Themes and subthemes of the formative phase.

The Ministries of Health in Zambia and Rwanda have adapted and validated their national antenatal care (ANC) guidelines in line with WHO 2016 recommendations. Both countries conducted implementation research, composed of five implementation strategies to support the adapted ANC package service delivery. One implementation strategy deploys a digital module, a point of service digital tool that encompasses clinical decision support and person-centric record management to support health workers in implementing the adapted ANC packages. The formative phase of the study, included countries’ adaptation of the WHO digital ANC module to their contexts in three steps: (i) the reference module was tailored to create Rwanda and Zambia ANC digital modules and training materials; (ii) health workers were trained to use the module and provide feedback; (iii) country research teams conducted qualitative assessments to understand the health worker experience using the adapted ANC module. ANC health workers at selected facilities completed a three-day training on the use of the module. Qualitative methods were used to understand health worker’s perspectives on the module’s use for service provision and feedback for its refinement. The three major themes emerged: i) experiences using digital interventions in the health profession; ii) strengths and challenges related to the use of digital interventions; iii) considerations for improving the use of digital interventions within health systems. Rwanda and Zambia ANC modules were modified to improve their use for ANC services delivery. Initial testing led to the identification and fixing of bugs in the system. The module was updated to include dashboards to support facility-based monitoring of ANC indicators. Training materials were also improved based on feedback from interviews of health workers. The iterative process in developing country-adapted digital ANC modules is key to their deployments for routine use and a key proof of concept for the WHO SMART guideline approach.