Results are reported in terms of actual intervention, ]policy context, and the innovation attributes.
Based on the analysis of interviews and project documents, we found that the list of intervention components that really constituted what the intervention was about went beyond the original vision. The project has been very dynamic experiencing several stages of changes mainly guided by the feedbacks received from users. Tdh has put in place regular dialog mechanisms with healthcare staff in order to ensure that the evolution of the tool and project take into account users’ feedback.
Between May 2015 and December 2017, the intervention evolved. Several activities and tools were added during the last year primarily to improve knowledge and data use for management and clinical care: (i) development of dashboards at health centre level; (ii) supply of a second tablet to larger health centres; and (iii) online learning modules on IMCI including short videos available on the tablets. The REC itself evolved several times during the project period experiencing several software improvements on the tablet and the backend of the tool (data analysis) resulting in several consecutive versions of the REC.
IeDA was implemented in all primary health facilities including those located in rural remote areas, where healthcare workers usually do not want to spend more than a few years and where staff turnover was anecdotally said to be high. For example, in Titao district, it was reported that up to 95% of newly transferred staff were healthcare workers coming straight from nursing school with no primary experience. During interviews, district managers estimated that newly arrived staff worked during an average of three years in the district before asking to be transferred to another district. Staff turnover was also seen as a challenge for Tdh who worried about training staff and sustaining the utilisation of REC in each health centre.
In July 2017, all health care workers working in the four districts where IeDA had been implemented, 31% of healthcare workers (62 out of 198) who were asked to use the REC had not benefited from the IMCI/REC training. This was exclusively explained by staff turnover: nurses who had been trained by the IeDA project had been transferred to other districts and replaced by staff who had not received the initial IMCI/REC training. To triangulate the information, all 40 health centres were surveyed to understand staff turnover. It was found that 36% of nurses had been changed within the last 12 years, period of time corresponding to the first IMCI/REC training. District managers confirmed that the rate is constant every year. This suggests that every 12 months, around 40% of the nurses or midwives move to another facility (most of the time outside the district).
The IeDA intervention and more specifically the technological innovation, the CDSS, provided to nurses on tablets was analysed in relation to Rogers’ attributes: comparative advantage, compatibility, complexity, triability and observability.
In terms of comparative advantage, the REC was compared by healthcare workers to the previous situation where only paper-based version of the IMCI was available. We learned from the stepped wedge trial that IMCI paper-form was used for 68% (916/1,343) of the consultations in the control arm, while the REC was used in nearly all consultations (97%, 674/694) in the intervention arm. The healthcare workers highlighted the advantages of the REC, which is described as a tool covering several functions. The REC was well accepted by healthcare workers and became a routine tool in their practice to the point that healthcare workers contributed to the maintenance of the tool, regular synchronisation and did not hesitate sometimes to use their own money to cover internet costs.
The REC is primarily an eCDSS tool that guides healthcare workers in their clinical decisions and help them respect the recommended IMCI protocol. Step-by-step decisions the clinicians need to make throughout the course of the consultation are guided by the software that forces the consultant to follow each step of the protocol in order to be able to complete the consultation. The district officers as well as the healthcare workers recognised that the tool is well designed and enables the healthcare workers to directly have access to the protocol without searching for the right information.
“If you directly register the child in the REC, it [the REC] provides the classification, the medicine you need to prescribe, even the dose. So no need anymore to search in the documents [i.e. IMCI paper protocol]. So to me, it is much easier like this: you ask questions, record the answer and this is finished. You get the treatment and the prescription. Huge advantage!” (healthcare worker).
The REC is described by many community interviewees as a living entity with its own autonomy and decision power. As a result, the “machine” brings its own independent opinion on the top of the healthcare worker’s opinion.
“It is the REC that helps quickly find the right products that are needed to treat my child when he is sick.” (Mother).
“The machine gives more information than the nurse”. (Father).
In a sense, the presence of the REC is reassuring for the community as it is a way to guarantee and triangulate the diagnosis provided by a nurse. To go further, it is as if the community had more trust in the REC viewed as generating a non-biased opinion:
“To me it is like a machine. It is a computer. This will diminish the errors. When I see some work done with a machine, I have no fear. I respect this work.” (Father).
A second advantage of the REC is the capacity to generate a patient registry and even the medical history of the child. Thanks to the patient history function, the healthcare worker can refine his/her consultation and ask further questions to the carer. Access to the medical history of the child is probably the most visible function from the perspective of the HCWs.
“When the child is here, you click here to see past treatments. You can see when he came and what reason. With the registry, it is very difficult. And we change registry all the time as soon as the pages are finished. But here, even one year later, you see everything.” (Healthcare worker).
Another important function of the REC is the centralisation and sharing of data. The patient registry is saved on the tablet, saved on a cloud and shared with district and national authorities.
“At the end of each week, data are sent to the district – very quickly – from the tablets without leaving the health centre. We can say that what we save is time.” (Townhall employee).
In terms of compatibility, we investigated the compatibility with the infrastructure, the use of IMCI, the health team and the relationship patient/clinician.
In terms of infrastructure, the REC did not create any specific challenge for the health centres, whatever their size. The introduction of the REC systematically generated amongst the health team an inventory of equipment missing or not functioning and the list of essential medicines. For example, in many health centres, after the IMCI training and the introduction of REC, we observed the creation of oral rehydration therapy (ORT) corners with plastic containers and oral rehydration solution (ORS).
“IMCI requires a consultation room dedicated to child consultations, which was possible in our health centre but we needed to move around furniture.” (Healthcare worker).
“At the start, we through that the REC was asking for drugs that we do not have in stock. We then realised that these drugs were part of the essential list of medicines. We had to order them.” (Drug stock manager).
In terms of team organisation, health staff realised that the use of REC was easier with several health agents involved than a single personnel. For example, one agent, usually the outreach health agent, stayed in the waiting room and take basic measures (weight and size). When possible, two agents managed the consultation as a team. One person close to the child and a second person guiding the consultation with the tablet through each step of the IMCI protocol and recording data on the tablet. We observed several times the involvement of one member of the health centre management committee when staff were overstretched.
There were however situations when the use of REC was challenged by the population: when the agent was on his/her own and during the malaria season.
“If I take months such as September-October-November, when the waiting room is full of patients, people are vomiting, people are on the floor with fever, it is very challenging when staff is limited. The population would insult us if we are slow.” (healthcare worker).
In terms of patient/clinician relationship, the REC introduced a new way of interacting with patients. One concern at the start of the project was that the REC would increase the physical distance between the patient and the healthcare worker. In fact, we observed in several centres that one agent moved away from his/her desk to sit down next to the child in order to consult the child and ask questions to the carer. The healthcare workers noticed the satisfaction of the community in this new approach and felt a gain of trust from the community. When the REC was not functioning or out of battery, the community noticed it, asked for explanations and demanded the use of the REC during consultation time.
Considering the limited level of computer literacy of their staff at primary health care level, complexity of REC was one of the main concerns the national policy makers had. It appears that the use of the tool is perceived as being easy to understand after initial training. We have also observed that new comers in a health centre are immediately trained by their peers on how to conduct consultation with the REC and use the tablet. All healthcare workers trained on REC recognised the importance of coaching provided by Tdh following the training in order to understand some of the troubleshooting methods when the software or tablet had issues and verify they are doing the correct tasks.
The feedback loops established by Tdh to understand users’ perspectives is also well valued as after each software version healthcare workers can see the improvements made compared to the previous in order to facilitate their work. The healthcare workers really understand that they are the key players in this project and that their voice and views are recorded and analysed to improve the usability of the tool.
The utilisation of REC becomes very complex when the system breakdowns. It happened that in the middle of the consultation, the software froze or the system shut down deleting all information registered during the consultation. We also observed that in some health centres, nurses were using the paper registry as they had serious issues with the battery of the tablet. The point here is to highlight that the introduction had become so much part of routine practice that its absence due to a breakdown was noticed by the healthcare workers and disrupted the organisation of consultations.
In terms of testability, we observed in a few health centres some resistance from heads of facilities. It was mainly due to the lack of self-confidence and literacy on using tablets and softwares. The coaching played a key role in accompanying individuals who had some reluctance in using REC and building their confidence. Coaches did not consider resistance as an exceptional event but rather assumed that resistance was the norm. As a result, any healthcare worker complaining about the innovation was not excluded from the intervention but on the contrary, their concerns were embraced by the coaches in order to build their skills and later their confidence.
In terms of observability (i.e. the possibility for the users to perceive visible benefits), interviewees listed quite a few aspects. First, the healthcare workers realised that the use of REC lead to a more rational prescription of medicine and reduced over-prescription, which is usually the result from community pressure. The presence of the tablet provided vis-à-vis the community arguments a rationale for the healthcare worker for not prescribing drugs when not necessary.
On the other hand, the healthcare worker through the use of REC had a better understanding of and adherence to the IMCI protocol as skipping steps were made unfeasible with REC. = As a result, healthcare workers felt more confident in their own classification and prescription.
“Without the REC, there are many questions we used to forget. But here, all the questions are listed and you cannot skip any of them. So to me, I think that we better manage patients. For example, when a child comes with a simple malaria, you can without the REC forget to identify anaemia.” (Healthcare worker).
The REC was also seen as a dynamic tool, which evolved with the national policies through low cost uploads. During the course of the project in 2016, a revised version of the national IMCI protocol was introduced by MoH. The protocol was then supposed to be rolled out by the MoH, which required dissemination of the document and ideally refreshers for all health staff. With the REC, a revision of the protocol in the software and the upload of the revised protocol on each tablet were the only tasks necessary to a full roll out of the revised protocol.
From the perspective of the healthcare workers, nurses or nurse assistants, the REC also represented a tool supporting continuous development through the eLearning tools. Indeed, in 2017 were introduced online training modules with short demonstration videos.
“For example, in terms of respiratory infections, to check whether a child has a stridor, you can click on the REC to watch a short video with a specific case of stridor. The REC provides a few more extra details on what information we need to check to confirm a stridor. They are plenty of details provided.” (Healthcare worker).
The quality of care approach promoted by MoH and Tdh went beyond the improvement of individual practice and behaviour change. A real support system was put in place engaging each level of the health system in the implementation and promotion of quality of care practices. This required the involvement of a wide range of actors ranging from national actors from all levels and sectors of the health system (different departments at MoH including family medicine, statistics and information) and international donors and United Nations agencies as well non-governmental organisations and civil society organisations and individuals (opinion leaders, religious leaders). Many of these actors were involved and engaged at each stage of the project to share views on the next steps of the implementation and scaling-up of IeDA. The recognition of everybody’s voice created an atmosphere of mutual support and trust within health centres and between health centre staff and district health teams.
“The culture of performance and quality needs to start from the institutional level. We need to be able to support the institutional level, which means the national, district and health centre levels.” (Tdh).
The behaviour of health workers was also influenced by the new accountability system introduced de facto by the REC. Indeed, every healthcare worker needs to log in every time he uses the REC. The information officer at the district level could easily retrieve this information in case of problem. This was a significant change in the Burkinabe public service culture as for the first time this information could be used to identify malpractice (if needed).
The high level of commitment from a wide range of actors generated more legitimacy for the project and created a devolution of powers and responsibilities within the health system to monitor the quality of the services provided. Even most Heads of the health centres had a sense that it was their responsibility to monitor the quality of the consultations performed by their team.
“The person who leads the consultation has to provide his personal details, which helps identify who is in charge of the consultation, so we know the proportion of consultations performed by nurses, as they are the ones who supposed to do it. And when there are problems, we can identify which person has difficult conduct correct consultations.” (District Officer).
During the later phases of the analysis, we found that the adoption process can be grouped according to their key mechanism and this led to the description of parallel CMO configurations, each with their own outcome.
the three CMO configurations related to IeDA
C1. Availability of a support team to be responsive to healthcare staff questions.
M1. Promoting amongst healthcare workers “doing the right thing the right way” approaches
O1. Notions of quality in childhood illnesses routinised during consultations
C2. In health centres where the nurse is assisted by at least two other members (nurse assistants or outreach workers) and where management flexibility is allowed
M2. Clear distribution of roles before and during child consultations (including triage, weight and size measurements, consultation and counselling)
O2. Efficient organisation of the health team
C3. Strong consensus amongst stakeholders on the benefits of introducing REC
M3. Introducing at primary health care level the notion of individual accountability and responsibility and collective contribution to the wider system.
O3. Sustained use of REC as a routine practice with no interruption of the functioning of the tool
The first CMO can be summarised as: with the support of a support team responsive to healthcare staff questions and needs (C1), promotion amongst healthcare workers of “doing the right thing the right way” approaches (M1) in order to routinise notions of quality in childhood illnesses during consultations (O1).
The project is trying to influence practice of health care workers by moving away from “simply doing”. The awareness from MoH and Tdh that reducing the child mortality with the same level of resources from government can only be achieved by improving quality of care, which in the context of the project relates to correctness of classification and prescription. This also concerns the shift from output indicators to quality and outcome indicators, which implied an organisational culture change within MoH staff. In addition to the initial training, regular supervision was put in place to complement initial training with in service-supervision. This was accompanied by quality assurance sessions where staff in health centre were asked to find solutions as a team. There was also much attention for a clear role distribution within a health centre. The notion of teamwork was emphasized by the project management team recognising the value and role of each member, whatever the title and background. In summary, both “hard” and “soft” management mechanisms were used to influence the organisational culture. The former included task distribution between health care staff by task - pre- (e.g. triage, child measurements), during (e.g. consultation and prescription), and post- (e.g. counselling) consultation tasks - and between clinical and administrative activities. The latter included initial IMCI/REC courses, peer pressure/support mechanisms and personnel development opportunities through eLearning modules. Availability of a support team to be responsive to healthcare staff questions and needs is an important context element and make possible the combination of all these management processes.
The second CMO configuration can be summarised as follows: a health centre team where the nurse is assisted by at least two other members (nurse assistants or outreach workers) and management flexibility is permitted (C2) can be better organised and efficient (O2) when the roles of each member are well distributed before and during child consultations (M2).
Key practices in this set included creating open discussions and dialog between all health team members on how the consultation should be organised considering the introduction of a new tool, the electronic tablet, and quality assurance sessions. In order to be more efficient, a triage was conducted in the waiting room by a nurse assistant or an outreach agent who identified the children in critical condition and take child measurement (e.g. size). This reinforced open relationships between health centre staff and contributed to solving practical problems and build solidarity between staff members. The quality assurance sessions were built around specific concrete issues experienced by the health centre team and elaborated realist solutions and action points, which achievement depended on how the members will work as a team. In turn, it stimulates the feeling of perceived organisational system and team mechanism. The leadership and management style introduced by Tdh is perceived by health centre staff to be effective and supportive.
The third CMO configuration can be formulated as after creating strong consensus at all levels on the benefits of using REC (C3), sustaining the use of REC as routine practice (O3) requires introducing the notion of individual responsibility and accountability (M3).
The members of the health centre, the primary users of the REC, had the feeling of belonging to a system that was wider than their health centre and contributing to a bigger enterprise than their own district. This was the result of early and ongoing engagement with a wide range of actors ranging from national and district authorities to opinion leaders at community level (Yukl 1999). REC users felt strong and wide consensus on the necessity of testing and using REC – a unique message sent by a multiplicity of key stakeholders influencing the environment of healthcare workers. The introduction of the notion of individual accountability in public services through personal login on the software also contributed to enhance a sense of individual responsibility and contribution to the wider system.
The new Medium Range Theory (MRT)
Our analysis identified four CMO configurations that indicate causal pathways between use of REC and sets of management practices, and we modified the MRT accordingly:
The adoption of a computer-based decision support tool by health staff at primary health care will be enhanced by having a leadership focusing on building wide consensus from surrounding stakeholders (local and national authorities) on the benefits of using such an innovation and having a wide of actors fully and truly engaged in the directions the project could take. This necessitates a system promoting flows of information between all levels of the health system where transparency of information is valued.
The introduction of such innovation needs to occur in an environment flexible enough to provide space to staff make decisions on the distribution of clearly-defined tasks within the team in order to better adapt their work to the new situation. On the other hand, the innovation, REC, needs to be flexible enough to take into account the constant changing policy environment and the emerging needs and requests from its users.
The REC is adopted when perceived by users and district managers as being encompassed within a broader quality improvement strategy where health staff is sensitised to the importance of quality and their capacity to address quality issues at their own level.
The introduction of the REC needs to be accompanied by a supportive atmosphere and environment (including community and policy makers support), which can be translated by peer support and district authorities support, and availability of support services responding to software or hardware issues. The supportive environment is based on reciprocity and acknowledges individual contributions to the wider system. Conditions for such environment to be promoted by a leadership that creates a decentralised decision space where initiatives are respected.