PRELIMINARY ASSESSMENT OF ETHIOPIAN PHYSICIANS TASTE FOR TELEMEDICINE: THE CASE OF BLACK LION HOSPITAL, ADDIS ABABA, ETHIOPIA

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1 Association for Information Systems AIS Electronic Library (AISeL) ECIS 2014 Proceedings PRELIMINARY ASSESSMENT OF ETHIOPIAN PHYSICIANS TASTE FOR TELEMEDICINE: THE CASE OF BLACK LION HOSPITAL, ADDIS ABABA, ETHIOPIA Getachew Mengesha Addis Ababa University, Addis Ababa, Ethiopia, Monica Garfield Bentley University, Waltham, Massachusetts, United States, Asfaw Kebede Addis Ababa University, Addis Ababa, Ethiopia, Philip Musa Univ. of Alabama at Birmingham, Birmingham, Alabama, United States, Follow this and additional works at: Getachew Mengesha, Monica Garfield, Asfaw Kebede, and Philip Musa, 2014, "PRELIMINARY ASSESSMENT OF ETHIOPIAN PHYSICIANS TASTE FOR TELEMEDICINE: THE CASE OF BLACK LION HOSPITAL, ADDIS ABABA, ETHIOPIA", Proceedings of the European Conference on Information Systems (ECIS) 2014, Tel Aviv, Israel, June 9-11, 2014, ISBN This material is brought to you by the European Conference on Information Systems (ECIS) at AIS Electronic Library (AISeL). It has been accepted for inclusion in ECIS 2014 Proceedings by an authorized administrator of AIS Electronic Library (AISeL). For more information, please contact

2 PRELIMINARY ASSESSMENT OF ETHIOPIAN PHYSICIANS TASTE FOR TELEMEDICINE: THE CASE OF BLACK LION HOSPITAL, ADDIS ABABA, ETHIOPIA Research in Progress Mengesha, Getachew Hailemariam, Addis Ababa University, Ethiopia Kebede, Asfaw Atnafu, Addis Ababa University, Ethiopia Garfield, Monica J., Bentley University, USA Musa, Philip F., Univ. of Alabama at Birmingham, USA Abstract Telemedicine is an ideal solution to low income African countries struggling with health facilities and care providers shortages. This preliminary study explores physician s level of acceptance and use of telemedicine system in Ethiopia. Data were gathered using a survey questionnaire based on UTAUT. Results show that physicians overall taste to the telemedicine system appears to be favourable. However, preliminary findings indicate that in order to contextualize UTAUT to the context of telemedicine three constructs from the conceptualization of Compatibility beliefs need to be added. Furthermore, an in depth investigation is needed to uncover the structural, organizational, and institutional factors impeding the adoption and use of telemedicine in the study area. Keywords: Telemedicine, Ethiopia, Physician Acceptance. Twenty Second European Conference on Information Systems, Tel Aviv

3 1 Introduction Making high-quality health care available to all, as espoused by the World Health Organization (WHO) is difficult because of the burdens imposed by the growing world population, the increase in longevity of life, and the rise of new diseases (Craig and Patterson, 2005). An additional barrier to achieving high-quality health care available to all is that in most cases the effort to do so stem on the traditional conceptualization of achieving equitable access to health care by having the provider and the recipient be present in the same place at the same time (Craig and Patterson, 2005). Recent advances in ICT, however, have created unprecedented opportunities for the delivery of healthcare by increasing the number of ways that health care can be delivered both in developing and industrialized countries (Craig and Patterson, 2005). Rapid developments in computer technology, the Internet, wireless, and satellite communications have led to major innovations in the nature and delivery of health care that will have broad implications for the way people receive health information and treatment in the future (Chepesiuk, 1999). Chepesiuk further noted that health care systems are now linked into broad computer networks and are capable of expanding their reach and effectiveness in bringing medical services to the patient instead of the patient having to go to them. Telemedicine is often defined as the delivery of medical services at a distance (Craig and Patterson, 2007; Merrell, 1995; Wootton, 1998; Garshnek and Hassell, 1999 & 2000). Similarly, the World Health Organization (WHO) defined telemedicine as the delivery of health-care service, whereby distance is a critical factor, by health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, and for continuing education of health care providers as well as research and evaluation, all in the interest of individuals and their communities (WHO, 1998) pp 10). The promising potentials of telemedicine, as has been described in the definitions cited above seem to attract the attention of low income countries struggling with health facilities and care providers shortages. For example, Fraser and McGrath (2000) state that on the average Sub-Saharan Africa (SSA) has fewer than 10 doctors per 100,000 people and most of the medical specialists and specialized services are concentrated in cities. As a result, workers in rural health care serving the majority of the population are isolated from specialist support. Road transports in most rural parts of the African content are very poor, which impairs the accessibility of the region where the majority of the continent s population lives. In view of exploring the potential applicability of ICT to rectify the prevailing problems in developing countries, Fraser and McGrath (2000) posed two questions: 1). Can information technology offer solutions? 2). If so, what technologies are likely to be the most effective and economical? International Organizations like WHO and ITU echo the questions raised by these scholars. In line to this, small and large scale telemedicine pilot projects were launched in various African countries such as Mozambique, Senegal, Uganda, Kenya, and Ethiopia in order to explore the applicability of telemedicine (Asfaw, 2009). Three telemedicine systems, namely the International Telecommunication Union (ITU) Telemedicine project in 2003, the Ethio-Indian Telemedicine Program in 2005, and Johns Hopkins University HIV/AIDS telemedicine program in 2006 had been implemented at Black Lion teaching hospital, Addis Ababa, Ethiopia (Mengesha, et al, 2013). Black Lion Hospital is the largest tertiary level referral hospital in Ethiopia. It provides major referral services to more than 80 million people across the country. As this hospital is located in the capital city, it has good number of highly trained and specialized physicians in most medical specialty areas. Apart from providing health care services, the hospital hosts more than two thousand health science students. Twenty Second European Conference on Information Systems, Tel Aviv

4 Mengesha, et al (2013) noted that despite the presence of adequate hardware and software facilities to conduct various telemedicine services, the telemedicine systems put in place remained underutilized and failed to meet the intended purpose. The report obtained from Centre for ehealth, Black Lion Hospital reveals that on the average 5-6 medical consultations and continuing medical consultations were carried out at the Ethio-Indian telemedicine centre. Likewise, only 270 cases were discussed live at the Johns Hopkins University telemedicine centre since its establishment about seven years ago. The current study attempts to explore determinants of telemedicine system uses in the study area. Although various factors impacts telemedicine adoption and use, this study specifically focuses on exploring physician s level of acceptance and use of the technology. To this end, the study used the Unified Theory of Acceptance and Use of Technology as a theoretical foundation and to guide the data collection, analysis and reporting. The remaining part of the study is structured as follows. First, the theoretical foundation of the study is presented. Following this the methodology used is described. Then, the preliminary finds of the study are presented. Finally, the study ends with a concluding remark. 2 Theoretical Foundation This study employed the Unified Theory of Acceptance and Use of Technology (UTAUT) as a theoretical foundation in general and to structure the empirical investigation in particular. This model has been developed from a review, synthesis, and validation of eight theories/models of technology use (Venkatesh et al, 2003). As a result, it was believed that the model would provide a useful tool for managers needing to assess the likelihood of success for new technology introduction and helps them to understand the drivers of acceptance in order to proactively design interventions (including training and marketing Venkatesh et al, 2003). The study conducted to develop UTAUT considered both voluntary and mandatory technology use contexts. Venkatesh et al (2003) identified three basic concepts underlying user acceptance models in general: 1). Individuals reaction to using information technology. 2). Intention to use Information technology. 3). Actual use of Information technology. Here, intention is assumed to capture only internal motivations to perform the behaviour (Venkatesh et al, 2003). The bearings of external factors on behavioural intention and use behaviour of information technology needs to be investigated to draw a full picture about the phenomena. In this regard, UTAUT is capable of integrating the internal and external factors into a unified whole for better conceptualization and investigation of organizational factors. Furthermore, UTAUT has distilled the critical factors and contingencies related to the prediction of behavioural intention to use a technology and technology use primarily in organizational contexts (Venkatesh, Thong, and Xu, 2012). Because of its cited merits, UTAUT has been chosen for this study in order to explore and describe health professional s intention to use and their actual use of telemedicine systems in the study area. 3 Research Method This study employed case study approach (Yin, 2009; Yin, 2003). Data for the study were gathered using three strategies. First, structured questionnaire was used to gather data from health professionals attended the telemedicine and tele-education sensitization workshop held on December 22, 2011, at Gion Hotel, Addis Ababa, Ethiopia. A total of 64 participants, which includes senior and Junior physicians, and deans of the medical school, final year medical science students, and participants drawn from different departments of the College of Medical Sciences, Addis Ababa, University, and from partner NGO s. Fifty questionnaires were distributed via the workshop registration spot and Twenty Second European Conference on Information Systems, Tel Aviv

5 respondents were asked to return the completed questionnaire when they went out for coffee break. Thirty five questionnaires were returned, which accounts70% response rate and 32 questionnaires were found usable. SMART PLS was used to test the validity and reliability of the survey instrument and SPSS version 20 was used to generate varied descriptive statistical reports. Results of the analysis have been presented using tables and graphs. Second, conference reports on e-health and e-learning technologies for medical education and clinical services held from July 12 th to 13 th, 2013 at Adama city, South East of Addis, Ababa, Ethiopia was reviewed and used for this study. Third, reports prepared by Center for ehealth, College of Health Sciences, Addis Ababa University regarding the current status of ehealth programs were reviewed and used for this study. 4. Preliminary Finding In this section, first the model validation results are presented. Following this, descriptive statistical reports on a few selected variables are provided 4.1 Measurement model validation Data gathered to pre-test the main study instruments was used to assess the measurement model. However, the collected data was found to be in adequate to perform the validation of the structural model. Among the criteria suggested to validate the measurement model, internal consistency reliability, uni-dimensionality, and indicator reliability (Urbach and Ahlemann, 2010; Straub et al, 2004; Gefen and Straub, 2005) have been used. Figure 1 shows the measurement and structural model along with indicator loadings and weight results respectively. In the interest of space, except the weight values shown in figure 1, further assessment criteria has not been used to measure the validity of the formative construct Use Behaviour. Figure.1 UTAUT measurement and structural model The first criterion used to assess the measurement model is internal consistency reliability (Hair et al, 2013; Urbach and Ahlemann, 2010). It provides estimates of reliability based on inter- correlations of Twenty Second European Conference on Information Systems, Tel Aviv

6 the observed indicator variables (Hair et al, 2013). Traditionally, the most widely used internal consistency measure was Cronbach s alpha, later composite reliability has emerged as alternate measure (Hair et al, 2013). Regardless of which measure is used for assessing internal consistency, values above 0.7 are desirable for exploratory research (Urbach and Ahlemann, 2010). Accordingly, all constructs meet composite reliability criteria. However, the Cronbach alpha value of one construct facilitating conditions is found to be lower than the desired threshold value. Further analysis will be carried out to figure out the underlying cause. Moreover, the Average Variance Extracted (AVE) is used to measure the convergent validity, which assesses the degree to which individual items reflecting a construct converge in comparison to items measuring different construct (Urbach and Ahlemann, 2010). An AVE value of at least 0.5 indicates that the latent construct under investigation is on the average able to explain more than half of the variance of its indicators (Urbach and Ahlemann, 2010). The AVE value presented in table 1 shows that all constructs meet the convergent validity criteria. Constructs AVE Composite Reliability Cronbachs Alpha Behavioral intention Effort expectancy Facilitating conditions Performance Expectancy Social influence Voluntariness Table 1. Internal consistency measure The other criterion used to evaluate the measurement model is discriminant validity, which investigates the degree to which measures of different construct differ from one another (Urbach and Ahlemann, 2010). Table 2 shows the cross loading values that shows all measures have higher loading onto their designated construct. Measures Behavioral Intention Effort expectancy Facilitating conditions Performance Expectancy Social influence Use Behavior Voluntariness BI BI BI EE EE EE EE FC FC PE PE Twenty Second European Conference on Information Systems, Tel Aviv

7 PE PE SI SI SI SI Use Use Vu Vu Descriptive Statistical Results Table 2. Measures Cross loading values In order to view the overall reaction of physicians regarding the telemedicine system, descriptive statistical reports are generated on selected key constructs of the UTAUT model such as Performance Expectancy, Behavioural Intension, and Use Behaviour. The results are indicated in table 3, table 4, and table 5 respectively. As it has been indicated in table 3 about 93.8% of respondents agree on the usefulness of telemedicine to their job. TM useful in my job Frequency Percent Strongly disagree Moderately agree Agree Strongly agree Total Table 3. Telemedicine Usefulness About 75% of respondents indicated that they intend to use the telemedicine system. I intend to use Frequency Percent Strongly disagree Moderately agree Agree Strongly agree Total Table 4. Intention to Use Telemedicine Systems Only about 18.8% respondents have used the system a few times a year. This result corresponds with the use statistical data obtained from Centre for ehealth and presented in the introduction part. Twenty Second European Conference on Information Systems, Tel Aviv

8 5 Conclusion Frequency of use Frequency Percent Never A few times a year Never at all Total Table 5. Frequency of use of telemedicine system This preliminary study reveals that the measurement model meets the required level of validity and reliability criteria. Although the Cronbach alpha value of Facilitating Conditions construct seems to be below the threshold level, the alternate measure, Composite Reliability value meets the standard threshold criteria. Further analysis is needed to figure out whether the result is caused by the inherent limitation of Cronbach alpha or due to measurement error. The sample data is found to be too small to conduct tests and draw valid conclusions regarding the structural model. The descriptive analysis shows that physicians overall taste to the telemedicine system is favourable. Paradoxically, the overall use of the system is very low. This casts the presence of further internal and external factors that impact the use of telemedicine. The preliminary findings pointed out the need to align the telemedicine system to the medical practice. Therefore, in order to draw UTAUT to the context of telemedicine three constructs from the conceptualization of Compatibility beliefs need to be added. The main study attempts to extend UTAUT in the context of telemedicine adding three compatibility constructs such as compatibility with existing work practices, compatibility with values, and compatibility with preferred work style from the theorization of Karahanna et al (2006). Furthermore, an in depth investigation is needed to uncover the structural, organizational, and institutional factors impeding the adoption References Asfaw, A., (2009). Assessment of Telemedicine System of Ethiopia: the case of Ethiopia. Unpublished Master s Thesis, Addis Ababa University, Addis Ababa, Ethiopia. Chepesiuk, R (1999). Making House Calls: Using Telecommunications to Bring Health Care into the Home. Environmental Health Perspectives, 107(11). A556-A560. Craig, J. and Patterson, V. (2005) Introduction to the Practice of Telemedicine, Journal of Telemedicine and Telecare, 11(1) Donaldson, T. and and Preston, L. E. (1995). The Stakeholder Theory of the Corporation: Concepts, Evidence, and Implications. 20(1) Fraser.H.F.S and McGrath. J. D. (2000). Information Technology And Telemedicine In Sub- Saharan Africa: Economical Solutions Are Available To Support Health Care In Remote Areas. BMJ: British Medical Journal, 321(7259) Frooman, J. (1999). Stakeholder Influence Strategies. Academy of Management Review, 24(2) Garshnek, V., Hassell, HL. (2000). Rethinking telemedicine evaluation for a new technological era. Int J Healthcare Techno Manage. 2: Gefen, D. and Straub, D. (2005). A practical guide to factorial validity using PLS-Graph: Tutorial and annotated example. Communications of the AIS Twenty Second European Conference on Information Systems, Tel Aviv

9 Hair, J.F., Hult, G.T.M., and Ringle, C.M., Sarstedt, M. (2013). A Primer on Partial Least Squares Structural Equation Modeling (PLS-SEM). Sage Publications Karahanna, E., Agarwal, R, Angst, C.M (2006). Re-conceptualizing Compatibility Beliefs in Technology Acceptance Research. MIS Quarterly. 30:4, Merrell, R.C. (1995). Telemedicine in the 90 s: Beyond the Future. Journal of Medical Systems. 19(1). Mengesha, G.H, Garfield, M.J, Kebede, A.A, and. Musa, P.F. (2013). Stakeholders Analysis of Ethiopian Telemedicine Projects: the case of Black Lion Hospital, Addis Ababa, Ethiopia. Proceedings of the Nineteenth Americas Conference on Information Systems, Chicago, Illinois, August Straub,D., Boudreau, M.C., Gefen,D. (2004). Validation guidelines for IS positivist research. Communication of AIS Urbach, N. and Ahlemann, F. (2010) Structural Equation Modeling in Information Systems Research Using Partial Least Squares. Journal of Information Technology Theory and Application. 11(2) Venkatesh, V., Michael G. M, Gordon B. Davis (2003). User Acceptance of Information Technology: Toward A Unified View. MIS Quarterly. 27(3) Venkatesh,V, Thong, J.Y.L, and Xu, X. (2012). Consumer Acceptance and Use of Information Technology: Extending the Unified Theory of Acceptance and Use of Technology. MIS Quarterly. 36 (1) Wootton, R., (1998). Telemedicine in the national health service. J.R. Soc Med. 91: WHO (1998). A Health Telematics Policy. Technical Report. WHO group consultation on Health telematics December, Geneva Zhan, C., Lin, L., and Wang, T., (2011). A Stakeholder Analysis for Telemedicine in China, International Conference on Information Management, Innovation Management and Industrial Engineering (ICIII), Nov 26-27, 3, Twenty Second European Conference on Information Systems, Tel Aviv