{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T09:41:36Z","timestamp":1790674896514,"version":"4.1.0"},"reference-count":57,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T00:00:00Z","timestamp":1785369600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Health Serv."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>In Rwanda, the introduction of a digital immunization registry based in the District Health Information Software 2 (DHIS2), the e-Tracker, has encountered several implementation challenges. This study aimed to design, implement, and evaluate targeted implementation strategies to enhance the adoption and sustained use of the e-Tracker within the National Immunization Program.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Method<\/jats:title>\n                    <jats:p>We used an implementation research design with a mixed methods approach. We conducted focus group discussions with immunization nurses and co-designed facilitation-based implementation strategies with health workers and implemented them in 12 purposively selected intervention facilities from 48 health facilities that were under-performing on the e-Tracker. The remaining 36 under-performing facilities served as a control group. Evaluations were conducted three months post-implementation with one immunization nurse per facility as respondents, using a process evaluation questionnaire assessing three implementation outcomes: acceptability, appropriateness, and feasibility. We assessed data consistency for the BCG, Penta3 and MR1 vaccines with routine reports before and after implementation of the co-designed strategies.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The co-designed strategies included educational videos, establishment of a collaborative group of immunization health workers to facilitate regular learning, and provision of support from champion users. The intervention group indicated higher acceptability ((Mdn=23 vs. Mdn=20.5,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u2009.026) and feasibility (Mdn=18 vs. Mdn=15,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u2009.002) of using the e-Tracker than the control group. Intervention and control groups had similar scores on appropriateness (Mdn\u2009=\u200922 vs. Mdn=23,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u2009.84). Data consistency for all indicators was nearly 100% in both groups before and after the introduction of implementation strategies.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>The co-designed strategies improved the acceptability and feasibility of the e-Tracker among immunization health workers, while there was no difference in data consistency. These findings suggest an association between participatory, facilitation-based approaches and nurses\u2019 commitment which in turn may support sustainable use of digital tools.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/frhs.2026.1816682","type":"journal-article","created":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T05:38:35Z","timestamp":1785389915000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Implementation strategies to promote e-Tracker use in the childhood immunization program in Rwanda \u2013 a mixed methods study"],"prefix":"10.3389","volume":"6","author":[{"given":"Thaoussi","family":"Uwera","sequence":"first","affiliation":[{"name":"Center for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen","place":["Bergen, Norway"]},{"name":"Regional Center of Excellence in Biomedical Engineering and e-Health, University of Rwanda","place":["Kigali, Rwanda"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ingvild Fossgard","family":"Sand\u00f8y","sequence":"additional","affiliation":[{"name":"Center for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen","place":["Bergen, Norway"]},{"name":"Bergen Centre for Ethics and Priority Setting in Health (BCEPS), Department of Global Public Health and Primary Care, University of Bergen","place":["Bergen, Norway"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J. Frederik","family":"Fr\u00f8en","sequence":"additional","affiliation":[{"name":"Global Health Cluster, Division for Health Services, Norwegian Institute of Public Health","place":["Oslo, Norway"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eleni","family":"Papadopoulou","sequence":"additional","affiliation":[{"name":"Global Health Cluster, Division for Health Services, Norwegian Institute of Public Health","place":["Oslo, Norway"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hassan","family":"Sibomana","sequence":"additional","affiliation":[{"name":"Maternal, Child and Community Health Division (MCCH), Vaccination programs Unit, Rwanda Biomedical Centre","place":["Kigali, Rwanda"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Muhire","sequence":"additional","affiliation":[{"name":"Digitalization Directorate General, Ministry of Health","place":["Kigali, Rwanda"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David K.","family":"Tumusiime","sequence":"additional","affiliation":[{"name":"Regional Center of Excellence in Biomedical Engineering and e-Health, University of Rwanda","place":["Kigali, Rwanda"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mahima","family":"Venkateswaran","sequence":"additional","affiliation":[{"name":"Global Health Cluster, Division for Health Services, Norwegian Institute of Public Health","place":["Oslo, Norway"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,7,30]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"1859","DOI":"10.1016\/j.vaccine.2019.02.017","article-title":"Redefining vaccination coverage and timeliness measures using electronic immunization registry data in low- and middle-income countries","volume":"37","author":"Dolan","year":"2019","journal-title":"Vaccine"},{"key":"B2","doi-asserted-by":"publisher","first-page":"2031","DOI":"10.1016\/S0140-6736(08)61869-3","article-title":"Tracking progress towards universal childhood immunisation and the impact of global initiatives: a systematic analysis of three-dose diphtheria, tetanus, and pertussis immunisation coverage","volume":"372","author":"Lim","year":"2008","journal-title":"Lancet"},{"key":"B3","year":"2025"},{"key":"B4","doi-asserted-by":"publisher","first-page":"265","DOI":"10.1186\/S13690-025-01758-2","article-title":"Immunization data management practices and data quality in Ethiopia","volume":"83","author":"Daka","year":"2025","journal-title":"Arch Public Health"},{"key":"B5","doi-asserted-by":"publisher","first-page":"340","DOI":"10.1186\/s12911-020-01366-w","article-title":"Data quality of the routine health management information system at the primary healthcare facility and district levels in Tanzania","volume":"20","author":"Rumisha","year":"2020","journal-title":"BMC Med Inform Decis Mak"},{"key":"B6","doi-asserted-by":"publisher","first-page":"1070","DOI":"10.4103\/njcp.njcp_291_22","article-title":"Assessing the quality of immunization data from administrative data in Enugu State, south-east Nigeria: a cross-sectional study","volume":"22","author":"Ogbuabor","year":"2019","journal-title":"Niger J Clin Pract"},{"key":"B7","doi-asserted-by":"publisher","first-page":"383","DOI":"10.3233\/SHTI240428","article-title":"Improving health information systems data quality in sub-Saharan Africa","volume":"316","author":"Sylla","year":"2024","journal-title":"Stud Health Technol Inform"},{"key":"B8","volume-title":"Designing and Implementing an Immunisation Information System. Technical Guidance Report","year":"2018"},{"key":"B9","volume-title":"Electronic Immunization Registry: Practical Considerations for Planning, Development, Implementation and Evaluation","year":"2017"},{"key":"B10","doi-asserted-by":"publisher","first-page":"621","DOI":"10.1186\/s12913-018-3435-9","article-title":"Assessment of select electronic health information systems that support immunization data capture - Kenya, 2017","volume":"18","author":"Namageyo-Funa","year":"2018","journal-title":"BMC Health Serv Res"},{"key":"B11","doi-asserted-by":"publisher","first-page":"227","DOI":"10.1097\/PHH.0000000000000069","article-title":"Immunization information systems to increase vaccination rates: a community guide systematic review","volume":"21","author":"Groom","year":"2015","journal-title":"J Public Heal Manag Pract"},{"key":"B12","doi-asserted-by":"publisher","first-page":"794","DOI":"10.1186\/s12913-018-3615-7","article-title":"Developing an implementation strategy for a digital health intervention: an example in routine healthcare","volume":"18","author":"Ross","year":"2018","journal-title":"BMC Health Serv Res"},{"key":"B13","year":"2020"},{"key":"B14","doi-asserted-by":"publisher","first-page":"e53071","DOI":"10.2196\/53071","article-title":"Electronic immunization registry in Rwanda: qualitative study of health worker experiences","volume":"11","author":"Uwera","year":"2024","journal-title":"JMIR Hum Factors"},{"key":"B15","doi-asserted-by":"publisher","first-page":"10","DOI":"10.1186\/s44247-024-00144-2","article-title":"Health worker experiences on the integration of digital health tools for HPV vaccination and cervical cancer services in Rwanda","volume":"3","author":"Sibomana","year":"2025","journal-title":"BMC Digit Heal"},{"key":"B16","first-page":"1357","article-title":"Improving healthcare through the use of co-design","volume":"125","author":"Boyd","year":"2012","journal-title":"J New Zeal Med Assoc"},{"key":"B17","doi-asserted-by":"publisher","first-page":"48","DOI":"10.1177\/01410768211070206","article-title":"Implementing and evaluating co-designed change in health","volume":"115","author":"Harrison","year":"2022","journal-title":"J R Soc Med"},{"key":"B18","doi-asserted-by":"publisher","first-page":"374","DOI":"10.1038\/s41746-024-01385-1","article-title":"An umbrella review on how digital health intervention co-design is conducted and described","volume":"7","author":"Kilfoy","year":"2024","journal-title":"NPJ Digit Med"},{"key":"B19","doi-asserted-by":"publisher","first-page":"38","DOI":"10.1080\/24709360.2018.1477468","article-title":"Quasi-experimental design","volume":"4","author":"Maciejewski","year":"2020","journal-title":"Biostat Epidemiol"},{"key":"B20","doi-asserted-by":"publisher","first-page":"132","DOI":"10.1080\/21642850.2020.1738935","article-title":"Focusing on fidelity: narrative review and recommendations for improving intervention fidelity within trials of health behaviour change interventions","volume":"8","author":"Toomey","year":"2020","journal-title":"Heal Psychol Behav Med"},{"key":"B21","doi-asserted-by":"publisher","first-page":"e65","DOI":"10.1017\/gmh.2026.10131","article-title":"Fidelity and feasibility of a pilot implementation of adapted WHO digital interventions to scale up mental health in Nigerian primary care: a mixed-methods process evaluation","volume":"13","author":"Adewuya","year":"2026","journal-title":"Cambridge Prism Glob Ment Heal"},{"key":"B22","doi-asserted-by":"publisher","first-page":"68","DOI":"10.1186\/S13012-020-01003-0","article-title":"The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature","volume":"15","author":"Bergstr\u00f6m","year":"2020","journal-title":"Implement Sci"},{"key":"B23","doi-asserted-by":"publisher","first-page":"25","DOI":"10.1186\/S43058-025-00704-1","article-title":"Combined use of the integrated-promoting action on research implementation in health services (i-PARIHS) framework with other implementation frameworks: a systematic review","volume":"6","author":"Hunter","year":"2025","journal-title":"Implement Sci Commun"},{"key":"B24","doi-asserted-by":"publisher","first-page":"78","DOI":"10.1186\/s13012-022-01254-z","article-title":"Conceptual and relational advances of the PARIHS and i-PARIHS frameworks over the last decade: a critical interpretive synthesis","volume":"17","author":"Duan","year":"2022","journal-title":"Implement Sci"},{"key":"B25","doi-asserted-by":"publisher","first-page":"158","DOI":"10.3389\/fpubh.2019.00158","article-title":"Implementation mapping: using intervention mapping to develop implementation strategies","volume":"7","author":"Fernandez","year":"2019","journal-title":"Front Public Heal"},{"key":"B26","doi-asserted-by":"publisher","first-page":"21","DOI":"10.1186\/s13012-015-0209-1","article-title":"A refined compilation of implementation strategies: results from the expert recommendations for implementing change (ERIC) project","volume":"10","author":"Powell","year":"2015","journal-title":"Implement Sci"},{"key":"B27","first-page":"1","year":"2015"},{"key":"B28","year":"2014"},{"key":"B29","doi-asserted-by":"publisher","first-page":"108","DOI":"10.1186\/s13012-017-0635-3","article-title":"Psychometric assessment of three newly developed implementation outcome measures","volume":"12","author":"Weiner","year":"2017","journal-title":"Implement Sci"},{"key":"B30","doi-asserted-by":"publisher","first-page":"igz036","DOI":"10.1093\/geroni\/igz036","article-title":"Effect size guidelines, sample size calculations, and statistical power in gerontology","volume":"3","author":"Brydges","year":"2019","journal-title":"Innov Aging"},{"key":"B31","first-page":"335","article-title":"Lessons in biostatistics: effect sizes for nonparametric tests","volume-title":"Past, Present, and Future of Statistical Science","author":"Breslow","year":"2014"},{"key":"B32","year":"2017"},{"key":"B33","year":"2021"},{"key":"B34","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/1748-5908-8-139","article-title":"Implementation strategies: recommendations for specifying and reporting","volume":"8","author":"Proctor","year":"2013","journal-title":"Implement Sci"},{"key":"B35","doi-asserted-by":"publisher","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":"Proctor","year":"2011","journal-title":"Adm Policy Ment Heal Ment Heal Serv Res"},{"key":"B36","doi-asserted-by":"publisher","first-page":"92","DOI":"10.1186\/s43058-023-00478-4","article-title":"Acceptability, appropriateness, and feasibility of rural school support strategies for behavioral interventions: a mixed methods evaluation over two years of a hybrid type 3 implementation-effectiveness trial","volume":"4","author":"Calvert","year":"2023","journal-title":"Implement Sci Commun"},{"key":"B37","doi-asserted-by":"publisher","first-page":"441","DOI":"10.1007\/s43477-025-00162-w","article-title":"Feasibility and acceptability of an implementation strategy bundle to implement a lifestyle intervention in community-care","volume":"5","author":"Van Der Laag","year":"2025","journal-title":"Glob Implement Res Appl"},{"key":"B38","doi-asserted-by":"publisher","first-page":"161","DOI":"10.1038\/s41746-023-00899-4","article-title":"Barriers and facilitators to utilizing digital health technologies by healthcare professionals","volume":"6","author":"Borges do Nascimento","year":"2023","journal-title":"NPJ Digit Med"},{"key":"B39","doi-asserted-by":"publisher","first-page":"100391","DOI":"10.1016\/j.jjimei.2026.100391","article-title":"A realist synthesis of the implementation of digital health strategies for enhanced health outcomes in sub-Saharan Africa","volume":"6","author":"Achieng","year":"2026","journal-title":"Int J Inf Manag Data Insights"},{"key":"B40","doi-asserted-by":"publisher","first-page":"315","DOI":"10.4258\/HIR.2021.27.4.315","article-title":"Stakeholders\u2019 perceptions of the implementation of a patient-centric digital health application for primary healthcare in India","volume":"27","author":"Faujdar","year":"2021","journal-title":"Healthc Inform Res"},{"key":"B41","doi-asserted-by":"publisher","first-page":"50","DOI":"10.1186\/1748-5908-4-50","article-title":"Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science","volume":"4","author":"Damschroder","year":"2009","journal-title":"Implement Sci"},{"key":"B42","doi-asserted-by":"publisher","first-page":"472","DOI":"10.1200\/op.2025.21.10_suppl.472","article-title":"Developing a learning collaborative: a strategy or a compilation of strategies for implementation of remote symptom monitoring","volume":"21","author":"Rocque","year":"2025","journal-title":"JCO Oncol Pract"},{"key":"B43","doi-asserted-by":"publisher","first-page":"e45224","DOI":"10.2196\/45224","article-title":"Strengths, weaknesses, opportunities, and threats analysis of the use of digital health technologies in primary health care in the sub-Saharan African region: qualitative study","volume":"25","author":"O'Brien","year":"2023","journal-title":"J Med Internet Res"},{"key":"B44","doi-asserted-by":"publisher","first-page":"20552076251357401","DOI":"10.1177\/20552076251357401","article-title":"Adoption of electronic health records by nurses in Africa: a scoping review","volume":"11","author":"Harerimana","year":"2025","journal-title":"Digit Heal"},{"key":"B45","doi-asserted-by":"publisher","first-page":"158","DOI":"10.4103\/jehp.jehp_182_19","article-title":"Comparison of the effect of electronic education and workshop on the satisfaction of nurses about Emergency Severity Index triage","volume":"9","author":"Yazdannik","year":"2018","journal-title":"J Educ Health Promot"},{"key":"B46","doi-asserted-by":"publisher","first-page":"1061","DOI":"10.1007\/s10488-025-01439-w","article-title":"A qualitative review of community health workers\u2019 training, supervision, and service delivery needs","volume":"52","author":"Boustani","year":"2025","journal-title":"Adm Policy Ment Heal Ment Heal Serv Res"},{"key":"B47","author":"Bogner","year":"2016"},{"key":"B48","doi-asserted-by":"publisher","first-page":"97","DOI":"10.1186\/s13690-025-01583-7","article-title":"Child immunization data quality in Rwanda: an assessment of routine health information system data","volume":"83","author":"Uwera","year":"2025","journal-title":"Arch Public Heal"},{"key":"B49","doi-asserted-by":"publisher","first-page":"e0000480","DOI":"10.1371\/journal.pdig.0000480","article-title":"Centering healthcare workers in digital health design: usability and acceptability of two-way texting to improve retention in antiretroviral therapy in a public HIV clinic in Lilongwe, Malawi","volume":"3","author":"Mureithi","year":"2024","journal-title":"PLOS Digit Heal"},{"key":"B50","doi-asserted-by":"publisher","first-page":"e0000213","DOI":"10.1371\/journal.pdig.0000213","article-title":"Maximizing the value of patient and public involvement in the digital health co-design process: a qualitative descriptive study with design leaders and patient-public partners","volume":"2","author":"Voorheis","year":"2023","journal-title":"PLOS Digit Heal"},{"key":"B51","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1186\/s13012-023-01286-z","article-title":"Ten years of implementation outcomes research: a scoping review","volume":"18","author":"Proctor","year":"2023","journal-title":"Implement Sci"},{"key":"B52","doi-asserted-by":"publisher","first-page":"1239","DOI":"10.1016\/j.jadohealth.2024.01.035","article-title":"Cyber Rwanda's pathway to impact: results from a cluster-randomized trial of adolescent family planning knowledge, beliefs, self-efficacy, and behavior","volume":"74","author":"H\u00e9mono","year":"2024","journal-title":"J Adolesc Heal"},{"key":"B53","doi-asserted-by":"publisher","first-page":"e616","DOI":"10.1093\/PUBMED\/FDAF084","article-title":"Exploring co-design: a systematic review of concepts, processes, models, and frameworks used in public health research","volume":"47","author":"Vargas","year":"2025","journal-title":"J Public Health (Oxf)"},{"key":"B54","doi-asserted-by":"publisher","first-page":"349","DOI":"10.1037\/H0047358","article-title":"A new scale of social desirability independent of psychopathology","volume":"24","author":"Crowne","year":"1960","journal-title":"J Consult Psychol"},{"key":"B55","doi-asserted-by":"publisher","first-page":"2050312118773261","DOI":"10.1177\/2050312118773261","article-title":"Inside help: an integrative review of champions in healthcare-related implementation","volume":"6","author":"Miech","year":"2018","journal-title":"SAGE Open Med"},{"key":"B56","doi-asserted-by":"publisher","first-page":"87","DOI":"10.1186\/S13012-020-01048-1","article-title":"Lessons learned about the effective operationalization of champions as an implementation strategy: results from a qualitative process evaluation of a pragmatic trial","volume":"15","author":"Bunce","year":"2020","journal-title":"Implement Sci"},{"key":"B57","first-page":"205","article-title":"Cooperative learning returns to college: what evidence is there that it works?","volume-title":"Learning from Change: Landmarks in Teaching and Learning in Higher Education from Change Magazine 1969\u20131999","author":"Johnson","year":"2023"}],"container-title":["Frontiers in Health Services"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/frhs.2026.1816682\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T05:38:37Z","timestamp":1785389917000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/frhs.2026.1816682\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,30]]},"references-count":57,"alternative-id":["10.3389\/frhs.2026.1816682"],"URL":"https:\/\/doi.org\/10.3389\/frhs.2026.1816682","relation":{},"ISSN":["2813-0146"],"issn-type":[{"value":"2813-0146","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,30]]},"article-number":"1816682"}}