Abstract
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Objective: Childhood immunization programs are essential components of health systems in low- and middle-income countries. In Rwanda, the introduction of the e-Tracker, a digital, longitudinal immunization registry, aimed to streamline immunization records. However, health facilities still underutilize the e-Tracker, relying on parallel paper-based documentation and reporting. This study seeks to implement and evaluate facilitation strategies to encourage the exclusive adoption of the e-Tracker.
Method: The study employed an implementation research design with a mixed-methods approach, guided by the i-PARIHS framework. Focus group discussions were conducted with an intervention group consisting of 12 immunization nurses, randomly selected from 46 underperforming e-Tracker health facilities identified through a national e-Tracker report. Together, we co-designed facilitation strategies, including the appointment of champion data managers to provide ongoing training. Training was delivered via a collaborative WhatsApp group and recorded videos addressing specific challenges faced by nurses in using the e- Tracker. The remaining 34 nurses from the same group of underperforming facilities served as the control. The strategies were evaluated six months post-implementation using a process evaluation questionnaire that assessed three key measures: acceptability (AIM), appropriateness (IAM), and feasibility (FIM) of the intervention. Data analysis was performed using SPSS (version 25), and an independent t-test was used to compare implementation outcomes between the intervention and control groups.
Results: The results indicated that the intervention group had a higher level of acceptability of implementation and use of e-Tracker (mean=23; SD=1.70) than the control group (mean=19.85; SD=5.21), p=.004). In addition, the intervention group reported a higher level of feasibility of implementation and the use of e-Tracker (mean=18; SD=1.47) than the control group (mean=14.21; SD=4.36), p=.000). However, no statistically significant difference was found in the appropriateness of implementation and use of e-Tracker (p =.381) in the intervention (mean=22.58; SD=1.97) and the control group (mean=21.06; SD=5.81).
Conclusion: Facilitation can overcome the resistance to change among health workers and improve acceptance of digital tools such as the e-Tracker. This study addresses the World Health Organization’s calls for implementation research to identify crucial factors affecting scalable and sustainable implementation of digital health interventions for health system strengthening for resource-limited settings.
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