Integration of a Digital Health Intervention Into Immunization Clinic Workflows in Kenya: Qualitative, Realist Evaluation of Technology Usability

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 of these electronic systems to improve the provision of health services, few digital health interventions have been institutionalized at scale in low- and middle-income countries. Objective In this paper, we aimed to describe how health care 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 refined program theory on the registry’s usability. Methods Informed by realist methodology, we developed a program 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 semistructured 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. Results Across the 12 facilities included in our study, 19 health care workers were interviewed, and 58 workflow sessions were observed. The common rules developed from our qualitative findings are as follows: rule 1—ensure that the 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 that the system captures all data needed for users to provide routine health care services and is easy to navigate; rule 3—identify work-arounds 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 or number of patients. Upon study completion, we revised the program theory to reflect the importance of the goals and workflows of electronic immunization registries aligning with reality. Conclusions We created a deeper understanding of the underlying mechanisms for usability of the registry. We found that the electronic immunization registry had high acceptability among users; however, there were numerous barriers to using the system, even under ideal conditions, causing a misalignment between the system and the reality of the users’ workflows and their environment. 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 that interventions are suitable for all user settings.

Time Utilization Among Immunization Clinics Using an Electronic Immunization Registry (Part 2): Time and Motion Study of Modified User Workflows

“…When the EIR was fully functional and syncing with the server, activities took less time. Our qualitative study found that HCWs felt more time pressure and frustration, that more effort was required when there were connectivity issues, and that these feelings were exacerbated when there were many patients to be seen or staffing shortages [25].…”

“…Information on a child registered in the EIR could be viewed and edited on the web from any tablet through the system. Additional information on EIR design and deployment can be found in our qualitative study [25].…”

“…These theories provided meaningful structure for designing data collection instruments, and our findings reinforced the importance of studying the linkages between individuals, tasks, and technology, as well as taking into consideration the broader environmental and organization context. Our qualitative paper describes the underlying mechanisms linking workflow processes to outcomes in more detail [25].…”

Usability and Acceptability of Electronic Immunization Registry Data Entry Workflows From the Health Care Worker Perspective in Siaya, Kenya (Part 3): Pre-Post Study

“…After the successful pilot phase in 20 facilities of Gem subcounty, the EIR was implemented in all 161 immunizing clinics in Siaya County between 2018 and 2019. This study is part of a comprehensive evaluation of the implementation of an EIR in Siaya County, including a baseline usability study and time-in-motion study [ 18 , 19 ].…”