Assessing Barriers To Adoption of Hospital Management Information

Barriers
to Hospital IS in Nigeria/Benson 1

ISSN 2159-6743 (Online)

Assessing Barriers to
Adoption of Hospital
Information Systems in
Nigeria
Ayodele Cole Benson, MB BCH, PhD DHA *

Abstract
This paper provides detailed information on the mixed method case study research using indepth interviews and a questionnaire-based survey to ascertain the barriers hindering
adoption of hospital information systems in Nigeria. The discussion in this paper provides
the problem that a robust health care policy on implementation of a hospital information
system is lacking in Nigeria and that caregivers in the country have yet to commence
noticeable implementation of hospital information technologies. The objective of the study
was to explore the reasons for the absence of hospital information systems (HIS)
implementation policy in Nigeria and the impact of the lack of adoption of HIS in the health
care delivery system of the nation. In this paper, an elaborate analysis on method is provided
with emphasis on design appropriateness, population, sampling, and data collection
procedure and rationale. Other essential elements of the paper include internal and external
validity approaches, data analysis, organization, and clarity. The analysis method involved
the integration of qualitative and quantitative data sets into two separate data sets of
coherent wholes, thereby presenting the entire research as a holistic, reflective, and
integrative process. Results obtained from the study are summarized in tables.

Keywords: Global health, health information systems, hospital information systems, review of
literature, Nigeria

*Principal, Echo-Scan Services, Ltd.
Correspondence: Ayodele Cole Benson, MB BCH, PhD, DHA, Email: benson_ayodele at yahoo.com

www.jghcs.info [ISSN 2159-6743 (Online)]
JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011
Barriers to Hospital IS in Nigeria/Benson 2
Assessing Barriers to
Adoption of Hospital
Information Systems in
Nigeria
Electronic Medical Record Systems (EMRs) in developing countries facilitate improved data collection
and information retrieval and generation of research reports (Williams & Boren, 2008). The problem is
that a robust health care policy on implementation of hospital information system is lacking in Nigeria.
Caregivers in the country have not yet commenced noticeable implementation of hospital information
technologies (Ouma & Herselman, 2008; William & Boren, 2008). Williams and Boren (2008) posited that a
poor technological base and lack of funding support by the developed countries may be responsible for
poor implementation of electronic medical record systems in the developing countries.
The consequences of non-adoption of hospital information technologies include: mix up with
laboratory results, misdiagnosis, medication order errors, and mismanagement of patients (Keenan et al.,
2006; Okeke, 2008). Williams and Boren believed that successful implementation of the Millennium
Development Goals (MDGs) will hinge on the assistance of the developed countries to poor nations in
Sub-Saharan Africa. Such assistance will be to develop human capital, increase funding aids, and
collaborate with local communities to facilitate implementation of hospital information systems adaptable
to their peculiar environment to improve delivery of care. This mixed method study examined the
perceptions of stakeholders by gathering information on the perceived reasons for the paucity of policy
on health information technology and causes of poor implementation of hospital information systems in
Nigeria.
STUDY PURPOSE
The purpose of this mixed method research was to identify the barriers hindering adoption of
hospital information systems in Nigeria. The study was designed to examine the perceptions of heads of
units at the federal Ministry of Health, members of the House Committee on Health, CEOs of health care
organizations, directors of State Ministry of Health, and COOs of information technology companies in
the six geo-political zones of Nigeria. Research instrument was structured to gather information on the
perceived paucity of health information technology policy in Nigeria and reasons for the poor
implementation of hospital information systems in the country.
Qualitative exploratory data was obtained through a purposive sampling of 18 members of the
sample population by selecting three persons in each geo-political zone. Sampling targeted a participant
each from health care policy makers, health care providers, and information technology experts in the six
geo-political zones of the country. However, interviews were eventually granted by 19 participants
because of additional interview granted by an Internet service provider in the North Central geo-political
zone. A questionnaire-based survey was conducted to gather quantitative descriptive data from 180
participants obtained by proportionate stratified random sampling methods to break the heterogeneous
population into its homogeneous components. Themes and theorems generated from the qualitative
aspect of the study was subjected to content data analysis and compared with SPSS statistical analysis of
the quantitative data. The mixed method approach helped to ascertain the relationship between health


care policy, health care funding, technological advancement, human capital, and health care
infrastructure as independent variables and the implementation of hospital information systems as the
dependent variable.
METHODS
Sample Size Determination
The determination of sample size is a common task for many organizational researchers.
Inappropriate, inadequate, or excessive sample sizes continue to influence the quality and accuracy of
research. A formula for selecting the sample size for a research problem based on a level of significance
and a set error rate was proposed by Cochran (1977). To obtain the most efficient, representative sample,
in this research, the following Cochrans formula for sample size determination was used:
Z
n / 2

Where;
n = minimum sample size required

Z / 2 = the value of the standard normal ordinate at % level of significance
Hence,
at the 5%level of significance, the computed values are;
Z / 2 = Z 0.025 = 1.96
= 0.22 (is the chosen error rate)
= 1.47 (the estimated population standard deviation)
Table 1 depicts the value of the sample standard deviation, which is an estimator for the population
standard deviation. A sample size of at least 172 is required to arrive at a sample with a sampling error of
at most 0.22. For convenience, a sample size of 180 was used so that the three strata could be included
adequately.
Table 1
Descriptive Statistics
Unclear health care policy on

hospital information systems is a
major barrier to implementation in
Nigerian hospitals
Minimum
Maximum
Mean
Standard
Deviation
180
3.07
1.47
The rest of the computation follows thus;

2
Z 1.96 1.47
n / 2 =
= 172
0.22
Research Questions
Presenting well-articulated research questions is an important step in any research process because
these questions convey the research objective and determine the research methodology. The specific
purpose of a research process is gleaned from research questions (Creswell, 2005; Onwuegbuzie & Leech,
2005). According to Onwuegbuzie and Leech (2005), research questions are evidently more important in
mixed methodology research because researchers employing the mixed methods approach combine
pragmatism with an elaborate system of philosophy. In mixed methods studies, the types of


instrumentation and data analysis employed are driven by research questions. The primary research
question in this study is phrased as follows: What factors explain the paucity of policy on health
information technology and the poor implementation of hospital information systems in Nigeria? To
answer the primary research question, the following sub-questions helped elicit the information needed.
1. What are the reasons for the absence of HIS implementation in Nigeria?
2. What are the implications of the absence of a policy on HIS in Nigeria?
3. What is the impact of funding on the implementation of HIS in Nigeria?
4. What is the impact of infrastructure on the implementation of HIS in Nigeria?
5. What is the impact of human capital on the implementation of HIS in Nigeria?
6. What is the impact of technology on the implementation of HIS in Nigeria?
Design Appropriateness
The present mixed method case study research using in-depth interviews and a questionnaire-based
survey provided the perceptions of the various stakeholders that could eventually be necessary in
planning a framework for implementation of hospital information systems in Nigeria. The intent of the
qualitative component was to understand the social situation affecting the Nigerian health care system
through an intuitive process in which the researcher gradually made sense of this social phenomenon by
contrasting, comparing, replicating, cataloging, and classifying the object of study (Simon et al., 2008).
Matching the discoveries of the qualitative aspect of the study with the descriptive research data and
the results of the literature review provides triangulation, and ascertain the appropriateness of the chosen
research design. The research questions aided the development and testing the adequacy of research
instruments, and assessing the reliability of the research findings. According to Levy and Lemeshow
(2008), survey objectives should include specification of the information to be gathered and the
population to which the discoveries of the survey were extrapolated. Collins, et al. (2006) asserted that the
mixed method research approach improves instrument fidelity, thereby maximizing the appropriateness
and usefulness of instruments to generate research data. The quantitative aspect of the mixed method
research employing descriptive statistical analysis was appropriate for this study because it enabled the
explanation of a cause and effect relationship and used statistics combined with mathematical models
and philosophy for relevant data analysis and hypothesis testing (Okeke, 2008).
According to Nerurkar (2008), the ultimate use of statistics is to make decisions about hypotheses and
to make inferences using obtained data to answer scientific questions. The mixed method analysis
fulfilled that objective. Whereas a qualitative case study alone would have been an appropriate design,
the large volume of data to be obtained from a large population would have become a limitation as biases
could be introduced during the various interviews that were conducted. Typically, as the size of a dataset
grows large, the complexity of questions that one addresses with it also increases, thereby introducing
problems of multiple variables and challenges of regression in time (Creswell, 2005).
A quantitative study alone would have eliminated the possibility of exploring relevant themes about
hospital information systems in Nigeria from major health care stakeholders that made up the study
population. Second, using a quantitative research approach would have involved primarily collecting,
analyzing, and interpreting numeric data, but the addition of non-numeric data from a qualitative design
provided valuable insights into the subject. The dual quantitative-qualitative feature evoked both
deductive and inductive reasoning and provides future researchers an avenue by which to verify,
validate, or replicate the study (Onwuegbuzie & Leech, 2005).
Although listening to the story about a social situation to gain participant's viewpoint was the
strength of qualitative research, the story also provided rich descriptive information that helped to
triangulate quantitative results and set them into their human context. Thus, the mixed method research
was appropriate for the study because it presented the exploratory-confirmatory continuum on the
hindrances to adoption of hospital information systems in Nigeria. Onwuegbuzie and Leech (2005)
elaborated that exploration demands using primarily inductive tools to examine a concept or construct,
and research a phenomenon or situation with an aim of developing tentative hypotheses or


generalizations. The descriptive component of research involves identification and explanation given to
antecedents, nature, and etiology of a phenomenon.
Validity
Almost two decades ago Maxwell (as cited in Onwuegbuzie & Leech, 2005) conceptualized that
validity can be classified into five types: descriptive validity, interpretive validity, theoretical validity,
evaluative validity, and generalizability. Maxwell further differentiated generalizability into internal and
external generalizability; with internal pertaining to generalizability within a particular setting or studied
population. Whereas, external generalizability, that also denotes external validity, is defined by Sproull
(2003) as the ability to generalize the results of a research to other populations, settings, treatment
variables, and measurement variables (p. 138). Threats to external validity are research shortcomings
that affect the ability to glean correct information from sample data and apply the same to other
populations, settings, past, present, and future situations (Creswell, 2005). The mixed method design
used in this research study that gathered data across the six geo-political zones in Nigeria creates a highpotential for generalizability of results in both current research and future studies.
Combining qualitative and quantitative paradigms in this study ensured that internal validity was
maintained. Sproull (2003) defined internal validity of research instruments as the ability to measure in
totality what it intends to measure from the population. Carter and Belanger (2005) suggested that using
factor analysis, the internal validity of research constructs are measured; most items are assessed if they
load properly on their expected factors. In the present study, research instruments were subjected to
factor analysis before using them to gather data. Such assessment of research instruments and application
of corrective measures to identify flaws were expected to ensure reliability.
Reliability of the Instruments
According to Carter and Belanger (2005), reliability is a measure of the degree to which an instrument
measures the same way each time it is used under the same research conditions on the same sample. The
reliability of a research instrument (questionnaire) is best measured by the Cronbachs alpha statistic
(Salkind, 2003). Cronbachs alpha is designed as a measure of internal consistency; that is, a test of
whether all items within the instrument measure the same thing. This simply means a measure of
reliability of the question items. Alpha is measured on the same scale as the Pearsons product-moment
correlation coefficient and typically varies between 0 and 1.
Although a negative value is possible, such a value indicates a scale in which same items measure the
opposite of what other items measure. The closer the alpha is to 1.00, the greater the internal consistency
of items in the research instrument. At a conceptual level, coefficient alpha may be thought of as the
coefficient between a sincere response and all other sincere responses of the same item drawn randomly
from the same population of interest (Salkind, 2003). In the present study, the researcher included 12
construct question items in the questionnaire to evaluate and assess the barriers to adoption of hospital
information systems in Nigeria using three categories of participants. The formula that determines
Cronbachs alpha makes use of the number of variables or question items in the scale (k) and the average
correlation between pairs of items (r):
kr
1 + (k 1)r
Based on the formula of alpha, a rule of thumb that applies to most situations for the interpretation of
reliability is as shown in Tables 2-4.

Table 2
Rules for Reliability Test
Cronbachs Alpha
Remark
Excellent
0.9
0.8 < 0.9
0.7 < 0.8
0.6 < 0.7
0.5 < 0.6
< 0.5
Good
Acceptable
Questionable
Poor
Unacceptable
Table 3
Case Processing Summary
Status of Participants
Policy makers
Items
Cases
Valid
Excluded*
Healthcare providers
Cases
Valid
Excluded*
Internet service providers
Cases
Valid
Excluded*
Total
Percent
60
100.0
0.0
60
100.0
0.0
60
100.0
0.0
180
100.0
* Listwise deletion based on all variables in the procedure.

Table 4
Reliability Statistics
Cronbach's Alpha
Cronbach's Alpha
Based on
Standardized Items
Number of Items
Policy makers
0.924
0.921
12
0.897
0.893
12
0.896
0.899
12
Apart from the already discussed measures, other approaches were used to ensure instrument
reliability in the study was as encouraged by Creswell (2005) that included the following:
1. Designing a research instrument to ask the same question in different ways to increase the
validity of the responses.
2. Avoiding causal arguments during interviews to avoid making cause-and-effect statements
that compel participants to introduce biases in their responses.
3. Staying within the study scope to ensure interpretative validity.
Based on the results in Table 5, the Cronbachs alpha of 0.924 for the instrument used for the policy
makers implies that the policy makers instrument is reliable. The Cronbachs alpha of 0.897 for the
healthcare providers implies that the healthcare providers instrument is also reliable. Last, the


Cronbachs alpha of 0.896 for the Internet service providers implies that the Internet service providers
instrument is also reliable. Hence, all instruments have excellent reliability indicative of internal
consistency.
Table 5
Summary Item Statistics
Policy makers
Mean
Minimum
Maximum
Range
Variance
N of Items
2.967
1.383
4.467
3.083
0.880
12
2.744
1.300
4.467
3.167
0.974
12
Internet service
providers
3.104
1.867
4.567
2.700
0.743
12
Population
Population is defined as a larger pool of entities on which a generalization can be made at the end of
a research study (Creswell, 2005; Neuman, 2003). The target population involves the subset of the larger
pool of entities from which the sample is drawn (Creswell, 2005). The Nigerian population stands
currently at more than 140 million people (National Population Commission, 2007). Nigeria is the largest
country in Africa with a land area of 910,000 square kilometers. For ease of political administration, the
country is divided into six geo-political zones. The target population in the present study was drawn
from heads of units at the Federal Ministry of Health, members of the House Committee on Health, CEOs
of health care organizations, directors of state Ministry of Health, and COOs of information technology
companies in the six geo-political zones of Nigeria. The sample was restricted to persons who form part
of health care policy-making in Nigeria, health care providers, and information technology experts and
service providers.
Sampling
The sampling method and sample size vary significantly in mixed method research. Collins, et al.
(2006) asserted that one rationale for the mixed method research is to optimize the sample size, which
includes increasing the number of research subjects. The sample was restricted to persons who form part
of health care policy-making in Nigeria, health care providers, and information technology experts and
service providers. Only CEOs of 100 bedded hospitals and above was included because such hospitals are
considered to have the financial capability and understands the need for adoption of hospital information
technology to service their large customer base. COOs of information technology companies included in
the research were those working in large corporations that have 500 or more workers in their
employment. These subjects are those professionals with requisite training and job experience that makes
them experts in their various fields of endeavor. Therefore, their opinions and judgments on the issue of
hospital information systems could be considered as expert opinion.
The purposive expert sampling approach was intended to examine the perceptions of persons with
demonstrable knowledge or experience in hospital information systems. In purposeful sampling, the
researcher intentionally selects participants who have experience with the central phenomenon or the
key concept being explored (Creswell & Plano Clark, 2007, p. 112). The qualitative part of the study ran
concurrently with the quantitative descriptive aspect of the study in which the sample was randomly
selected from the same population subset. Ten participants was drawn from each group made up of
health care policy makers, health care providers, and information technology experts in the six geopolitical zones of the country to make up the total of 180 participants for the quantitative aspect of the
mixed method study.
A letter explaining the study accompanied by a survey questionnaire was delivered by hand to the
180 potential participants inviting them to sign the consent form and return the form and the completed


survey to the researcher. Poor response to postal mails and E-mail communications compelled researcher
to employ the services of two trained field research personnel to administer the instruments in the six
geo-political zones in Nigeria. Using the convenience and opportunity of the one-on-one interaction with
participants, the trained field research personnel arranged convenient time for the personal interviews
with participants in their respective offices. The 18 interview participants handed-in the signed consent
form and completed survey questionnaire to the researcher during the one-on-one face-to-face recorded
interviews.
Participants Consent and Confidentiality
Prior to distributing the survey, the participants were given the informed consent form. The purpose
of this form was to protect the privacy and confidentiality of the individuals who participated in the
study. Prior explanations of the consent and confidentiality clauses to the participant improved
compliance and decreased the incidence of biased responses during interviews. The study participants
were not exposed to any foreseeable risks. However, because of the sensitive nature of the interview
questions, especially with regard to health care policy makers, the consent information was repeated in
advance to participants recruited for the recorded interviews. To avoid physical or psychological stress to
participants, the interview duration was short to last between 15 to 25 minutes. All participants submitted
a signed consent form before becoming involved in the study. A copy of the informed consent letter is in
Appendix A.
To avoid reprisals, backlash, or social stress, each participants interview was discretely conducted as
one-on-one interviews, and their names and any identifying information was deleted from the recorded
data. The codes applied to names were replaced with alphanumeric identifiers in chronological order and
was known only by the researcher to ensure confidentiality. For example, the first participant was labeled
P1; the second participant, P2, up to P18. The surveys are stored and locked in a cabinet and these
materials will be kept for 3 years. At that time, all data will be shredded, bagged, and discarded. The hard
drive and other media will be electronically erased and all paper data will be incinerated. Only the
researcher will have access to the stored research material.
Data Collection
Some qualitative aspect of the mixed method research requires purposive homogeneous data
gathering that usually entails focus group interviewing (Patton, 2002). However, focus group
interviewing may be plagued with gaming behavior and concealment of vital opinions by participants
who may fear backlash, thereby affecting the development of themes in a qualitative study (Somiah,
2006). Numeric and non-numeric data were collected in this research to provide information on the
perceived barriers for poor adoption of hospital information systems in Nigerian hospital. From literature
review, various variables seem to contribute to poor adoption of hospital information systems. Based on
the peculiar Nigerian situation, data from this research were examined to elicit the impact of health care
policy, funding, human capital, infrastructure, and the technological base of the country on adoption of
hospital information systems.
Data were collected using structured questionnaire for the quantitative component of the study and
guided one-on-one, face-to-face interviews for the qualitative component. Nigeria is a country of more
than 140 million people based on last population census in 2006. For effective political administration, the
country is divided into six geo-political zones of almost equal state distribution and balanced population
distribution. Within this framework, a sample selection matrix (see Appendix C) was created to select a
random sample of 10 participants among health care policy makers, 10 participants among health care
providers, and 10 participants among information technology experts.
The participants in the groups lived in the six geo-political zones of the country, comprising a total of
180 participants for the quantitative aspect of the study. A sample of 10% of the 180 participants was
purposively selected to participate in the qualitative aspect of the study. This equitable but randomly
selected sample from the six geo-political zone of Nigeria was aimed at attaining fair representation of
responses across the nation and to arrive at a generalizeable research result devoid of biases. The method


of data collection was intended to yield desired research results because the findings of the qualitative
aspect of the study would be triangulated with the quantitative research data and the results of the
literature review.
The mixed method research approach improves instrument fidelity, thereby maximizing the
appropriateness and usefulness of instruments to generate research data. The quantitative aspect of the
mixed method research employing descriptive statistical analysis was appropriate for this study.
According to Creswell (2005), surveys are useful in data collection when opinions are sought about the
state of affairs of a particular phenomenon at any time. Surveys permit a quick turnaround time for data
gathering. The quantitative aspect of this mixed method study involved collecting, analyzing, and
interpreting numeric data. The qualitative aspect of the research generated rich non-numeric descriptions
of the hospital information systems phenomena in Nigeria, which required thematic content analysis for
interpretation.
Descriptive coding of responses by application of the keywords and themes numbering 110 from
participants coded P1P18, enabled conversion of the non-numeric responses into quantified numeric
data for subsequent descriptive data analysis using SPSS software and test for significance using various
statistical tools. The present mixed methods research components were conducted concurrently because
the quantitative phase of the study did not determine or drive the qualitative phase, or vice versa..
Descriptive statistical analysis enabled the explanation of a cause and effect relationship and also uses
statistics combined with mathematical models and philosophy for relevant data analysis and hypothesis
testing. Without an offer of financial reward, this approach to data collection yielded unbiased responses,
especially with confidentiality guaranteed.
Face-to-face interviews encouraged open discussion, and using semi-structured questions throughout
the systematic and logical interviews ensures repeatability and improves rigor in a scientific inquiry
(Neuman, 2003). The use of guided interviews also ensured consistency compared to focus group
discussions. Participants were guided to answer specific research questions. Somiah (2006) used the same
methodology to gather data in an ethical dilemma study that explored and examined factors that induced
acceptance of rejection of bribes in Ghana, another West African country that has some demographic
similarities to Nigeria. Somiahs successful research provides some proof of efficacy that guided
interviews deliver appropriate qualitative data in a sensitive study that required the input of serving
government officials.
Data Analysis
Owuegbuzie and Teddlie (as cited in Onwuegbuzie & Leech, 2005) conceptualized that analysis of
mixed method research goes through some of the following steps: data reduction, data display, data
transformation, data correlation, data consolidation, data comparison, and data integration. In the
Owuegbuzie and Teddlie study, data reduction was achieved through exploratory thematic analysis,
reducing the dimensionality of the qualitative data, whereas descriptive statistics compounds
quantitative data. The data display involved the use of tables, and illustrations to represent the
quantitative data. The data display was followed by data transformation in which qualitative data were
quantified by application of numerical coding to permit direct data correlation and analysis of reduced
quantitative data with quantified qualitative data.
Data consolidation was achieved by combining quantitative and qualitative data into a new or
consolidated variables or data sets. The next stage was data comparison, which is crucial for triangulation
in this study. Data comparison involved comparing the data from the qualitative and quantitative aspects
of the mixed method research as a form of triangulation and to strengthen inferences that was made from
the research process. The final stage of the analysis involved the integration of qualitative and
quantitative data sets into two separate data sets of coherent wholes. The entire research study is
presented as a holistic, reflective, and integrative process capable of becoming reference material for
future studies (Onwuegbuzie & Leech, 2005).
In this study, a combination of parametric and non-parametric tests provided the basis for rejecting
the null hypotheses. Analysis of the quantitative data obtained by sorting and scoring of survey
responses was accomplished using the normal descriptive statistics package available in SPSS software.


The outputs generated from this analysis include information on the mean, mode, median, minimum
value, maximum value, standard deviation, variance, sum, and the range of values. These values
facilitated the interpretation of the results obtained from the data analysis. The statistical methods were
designed to achieve the objectives of data access, reliability, and acceptability among others (Lind,
Mason, & Marchai, 2000).
The hypotheses of the study was tested using Chi-square (X2) method of data analysis. Based on the
data collected, the hypotheses, which were non-directional, were tested at 95% level of significance (that
is, = 0.05). This formed the basis for rejecting the null hypothesis. Sorting and scoring survey responses
provided data strata for conversion into percentages or proportions. These figures were then used to
compute the observed and expected frequencies needed for testing the hypotheses. For the purpose of
this analysis, definition of the Chi-square (X2) expression will be:
!! =
!! !!
!!
Where:
X2 = Chi-square
fo
= Frequency observed
fe
= Frequency expected
The Chi-square statistical test method has certain assumptions, which are as follows:
1. Where two or more than two samples are used, they are independent of one another;
2. The samples are randomly selected;
3. The data are classifiable and satisfy the nominal level of measurement requirement; and
4. The sample size is between 25 and 250.
For the purpose of hypothesis testing, the degree of freedom (df) was defined as:
df = (r -1) (c 1)
Where:
r = Number of rows
c = Number of columns
1 = Constant
The decision criteria was to reject
H0
if
p < 0.05 and uphold H 0
Analysis of the qualitative data in the study was in two stages. Using the descriptive coding format in
appendix D to conduct thematic analysis, the responses were scored to convert the non-numeric
responses into quantified numeric data. The second stage involved conducting same quantitative analysis
as was done with the survey data as described above using the quantified data.


RESULTS
The data presented below are the frequency distribution of variables in the questionnaires. First, the data
was classified into logical categories. Subsequently, the desired analytical tables were extracted for the
proper data analysis. The interpretation of the results and implications will come in the next paper in the
series.
Table 6
Responses to Effect of Healthcare Policy on HIS by Participant Status
Policy makers
Internet service
providers
Responses
Strongly agree
Percent
Cumulative
Percent
14
23.3
23.3
Agree
15
25.0
48.3
Undecided
5.0
53.3
Disagree
Strongly disagree
Total
22
6
60
36.7
10.0
100.0
90.0
100.0
--
Strongly agree
13
21.7
21.7
Agree
12
20.0
41.7
Undecided
6.7
48.3
Disagree
17
28.3
76.7
Strongly disagree
14
23.3
100.0
Total
60
100.0
--
14
23.3
23.3
Agree
18
30.0
53.3
Undecided
8.3
61.7
Disagree
11
18.3
80.0
12
20.0
100.0
60
100.0
--
Strongly agree
Strongly disagree
Total
Overall Responses
Frequency
Strongly agree
41
22.8
22.8
Agree
45
25.0
47.8
Undecided
12
6.6
54.4
Disagree
50
27.8
82.2
32
17.8
100.0
180
100.0
--
Strongly disagree
Total

Table 7
Responses to Relevancy of Healthcare Policy on Nigerian HIS by Participant Status
Policy makers
Internet service
providers
Overall Responses
Responses
Strongly agree
Frequency
Percent
Cumulative
Percent
3.3
3.3
Agree
8.3
11.7
Disagree
27
45.0
56.7
Strongly disagree
26
43.3
100.0
Total
60
100.0
--
Strongly agree
5.0
5.0
Agree
3.3
8.3
Undecided
1.7
10.0
Disagree
Strongly disagree
18
30.0
40.0
36
60.0
100.0
Total
60
100.0
--
15.0
15.0
Agree
6.7
21.7
Undecided
1.7
23.3
Disagree
19
31.7
55.0
Strongly disagree
27
45.0
100.0
Total
60
100.0
--
Strongly agree
Strongly agree
14
7.8
7.8
Agree
11
6.1
13.9
Undecided
1.1
15.0
Disagree
64
35.6
50.6
Strongly disagree
89
49.4
100.0
180
100.0
--
Total

Table 8
Responses to Effect of HIS on Quality of Medical Outcome by Participant Status.
Policy makers
Responses
Strongly agree
68.3
13
21.7
90.0
Undecided
1.7
91.7
Disagree
5.0
96.7
Strongly disagree
3.3
100.0
Total
60
100.0
--
Strongly agree
38
63.3
63.3
Agree
16
26.7
90.0
Undecided
5.0
95.0
Disagree
3.3
98.3
Strongly disagree
1.7
100.0
60
100.0
--
39
65.0
65.0
18
30.0
95.0
1.7
96.7
3.3
100.0
60
100.0
--
118
65.6
65.6
Strongly agree
Agree
Undecided
Disagree
Total
Overall Responses
Cumulative
Percent
68.3
Total
Internet service
providers
Percent
41
Agree
Frequency
Strongly agree
Agree
47
26.1
91.7
Undecided
2.8
94.4
Disagree
3.9
98.3
Strongly disagree
1.7
100.0
180
100.0
--
Total

Table 9
Responses to Effect of Implementation of HIS on Health Care Outcomes by Participant Status.
Policy makers
Responses
Strongly agree
Overall Responses
Percent
Cumulative
Percent
3.3
Agree
15
3.3
25.0
Undecided
43
71.7
100.0
Total
Strongly agree
60
100.0
--
28.3
1.7
1.7
1.7
3.3
Disagree
12
20.0
23.3
Strongly disagree
46
76.7
100.0
Total
60
100.0
--
10.0
10.0
Agree
3.3
13.3
Undecided
3.3
16.7
Disagree
18
30.0
46.7
Strongly disagree
32
53.3
100.0
Total
60
100.0
--
Strongly agree
5.0
5.0
Agree
1.1
1.1
Undecided
1.7
1.7
45
25.0
25.0
Strongly disagree
121
67.2
67.2
Total
180
100.0
--
Undecided
Internet service
providers
Frequency
Strongly agree
Disagree


Table 10
Responses to Dependence on Imported Finished Products as a Major Barrier to Adoption of HIS by Participant
Status
Policy makers
Responses
Strongly agree
Cumulative
Percent
10.0
10.0
17
28.3
38.3
Undecided
14
23.3
61.7
Disagree
13
21.7
83.3
Strongly disagree
10
16.7
100.0
Total
60
100.0
--
Strongly agree
3.3
3.3
Agree
10
16.7
20.0
Undecided
13
21.7
41.7
Disagree
18
30.0
71.7
Strongly disagree
17
28.3
100.0
Total
60
100.0
--
Strongly agree
8.3
8.3
Agree
11
18.3
26.7
Undecided
11
18.3
45.0
15.0
60.0
Strongly disagree
24
40.0
100.0
Total
60
100.0
--
Strongly agree
13
7.2
7.2
Agree
38
21.1
28.3
Undecided
38
21.1
49.4
Disagree
40
22.2
71.7
Strongly disagree
51
28.3
100.0
180
100.0
--
Total

Percent
Agree
Disagree
Overall Responses
Frequency

Table 11
Current State of Local Technological Capabilities in the Adoption of HIS
Policy makers
Responses
Strongly agree
Cumulative
Percent
10.0
10.0
21
35.0
45.0
Undecided
17
28.3
73.3
Disagree
10
16.7
90.0
Strongly disagree
10.0
100.0
Total
60
100.0
--
Strongly agree
11.7
11.7
Agree
17
28.3
40.0
Undecided
16
26.7
66.7
Disagree
11
18.3
85.0
Strongly disagree
15.0
100.0
Total
60
100.0
--
Strongly agree
13
21.7
21.7
Agree
15
25.0
46.7
Undecided
11
18.3
65.0
Disagree
12
20.0
85.0
100.0
15.0
Total
60
100.0
Strongly agree
26
14.4
14.4
Agree
53
29.4
43.9
Undecided
44
24.4
68.3
Disagree
33
18.3
86.7
Strongly disagree
24
13.3
100.0
180
100.0
--
Total

Percent
Agree
Strongly disagree
Overall Responses
Frequency
--

Table 12
Resistance to the Use of Technology by Clinicians is a Reason for Poor Adoption of HIS in Nigerian Hospitals
Status of
Participants
Policy makers
Healthcare
Providers
Internet service
Providers
Overall
Responses
Responses
Frequency
Cumulative
Percent
Percent
Strongly agree
Agree
Undecided
Disagree
Strongly disagree
Total
Strongly agree
8
13
7
19
13
60
7
13.3
21.7
11.7
31.7
21.7
100.0
11.7
13.3
35.0
46.7
78.3
100.0
-11.7
Agree
Undecided
Disagree
Strongly Disagree
Total
Strongly agree
Agree
Undecided
Disagree
Strongly disagree
Total
16
4
19
14
60
11
19
6
14
10
60
26.7
6.7
31.7
23.3
100.0
18.3
31.7
10.0
23.3
16.7
100.0
38.3
45.0
76.7
100.0
-18.3
50.0
60.0
83.3
100.0
--
Strongly agree
26
14.4
Agree
48
26.7
41.1
Undecided
17
9.4
50.6
Disagree
52
28.9
79.4
Strongly disagree
37
20.6
100.0
180
100.0
--
Total

Table continued
14.4

Table 13
Clinicians in Nigeria Show Significant Technological Bias in the Provision of Healthcare
Policy makers
Responses
Strongly agree
Internet service
providers
Cumulative
Percent
10.0
10.0
16
26.7
36.7
Undecided
14
23.3
60.0
Disagree
18
30.0
90.0
10.0
100.0
Total
60
100.0
--
Agree
11
18.3
18.3
Undecided
10
16.7
35.0
Disagree
26
43.3
78.3
Strongly disagree
13
21.7
100.0
Total
60
100.0
--
10
16.7
16.7
Agree
18
30.0
46.7
Undecided
17
28.3
75.0
Disagree
10
16.7
91.7
8.3
100.0
60
100.0
--
Strongly agree
Strongly disagree
Total
Overall Responses
Percent
Agree
Strongly disagree
Frequency
Strongly agree
16
8.9
8.9
Agree
45
25.0
33.9
Undecided
41
22.8
56.7
Disagree
54
30.0
86.7
Strongly disagree
24
13.3
100.0
180
100.0
--
Total


Table 14
Funding Support will improve the Adoption of HIS in Nigeria
Policy makers
Responses
Strongly agree
Frequency
50.0
50.0
24
40.0
90.0
Undecided
1.7
91.7
Disagree
1.7
93.3
Strongly disagree
6.7
100.0
Total
60
100.0
--
Strongly agree
31
51.7
24
40.0
51.7
91.7
Disagree
3.3
95.0
Strongly disagree
5.0
100.0
Total
60
100.0
--
Strongly agree
33
55.0
55.0
Agree
22
36.7
91.7
Undecided
1.7
93.3
Disagree
3.3
96.7
Strongly disagree
3.3
100.0
60
100.0
--
Agree
Internet service
providers
Total
Overall Responses
Cumulative Percent
30
Agree
Percent
Strongly agree
94
52.2
52.2
Agree
70
38.9
91.1
Undecided
1.1
92.2
Disagree
2.8
95.0
Strongly disagree
5.0
100.0
Total

180
100.0
--

Table 15
Availability of Financial Aid to Healthcare Providers Who will Compromise the Adoption of HIS in Nigeria
Policy makers
Responses
Strongly agree
Agree
Undecided
Internet service
providers
Overall Responses
Frequency
Percent
Cumulative Percent
3.3
3.3
12
20.0
23.3
10.0
33.3
Disagree
18
30.0
63.3
Strongly disagree
22
36.7
100.0
Total
60
100.0
--
Strongly agree
6.7
6.7
Agree
6.7
13.3
Undecided
13.3
26.7
Disagree
14
23.3
50.0
Strongly disagree
30
50.0
100.0
Total
60
100.0
--
10.0
10.0
Agree
10
16.7
26.7
Undecided
13
21.7
48.3
Disagree
15
25.0
73.3
Strongly disagree
16
26.7
100.0
Total
60
100.0
Strongly agree
Responses
Strongly agree
Frequency
12
Percent
6.7
-Table continued
Cumulative
Percent
6.7
Agree
26
14.4
21.1
Undecided
27
15.0
36.1
Disagree
47
26.1
62.2
Strongly disagree
68
37.8
100.0
180
100.0
--
Total


Table 16
Corruption is a Barrier to the Adoption of HIS in Nigeria
Policy makers
Responses
Strongly agree
Frequency
Cumulative Percent
29
48.3
48.3
Agree
16
26.7
75.0
Undecided
10.0
85.0
Disagree
6.7
91.7
Strongly disagree
8.3
100.0
60
19
100.0
31.7
22
6
4
9
60
28
36.7
10.0
6.7
15.0
100.0
46.7
68.3
78.3
85.0
100.0
-46.7
19
5
2
6
60
76
31.7
8.3
3.3
10.0
100.0
42.2
78.3
86.7
90.0
100.0
-42.2
57
31.7
73.9
Undecided
17
9.4
83.3
Disagree
10
5.6
88.9
Strongly disagree
20
11.1
100.0
Total
Healthcare
providers
Percent
Strongly agree
Agree
Undecided
Disagree
Strongly disagree
Total
Internet Service Strongly agree
Providers
Agree
Undecided
Disagree
Strongly disagree
Total
Overall
Strongly agree
Responses
Agree
Total

180
100.0
-31.7
--

Table 17
Corruption Could Significantly Increase the Adoption of HIS in Nigeria
Status of
Participants
Policy makers
Responses
Strongly agree
Agree
Healthcare
providers
12
20.0
20.0
10
16.7
36.7
3.3
40.0
Disagree
10.0
50.0
Strongly disagree
30
50.0
100.0
Total
60
100.0
--
Strongly agree
Undecided
Disagree
Strongly disagree
Total
10
16.7
16.7
10
16.7
33.3
5.0
38.3
5.0
43.3
34
56.7
100.0
60
00.0
11
18.3
18.3
12
20.0
38.3
Undecided
5.0
43.3
Disagree
8.3
51.7
29
48.3
100.0
60
100.0
33
18.3
18.3
32
17.8
17.8
Strongly agree
Agree
Strongly disagree
Total
Overall
Responses
Cumulative
Percent
Undecided
Agree
Internet service
providers
Percent
Frequency
Strongly agree
Agree
Undecided
--
--
4.4
4.4
Disagree
14
7.8
7.8
Strongly disagree
93
51.7
51.7
180
100.0
Total
--
Level of Agreement by the Participants

Three categories of participants were studied to assess the barriers to adoption of hospital
information systems in Nigeria. The goal was to ascertain the extent to which the policy makers, health
care providers, and Internet service providers concurred in their responses on the various items in the
instrument. Hence, the Kendalls coefficient of concordance was applied as follows.
Kendalls test.
Hypothesis for Kendalls Test.
H0 There is no agreement between the responses by the three categories
H1 There is agreement between the responses by the three categories


Level of Significance. = 0.05
Test statistic.
2 = k (n 1)W
where
W=
n
12
k (n + 1)
Ri
2
2
2
k n(n 1) i =1
Decision Criterion. Reject
H0
if
p < 0.05
Computations. The computations obtained using the SPSS in the following tables:
Conclusion for Kendalls Test. The descriptive statistics for the three categories of participants are
displayed in Table 18, while the inferential statistics are in Table 19. From Table 19, since
p = 0.026 < 0.05 the null hypothesis is rejected, with the conclusion that there is a weak agreement
between the responses from the policy makers, healthcare providers, and Internet service providers. As
shown in Table 19, the value of the Kendalls coefficient of concordance of 0.215 signified a weak
agreement between the assessment and evaluation of the barriers to adoption of hospital information
systems in Nigeria. The numbers imply that the stratification into the three subpopulations of
participants is vital to acquiring more research information. Stratification has contributed to the accuracy
and precision of the results.
Table 18
Descriptive Statistics for Kendalls Test
Policy makers
Mean
Mean Ranks
Std. Deviation
60
4.28
1.94
1.106
Healthcare service providers
60
4.47
2.00
0.873
60
4.57
2.06
0.698
Table 19
Kendalls Test Statistic
Test statistic
N
Test values
60
Kendall's Coefficient of Concordance
0.215
Chi-Square
7.316
Degrees of freedom
Asymptotic Sig.

2
0.026

Table 20
Descriptive Statistics
Responses to Questions
Mean
Std.
Error
Std.
Deviation
Remark
180
3.07
0.109
1.469
Agree
180
1.87
0.089
1.201
Disagree
Hospital information systems significantly improve

the quality of medical outcome
180
4.50
0.064
0.862
Strongly
Agree
Implementation of hospital information systems

has no healthcare outcome implications
180
1.52
0.073
0.977
Disagree
180
2.57
0.097
1.295
Undecided
180
3.13
0.094
1.257
Agree
Mean
Std.
Error
180
2.86
0.104
1.395
Undecided
Clinicians in Nigeria show significant technological

bias in the provision of healthcare
180
2.86
0.089
1.195
Undecided
Funding support will improve the adoption of

hospital information systems in Nigeria
180
4.31
0.075
1.003
Agree
180
2.26
0.096
1.283
Disagree
Corruption is a major barrier to the adoption of

hospital information systems in Nigeria
180
3.88
0.098
1.317
Agree
Corruption could significantly increase the

adoption of hospital information systems in Nigeria
180
2.43
0.124
1.658
Disagree
Unclear healthcare policy on hospital information

systems is a major barrier to implementation in
Nigerian hospitals
Healthcare policies issues are irrelevant in the
implementation of hospital information system in
Nigeria
Dependence on imported finished products is a

major barrier to adoption of hospital information
systems in Nigeria
Current state of local technological capabilities in
the country could improve the adoption of hospital
information systems in Nigeria
Responses to Questions
Resistance to the use of technology by clinicians is a
reason for poor adoption of hospital information
systems in Nigerian hospitals
Availability of financial aids to healthcare providers

will compromise the adoption of hospital
information systems in Nigeria
Table continued
Std.
Remark
Deviation
Quantification and Analysis of Qualitative Data

The second set of data was collected through a structured interview particularly designed to validate
the data collected from the target population. The same stratification was adopted for the same


subpopulations of policy makers, healthcare providers, and Internet service providers. Similarly, the
interviews were set to explore the barriers to adoption of hospital information systems in Nigeria. After
the interview process, the data were coded and classified into multiple response tables with cumulative
categories as shown in table 21 through 24.
Table 21
Policy Makers Responses on the Barriers Hindering the Adoption of HIS
Responses
Major barriers
Percent of Cases
Percent
Unfavorable government policy
13.9%
83.3%
Lack of funding support
11.1%
66.7%
High cost of hospital information system
2.8%
16.7%
Poor infrastructural base of the country

Inadequate human capital
6
5
16.7%
13.9%
100.0%
83.3%
16.7%
100.0%
Non-implementation causing poor healthcare

outcome
Corruption as part of the barrier
16.7%
100.0%
Problems associated with poor Internet access
2.8%
16.7%
Over dependence on importation
0.0%
0.0%
End-users' resistance
5.6%
33.3%
Total
36
100.0%
600.0%
Table 22
Healthcare Providers Responses on the Barriers Hindering the Adoption of HIS
Responses
Major barriers
Percent of Cases
Percent
11.1%
66.7%
13.9%
83.3%
11.1%
66.7%

6
3
16.7%
8.3%
100.0%
50.0%
11.1%
66.7%

outcome
11.1%
66.7%
8.3%
50.0%
Over dependence on importations
5.6%
33.3%
2.8%
16.7%
Total
36
100.0%
600.0%


Table 23
Internet Service Providers Responses on the Barriers Hindering the Adoption of HIS
Responses
Major barriers
Percent of Cases
Percent
12.5%
85.7%
12.5%
85.7%
10.4%
71.4%

7
5
14.6%
10.4%
100.0%
71.4%
14.6%
100.0%

outcome
10.4%
71.4%
10.4%
71.4%
0.0%
0.0%
4.2%
28.6%
Total
48
100.0%
685.7%
Table 24
Cumulative Responses on the Barriers Hindering the Adoption of HIS
Responses
Major barriers
Percent of Cases
Percent
15
12.5%
78.9%
15
12.5%
78.9%
10
8.3%
52.6%

19
13
15.8%
10.8%
100.0%
68.4%
17
14.2%
89.5%
15
12.5%
78.9%
7.5%
47.4%
1.7%
10.5%
4.2%
26.3%
120
100.0%
631.6%

outcome
Total


SUMMARY
This paper provides detailed information on the mixed method case study research using in-depth
interviews and a questionnaire-based survey to ascertain the barriers hindering adoption of hospital
information systems in Nigeria. The discussion in this paper provided the problem that a robust health
care policy on implementation of a hospital information system is lacking in Nigeria and that caregivers
in the country have yet to commence noticeable implementation of hospital information technologies. The
data were collected using instruments particularly designed for the target population: health care policy
makers, health care service providers and Internet service providers. After the actual data collection
process, the data were classified into tables with purposeful and logical categories to facilitate the
analysis. The interpretations and implications will be in another paper in the series.
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Barriers

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 2

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 3

n = minimum sample size required

at the 5%level of significance, the computed values are;

Unclear health care policy on

The rest of the computation follows thus;

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 4

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 5

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 6

Internet service providers

* Listwise deletion based on all variables in the procedure.

Internet service providers

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 7

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 8

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 9

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 10

p < 0.05 and uphold H 0

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 11

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 12

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 13

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 14

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 15

Internet service providers

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 16

Internet service providers

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 17

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 18

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Barriers to Hospital IS in Nigeria/Benson 19

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 20

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 21

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 22

Level of Agreement by the Participants

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 23

Decision Criterion. Reject

Healthcare service providers

Internet service providers

Kendall's Coefficient of Concordance

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 24

Hospital information systems significantly improve