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. 2025 Nov 27;10(Suppl 8):e017303.
doi: 10.1136/bmjgh-2024-017303.

Understanding health innovation adoption: a realist evaluation of pulse oximeter implementation in primary care for children under 5 in four West African countries

Sarah Louart  1 , Habibata Balde  2 , Abdourahmane Coulibaly  3   4 , Abdoua Elhadji Dagobi  5 , Kadidiatou Kadio  6 , Kessièdé Gildas Boris Hedible  7 , Valériane Leroy  7 , Emilie Robert  8 , Valéry Ridde  9   10 ; AIRE study group
Collaborators, Affiliations

Understanding health innovation adoption: a realist evaluation of pulse oximeter implementation in primary care for children under 5 in four West African countries

Sarah Louart et al. BMJ Glob Health. .

Abstract

Introduction: Hypoxaemia is an important contributor to child mortality, particularly in low-resource settings where diagnostic tools are scarce. The Améliorer l'Identification des détresses Respiratoires chez l'Enfant project introduced pulse oximeters (POs) into 202 primary healthcare centres (PHCs) in Burkina Faso, Guinea, Mali and Niger, integrating them into the Integrated Management of Childhood Illness guidelines. This initiative aimed to strengthen diagnostic capacities for identifying hypoxaemia and to improve care management for critically ill children under 5. This study examined how healthcare workers (HCWs) adopted POs and explored the contexts and mechanisms influencing their adoption.

Methods: We conducted a realist evaluation to analyse adoption patterns, focusing on interactions between the Intervention, Contexts, Actors, Mechanisms and Outcomes (ICAMO configurations). Data collection included 299 interviews with HCWs, patients' families and institutional actors, conducted in 16 selected PHCs, at the institutional level and in district hospitals, complemented by site observations. Analysis was performed using NVivo software, identifying ICAMO configurations as demi-regularities to explain variations in PO use and adoption.

Results: Training enabled HCWs to recognise the utility of POs, further motivating their use. Support-focused supervision fostered a sense of support, while control-focused approaches sometimes resulted in mechanical use driven by external pressure. In contexts of high workloads and children's agitation, difficulties in using POs were observed. In settings with limited diagnostic tools, POs increased HCWs' diagnostic confidence, encouraging adoption and improving decision-making. Observing or knowing the benefits of POs on children's health provided HCWs with a sense of relief and pride, further reinforcing PO adoption. However, structural barriers and challenges related to institutional adoption may threaten long-term use.

Conclusions: This study sheds light on the contexts and mechanisms that influence the use and adoption of the PO in PHCs. While widely used by HCWs, addressing challenges related to training, supply chain logistics and referral systems to hospitals is essential to ensure long-term sustainability and improve child health outcomes.

Keywords: Child health; Diagnostics and tools; Health Personnel; Other study design; Respiratory infections.

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Conflict of interest statement

Competing interests: VR is a member of the Editorial Board of the journal BMJ Global Health. He was not involved in the peer review or handling of the manuscript. All other authors have no competing interest to declare.

Figures

Figure 1
Figure 1. Countries and health districts involved in the AIRE study. AIRE, Améliorer l'Identification des détresses Respiratoires chez l'Enfant.
Figure 2
Figure 2. Realist evaluation design of the AIRE Project. AIRE, Améliorer l'Identification des détresses Respiratoires chez l'Enfant; PHC, primary healthcare.
Figure 3
Figure 3. Middle-range theory of PO adoption. HCWs, healthcare workers; PHC, primary healthcare; PO, pulse oximeter.
See this image and copyright information in PMC

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