JMIR Publications

ABSTRACT

Background:

In an effort to increase vaccination coverage in low-resource settings, digital tools have been introduced to better track immunization records, improve data management practices, and provide improved access to vaccination coverage data for decision-making. Despite the potential for these electronic systems to improve provision of health services, few digital health interventions have been institutionalized at scale in low- and middle-income countries.

Objective:

We aimed to describe how healthcare workers in Kenya had integrated an electronic immunization registry into their immunization clinic workflows and to use these findings to inform the development of a middle-range theory on the registry’s usability.

Methods:

Informed by realist methodology, we developed a middle-range theory to explain usability of the electronic immunization registry. We designed a qualitative study based on our theory to describe the barriers and facilitators influencing data entry and use. Qualitative data were collected through semi-structured interviews with users and workflow observations of immunization clinic sessions. Our findings were summarized by context-mechanism-outcome relationships formed after analyzing our key themes across interviews and workflow observations. Using these relationships we were able to identify common rules for future implementers to successfully introduce digital health tools.

Results:

Across the 12 facilities included in our study, 19 healthcare workers were interviewed and 58 workflow sessions were observed. The common rules developed from our qualitative findings included: Rule 1- Ensure users complete training to build familiarity with the system, understand the value of the system and data, and know where to find support, Rule 2- Confirm the system captures all data needed for users to provide routine healthcare services and is easy to navigate, Rule 3- Identify workarounds for poor network, system performance, and too few staff or resources, and Rule 4- Make users aware of expected changes to their workflow, and how these changes might differ over time and by facility size/number of patients. Upon study completion, we revised the middle-range theory to reflect the importance of the goals and workflows of information systems aligning with reality.

Conclusions:

We identified the major barriers and facilitators of usability and created a deeper understanding of the underlying mechanisms. We found that the electronic immunization registry had high acceptability amongst users, however, there were numerous barriers to using the system, even under ideal conditions. Implementers should consider users’ workflows during design and implementation phases. Human centered design and human factors methods can assist during pilot stages to better align systems with users’ needs and again after scale-up to ensure interventions are suitable for all user-settings.