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Lack of trained health care workers and nonadherence to national guidelines are key barriers to achieving high-quality newborn care in health care facilities in low- and middle-income countries. Traditional didactic approaches addressing these barriers fail to account for high staff turnover rates and result in temporary behavior change. NoviGuide, a clinical decision support software designed to standardize neonatal care through point-of-care assessments, has the potential to align bedside practice to national guidelines in settings lacking subspecialty neonatal providers.
This study aims to determine the adaptation, adoption, feasibility, acceptability, and sustainability of NoviGuide and its impact on nurse-midwives’ knowledge in a rural hospital in eastern Uganda.
This mixed methods observational study was guided by the Proctor framework. Experts reviewed the clinical content of NoviGuide to ensure fidelity to Uganda guidelines. We enrolled nurses and midwives providing newborn care at Tororo District Hospital, trained them on NoviGuide use, and followed them for 12 months. We assessed adoption, feasibility, acceptability, and sustainability by analyzing NoviGuide use data, comparing it with maternity registry data and administering the System Usability Scale (SUS) and the Center for Health Care Evaluation Provider Satisfaction Questionnaire. We compared the mean knowledge assessment score at baseline, 6 months, and 12 months using a two-tailed
Five Ugandan experts suggested two minor changes to NoviGuide: the inclusion of an unsterile birth environment as an indication for empiric antibiotics and the addition of a reminder to follow-up with newborns with temperatures between 37.7°C and 37.9°C. Of the 19 nurse-midwives enrolled in February 2017, 74% (n=14) completed the follow-up in March 2018. The participants entered a total of 1705 assessments of varying newborn characteristics into NoviGuide throughout the day, evening, and night nursing shifts. The SUS score at the end of the study was very high (93.5, above the average of 68). Participants had a positive perception about NoviGuide, reporting that NoviGuide saved time (mean 5, SD 0) and prevented mistakes (mean 5, SD 0), and that they felt more confident in taking care of newborns when they used NoviGuide (mean 5, SD 0). Participants were highly satisfied with NoviGuide (mean 4.86, SD 0.36), although they lacked medical supplies and materials needed to follow NoviGuide recommendations (mean 3.3, SD 1.22). The participants’ knowledge scores improved by a mean change of 3.7 (95% CI 2.6-4.8) at 6 months and 6.7 (95% CI 4.6-8.2) at 12 months (
NoviGuide was easily adapted to the Uganda guidelines. Nurse-midwives used NoviGuide frequently and reported high levels of satisfaction despite challenges with medical supplies and high staff turnover. NoviGuide improved knowledge and confidence in newborn care without in-person didactic training. NoviGuide use has the potential to scale up quality newborn care by facilitating adherence to national guidelines.
In 2018, 2.5 million children died in their first 28 days of life worldwide, with the highest neonatal mortality rate observed in sub-Saharan Africa (28 per 1000 live births) [
Traditional approaches to implementing neonatal care clinical guidelines in LMICs are based on lectures, the distribution of educational material, and hands-on training; although these approaches can be effective for focused topics or procedures such as neonatal resuscitation [
Clinical decision support (CDS) software has the potential to enable health care providers to deliver complex medical protocols as responsive point-of-care assessments [
Our team developed NoviGuide (Global Strategies) [
NoviGuide has 3 main sections:
NoviGuide screenshots: Home page, NoviGuide clinical assessments, and Medication dosing instructions pages.
The
When initiating an assessment, health providers are asked to indicate if the assessment is being completed on a
With this study, our aim is to describe the adaptation, adoption, feasibility, acceptability, and sustainability of NoviGuide use in a rural district hospital in eastern Uganda. We used a mixed methods observational study design among nurses and midwives in the context of newborn care. In addition, we analyzed the impact of NoviGuide use on the knowledge of nurse-midwives. The Proctor framework [
With the assistance of the Uganda Pediatrics Association, we recruited a team of 5 Ugandan experts to review the content of NoviGuide over a series of meetings between August and November 2016. The aim was to ensure the fidelity of NoviGuide to the Uganda neonatal care clinical guidelines and to refine the NoviGuide design to suit the Uganda local context [
Description of content areas for Ugandan expert panel review.
Area | Description |
Content | Verifying that the clinical information is consistent with national protocols. For example, the study team shows the expert panel the temperature threshold where a newborn is considered febrile. The expert panel then votes to confirm or modify. |
Order | Verifying that the order of questions in each assessment is consistent with national protocols. For example, confirming that lines of questioning concerning hypoglycemia should precede lines of questioning concerning the initiation of antibiotics. |
Branch-point logic | Reviewing how the software responds to user input and verifying that the response is consistent with national protocols. For example, the study team shows the expert panel the alert message a user sees after entering a risk factor for infection. The expert panel then votes to confirm or modify. |
We conducted an implementation study from February 2017 to March 2018 at Tororo District Hospital (TDH), a rural government-owned district hospital in eastern Uganda. TDH, a 200-bed facility, serves approximately 517,000 people, the majority of whom live in rural areas [
We screened all the nurses and midwives working in the maternity ward at the TDH and enrolled them into the study in February 2017. Inclusion criteria for nurse-midwives included providing newborn care at TDH, having current licenses to practice, and willingness to participate in the study. In addition, nurse-midwives had to have completed the WHO Integrated Management of Childhood Illnesses modules [
To recruit participants, we invited all nurse-midwives working at the TDH and their supervisors to attend an organized meeting in the hospital boardroom. The study team provided a brief introduction about the study, including NoviGuide and evaluation methods, and obtained written informed consent from the nurse-midwives who met the eligibility criteria. We asked the nurses and midwives who declined participation for their reasons. The medical superintendent, matron, and wards-in-charge were recruited as key informants in the study development; hospital leadership encouraged but did not mandate or require the use of NoviGuide.
Following enrollment, the study participants attended a 3-hour training conducted by representatives of Global Strategies on how to use NoviGuide. Following the training, the participants created individual unique usernames and passwords to log in to the tablet and the NoviGuide software. The study team provided 7 tablets (Amazon Fire HD 8 tablet) loaded with NoviGuide in February 2017. The tablets were stored in a lockable wooden cabinet in the nurses’ office in the labor suite. During the first week, the study team provided on-site technical support to troubleshoot technical issues. We followed the study participants through March 2018.
At baseline, participants completed a survey that included demographic data (age, sex, and level of education), years of clinical experience, experience using technology, and perceived challenges in caring for newborns at TDH.
The study participants also completed a questionnaire assessing basic knowledge in newborn care, including questions about the management of hypoglycemia, indications for antibiotics, management of the HIV-exposed infant, and the specific order of tasks in neonatal resuscitation. This questionnaire was then repeated at 6 and 12 months with modifications of the question order and variables, such as newborn weights, in the clinical scenarios (
Throughout the study period, the study team connected the tablets to a Wi-Fi network once per day to upload NoviGuide use data, stored in the tablet, onto a secure cloud-based database. NoviGuide use data were linked to the participants’ unique study identification number. We compared the total number of assessments entered into the NoviGuide with the total number of births and admissions of newborns at the hospital during the study period. The study team instructed the participants to keep notes on any technical problems encountered during NoviGuide use in a study logbook or contact the study team by SMS, phone, or email for urgent concerns.
At 12 months, the participants completed 2 validated measures of software usability. We used the System Usability Scale (SUS) [
We defined adoption as the measure of the initial uptake or intention to use the NoviGuide and measured it by reviewing the NoviGuide use data for (1) the different assessments made into the NoviGuide and how many of these were completed through to the summary page, (2) the time participants spent during the NoviGuide assessments, (3) NoviGuide use during the different nursing shifts (day, evening, and night), (4) whether participants accessed the NoviGuide’s educational videos or reading materials and whether the participants used the NoviGuide for practice or with a real newborn, and (5) total NoviGuide assessments in relation to the total births and admissions at the hospital during the study period.
We defined acceptability as the measure of the participants’ satisfaction with the various components of NoviGuide, including content, complexity, navigation, ease of use, and general experience using NoviGuide for newborn care, and measured it by (1) comparing the overall SUS score with an average score of 68, as described by John Brooke [
We defined feasibility as the actual fit and the use of NoviGuide within the rural hospital context and measured it by reviewing the NoviGuide use data for (1) the characteristics of newborns cared for using NoviGuide and (2) whether the study participants indicated resource or health system constraints that could prevent the use of NoviGuide. We also measured feasibility by determining the mean scores and SD of questions 11 to 15 of the end-of-study questionnaire assessing the availability of medical supplies and materials needed to follow NoviGuide recommendations; time to use the NoviGuide; and support from colleagues, supervisors, and hospital administrators.
We defined sustainability as the extent to which NoviGuide use was maintained throughout the study period and the frequency and degree of technical problems preventing NoviGuide use. We measured use over the study period by individual users and collectively, across 100-day interval study periods (day 0-99, 100-199, 200-299, and 300-397).
We measured the impact of NoviGuide use on participant knowledge by comparing the mean knowledge assessment score at baseline with scores at 6 and 12 months using a paired
The University of California San Francisco Committee on Human Research (16-19241), the Makerere University School of Biomedical Sciences (SB-352), and Uganda National Council for Science and Technology (IS 125) approved the study. All study participants provided written informed consent before participation in the study-related activities.
The study team selected 4 Ugandan neonatologists and 1 Ugandan neonatal nurse as expert reviewers. The experts suggested 2 modifications to the decision trees. First, they recommended that birth in an unsterile environment should be added as a sepsis risk factor and that its presence should prompt a recommendation for empiric antibiotics. Second, they recommended that a specific pop-up message be generated for temperatures between 37.7°C and 37.9°C to alert users that the newborn was
The study team screened 13 nurse-midwives and enrolled 12 nurse-midwives in February 2017 (
Study flow diagram. TDH: Tororo District Hospital.
Baseline demographics and participant characteristics (n=19).
Characteristics | Values | ||
Female, n (%) | 19 (100) | ||
Age (years), mean (SD) | 39 (14) | ||
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Bachelor’s | 1 (5) | |
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Registered nurse | 12 (63) | |
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Certified midwife | 6 (32) | |
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|||
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0-2 | 4 (21) | |
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3-10 | 5 (26) | |
|
11-20 | 4 (21) | |
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>21 | 6 (32) | |
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None | 2 (11) | |
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Home computer or laptop | 1 (5) | |
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Tablet | 0 (0) | |
|
Smartphone | 9 (47) | |
|
Ordinary phone | 9 (47) | |
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|||
|
Never | 5 (26) | |
|
Rarely or at least once a month | 6 (32) | |
|
Occasionally | 1 (5) | |
|
Weekly | 3 (16) | |
|
Daily at least once a day | 4 (21) | |
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Easier | 17 (89) | |
|
No difference | 2 (11) | |
|
Harder | 0 (0) | |
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|||
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Yes | 19 (100) | |
|
No | 0 (0) | |
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I am the first to try something new | 6 (32) | |
|
Before I try, I watch others try it and see if it fits my life | 13 (68) | |
|
I am usually among the last to try something new | 0 (0) | |
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|||
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1 (least satisfied) | 1 (13) | |
|
2 | 2 (11) | |
|
3 | 8 (44) | |
|
4 | 2 (11) | |
|
5 | 5 (28) | |
|
6 | 0 (0) | |
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7 (most satisfied) | 0 (0) | |
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|
By handheld calculator | 3 (16) | |
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By calculator on the phone | 11 (58) | |
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I do them in my head | 5 (26) | |
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Check the World Health Organization chart at the maternity ward | 14 (74) | |
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Consult with the medical doctor | 12 (63) | |
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I use my judgment and experience | 6 (32) |
The study participants entered a total of 1705 assessments into NoviGuide over the study period. Of these 1705 assessments, 1412 (82.82%) were completed through to the summary page. The most common completed entries were birth assessments with 65.93% (931/1412) assessments for
The median time for a participant to complete assessments was 2.0 (IQR 1.0-5.0) min for
All but 1 of the 19 study participants recorded entries into the NoviGuide. The mean (range) number of completed assessments per study participant was 90 (0-321). The participant without entries had been transferred to another hospital shortly after enrolling. Of the 1092 assessments of babies born within the last 24 hours, 68.13% (744/1092) were completed by only 26% (5/19) study participants. Participants entered 46 practice cases, denoted by answering “N” (no) to the question, “Are you with a real baby? (Touch N if practicing).”
Data from the maternity register included 4704 admissions from February 1, 2017, to February 20, 2018. Of these, 97.55% (4589/4704) were identified as born at TDH, 2.32% (109/4704) were born outside of TDH, and 0.13% (6/4704) entries did not specify the birth site. Six deaths (0.13%) were recorded in the registry, and 0.64% (30/4704) newborns were transferred to a higher acuity facility. The registry, while noting whether the newborn was born at TDH, does not include the requisite data to determine whether the care encounter occurred immediately postpartum or upon return to the hospital following discharge.
NoviGuide use by assessment type.
NoviGuide use by work shifts and time of day.
Assessment type | Assessments made during the different shifts and time of day | Total | |||
|
Day (8 AM to 2:59 PM) | Evening (3 PM to 7:59 PM) | Night (8 PM to 8 AM) |
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New baby born in the last 24 hours, n | 529 | 451 | 112 | 1092 | |
New baby more than 24 hours old, n | 176 | 151 | 40 | 367 | |
Rounding, n | 64 | 44 | 3 | 111 | |
Discharge, n | 54 | 33 | 7 | 94 | |
Abdominal emergency, n | 4 | 1 | 0 | 5 | |
Seizure emergency, n | 12 | 20 | 4 | 36 | |
Total (%) | 49.2 | 41.1 | 9.7 | 100 |
The overall SUS score at the end of the study was very high at 93.5 (
In the end-of-study questionnaire (
Usability scores.
SUSa | Score, meanb (SD) | Convertedc |
1. I think that I would like to use the NoviGuide frequently. | 5 (0) | 4 |
2. I found the NoviGuide unnecessarily complex. | 1.14 (0.36) | 3.9 |
3. I thought the NoviGuide was easy to use. | 4.7 (0.46) | 3.7 |
4. I think that I would need the support of a technical person to be able to use NoviGuide. | 1.21 (0.43) | 3.8 |
5. I found the various functions in the NoviGuide were well integrated. | 4.86 (0.36) | 3.9 |
6. I thought there was too much inconsistency in the NoviGuide. | 1.36 (0.74) | 3.6 |
7. I would imagine that most people would learn to use the NoviGuide very quickly. | 4.57 (0.65) | 3.6 |
8. I found NoviGuide very cumbersome to use. | 1.21 (0.80) | 3.8 |
9. I felt very confident using the NoviGuide. | 5 (0) | 4 |
10. I needed to learn a lot of things before I could get going with the NoviGuide. | 1.86 (1.23) | 3.1 |
Total converted mean scores × 2.5 (overall SUS score) | N/Ad | 93.5 |
aSUS: System Usability Scale.
b1: strongly disagree, 2: somewhat disagree, 3: neutral or no opinion, 4: somewhat agree, and 5: strongly agree.
cFor items 1, 3, 5, 7, and 9, the converted score is the mean score minus 1. For items 2, 4, 6, 8, and 10, the converted score is 5 minus the mean score.
dN/A: not applicable.
Mean scores of the Center for Health Care Evaluation Provider Satisfaction Questionnaire and the end-of-study questionnaire.
Questionnaires | Value, mean (SD) | ||
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1. How useful is the information provided in the NoviGuide? | 4.79 (0.43) | |
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2. How easy is it to understand the information in the NoviGuide? | 4.5 (0.52) | |
|
3. How effective are the graphics in NoviGuide? | 4.07 (0.47) | |
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4. What is your general satisfaction with the NoviGuide? | 4.86 (0.36) | |
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5. The NoviGuide could improve patient-nurse encounters | 5 (0) | |
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6. The NoviGuide saved me time | 5 (0) | |
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7. I would use it regularly in the clinic or hospital | 4.71 (0.47) | |
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8. I would recommend that other nurses use this tool | 5 (0) | |
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1. The NoviGuide helped me deliver better care to newborns | 5 (0) | |
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2. The NoviGuide prevented me from making a mistake while providing care to newborns | 5 (0) | |
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3. The NoviGuide improved my documentation on newborns and mothers | 4.79 (0.43) | |
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4. I was proud to use the NoviGuide | 4.93 (0.27) | |
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5. I feel more confident taking care of newborns when I use the NoviGuide | 5 (0) | |
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6. I think that using NoviGuide made a good impression on parents of the newborns I have seen | 4.71 (0.61) | |
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7. I think that using NoviGuide made a good impression on other parents in the community | 4.43 (0.65) | |
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8. I think that NoviGuide improved newborn care at my hospital | 4.93 (0.27) | |
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9. I think that using the NoviGuide to deliver newborn care at other hospitals is a positive idea | 5 (0) | |
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10. I think that NoviGuide is an important part of meeting my needs in caring for newborns | 5 (0) | |
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11. I had the medical supplies and materials needed to follow NoviGuide recommendations | 3.36 (1.22) | |
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12. I had enough time to use the NoviGuide | 4.57 (0.65) | |
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13. My colleagues supported my use of the NoviGuide | 4.71 (0.47) | |
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14. My supervisor and the hospital administration supported my use of the NoviGuide | 4.71 (0.47) | |
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15. Technical support was always available for any difficulties I had with the NoviGuide | 4.93 (0.27) |
aFor Center for Health Care Evaluation Provider Satisfaction Questionnaire questions 1 to 4: 1, poor; 2, fair; 3, good; 4, very good; and 5, excellent; and for questions 5 to 8: 1, strongly disagree; 2, somewhat disagree; 3, neutral or no opinion; 4, somewhat agree; and 5, strongly agree.
bFor the end-of-study questionnaire: 1, strongly disagree; 2, somewhat disagree; 3, neutral or no opinion; 4, somewhat agree; and 5, strongly agree.
Study participants initiated and completed assessments on both well-appearing and ill-appearing newborns with diverse clinical characteristics (
Rounding assessments included 6.51% (111/1705) of the total 1705 assessments entered into NoviGuide. Of these, 77.5% (86/111) were for
In a number of instances, participants working in the same maternity ward reported varying resource capabilities. In 738 assessments where participants were guided to check a glucose level, 46.3% (342/738) reported that a glucometer was available and entered a level, whereas 53.7% (396/738) responded
In the end-of-study questionnaire, participants responded with a mean score of 3.3 (SD 1.22) when asked whether they had the requisite resources to follow NoviGuide’s recommendations (
Characteristics of newborns entered into NoviGuide.
Newborn characteristics | New baby born in the last 24 hours (n=1092), percent birth assessments, n (%) | New baby more than 24 hours old (n=367), percent birth assessments, n (%) |
Sick appearing | 319 (29.21) | 284 (77.4) |
Difficulty in breathing | 271 (24.82) | 101 (27.5) |
Weight under 2.5 kg | 213 (19.51) | 111 (30.2) |
Preterm (<37 weeks) | 133 (12.18) | 59 (16.1) |
Abnormal vital signsa | 415 (38.00) | 195 (53.1) |
HIV exposed | 55 (5.04) | 12 (3.3) |
Maternal fever | 70 (6.41) | N/Ab |
Foul smelling amniotic fluid | 109 (9.98) | N/A |
Born in an unsterile environment | 51 (4.67) | N/A |
Antibiotics calculated during assessment | 440 (40.29) | 220 (59.9) |
aAbnormal vital signs were defined as follows: temperature <36.5°C or >37.9°C, respiratory rate <30 or >60 breaths per minute, or heart rate <100 beats per minute or >160 beats per minute.
bN/A: not applicable.
Although NoviGuide continued to be used regularly throughout the study (
NoviGuide use by user. Individual study participants had unique identification numbers starting with NG, followed by the number, for example, NG01.
The results from the knowledge assessment questionnaires demonstrated significant improvement in basic newborn care knowledge over time. Among the 18 participants who were assessed at 6 months, scores increased from a mean of 10.4 to 14.1, reflecting a mean change of 3.7 (95% CI 2.6-4.8;
NoviGuide was easily adapted to Uganda clinical guidelines, and its implementation in a rural district hospital was feasible and acceptable to nurse-midwives caring for newborns. The nurse-midwives used NoviGuide across a range of clinical scenarios, reported high levels of satisfaction with the software, and reported that it significantly improved their knowledge of newborn care. This study adds to the growing evidence that CDS software designed for facility-based health care workers delivering complex inpatient care can increase the use of national clinical guidelines in LMICs [
There are a number of features that distinguish NoviGuide from previously reported neonatal CDS software designed for LMICs [
Ugandan experts suggested only two minor modifications to NoviGuide’s decision trees. Although the suggested additions are not explicitly detailed in the Uganda clinical guidelines, they do align with the national strategy to reduce deaths from newborn infections and with general standards of care. The paucity of modifications suggests that NoviGuide was well aligned to the Ugandan local context and suggests that there may be similar ease of adaptation in other countries where national guidelines are based on WHO recommendations on newborn health [
A key finding is that nurse-midwives had very high levels of satisfaction with NoviGuide; participants reported that the NoviGuide saved time, that they would recommend it to other nurses, and that they were even proud to use it. These findings highlight the potential of CDS as a delivery system for implementing complex clinical protocols. CDS-enabled functionalities, such as automated drug dose calculations, combined with a streamlined and attractive user interface, may confer a benefit on the user separate from that acquired by adhering to a specific clinical standard. Interestingly, these high levels of satisfaction with the NoviGuide persisted despite evidence that participants did not use it on every baby, there was wide variation in use, and there was an overall decrease in use over time. There are a number of possible explanations for the wide variation in use among participants, including differences in hours worked per individual, role within the ward, and planned absences. It is possible that autonomy in using, or not using, NoviGuide contributed to overall satisfaction with the software; NoviGuide may have been time saving because participants could self-select when they wanted to use it. Regardless, as in previous studies on CDS [
Participants improved their knowledge scores over the study period, even as they only rarely engaged with the parts of NoviGuide intended for self-directed learning outside of clinical care. This finding suggests that rather than becoming dependent on CDS to the detriment of internalized knowledge, CDS can improve provider knowledge through exposure. The finding that participants visited the self-directed learning section only 14 times over the study period requires additional qualitative investigation. One possibility is that health care providers form an early perception of the software as either a point-of-care software or a continuing education software, but not both.
A potentially important finding was that NoviGuide’s use data captured entries where participants working at the same hospital reported that they had different resources to treat patients. This finding has potentially important implications, as it suggests that CDS could be used to identify instances where either an individual or system barrier prevents available resources from being used. The same data, if transmitted frequently, could facilitate the rapid identification of resource gaps, such as the stock out of drugs or malfunction of a previously functioning medical equipment.
We acknowledge several limitations of our study. The newborn clinical characteristics entered into NoviGuide were not corroborated by reference to clinical charts or direct observation. Some of the investigators performing this evaluation were the designers of this tool, raising the possibility of bias; additional evaluation of our tool at a later stage in development could be informative. The lack of rolling enrollment may have influenced our adoption measurements, as new staff in the maternity ward began work before being enrolled in the study, resulting in a period where these staff observed NoviGuide in use but could not use it themselves. We also lack data to draw conclusions regarding the resource availability discrepancies identified through NoviGuide use. Specifically, we cannot determine whether these variances corresponded to a lack of provider comfort in using the resource, lack of access, equipment malfunction, or other causes. Finally, the Likert scale, which is commonly used to evaluate software acceptability and feasibility, is an imperfect tool and can result in
A CDS software for neonatal health care providers can be an alternative method for implementing complex neonatal protocols in LMICs and may improve upon, and complement, the standard didactic approach because of its ability to couple clinical protocols with job aide functionalities. The NoviGuide software was easily adapted to Uganda neonatal care clinical guidelines, was used across a range of clinical scenarios, resulted in high levels of satisfaction, and significantly improved knowledge among nurse-midwives. Although CDS is not a solution for all the training needs of a health care workforce in LMICs, it may be the optimal choice for content that is complex, not easily retained or applied, and for which immediate performance feedback is not possible.
NoviGuide resuscitation video.
NoviGuide step-by-step prompts.
System Usability Scale and provider satisfaction questionnaire adapted from the Center for Health Care Evaluation Provider Satisfaction Questionnaire, the end-of-study questionnaire, and the knowledge assessment questionnaire.
clinical decision support
Center for Health Care Evaluation Provider Satisfaction Questionnaire
intravenous
low- and middle-income country
Preterm Birth Initiative
System Usability Scale
Tororo District Hospital
World Health Organization
The authors would like to acknowledge the 5 Ugandan experts for their participation in the adaptation of NoviGuide to the Uganda neonatal care clinical guidelines: Dr Jolly Nankunda, consultant pediatrician, Mulago National Referral Hospital; Dr Victoria Nakibuuka, neonatologist, Nsambya Hospital; Dr Harriet Nambuya, consultant pediatrician, Jinja Regional Referral Hospital; Dr Tom Ediamu, consultant pediatrician, Hoima Regional Referral Hospital; and Damalie Mwogererwa, neonatal nurse, Mulago National Referral Hospital. The authors also acknowledge Dr Rebecca Nantada, the president of Uganda Pediatrics Association, and Prof Peter Waiswa, School of Public Health, Makerere University College of Health Sciences, for their guidance and support. The authors are grateful to the nurse-midwives for taking part in the study and to Dr Ochar Thomas, the medical superintendent, TDH, for the generous support. This study was supported by the East Africa Preterm Birth Initiative (PTBi), a multiyear, multicountry effort generously funded by the Bill & Melinda Gates Foundation. The funders of the study had no role in data collection, analysis, interpretation, writing of this manuscript, or discussion to submit for publication.
TR, LB, and JB conceived and designed the study. MM, JA, and KR designed the data collection forms. MM and KR collected, cleaned, and analyzed the data. TR, LB, and MK provided technical and mentorship support for MM, a research fellow with University of California San Francisco PTBi. JB and ED developed NoviGuide. All the coauthors critically revised the manuscript and approved the final draft before submission.
The following authors work with Global Strategies, the organization that developed NoviGuide: JB as President, ED as Director of Software Design and Development, and JA works as a Program Coordinator. JB, ED, and JA did not participate in the data collection process. TR is a member of the board of directors of Global Strategies and advised in the development of NoviGuide. However, he receives no financial compensation from the organization or is in any other way related to NoviGuide; neither he nor his family members have any potential financial benefit from this manuscript’s publication. The remaining authors declare no conflicts of interest.