Feasibility, usability and acceptability of a novel digital hybrid-system for reporting of routine maternal health information in Southern Tanzania: A mixed-methods study

Abstract

Health information systems are important for health planning and progress monitoring. Still, data from health facilities are often of limited quality in Low-and-Middle-Income Countries. Quality deficits are partially rooted in the fact that paper-based documentation is still the norm at facility level, leading to mistakes in summarizing and manual copying. Digitization of data at facility level would allow automatization of these procedural steps. Here we aimed to evaluate the feasibility, usability and acceptability of a scanning innovation called Smart Paper Technology for digital data processing. We used a mixed-methods design to understand users' engagement with Smart Paper Technology and identify potential positive and negative effects of this innovation in three health facilities in Southern Tanzania. Eight focus group discussions and 11 in-depth interviews with users were conducted. We quantified time used by health care providers for documentation and patient care using time-motion methods. Thematic analysis was used to analyze qualitative data. Descriptive statistics and multivariable linear models were generated to compare the difference before and after introduction and adjust for confounders. Health care providers and health care managers appreciated the forms' simple design features and perceived Smart Paper Technology as time-saving and easy to use. The time-motion study with 273.3 and 224.0 hours of observations before and after introduction of Smart Paper Technology, respectively, confirmed that working time spent on documentation did not increase (27.0% at baseline and 26.4% post-introduction; adjusted p = 0.763). Time spent on patient care was not negatively impacted (26.9% at baseline and 37.1% at post-intervention; adjusted p = 0.001). Health care providers described positive effects on their accountability for data and service provision relating to the fact that individually signed forms were filled. Health care providers perceived Smart Paper Technology as feasible, easy to integrate and acceptable in their setting, particularly as it did not add time to documentation.

Fig 1. The difference between HMIS and SPT systems at health facility level.

HMIS: A nurse documents patient and service information into a woman’s antenatal care card and in a register book. Daily tally sheets and monthly report forms are manually created. The latter are brought to the district headquarter up to 10^th of each month. SPT: A nurse documents patient and service information in a woman’s antenatal care card and on one scannable SPT form. Forms are brought to district headquarter in regular intervals.

Fig 2. The difference between HMIS and SPT systems at district level.

HMIS: Several health care managers manually enter information from monthly report forms of all health facilities into the electronic DHIS2 system. Obvious inconsistencies or errors detected during data entry are followed up by phone or during physical visits where registers are checked. In DHIS2 aggregated data can be viewed from facilities with paper-based data entry (dispensaries) and both individual and aggregated data from fully digitized data entry (many health centres and all hospitals). SPT: One scanning officer scans all forms per facility. Data is automatically read by the software. Inconsistencies or errors are flagged by the system. A data verification officer works on these using the electronic register and phone calls to facilities if needed. Daily tally sheets and monthly summary reports are created automatically. Individual and aggregated data can be viewed.

Fig 3. Factors influencing the use of digital technology to impact documentation processes, outputs and outcome.