Implementation strategies to promote e-Tracker use in the childhood immunization program in Rwanda – a mixed methods study

Background 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. Method 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. Results 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, p  = .026) and feasibility (Mdn=18 vs. Mdn=15, p  = .002) of using the e-Tracker than the control group. Intervention and control groups had similar scores on appropriateness (Mdn = 22 vs. Mdn=23, p  = .84). Data consistency for all indicators was nearly 100% in both groups before and after the introduction of implementation strategies. Discussion 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’ commitment which in turn may support sustainable use of digital tools.