JMIR Publications

ABSTRACT

Background:

Complementary subscriptions to UpToDate, a decision support tool, were provided to community health workers (CHWs) in rural and remote primary care sites as part of a government-funded program. A feasibility evaluation conducted after the first year of implementation showed that UpToDate was acceptable among CHWs despite infrastructural barriers.

Objective:

This follow-up study aimed to evaluate how UpToDate aligned with the needs and roles of CHWs and how socio-cultural, political, and environmental factors influenced its adoption.

Methods:

An explanatory mixed methods design was used, combining analysis of CHW usage, program activity logs, program reports, and focus groups with CHWs, healthcare professionals, and program implementers. Quantitative data were analyzed using descriptive statistics, while reflexive thematic analysis was used for qualitative data. Results were integrated to provide explanations for observed usage patterns.

Results:

UpToDate usage declined over the three years. Most content views were on patient education, with higher use observed during periods of supervised CHW training. CHWs primarily used UpToDate as a reference for their reports during the training sessions, to correct misinformation, and to enhance social status. Its use as a decision support tool was limited. Political and environmental factors amplified digital access gaps which were worse in the remote site, although interdependence within families and communities mitigated some challenges. Differences in national and local government priorities caused ambiguity in support and accountability needed to sustain UpToDate adoption.

Conclusions:

CHWs predominantly used UpToDate as an educational resource and symbolic asset rather than a decision support tool, highlighting its alternative value for this cadre. Despite its promise, political and environmental barriers threaten to stall the scale-up and spread of the intervention and risk worsening inequitable access, if left unaddressed. This follow-up study showed the importance of understanding organizational issues and stakeholder dynamics to promote the scale-up, spread, and sustainability of the intervention.