{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T17:40:57Z","timestamp":1792777257243,"version":"4.5.0"},"reference-count":44,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T00:00:00Z","timestamp":1792713600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["INV-048710"],"award-info":[{"award-number":["INV-048710"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000265","name":"Medical Research Council","doi-asserted-by":"publisher","award":["MR\/Y033752\/1"],"award-info":[{"award-number":["MR\/Y033752\/1"]}],"id":[{"id":"10.13039\/501100000265","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>Many low- and middle-income countries rely on paper-based maternal and child health records that are often incomplete, fragmented, and difficult to use for continuity of care and decision-making. Smart Paper Technology (SPT), a hybrid paper\u2013digital documentation system, has been proposed as a practical alternative to fully electronic medical records in resource-constrained settings. This study explored the early implementation of SPT in maternal and infant health services in The Gambia, focusing on feasibility and acceptability. We conducted a qualitative descriptive implementation evaluation guided by Rapid Assessment Procedures (RAP) in two pilot facilities in the Western Region of The Gambia between September and December 2024. Data were collected through 30 semi-structured interviews; four focus group discussions with 30 participants spanning facility-level clinical, management, and administrative staff, Ministry of Health staff, and technical and implementing partners; and non-participant observations across key service delivery areas. Data were analysed thematically using NVivo 14. Participants described SPT as feasible and broadly acceptable because it built on familiar paper-based workflows, was introduced through a participatory process, and offered advantages in reporting, information retrieval, and maternal\u2013infant record linkage. However, these benefits were contingent on the implementation context. Key challenges included uneven training coverage, dual documentation, limited internet connectivity, scanning and data capture errors, storage constraints, and concerns about data governance. Staff adapted through peer mentoring, remote troubleshooting, and local workarounds. Participants emphasised that successful scale-up would require sustained training, clear governance arrangements, adequate human and technical resources, and a phased transition to government ownership. SPT offers a practical pathway towards digitisation in maternal and infant health services in LMICs, but its success depends on strong organisational systems, workforce support, and implementation processes that are responsive to routine service realities.<\/jats:p>","DOI":"10.1371\/journal.pgph.0006244","type":"journal-article","created":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T17:25:22Z","timestamp":1792776322000},"page":"e0006244","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Smart Paper Technology for maternal and newborn health data in The Gambia: A qualitative study of early implementation"],"prefix":"10.1371","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6194-6228","authenticated-orcid":true,"given":"Oluwatosin","family":"Nkereuwem","sequence":"first","affiliation":[{"name":"Vaccines & Immunity Theme, Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine","place":["Fajara, The Gambia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jana","family":"Prauseov\u00e1","sequence":"additional","affiliation":[{"name":"Charit\u00e9 Centre for Global Health and Institute for International Health, Charit\u00e9 Universitatsmedizin","place":["Berlin, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6212-9876","authenticated-orcid":true,"given":"Rachel","family":"Ford","sequence":"additional","affiliation":[{"name":"London School of Hygiene & Tropical Medicine","place":["London, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alpha Omar","family":"Jallow","sequence":"additional","affiliation":[{"name":"Vaccines & Immunity Theme, Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine","place":["Fajara, The Gambia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Musa","family":"Marena","sequence":"additional","affiliation":[{"name":"Reproductive, Maternal, Newborn Child and Adolescent Health Programme, Ministry of Health","place":["The Gambia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gibril","family":"Jarju","sequence":"additional","affiliation":[{"name":"Directorate of Planning and Information, Ministry of Health","place":["Kotu, The Gambia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sidat","family":"Fofana","sequence":"additional","affiliation":[{"name":"Expanded Programme on Immunisation, Ministry of Health","place":["Kotu, The Gambia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mamady","family":"Cham","sequence":"additional","affiliation":[{"name":"Bundung Maternal and Child Health Hospital","place":["Kanifing, The Gambia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Buba","family":"Manjang","sequence":"additional","affiliation":[{"name":"Directorate of Health Research, Ministry of Health","place":["Kairaba Avenue, The Gambia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Beate","family":"Kampmann","sequence":"additional","affiliation":[{"name":"Vaccines & Immunity Theme, Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine","place":["Fajara, The Gambia"]},{"name":"Charit\u00e9 Centre for Global Health and Institute for International Health, Charit\u00e9 Universitatsmedizin","place":["Berlin, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6334-0318","authenticated-orcid":true,"given":"Joanna","family":"Busza","sequence":"additional","affiliation":[{"name":"London School of Hygiene & Tropical Medicine","place":["London, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,10,23]]},"reference":[{"issue":"8","key":"pgph.0006244.ref001","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0267192","article-title":"A systematic review of home-based records in maternal and child health for improving informational continuity, health outcomes, and perceived usefulness in low and middle-income countries","volume":"17","author":"L Joseph","year":"2022","journal-title":"PLoS One"},{"key":"pgph.0006244.ref002","doi-asserted-by":"crossref","DOI":"10.1177\/11786329221100310","article-title":"Maternal healthcare in low- and middle-income countries: a scoping review","volume":"15","author":"SB Kitila","year":"2022","journal-title":"Health Services Insights"},{"key":"pgph.0006244.ref003","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2022-010992","article-title":"WHO recommendations on maternal and newborn care for a positive postnatal experience: strengthening the maternal and newborn care continuum","volume":"8","author":"AM Wojcieszek","year":"2023","journal-title":"BMJ Glob Health"},{"key":"pgph.0006244.ref004","doi-asserted-by":"crossref","DOI":"10.2196\/42161","article-title":"Digital health technologies for maternal and child health in Africa and other low- and middle-income countries: cross-disciplinary scoping review with stakeholder consultation","volume":"25","author":"S Till","year":"2023","journal-title":"J Med Internet Res"},{"issue":"1","key":"pgph.0006244.ref005","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pdig.0000434","article-title":"Applying the principles for digital development to improve maternal and child health in the Peri-urban areas of Karachi, Pakistan","volume":"3","author":"H Ahmer","year":"2024","journal-title":"PLOS Digit Health"},{"key":"pgph.0006244.ref006","volume-title":"WHO recommendations on maternal and newborn care for a positive postnatal experience","year":"2022"},{"issue":"1","key":"pgph.0006244.ref007","doi-asserted-by":"crossref","first-page":"306","DOI":"10.1186\/s12911-021-01670-z","article-title":"Implementation challenges and perception of care providers on electronic medical records at St. Paul\u2019s and Ayder Hospitals, Ethiopia","volume":"21","author":"A Bisrat","year":"2021","journal-title":"BMC Med Inform Decis Mak"},{"issue":"9","key":"pgph.0006244.ref008","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2020-046965","article-title":"Systematic review on the use of patient-held health records in low-income and middle-income countries","volume":"11","author":"L Joseph","year":"2021","journal-title":"BMJ Open"},{"key":"pgph.0006244.ref009","doi-asserted-by":"crossref","first-page":"20552076231203660","DOI":"10.1177\/20552076231203660","article-title":"An electronic health record system implementation in a resource limited country-lessons learned","volume":"9","author":"SK Ali","year":"2023","journal-title":"Digit Health"},{"key":"pgph.0006244.ref010","doi-asserted-by":"crossref","first-page":"100991","DOI":"10.1016\/j.imu.2022.100991","article-title":"Barriers to the acceptance of electronic medical records from the perspective of physicians and nurses:A scoping review","volume":"31","author":"BL Jimma","year":"2022","journal-title":"Info Med Unlocked"},{"issue":"12","key":"pgph.0006244.ref011","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0001162","article-title":"Reducing maternal and neonatal mortality through integrated and sustainability-focused programming in Zambia","volume":"2","author":"A Kamanga","year":"2022","journal-title":"PLOS Glob Public Health"},{"key":"pgph.0006244.ref012","doi-asserted-by":"crossref","first-page":"101668","DOI":"10.1016\/j.ssmph.2024.101668","article-title":"Travelling numbers and broken loops: A qualitative systematic review on collecting and reporting maternal and neonatal health data in low-and lower-middle income countries","volume":"26","author":"J Molenaar","year":"2024","journal-title":"SSM Popul Health"},{"issue":"1","key":"pgph.0006244.ref013","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0000972","article-title":"Feasibility, usability and acceptability of a novel digital hybrid-system for reporting of routine maternal health information in Southern Tanzania: A mixed-methods study","volume":"3","author":"R Unkels","year":"2023","journal-title":"PLOS Glob Public Health"},{"issue":"1","key":"pgph.0006244.ref014","doi-asserted-by":"crossref","first-page":"367","DOI":"10.1186\/s12913-020-05242-1","article-title":"Assessment of a novel scanner-supported system for processing of child health and immunization data in Uganda","volume":"20","author":"A \u00c4ij\u00f6","year":"2020","journal-title":"BMC Health Serv Res"},{"key":"pgph.0006244.ref015","volume-title":"Smart paper technology (SPT)","author":"Africa WROf","year":"2024"},{"key":"pgph.0006244.ref016","volume-title":"Smart Paper Technology Adoption at Scale in Western Regions, The Gambia","author":"S Strassburger","year":"2020"},{"key":"pgph.0006244.ref017","unstructured":"Times TA. The Gambia launches digital immunization registry. Global Voices. 2022. https:\/\/globalvoices.org\/2022\/07\/06\/the-gambia-launches-digital-immunization-registry\/"},{"issue":"42","key":"pgph.0006244.ref018","doi-asserted-by":"crossref","first-page":"6618","DOI":"10.1016\/j.vaccine.2020.07.074","article-title":"An assessment of the quality of vaccination data produced through smart paper technology in The Gambia","volume":"38","author":"A Sowe","year":"2020","journal-title":"Vaccine"},{"key":"pgph.0006244.ref019","doi-asserted-by":"crossref","DOI":"10.1097\/INF.0000000000004677","article-title":"Toward an electronic pregnancy registry in the Gambia: linking up maternal and newborn health data using the smart paper technology","volume":"44","author":"J Prauseov\u00e1","year":"2025","journal-title":"Pediatr Infect Dis J"},{"issue":"2","key":"pgph.0006244.ref020","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1007\/s10488-010-0319-7","article-title":"Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda","volume":"38","author":"E Proctor","year":"2011","journal-title":"Adm Policy Ment Health"},{"issue":"1","key":"pgph.0006244.ref021","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1186\/s13012-020-0972-5","article-title":"Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: a case example of patient quality and safety interventions in the ICU","volume":"15","author":"LM Holdsworth","year":"2020","journal-title":"Implement Sci"},{"issue":"2","key":"pgph.0006244.ref022","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1007\/s10488-018-0909-3","article-title":"Rapid assessment procedure informed clinical ethnography (RAPICE) in pragmatic clinical trials of mental health services implementation: Methods and applied case study","volume":"46","author":"LA Palinkas","year":"2019","journal-title":"Adm Policy Ment Health"},{"issue":"1","key":"pgph.0006244.ref023","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1186\/s13012-024-01397-1","article-title":"Planning for and Assessing Rigor in Rapid Qualitative Analysis (PARRQA): a consensus-based framework for designing, conducting, and reporting","volume":"19","author":"CP Kowalski","year":"2024","journal-title":"Implement Sci"},{"key":"pgph.0006244.ref024","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.g1687","article-title":"Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide","volume":"348","author":"TC Hoffmann","year":"2014","journal-title":"BMJ"},{"issue":"2","key":"pgph.0006244.ref025","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology","volume":"3","author":"V Braun","year":"2006","journal-title":"Qual Res Psychol"},{"issue":"11","key":"pgph.0006244.ref026","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0335644","article-title":"Exploring healthcare staff experiences with a hybrid paper\/digital health management information system and their perspectives on digitalization as an alternative - A Tanzanian qualitative case study on perinatal data","volume":"20","author":"M Cronin","year":"2025","journal-title":"PLoS One"},{"issue":"1","key":"pgph.0006244.ref027","doi-asserted-by":"crossref","first-page":"372","DOI":"10.1186\/s12911-025-03190-6","article-title":"Factors influencing the availability and use of electronic medical records systems in public health facilities in Uganda: a cross-sectional assessment","volume":"25","author":"A Ddamba","year":"2025","journal-title":"BMC Med Inform Decis Mak"},{"issue":"1","key":"pgph.0006244.ref028","doi-asserted-by":"crossref","DOI":"10.1136\/bmjhci-2022-100704","article-title":"Adoption of electronic health record systems to enhance the quality of healthcare in low-income countries: a systematic review","volume":"30","author":"MT Woldemariam","year":"2023","journal-title":"BMJ Health Care Inform"},{"issue":"1","key":"pgph.0006244.ref029","doi-asserted-by":"crossref","first-page":"240","DOI":"10.1186\/s12913-024-12129-y","article-title":"Digital health readiness - insights from healthcare leaders in operational management: a cross-sectional survey","volume":"25","author":"I Steenkamp","year":"2025","journal-title":"BMC Health Serv Res"},{"issue":"2","key":"pgph.0006244.ref030","doi-asserted-by":"crossref","first-page":"194","DOI":"10.1016\/j.infoh.2025.09.001","article-title":"Assessing the challenges to digital technology adoption in the healthcare sector: Implications for sustainability in emerging economies","volume":"2","author":"FF Raunaq","year":"2025","journal-title":"Informatics and Health"},{"key":"pgph.0006244.ref031","doi-asserted-by":"crossref","first-page":"102137","DOI":"10.1016\/j.cegh.2025.102137","article-title":"Challenges, barriers, and facilitators in implementing digital health initiatives for NP-NCD management in India\u2019s public health system: A scoping review","volume":"35","author":"RVNSP Meghana","year":"2025","journal-title":"Clinical Epidemiology and Global Health"},{"key":"pgph.0006244.ref032","article-title":"Motivators and barriers to the uptake of digital health platforms for family planning services in Lagos, Nigeria: A mixed-methods study","volume":"11","author":"MM Alhaji","year":"2025","journal-title":"Digit Health"},{"key":"pgph.0006244.ref033","article-title":"Facilitators and barriers to the implementation of digital health technologies in hospital settings in lower- and middle-income countries since the onset of the COVID-19 Pandemic: Scoping Review","volume":"27","author":"SQ Yew","year":"2025","journal-title":"J Med Internet Res"},{"key":"pgph.0006244.ref034","article-title":"Barriers and facilitators of the electronic medical record adoption among healthcare providers in Addis Ababa, Ethiopia","volume":"10","author":"TA Bekele","year":"2024","journal-title":"Digit Health"},{"issue":"1","key":"pgph.0006244.ref035","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1186\/s12911-024-02672-3","article-title":"Health professionals\u2019 perceptions of electronic health records system: a mixed method study in Ghana","volume":"24","author":"NK Mensah","year":"2024","journal-title":"BMC Med Inform Decis Mak"},{"issue":"1","key":"pgph.0006244.ref036","doi-asserted-by":"crossref","first-page":"271","DOI":"10.1186\/s12913-025-12414-4","article-title":"Impact of digital health technologies adoption on healthcare workers\u2019 performance and workload: perspective with DOI and TOE models","volume":"25","author":"A Jeilani","year":"2025","journal-title":"BMC Health Serv Res"},{"key":"pgph.0006244.ref037","doi-asserted-by":"crossref","first-page":"1457","DOI":"10.2147\/JMDH.S368704","article-title":"Perceptions on data quality, use, and management following the adoption of tablet-based electronic health records: results from a pre-post survey with district health officers in Ghana","volume":"15","author":"S Lee","year":"2022","journal-title":"J Multidiscip Healthc"},{"issue":"1","key":"pgph.0006244.ref038","first-page":"38","article-title":"Perceptions of factors influencing the introduction and adoption of electronic immunization registries in Tanzania and Zambia: a mixed methods study","volume":"1","author":"SB Dolan","year":"2020","journal-title":"Imp Sci Commun"},{"key":"pgph.0006244.ref039","doi-asserted-by":"crossref","DOI":"10.2196\/66288","article-title":"Use of technology to support health care providers delivering care in low- and lower-middle-income countries: systematic umbrella review","volume":"27","author":"A Craig","year":"2025","journal-title":"J Med Internet Res"},{"issue":"13","key":"pgph.0006244.ref040","doi-asserted-by":"crossref","first-page":"2629","DOI":"10.3390\/electronics14132629","article-title":"From regulation to reality: a framework to bridge the gap in digital health data protection","volume":"14","author":"DC Ogbodo","year":"2025","journal-title":"Electronics"},{"issue":"1","key":"pgph.0006244.ref041","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1186\/s12961-024-01230-7","article-title":"Data protection legislation in Africa and pathways for enhancing compliance in big data health research","volume":"22","author":"NS Munung","year":"2024","journal-title":"Health Res Policy Syst"},{"issue":"3","key":"pgph.0006244.ref042","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1108\/IJHG-11-2022-0104","article-title":"Strengthening health data governance: new equity and rights-based principles","volume":"28","author":"L Holly","year":"2023","journal-title":"IJHG"},{"key":"pgph.0006244.ref043","doi-asserted-by":"crossref","DOI":"10.2196\/62746","article-title":"The costs of digital health interventions to improve immunization data in low- and middle-income countries: multicountry mixed methods study","volume":"27","author":"C Federici","year":"2025","journal-title":"J Med Internet Res"},{"key":"pgph.0006244.ref044","article-title":"Digital technologies for health workforce development in low- and middle-income countries: A scoping review","volume":"6","author":"LA Long","year":"2018","journal-title":"Glob Health Sci Pract"}],"container-title":["PLOS Global Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0006244","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T17:25:29Z","timestamp":1792776329000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0006244"}},"subtitle":[],"editor":[{"given":"Md. Alamgir","family":"Hossain","sequence":"first","affiliation":[{"name":"ICDDR: International Centre for Diarrhoeal Disease Research Bangladesh","place":["BANGLADESH"]}],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,10,23]]},"references-count":44,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2026,10,23]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pgph.0006244","relation":{},"ISSN":["2767-3375"],"issn-type":[{"value":"2767-3375","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,23]]}}}