Diffusion of a micronutrient home fortification program for infants and toddlers in a multi-ethnic population in rural western China.

BACKGROUND: The micronutrient home fortification programs contribute to the prevention of childhood anemia. WHO suggested applying culturally appropriate strategies to implement the micronutrient home fortification programs in various communities. However, there is little knowledge on evidence-based effective diffusion strategies of the micronutrient home fortification programs in multi-ethnic populations. This study aims to examine the diffusion of a micronutrient home fortification program with micronutrient powder (MNP) in a multi-ethnic population by investigating factors associated with being an 'early' or a 'later' adopter of MNP. METHODS: We conducted a cross-sectional study in rural western China. Multistage sampling was used to select children's caregivers in Han, Tibetan, and Yi ethnic communities (N = 570). The diffusion of innovations theory informed the data collection on caregivers' decision process and was applied to classify participants into the MNP adopter categories of 'leaders', 'followers', 'loungers', and 'laggards'. The ordered logistic regression model estimated the factors associated with the MNP adopter categories. RESULTS: Caregivers from the Yi ethnic subgroup were likely to adopt MNP relatively late (AOR = 1.67; 95%CI = 1.09, 2.54) compared with Han and Tibetan ethnic subgroups. Caregivers with more knowledge regarding the MNP feeding method (AOR = 0.71; 95%CI = 0.52, 0.97) and those with stronger self-efficacy in adopting MNP (AOR = 0.85; 95%CI = 0.76, 0.96) were more likely to adopt MNP earlier than others. The following messages and channels also tend to make caregivers adopt MNP earlier: hearing that 'MNP was free' from villagers (AOR = 0.45; 95%CI = 0.20, 0.98), and learning 'MNP feeding method' from township doctors (AOR = 0.16; 95%CI = 0.06, 0.48). CONCLUSIONS: Disparities in adopting MNP existing among different ethnic groups require more effective diffusion strategies in disadvantaged minority ethnic groups. Enhancing self-efficacy in adopting MNP and knowledge on feeding method of MNP have the potential to make caregivers adopt MNP earlier. Peer networks and township doctors can be effective agencies to facilitate the diffusion and adoption of MNP.

Differences in Team Mental Models Associated With Medical Home Transformation Success.

PURPOSE: Primary care transformation is widely seen as essential to improving patient outcomes and health care costs. The medical home model can achieve these ends, but dissemination and scale-up of practice transformation is challenging. We sought to understand how to move past successful pilot efforts by early adopters to widespread adoption by applying cognitive task analysis using the diffusion of innovations framework. METHODS: We undertook a qualitative cross-sectional comparison of 3 early adopter practices and 15 early majority practices in Alberta, Canada. Practices completed a total of 42 cognitive task analysis interviews. We conducted a framework-guided qualitative analysis, with allowance for emergent themes, using the macrocognition framework on which cognitive task analysis is based. Independent codings of interview transcripts for key macrocognitive functions were reviewed in group analysis meetings to describe macrocognitive functions and team mental models, and identify emergent themes. Two external focus groups provided support for these findings. RESULTS: Three prominent findings emerged. The first was a spectrum of mental models from "doctor with helpers," through degrees of delegation, to fully team based care. The second was differences in how teams distributed macrocognitive functions among members, with early adopters distributing these functions more widely across the team than early majority practices. Finally, we saw emergence of several themes also common in the diffusion of innovations literature, such as the importance of trying new practices in small, reversible steps. CONCLUSIONS: Our findings provide guidance to practice teams, health systems, and policymakers seeking to move beyond early adopters, to improve team functioning and advance the medical home transformation at scale.

Comfort Relying on HIV Pre-exposure Prophylaxis and Treatment as Prevention for Condomless Sex: Results of an Online Survey of Australian Gay and Bisexual Men.

HIV-negative and untested gay and bisexual men from Victoria, Australia (n = 771) were surveyed during August-September 2016 about their comfort having condomless sex with casual male partners in scenarios in which pre-exposure prophylaxis (PrEP) or treatment as prevention were used. Men not using PrEP were most comfortable with the idea of condomless sex with HIV-negative partners (31%), followed by partners using PrEP (23%). PrEP users were more comfortable with the idea of condomless sex with these partner types (64 and 72%, respectively). Very few men not taking PrEP were comfortable with condomless sex with HIV-positive partners (3%), even with undetectable viral loads (6%). PrEP users were more comfortable with condomless sex with HIV-positive partners (29%), and those with undetectable viral loads (48%). Being on PrEP, having recent condomless sex with casual partners or a HIV-positive regular partner were independently associated with comfort having condomless sex.

Engaging national and regional partners to accelerate broad-scale implementation of nurse-developed interventions.

Only a small proportion of research-tested interventions translate into broad-scale implementation in real world practice, and when they do, it often takes many years. Partnering with national and regional organizations is one strategies that researchers may apply to speed the translation of interventions into real-world practice. Through these partnerships, researchers can promote and distribute interventions to the audiences they want their interventions to reach. In this paper, we describe five nurse scientists' programs of research and their partnerships with networks of national, regional, and local organizations, including their initial formative work, activities to engage multi-level network partners, and lessons learned about partnership approaches to speeding broad-scale implementation.

Factors influencing health care and service providers' and their respective "at risk" populations' adoption of the Air Quality Health Index (AQHI): a qualitative study.

BACKGROUND: The Air Quality Health Index (AQHI) provides air quality and health information such that the public can implement health protective behaviours (reducing and/or rescheduling outdoor activity) and decrease exposure to outdoor air pollution. The AQHI's health messages account for increased risk associated with "at risk" populations (i.e. young children, elderly and those with pre-existing respiratory and/or cardiovascular conditions) who rely on health care and service providers for guidance. Using Rogers' Diffusion of Innovations theory, our objective with respect to health care and service providers and their respective "at risk" populations was to explore: 1) level of AQHI knowledge; 2) factors influencing AQHI adoption and; 3) strategies that may increase uptake of AQHI, according to city divisions and socioeconomic status (SES). METHODS: Semi-structured face-to-face interviews with health care (Registered Nurses and Certified Respiratory Educators) and service providers (Registered Early Childhood Educators) and focus groups with their respective "at risk" populations explored barriers and facilitators to AQHI adoption. Participants were selected using purposive sampling. Each transcript was analyzed using an Interpretive Description approach to identify themes. Analyses were informed by Rogers' Diffusion of Innovations theory. RESULTS: Fifty participants (6 health care and service providers, 16 parents, 13 elderly, 15 people with existing respiratory conditions) contributed to this study. AQHI knowledge, AQHI characteristics and perceptions of air quality and health influenced AQHI adoption. AQHI knowledge centred on numerical reliance and health protective intent but varied with SES. More emphasis on AQHI relevance with respect to health benefits was required to stress relative advantage over other indices and reduce index confusion. AQHI reporting at a neighbourhood scale was recognized as addressing geographic variability and uncertainty in perceived versus measured air quality impacting health. Participants predominantly expressed that they relied on sensory cues (i.e. feel, sight, taste) to determine when to implement health protective behaviours. Time constraints were identified as barriers; whereas local media reporting and wearable devices were identified as facilitators to AQHI adoption. CONCLUSION: Increasing knowledge, emphasizing relevance, and reporting AQHI information at a neighbourhood scale via local media sources and wearable devices may facilitate AQHI adoption while accounting for SES differences.

Dealing with the complex dynamics of teaching hospitals.

Innovation and change in postgraduate medical education programs affects teaching hospital organizations, since medical education and clinical service are interrelated.Recent trends towards flexible, time-independent and individualized educational programs put pressure on this relationship. This pressure may lead to organizational uncertainty, unbalance and friction making it an important issue to analyze.The last decade was marked by a transition towards outcome-based postgraduate medical education. During this transition competency-based programs made their appearance. Although competency-based medical education has the potential to make medical education more efficient, the effects are still under debate. And while this debate continues, the field of medical education is already introducing next level innovations: flexible and individualized training programs. Major organizational change, like the transition to flexible education programs, can easily lead to friction and conflict in teaching hospital organizations.This article analyses the organizational impact of postgraduate medical education innovations, with a particular focus on flexible training and competency based medical education. The characteristics of teaching hospital organizations are compared with elements of innovation and complexity theory.With this comparison the article argues that teaching hospital organizations have complex characteristics and behave in a non-linear way. This perspective forms the basis for further discussion and analysis of this unexplored aspect of flexible and competency based education.

Lessons Learned from a Shared Curriculum on Tobacco Cessation Using a Mixed-Methods Approach.

Although the sharing of curricular content between health professional schools can reduce faculty burden, the literature provides little guidance to support these efforts. The objective of this investigation was to synthesize data from two prior studies to delineate recommendations guiding the future development of shared curricula in health professional education. Applying Rogers' Diffusion of Innovations Theory as a guiding framework, relevant data were extracted from a two-phase mixed-methods study evaluating the long-term impact of the shared Rx for Change: Clinician-Assisted Tobacco Cessation program. Phase 1, a qualitative study, involved telephone interviews with faculty participants of train-the-trainer workshops conducted between 2003 and 2005. These results informed the development of a phase 2 national survey, administered electronically as a long-term follow-up (13 to 15 years later) with train-the-trainer workshop participants. Results from the two studies were synthesized and summarized, producing seven key recommendations to guide development of shared curricula: (1) appeal to attendees, (2) relate content to clinical practice, (3) deliver live, in-person training, (4) develop high-quality materials, delivered by experts, (5) provide support, (6) meet accreditation standards, and (7) demonstrate effectiveness. Future program developers should consider these recommendations to enhance dissemination, adoption, and long-term sustainability of shared curricular content.

Recognizing the preventive quality in the adoption of innovations: The case of third-party ownership photovoltaic systems in Finland.

This study explores the role of the preventive quality of innovations on their adoption intention. The preventive quality of innovations is a distinctive feature of innovations that is directed towards avoiding a future, possibly harmful event. Empirically grounded in third-party ownership of photovoltaic systems in Finland, this study examines data collected from an online survey measuring respondent intention to adopt. A series of hypotheses theoretically grounded in the Diffusion of Innovations theory and the preventive quality of innovations were tested through Partial Least Squares Structural Equation Modeling with SmartPLS4. Findings for the overall sample reveal that the preventive quality and the relative advantage of innovations influenced adoption intention positively. Findings highlight the preventive quality of innovations as a construct that acts as the greatest contributor to the dependent variable.

Long-Term Trends in Obesity Prevalence by Socio-Economic Group in Five European Countries and the USA: The Relevance of the Diffusion of Innovations Theory.

INTRODUCTION: Cross-national comparison suggests that the timing of the obesity epidemic differs across socio-economic groups (SEGs). Similar to the smoking epidemic, these differences might be described by the diffusion of innovations theory, which states that health behaviours diffuse from higher to lower SEGs. However, the applicability of the diffusion of innovations theory to long-term time trends in obesity by SEG is unknown. We studied long-term trends in the obesity prevalence by SEG in England, France, Finland, Italy, Norway, and the USA and examined whether trends are described by the diffusion of innovations theory. METHODS: Obesity prevalence from 1978 to 2019 by educational level, sex, and age group (25+ years) from health surveys was harmonized, age-standardized, Loess-smoothed, and visualized. Prevalence rate differences were calculated, and segmented regression was performed to obtain annual percentage changes, which were compared over time and across SEGs. RESULTS: Obesity prevalence among lower educated groups has exceeded that of higher educated groups, except among American men, in all countries throughout the study period. A comparable increase across educational levels was observed until approximately 2000. Recently, obesity prevalence stagnated among higher educated groups in Finland, France, Italy, and Norway and lower educated groups in England and the USA. DISCUSSION: Recent trends in obesity prevalence by SEG are mostly in line with the diffusion of innovations theory; however, no diffusion from higher to lower SEGs at the start of the epidemic was found. The stagnation among higher SEGs but not lower SEGs suggests that the latter will likely experience the greatest future burden.

An Exploration of the Unintended Consequences of Performance-Based Financing in 6 Primary Healthcare Facilities in Burkina Faso.

BACKGROUND: Performance-based financing (PBF) is promoted to improve the quality and quantity of healthcare services in low-income countries. Despite the complexity of the intervention, little attention has been given to studying its unintended consequences. Our objective is to increase evidence on the unintended consequences of PBF in Burkina Faso. METHODS: Using the diffusion of innovations theory, we conducted a multiple case study. The cases were 6 healthcare facilities in two districts. Between April 2015 and 2016, we collected data through 101 semi-structured interviews, discussions, observations, and documents. We conducted thematic analysis using a hybrid deductive-inductive approach. Secondary data was used to illustrate the evolution of reported services. We conducted a cross-case synthesis to identify the results arising independently from more than 1 case. RESULTS: A desirable unintended consequence of PBF was that 3 facilities limited the sale of non-prescribed medication to encourage patients to consult. Undesirable unintended consequences were found in the majority of facilities including fixation on measures rather than on underlying objectives, the pursuit of narrow and less relevant performance indicators, gaming, and teaching trainees improper practices. Providers in all facilities deliberately manipulated medical registers and documents, such that the reported quantity and quality of care differed from what was actually delivered. While most participants indicated that PBF was more advantageous than previous practices, the long payment delays were a source of dissatisfaction and demotivation across all facilities. Dissatisfaction also emerged in relation to the distribution of subsidies and the non-attribution of quality points for services delivered by certain staff considered "unqualified" in guidelines. Results in many facilities revealed suboptimal planning, a perception of the intervention as "budgetivorous," as well as tensions related to the principle of managerial autonomy. CONCLUSION: PBF led to numerous unintended consequences that could undermine the intervention's effectiveness. The findings contribute to a more comprehensive picture of the consequences of implementing PBF. Policy-makers can use the results of this study to devise effective strategies before, during and after the implementation of the intervention to minimize undesirable unintended consequences and promote desirable ones.

Behavioral intention to use distance teaching in the pandemic era.

This study aimed at exploring the impact of post-epidemic era on teachers' behavioral intention of distance education. In this study, purposive sampling method was used to enroll 390 teachers in colleges and universities, high schools and vocational schools, and junior high and elementary schools to be the research subjects for the questionnaire survey. A total of 360 questionnaires were collected for statistics, and AMOS 23.0 statistical software was used to analyze the correlation between variables. Meanwhile, a structural equation model was used to analyze and verify the impact of the technology acceptance model, information system success model, and diffusion of innovations theory. According to the results, the system quality of distance teaching platforms certainly affected perceived usefulness, and perceived usefulness affected teachers' attitudes toward using distance teaching systems. In addition, perceived ease of use had an impact on perceived usefulness, and trialability had an impact on teachers' attitudes toward using distance teaching systems. Finally, teachers' attitude toward using a distance teaching system also affected their behavioral intention. According to the results, suggestions were made in this study to teachers and students for distance teaching. Additionally, the main contribution of this study lies in providing specific strategies for further distance teaching through empirical results in combination with on-site teaching.

Effects of diffusion of innovations, spatial presence, and flow on virtual reality shopping.

Virtual reality (VR) has developed rapidly, drawing more businesses to such development. Based on the diffusion of innovations theory (DIT), the study combines the flow theory and the satisfaction perspective to explore purchase intention influencing customers' adoption of the VR shopping platform system. This study found that satisfaction and flow experience enhance their purchase intention. In technological characteristics, relative advantage, service compatibility, spatial presence, and complexity are important in satisfaction. Among them, both relative advantage and spatial presence impact flow experience. Additionally, a cluster analysis based on gender was conducted, and the study found a significant difference between relative advantages, service compatibility, and complexity in women and men users. The flow experience is an important factor affecting women users' shopping intention, while insignificant for male users. The implications of these findings are discussed.

Intention to Receive the COVID-19 Vaccination in China: Application of the Diffusion of Innovations Theory and the Moderating Role of Openness to Experience.

COVID-19 has caused a devastating impact on public health and made the development of the COVID-19 vaccination a top priority. Herd immunity through vaccination requires a sufficient number of the population to be vaccinated. Research on factors that promote intention to receive the COVID-19 vaccination is warranted. Based on Diffusion of Innovations Theory, this study examines the association between the perceived efficacy of the COVID-19 vaccination, use of social media for COVID-19 vaccine-related information, openness to experience and descriptive norm with the intention to receive the COVID-19 vaccination, and the moderating role of openness to experience among 6922 university students in mainland China. The intention to receive the free and self-paid COVID-19 vaccination is 78.9% and 60.2%, respectively. Results from path analyses show that perceived efficacy of the COVID-19 vaccination, use of social media for COVID-19 vaccine-related information, and openness to experience and descriptive norm are all positively associated with the intention to receive COVID-19 free and self-paid vaccination. The association between the perceived efficacy of the COVID-19 vaccination and descriptive norm with the intention to receive the COVID-19 vaccination is stronger among those with a lower level of openness to experience. Our findings support the usefulness of Diffusion of Innovations Theory and the moderating role of openness of experience in explaining intention to receive the COVID-19 vaccination.

Adoption of Moringa oleifera to combat under-nutrition viewed through the lens of the "Diffusion of innovations" theory.

Moringa oleifera, an edible tree found worldwide in the dry tropics, is increasingly being used for nutritional supplementation. Its nutrient-dense leaves are high in protein quality, leading to its widespread use by doctors, healers, nutritionists and community leaders, to treat under-nutrition and a variety of illnesses. Despite the fact that no rigorous clinical trial has tested its efficacy for treating under-nutrition, the adoption of M. oleifera continues to increase. The "Diffusion of innovations theory" describes well, the evidence for growth and adoption of dietary M. oleifera leaves, and it highlights the need for a scientific consensus on the nutritional benefits.

Big Data Analytics in Healthcare: Investigating the Diffusion of Innovation.

The shortage of data scientists has restricted the implementation of big data analytics in healthcare facilities. This survey study explores big data tool and technology usage, examines the gap between the supply and the demand for data scientists through Diffusion of Innovations theory, proposes engaging academics to accelerate knowledge diffusion, and recommends adoption of curriculum-building models. For this study, data were collected through a national survey of healthcare managers. Results provide practical data on big data tool and technology skills utilized in the workplace. This information is valuable for healthcare organizations, academics, and industry leaders who collaborate to implement the necessary infrastructure for content delivery and for experiential learning. It informs academics working to reengineer their curriculum to focus on big data analytics. The paper presents numerous resources that provide guidance for building knowledge. Future research directions are discussed.

Understanding the impact of adaptations to a parent-mediated intervention on parents' ratings of perceived barriers, program attributes, and intent to use.

Within the autism spectrum disorder field, rates of attrition in parent-mediated interventions have highlighted the need to engage families around improving the delivery of these services. The primary goal of this study was to approximate the impact of adaptations to an evidence-based, parent-mediated intervention, Project ImPACT (Improving Parents as Communication Teachers), that had been made in collaboration with families in a Medicaid system. A total of 103 parents of a child with autism spectrum disorder were randomized to watch a presentation of either the original or adapted Project ImPACT program. After watching the presentation, participants rated (1) demographic information, (2) perceived structural barriers, (3) Project ImPACT attributes, and (4) intent to use the program. Results from hierarchical linear regression models demonstrated that program type alone predicted parents' ratings of perceived structural barriers. Additionally, both program type and the interaction of program type and annual household income were unique predictors of parents' ratings of program attributes and intent to use. Qualitatively, although many parents reflected positively on both Project ImPACT programs, parents who viewed the adapted program appeared more likely to report positive program attributes. Results suggest the importance of engaging families in improving the fit of parent-mediated interventions for use within a variety of community settings.

A prospective longitudinal relation between elevated use of electronic devices and use of electronic nicotine delivery systems.

BACKGROUND: In recent years, there has been a rapid increase in the use of both electronic nicotine delivery systems (ENDS) and electronic devices among U.S. youth. Informed by the Diffusion of Innovations Theory (DIT), it was hypothesized that elevated use of electronic devices (EUED) prospectively would predict ENDS use among youth. METHODS: Data were drawn from the Population Assessment of Tobacco and Health (PATH) Study, a longitudinal cohort study in a nationally representative sample. Participants who were 12-17 years old, and naïve to both conventional cigarettes and ENDS at baseline (N = 11,325) were sampled. A total of 8723 respondents had matched data from Wave 1 to Wave 2 and 6051 respondents had matched data for all the three waves. Multivariable sequential logistic regressions were conducted to examine determinants of ENDS use in later waves using R version 3.5.2. RESULTS: Among youth who were naïve to both ENDS and conventional cigarettes at baseline, those with EUED were more likely to initiate ENDS use in later years than those without EUED even after controlling for exposure to ENDS advertisements and other well-established covariates of ENDS use. Daily (adjusted odds ratio [AOR] ranges from 2.76 to 3.56) and weekly (AOR ranges from 2.16 to 2.65) social networking service (SNS) users were more likely to initiate ENDS use than non-users of SNS in the adjusted models. CONCLUSIONS: The findings support the hypothesis that EUED prospectively predicts ENDS use among youth. The use of DIT framework helps understand the link between EUED and ENDS use.

Equipping community pharmacy workers as agents for health behaviour change: developing and testing a theory-based smoking cessation intervention.

OBJECTIVE: To develop a complex intervention for community pharmacy staff to promote uptake of smoking cessation services and to increase quit rates. DESIGN: Following the Medical Research Council framework, we used a mixed-methods approach to develop, pilot and then refine the intervention. METHODS: Phase I: We used information from qualitative studies in pharmacies, systematic literature reviews and the Capability, Opportunity, Motivation-Behaviour framework to inform design of the initial version of the intervention. Phase II: We then tested the acceptability of this intervention with smoking cessation advisers and assessed fidelity using actors who visited pharmacies posing as smokers, in a pilot study. Phase III: We reviewed the content and associated theory underpinning our intervention, taking account of the results of the earlier studies and a realist analysis of published literature. We then confirmed a logic model describing the intended operation of the intervention and used this model to refine the intervention and associated materials. SETTING: Eight community pharmacies in three inner east London boroughs. PARTICIPANTS: 12 Stop Smoking Advisers. INTERVENTION: Two, 150 min, skills-based training sessions focused on communication and behaviour change skills with between session practice. RESULTS: The pilot study confirmed acceptability of the intervention and showed preliminary evidence of benefit; however, organisational barriers tended to limit effective operation. The pilot data and realist review pointed to additional use of Diffusion of Innovations Theory to seat the intervention in the wider organisational context. CONCLUSIONS: We have developed and refined an intervention to promote smoking cessation services in community pharmacies, which we now plan to evaluate in a randomised controlled trial. TRIAL REGISTRATION NUMBER: UKCRN ID 18446, Pilot.

Assessing advantages and barriers to telemedicine adoption in the practice setting: A MyCareTeam(TM) exemplar.

PURPOSE: Telemedicine is an evolving field that holds great potential to improve patient outcomes. The National Organization of Nurse Practitioner Faculties core competencies now require all nurse practitioners (NPs) to be competent utilizing telemedicine to address various patient and healthcare system needs. While telemedicine offers advantages to patient care, adoption of new technologies can be challenging. DATA SOURCES: An assessment of perceived advantages and barriers to MyCareTeam, an online diabetes management system, was conducted at an adult diabetes clinic. Two survey questionnaires were developed based on the Diffusion of Innovations (DOI) theory. The surveys were administered to patients in the clinic waiting room and sent to all clinical staff via an e-mail link. CONCLUSIONS: The findings of this project suggested a novel way to classify patients with regard to their use of the technology with implications for practice. Recommendations include outreach to enhance knowledge and awareness of MyCareTeam, reinforcing the full scope of the system, and improved technical support. IMPLICATIONS FOR PRACTICE: DOI theory is a framework that may be utilized by NPs as a tool for assessing advantages and barriers to telemedicine applications in the practice setting in order to identify strategies to promote adoption and use.

Challenges to the Scaling of Computer- Based Patient Record System for Antiretroviral Therapy Program in Ethiopia

Drawing upon interpretive paradigm and an action research approach, this study investigated the challenges to the scaling of computer-based health information systems in the public health sector of Ethiopia. The research was situated within a broader action research project by HISP (Health Information System Program) Ethiopia which was aimed at developing and implementing an integrated HIV/AIDS management system in the country. The ART module of the system was developed and implemented in two pilot sites in the capital city, Addis Ababa. The research problem was addressed using this system; specifically through participation in its scaling (both in functionality and geographically). The fieldwork was conducted in two logically connected phases between July 2006 and January 2007. In the first phase, I studied how the computerized system was functioning at the pilot sites with the aim to understand what needs to be done when it is implemented elsewhere; and identify any problems with it which might need to be addressed before its deployment to other sites (geographic scaling). The second phase of the study was the actual deployment of the system to the main case study site, the Southern Nations Nationalities and People's Region. Efforts to deploy the system to other clinics within Addis Ababa; and Amhara, Oromia, and Somali regions were also investigated. Qualitative data collection techniques including interviews, observation, and document review were used to collect the empirical data. The findings were analyzed using qualitative techniques. Analysis of the findings concerning the geographic scaling of the system (through the processes of adoption and implementation) was informed by a theoretical framework which was developed by combining key concepts from the diffusion of innovations and institutional theories; and findings of previous information systems implementation studies. The framework was developed in way that facilitates an integrated analysis of the challenges to the geographic scaling, including the technological factors, organizational issues, and external influences on the public health organizations. The research identified frequent changes in the requirements (information needs) of users, differences in work practices, lack of technical workforce, and the use of complicated pilot sites as the key challenges to the scaling in functionality of the system. A variety of technological, organizational, and environmental factors were found to influence the adoption and implementation of the system by public health organizations. Functionality of the system; and perceived characteristics of the system, specifically perceived benefits, technical compatibility with the existing systems, perceived complexity, trialability (the possibility of trying it before the decision to implement is made), and perceived reliability were the technology-related factors which influenced the adoption and implementation processes. The major organizational factors which affected the processes were inadequate organizational readiness, and the administrative structure of public health organizations. In addition, coercive influences from the NGOs supporting the Antiretroviral Therapy program had significant impact. Analysis of the findings also revealed that the lack of formal rules (such as IS implementation guidelines), which could provide a framework for the actions of iii the decision-makers and the implementers, to be the key problem, and a possible explanation for most of the observed challenges. It is argued that the influences on the adoption and implementation of the system are complex and inter-related; and thus cannot be fully understood in isolation. The research proposes a holistic approach to the investigation and understanding of challenges to computer-based health information systems development and implementation in developing countries. The major implications of the findings for the public health sector in developing countries are also outlined. In the context of the ART program, and the current massive scale-up of the treatment in developing countries, the need to anticipate the information management challenges and strengthen the health information system ­ including the development of clear strategic directions for the adoption of innovative solutions, the strengthening of the manual system and its infrastructure base; and alignment between various stakeholders ­ are emphasized.