This study aimed to identify the individual determinants of healthcare providers’ perceptions regarding the impact of a national electronic HIS in Gabon. We used a model adapted from the Information System Success Model [21, 27] that showed very good measurement properties and acceptable predictive power. In fact, a total of 30% of the variance in providers’ perceptions of the positive impact resulting from the use of the HIS was explained by five variables of our adapted model, namely Support Quality, Information Quality, System Quality, Actual Use, and Useful Functions. This latter variable was added to the initial ISSM in order to consider not only the actual use of an HIS but also the extent of its use by asking participants to indicate which specific functions of the HIS they use. The more functions they used, the higher their score. This variable could be related to the concept of ‘meaningful use’ of an information system by healthcare providers, which implies they optimally use the core functionalities of an information system .
There are very limited data from similar studies in low income countries. A study in Ethiopia  applied an adaptation of the ISSM and found that system quality, information quality, and service quality had a significant influence on EMR use and user satisfaction. Both actual use and user satisfaction were significantly associated with the perceived benefit of EMR. Surprisingly, our results do not support the influence of user satisfaction on perceived benefits since this construct is not significantly associated with Impact in the final model. A plausible explanation could be that the ISSM variables are seen as interdependent, meaning that other constructs, such as useful functions and actual use, might capture the influence of user satisfaction on perceived benefits .
A recent study conducted in Tanzania has tested a model that combines constructs from the ISSM and the TAM to understand user satisfaction and use of an EMR system . The final model suggests that attitude and system quality are the only significant predictors of user satisfaction and system use.
Another study from Tanzania applied a modified ISSM to identify the factors influencing user satisfaction with an electronic logistic management information system . The model includes perceived usefulness, a variable from the TAM, as well as facilitating conditions from the UTAUT. These two variables, together with system quality, information quality, and system support contributed significantly to the model, explaining 59.1% of the variance in user satisfaction.
Our adapted model allowed us to verify whether variables that are external to the ISSM could influence healthcare providers’ perceptions of the HIS. However, none of the added variables except useful functions significantly contributed to the model.
Some authors have suggested that inadequate computer literacy could hinder the success of EMR implementation in low income countries [36, 37], but this effect has not been rigorously tested . In our study, we used a single self-reported measurement of computer skills but found no significant influence of this variable on healthcare providers’ perceptions of the HIS. It has been shown that self-reported computer literacy is not reliable because people tend to overestimate their skills . However, the level of self-reported computer skills was generally low in our sample, making it unlikely that an overestimation would have biased the results.
Implications for Research and Practice
The results from this study show that it is possible to adapt the ISSM model to a low-income setting, but the limited performance of the model in explaining healthcare providers’ perceptions calls for further research in order to better grasp the factors influencing HIS adoption in this context.
Based on our results and those of previous studies in similar contexts, it would be useful to include additional factors when assessing the conditions for successful implementation of health information systems in low income countries, notably the availability of adequate infrastructure, funding, and incentives .
Our results could inform the design of strategies to support the implementation of the national electronic HIS in Gabon and in other similar contexts, notably, the importance of ensuring the quality of the system and the information it contains. Ensuring that users are appropriately trained and supported is another key element for successful implementation. We also recommend that several useful functions be integrated within the HIS, helping users gain positive experiences and confidence in the usefulness of the system.
Strengths and Limitations
This study is one of the few focusing on the acceptance of a large-scale HIS in a low-income country and also one of the few that considers the perceptions of various groups of end users, including nurses, physicians, midwives, and health administrators. However, other important user groups working in Gabon’s healthcare structures, such as information technology staff and radiology, laboratory, and pharmacy technicians, were not included in the survey since the aim was to investigate the perceptions of direct healthcare providers. It would be interesting to survey these other groups given that their work will be directly impacted by the introduction of the national electronic HIS in Gabon.
Although we used an adaptation of a well-known theoretical model, the DeLone and McLean ISSM , the percentage of variance explained by this model is modest. Other models, such as the TAM and the UTAUT, are often applied to study user acceptance of HIS. However, some authors have questioned the appropriateness of such models in the context of low income countries . In future studies, it could be interesting to compare different models in order to assess their applicability to the context of resource limited nations.
Our survey instrument showed very good psychometric properties, and we are confident that it could be adapted and used in other similar settings. Our theoretical model adapted from the ISSM is also promising but still needs improvement. Even though the scores obtained for the VIFs were relatively low, we cannot exclude the possibility of multicollinearity. Furthermore, the interdependence between the ISSM variables, particularly the mutual influence between use and user satisfaction, has been acknowledged previously and could constitute a limitation of this model [35, 39].