title: Promising adoption of an electronic clinical decision support system for antenatal and intrapartum care in rural primary healthcare facilities in sub-Saharan Africa: The QUALMAT experience.
abstract: BACKGROUND
  The QUALMAT project has successfully implemented an electronic clinical decision support system (eCDSS) for antenatal and intrapartum care in two sub-Saharan African countries. The system was introduced to facilitate adherence to clinical practice guidelines and to support decision making during client encounter to bridge the know-do gap of health workers.
  
  
  OBJECTIVE
  This study aimed to describe health workers' acceptance and use of the eCDSS for maternal care in rural primary health care (PHC) facilities of Ghana and Tanzania and to identify factors affecting successful adoption of such a system.
  
  
  METHODS
  This longitudinal study was conducted in Lindi rural district in Tanzania and Kassena-Nankana district in Ghana between October 2011 and December 2013 employing mixed methods. The study population included healthcare workers who were involved in the provision of maternal care in six rural PHC facilities from one district in each country where the eCDSS was implemented.
  
  
  RESULTS
  All eCDSS users participated in the study with 61 and 56 participants at the midterm and final assessment, respectively. After several rounds of user training and support the eCDSS has been successfully adopted and constantly used during patient care in antenatal clinics and maternity wards. The eCDSS was used in 71% (2703/3798) and 59% (14,189/24,204) of all ANC clients in Tanzania and Ghana respectively, while it was also used in 83% (1185/1427) and 67% (1435/2144) of all deliveries in Tanzania and in Ghana, respectively. Several barriers reported to hinder eCDSS use were related to individual users, tasks, technology, and organization attributes.
  
  
  CONCLUSIONS
  Implementation of an eCDSS in resource-constrained PHC facilities in sub-Saharan Africa was successful and the health workers accepted and continuously used the system for maternal care. Facilitators for eCDSS use included sufficient training and regular support whereas the challenges to sustained use were unreliable power supply and perceived high workload. However our study also shows that most of the perceived challenges did not substantially hinder adoption and utilization of the eCDSS during patient care.
authors.affiliation: Heidelberg University Hospital, Department of Clinical Pharmacology & Pharmacoepidemiology, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany; Muhimbili University of Health and Allied Sciences (MUHAS), Directorate of Information and Communication Technology, P.O. Box 65001, Dar es Salaam, Tanzania. Electronic address: felix@muhas.ac.tz.
authors.forename: Felix
authors.initials: F
authors.lastname: Sukums
authors.affiliation: Heidelberg University Hospital, Department of Clinical Pharmacology & Pharmacoepidemiology, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany; Navrongo Health Research Centre, P.O. Box 114, Navrongo, Ghana. Electronic address: mensahnathan@yahoo.com.
authors.forename: Nathan
authors.initials: N
authors.lastname: Mensah
authors.affiliation: Muhimbili University of Health and Allied Sciences (MUHAS), School of Public Health and Social Sciences, Department of Epidemiology and Biostatistics, P.O. Box 65015, Dar es Salaam, Tanzania. Electronic address: rcmpembeni@yahoo.com.
authors.forename: Rose
authors.initials: R
authors.lastname: Mpembeni
authors.affiliation: Muhimbili University of Health and Allied Sciences (MUHAS), School of Medicine, Department of Gynaecology and Obstetrics, P.O. Box 65001, Dar es Salaam, Tanzania. Electronic address: snanzia@gmail.com.
authors.forename: Siriel
authors.initials: S
authors.lastname: Massawe
authors.affiliation: International Centre for Reproductive Health (ICRH), Ghent University, De Pintelaan 185, UZP114, 9000 Ghent, Belgium. Electronic address: els.duysburgh@ugent.be.
authors.forename: Els
authors.initials: E
authors.lastname: Duysburgh
authors.affiliation: Navrongo Health Research Centre, P.O. Box 114, Navrongo, Ghana. Electronic address: afuawilliams@yahoo.com.
authors.forename: Afua
authors.initials: A
authors.lastname: Williams
authors.affiliation: Heidelberg University Hospital, Department of Clinical Pharmacology & Pharmacoepidemiology, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany. Electronic address: jens.kaltschmidt@med.uni-heidelberg.de.
authors.forename: Jens
authors.initials: J
authors.lastname: Kaltschmidt
authors.affiliation: Institute of Public Health, University of Heidelberg, Im Neuenheimer Feld 327, 69120 Heidelberg, Germany. Electronic address: svetla.loukanova@urz.uni-heidelberg.de.
authors.forename: Svetla
authors.initials: S
authors.lastname: Loukanova
authors.affiliation: Heidelberg University Hospital, Department of Clinical Pharmacology & Pharmacoepidemiology, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany. Electronic address: walter.emil.haefeli@med.uni-heidelberg.de.
authors.forename: Walter E
authors.initials: WE
authors.lastname: Haefeli
authors.affiliation: Heidelberg University Hospital, Department of Clinical Pharmacology & Pharmacoepidemiology, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany. Electronic address: antje.blank@med.uni-heidelberg.de.
authors.forename: Antje
authors.initials: A
authors.lastname: Blank
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D001291:Attitude of Health Personnel; D020000:Decision Support Systems, Clinical / Q000592:standards*; D005260:Female; D006282:Health Personnel; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008427:Maternal Health Services / Q000592:standards*; D011247:Pregnancy; D011295:Prenatal Care / Q000592:standards*; D011320:Primary Health Care / Q000592:standards*; D019035:Rural Health Services / Q000458:organization & administration*
keywords: Barriers; Clinical decision support; Facilitators; Information technology adoption; Maternal care; Rural health facilities