (n = 27)
90
85
96
67
67

Total

Ekitid (n = 25)
75
75
60
85
67

292
234
210
264
292

Nigere (n = 14)
53
41
31
48
37

Sokotof (n = 9)
24
25
29
31
26

284
277
264
291
262

Abbreviation: ICT, information and communication technology.

A = electronic record system that allows easy external data report to government; B = information technology system that allows video-call
consultation with general hospital; C = decision support tools that reminds the worker of all necessary checkups based on gestation age and
patient history; D = information technology system that allows continuous education and training via computer; E = electronic record system
that collects individual patient history for easy access and fewer multiple entries.
b
Possible score: midwives, 23115; community health extension workers, 1890.
c
Possible score: midwives 1470; community health extension workers, 27135.
d
Possible score: midwives 20100; community health extension workers, 25125.
e
Possible score: midwives 1575; community health extension workers, 1470.
f
Possible score: midwives 1575; community health extension workers, 945.
a

The purpose of this study was to use a modied TAM as a

tool for predicting adoption of ICT tools by health workers in
developing countries. This approach can be viewed not only as
a diagnostic tool, but also as an evaluation tool, as some TAM
studies have reported a shift in ICT attitude, perceived ease of
use, and perceived usefulness after implementation [28]. We
now have some suggestion of how worker group and age may
predict the potential for ICT adoption among health workers in
sub-Saharan Africa. The regression analysis on endemic barriers showed no signicant difference on barriers based on
worker group or age. It may be reasonable to assume that the
variation in barriers to technology scoring might be due to
other local factors beyond the infrastructural development of
the different geographies and less to do with worker group
mix. Mathieson and Musa have both proposed the importance
of external variables such as endemic barriers to technology
in predicting adoption potential in developing countries. We
suggest that prior computer experience be included directly as
a construct and tested using a structural modeling technique
in future expanded TAM models for developing countries.

denitive conclusions that should be applied to all maternal

and child health workers in Nigeria.
Another limitation is the strength of the survey instrument used in the study. This survey tool was created from
scratch, because no previously used survey instrument t our
needs. The survey was pilot-tested before use and, though it
is unwieldy and comprehensive, it provides a good starting
point for the creation of more focused survey instruments.
Efforts to calculate the reliability of the constructs were limited due to the difference in the inherent nature of some of
the constructs (e.g., knowledge). The small number of items
under each construct also limits the usefulness of the Cronbach alpha scores, which ranged from 0.1 to 0.7. During the
administration of the survey, a few community health extension workers required more direction than others. Despite the
pre-training of survey administrators, it is possible that some
participants simply copied the answers or opinions of their
peers if they had difculty understanding a question.

4.1.

Although some of our ndings are intuitive (e.g., endemic barriers such as wireless signal unavailability limit the success
of a mobile phone-based electronic health record system),
some ndings are not. In the developed world, age and gender were not signicant predictors of technology acceptance
[29]; in Nigeria, age is (95% of our respondents were women).
We now have evidence on how health worker groups differ
along the TAM constructs and even beyond. We also have
evidence that knowledge and attitude co-vary even in a lowresource setting. Health worker preferences differ and reect
job description; however, most ICT implementation projects in

Limitations

Our study has some limitations. The data from Bayelsa state,
which was to be the sixth participating geopolitical zone, were
lost in transit within the country. Although this loss takes
away from the completeness of the study as a national study,
we do not believe it would have affected the overall outcomes
signicantly. There was signicant variability among the data
from the other 5 zones. The health facilities were randomly
selected by the governmental primary care agency. The study
is an exploratory study, and therefore not powered to make

5.

Conclusions

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i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 1 ( 2 0 1 2 ) 773781

Summary points
What is already known on this topic
TAM has been tested in developed countries and has
been shown to have predictive power.
Human factors and adoption by end users has been
a major limiting factor to successful ICT adoption in
developing countries.
What this study has added to our knowledge
Although knowledge and attitude covaried in developing countries like they do in developed countries,
they were not predictive of perceived usefulness or
perceived ease of use.
Endemic barriers to technology are an important addition to the TAM model in low-resource settings such
as developing countries.
End-user preference is an important human factor
that should be considered in developing a suitable ICT
implementation strategy in developing countries.

developing countries are disease-focused and built for use by

multiple health worker groups. We hope this study will guide
future decision making around ICT investment in Nigerias
(and perhaps sub-Saharan Africas) public health sector. A
post-implementation conrmatory study will be conducted to
evaluate the predictive power of our proposed modied TAM
approach.

Author contributions
LJ conceived of the study. LJ, MAP, and KAS designed the study.
LJ collected the data. LL conducted the statistical analyses. LJ,
MAP, LL, and KAS analyzed and interpreted the data. LJ drafted
the manuscript. LJ, MAP, LL, and KAS revised the manuscript
for important intellectual content. MAP and KAS supervised
the study.

Competing interest
The authors declared no conicts of interest.

Acknowledgments
We thank all mMCHIT team members who participated in the
needs assessment study. The nancial and logistical support
from the National Primary Health Care Development Agency
(NPHCDA) was critical. The efforts of Dr. Adedapo Adejumo
as a team leader in 3 of the 6 states are much appreciated.
Mr. Seye Abimbola assisted in the literature review for this
new area of research. A special thank you goes to Dr. Funsho
Oladunjoye of the University College Hospital (UCH) Ibadan for
his technical support on data analysis.

Appendix A. Supplementary data

Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/j.
ijmedinf.2012.08.005.

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