Unveiling the black box of diagnostic and clinical decision support systems for antenatal care: Realist evaluation

Ibukun Oluwa Omolade Abejirinde*, Marjolein Zweekhorst, Azucena Bardají, Rudolf Abugnaba-Abanga, Norbert Apentibadek, Vincent De Brouwere, Jos van Roosmalen, Bruno Marchal

*Corresponding author for this work

Research output: Contribution to JournalArticleAcademicpeer-review

Abstract

Background: Digital innovations have shown promise for improving maternal health service delivery. However, low-and middle-income countries are still at the adoption-utilization stage. Evidence on mobile health has been described as a black box, with gaps in theoretical explanations that account for the ecosystem of health care and their effect on adoption mechanisms. Bliss4Midwives, a modular integrated diagnostic kit to support antenatal care service delivery, was piloted for 1 year in Northern Ghana. Although both users and beneficiaries valued Bliss4Midwives, results from the pilot showed wide variations in usage behavior and duration of use across project sites. Objective: To strengthen the design and implementation of an improved prototype, the study objectives were two-fold: to identify causal factors underlying the variation in Bliss4Midwives usage behavior and understand how to overcome or leverage these in subsequent implementation cycles. Methods: Using a multiple case study design, a realist evaluation of Bliss4Midwives was conducted. A total of 3 candidate program theories were developed and empirically tested in 6 health facilities grouped into low and moderate usage clusters. Quantitative and qualitative data were collected and analyzed using realist thinking to build configurations that link intervention, context, actors, and mechanisms to program outcomes, by employing inductive and deductive reasoning. Nonparametric t test was used to compare the perceived usefulness and perceived ease of use of Bliss4Midwives between usage clusters. Results: We found no statistically significant differences between the 2 usage clusters. Low to moderate adoption of Bliss4Midwives was better explained by fear, enthusiasm, and high expectations for service delivery, especially in the absence of alternatives. Recognition from pregnant women, peers, supervisors, and the program itself was a crucial mechanism for device utilization. Other supportive mechanisms included ownership, empowerment, motivation, and adaptive responses to the device, such as realignment and negotiation. Champion users displayed high adoption-utilization behavior in contexts of participative or authoritative supervision, yet used the device inconsistently. Intervention-related (technical challenges, device rotation, lack of performance feedback, and refresher training), context-related (staff turnover, competing priorities, and workload), and individual factors (low technological self-efficacy, baseline knowledge, and internal motivation) suppressed utilization mechanisms. Conclusions: This study shed light on optimal conditions necessary for Bliss4Midwives to thrive in a complex social and organizational setting. Beyond usability and viability studies, advocates of innovative technologies for maternal care need to consider how implementation strategies and contextual factors, such as existing collaborations and supervision styles, trigger mechanisms that influence program outcomes. In addition to informing scale-up of the Bliss4Midwives prototype, our results highlight the need for interventions that are guided by research methods that account for complexity.

Original languageEnglish
Article numbere11468
Pages (from-to)1-13
Number of pages13
JournalJMIR mHealth and uHealth
Volume6
Issue number12
DOIs
Publication statusPublished - 1 Dec 2018

Funding

The authors thank the research assistants, translators, transcribers, study participants, the district administrators, and health facility personnel who were involved in the study. The authors acknowledge the support of the B4M implementing organizations in Ghana and the Netherlands (Association of Church Development Projects, Ghana; Presbyterian Health Services-North, Ghana; Cordaid; Relitech B.V; The Netherlands Organisation for Applied Scientific Research; Simavi; and Enviu Netherlands). The first author thanks Professor Vincent De Brouwere who financially supported the stakeholders’ dissemination meeting. The Erasmus Mundus Joint Doctorate Fellowship Specific Grant Agreement 2015-1595, which IOA is a beneficiary of, financed this study. Additional financial support was received from the B4M implementing partners through the Life Sciences and Health for Development (LS&H4D) grant: Number-LSH14GH16, which funded the B4M intervention. Funders had no role in study design, analysis, or preparation of the paper.

FundersFunder number
Life Sciences and Health for DevelopmentNumber-LSH14GH16
Netherlands Organisation for Applied Scientific Research2015-1595

    Keywords

    • Antenatal care
    • Clinical decision support
    • Ghana
    • MHealth
    • Program evaluation
    • Systems analysis

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