LAUSR

ABSTRACT Background Digital innovations incorporating clinical digital support can improve the delivery of perinatal and postnatal care, yet few interventions exist in primary care settings. Objectives We aimed to adapt a digital quality improvement system (Neotree) from tertiary facilities to lower-level facilities providing Level 1 newborn care. Methods We conducted a mixed method stepwise study using the ADAPT framework. We conducted a needs and technology assessment of eight facilities in Lilongwe district, Malawi. We next adopted a user-centred approach to modify the clinical decision support and data capture functionalities to fit the new context. We completed ‘think aloud’ usability testing with six prospective users to refine the system, alongside qualitative research informed by behavioural science frameworks with 10 healthcare professionals to identify potential barriers and facilitators to implementation. Finally, we carried out a stakeholder assessment to identify a potential pathway to scale. Results The adapted application was highly usable achieving a mean System Usability Scale (SUS) score of 92.5 among prospective users during the final round of testing. Our qualitative findings indicated Neotree was anticipated to be acceptable among healthcare professionals. We found high levels of motivation to implement Neotree, but key perceived implementation barriers included psychological and physical capability (such as skills and knowledge in neonatal care), as well as physical opportunity (e.g. human resources, equipment and adequate space for newborn care). Conclusion Using a stepwise user-centred approach, we successfully adapted a digital quality improvement intervention (Neotree) ready for real-world piloting in community hospital and primary health centres in Malawi. Paper Context Main findings: Despite the dearth of digital data capture and clinical decision support systems for newborn care outside of tertiary settings, we found healthcare professionals in lower-level facilities were highly motivated to use an adapted digital quality improvement system to support the delivery of newborn care. Added knowledge: In our intervention adaptation process, we found that lower-level facilities providing basic essential newborn care in Malawi are falling short of global standards, with respect to training, routine data collection and basic equipment. Global health impact for policy and action: International guidance for the provision of newborn care across all levels of the health system need to be adopted within national contexts, thereby ensuring implementers have contextually relevant benchmarks to achieve quality improvements across the care continuum.