Overview
Fifty-four health workers participated in the study: 18 CHWs, 18 nutritionists and 18 data managers, as shown in Table 2. In brief, most CHWs had lower educational attainment levels, were older and had less work experience compared to nutritionists and data managers. Most (56%) of the data managers had computer science as their main background and most nutritionists had studied human nutrition.
Table 4
Characteristics of the study participants (n = 36).
| Characteristics | Participant categories |
| CHWs (n = 18) | Nutritionists (n = 18) | Data managers (n = 18) |
| N (%) | N (%) | N (%) |
| Age in years (range) | 21–29 | 1 (6) | 2 (11) | 4 (22) |
| | 30–39 | 2 (11) | 14 (78) | 14 (78) |
| | 40–49 | 6 (33) | 1 (11) | 0 (0) |
| | 50 & above | 9 (50) | 0 (0) | 0 (0) |
| Work experience (years) | 0–5 | 3 (17) | 10(56) | 14 (78) |
| | 5–10 | 5 (28) | 4 (22) | 4 (22) |
| | 10–15 | 6 (33) | 2 (11) | 0 (0) |
| | 15–20 | 3 (17) | 2 (11) | 0 (0) |
| Education level (years) | Primary (0–6) | 4 (22) | 0 (0) | 0 (0) |
| | Lower secondary (7–10) | 11 (61) | 0 (0) | 0 (0) |
| | Upper secondary (> 10) | 2 (11) | 6 (33) | 0 (0) |
| | University (> 12) | 1 (6) | 12 (67) | 18 (100) |
| Field of study | General training | 18 (100) | | |
| | Sociology | | 4 (22) | |
| | Human nutrition | | 6 (33) | |
| | Environmental Health | | 4 (22) | |
| | Economics/Accountancy | | 4 (22) | |
| | Nurse/Midwifery | | | 4 (22) |
| | Laboratory | | | 4 (22) |
| | IT | | | 10 (56) |
As reported in data analysis section, the structure of the findings follows the HOT-Fit framework (29). This framework illustrates the alignment of technological, organizational, and human factors to investigate how public primary healthcare centers utilize HMIS to when delivering children's nutrition and growth care.
Technology
System quality:
Data managers frequently expressed concerns regarding the inefficiency of their digital tools, citing persistent connectivity issues, the absence of an integrated system for data entries, and the use of obsolete technology (Table 5: Section A, Constructs 4 & 5). Despite efforts to synchronize paper and electronic logs, the varying requirements of different health programs resulted in a misalignment of data (Table 5: Section A, Construct 2). Furthermore, some nutritionists and data managers expressed concerns that the HMIS was overloaded with numerous nutritional indicators, many of which were entered but never utilized for reporting or decision-making purposes.
Participants raised concerns about the limitations of the paper-based system, especially regarding data security, accessibility, and overall effectiveness. They noted that the introduction of new paper-based reporting templates by the central authorities for use in lower primary healthcare facilities could compromise data security and privacy. Specifically, when older registers become obsolete, there is a risk of data loss, making it difficult to retrieve critical information, particularly during routine reporting (Table 5: Section A, Construct 3).
While CHWs and nutritionists frequently used paper for data collection, reporting, and feedback, participants generally preferred digital tools. Data managers prioritized digital system security by emphasizing data access restrictions for authorized users (Table 5: Section A, Construct 1).
A significant number of participants, primarily nutritionists and CHWs, currently rely exclusively on paper-based tools, as these are the only systems available to them. While they recognize the potential benefits of digital tools, their limited digital literacy significantly hinders their ability to use these systems effectively. This situation underscores a general awareness among health workers that digital solutions could enhance their workflows and improve data management. However, without the necessary skills and training, their reliance on paper documentation continues.
This dependency not only limits their current capabilities but also impedes the development of their digital skills (Table 5: Section A, Construct 2). Moreover, those with prior technological experience often find digital systems user-friendly, whereas some healthcare providers and individuals skeptical of technology struggle to navigate them, resulting in uneven proficiency levels and an ongoing reliance on paper documentation.
Information quality:
Data managers highlighted a problem with delays in entering information into the digital system and recording nutrition data promptly. This issue affected the completeness and timeliness of data availability especially when verifying data through paper registries and forms, particularly data collected by community health workers during community interactions (Table 5: Section A, Construct 7).
Moreover, shifting from paper records to digital entry forms introduces data reliability concerns as errors can occur at various points of entry (Table 5: Section A, Construct 6). Nutritionists and CHWs raised issues about data reliability, suggesting that the data input process was not entirely reliable (Table 5, Section A, Construct 8), illustrating potential data inaccuracies throughout the process.
System quality:
According to the data managers, a significant portion of their technical support inquiries were promptly handled by specialized technical staff assigned to the HMIS unit at the central level (Table 5: Section A, Construct 10). Nevertheless, the duration required to obtain this help can differ. While it is common for straightforward technical difficulties to be resolved within 24 hours, more intricate problems may require a resolution duration of up to 14 days (Table 5, Section A, Construct 9).
Humans
System use:
Data managers use digital systems for various tasks, such as transitioning individual paper records to a digital aggregated format, reconciling differences between paper and digital data, analyzing trends, and generating reports at central and district levels. They adhere to a specific schedule, entering data between the first and fifth of each month and validating it before the fifteenth. At monthly meetings, data from the digital platform and paper registries are reviewed and authorized. Despite the benefits of enhanced data security and real-time tracking with the digital system, data managers noted a lack of training and continuous learning opportunities.
On the other hand, nutritionists acknowledge the advantages of utilizing digital entry formats and other nutrition-related information systems. Nevertheless, their hesitance stems from the platform inability to function offline, especially considering the limited internet access at their workplace. Despite these reservations, they recognize the system's potential benefits, such as improved data security, reduced redundancy in tasks with CHWs, and enhanced productivity (Table 5: Section B, Construct 12).
Data managers expressed enthusiasm about the current system's ability to enhance their workflow by replacing traditional paper-based tools, particularly in tracking families as they move within the country. They emphasized that the platform facilitates data retrieval and allows for cross-referencing information collected by CHWs (Table 5: Section A, Construct 13).
Moreover, the digital system was generally well-received by nutritionists and CHWs, who acknowledged its potential to assist with various tasks, including child tracking, simple data retrieval, scheduling reminders, and event listing (Table 5: Section A, Construct 14). While the current system has limitations, the feedback indicates a clear desire for improvements that could further enhance functionality and efficiency in data management in future iterations of the system.
An addition of the offline mode found, both groups—nutritionists and CHWs in agreement. The data managers underlined the importance of on-the-job training as a prerequisite for the successful integration of digital technology at the point of care. Further complicating the use of these digital tools for many users was the fact that English was the only language available.
User satisfaction:
The data managers held a favorable view of the existing digital system, particularly appreciating its detailed data on FBF beneficiaries (Table 5: Section A, Construct 15). The auto calculations or "validation rules" provided by the system are a noteworthy element. Overall, interviewees expressed a generally positive attitude toward the usefulness of digital systems, especially for growth monitoring. However, there was noticeable dissatisfaction with non-digital systems, primarily due to concerns about data sharing, loss, and retrieval, as paper documentation continues to be the predominant method of data collection.
Organization
Structure:
A significant barrier to effective collaboration highlighted by data managers is the lack of digital literacy among healthcare professionals, especially nutritionists or other professionals who provide this type of service (Table 5: Section C, Construct 18).
The participants noted inadequate integration between the digital platform and traditional data-capturing tools (Table 5: Section C, Construct 16). This lack of integration not only impedes effective communication within a health center but also leads to duplicate data entry, especially when patients are transferred between different levels of care. Despite difficulties in inter-facility communication, the transmission of information among various stakeholders and organizations was reported to be effective (Table 5: Section C, Construct 17).
Additional challenges identified relate to the implementation of outreach programs by CHWs. While these programs have the potential to enhance data recording and collect detailed nutrition information at the individual level, a shortage of skilled personnel proficient in using digital tools, combined with insufficient digital infrastructure—such as handheld devices—hinders both the current and future program systems (Table 5: Section C, Construct 19).
Environment:
The respondents unanimously recognized the usefulness of the FBF tracker system in collecting data on vulnerable children belonging to the two most socioeconomically disadvantaged demographics. One significant issue of concern revolves around the evident communication gap that exists among various child health programs (i.e. child vaccination program), potentially resulting in the duplication of data. The data pertaining to child registration are consistently entered into separate systems, even if they have previously been documented in the civil registration and vital statistics (CRVS) system (Table 5: Section C, Construct 20).
Net benefits:
Data managers, while expressing their concerns about the administration of the digital platform, emphasized its benefits for enhancing child nutrition and growth monitoring programs (Table 5: Section D, Construct 21). They acknowledged the system's capacity to reduce dependency on paper, streamline data access, and help decision-making (Table 5: Section C, Build 22).
However, concerns arise regarding the integration of technology and human tasks. Initial paper-based data collection by nutritionists and CHWs, followed by digital entry of the data by data managers, raised issues of increased workloads and reduced motivation. This challenge is exacerbated by the significant shortage of nutritionists in many health centers, hindering broader adoption of digital solutions within the nutrition program.
One of the challenges identified by health workers is the reliance on paper-based formats as the primary data collection tool. This reliance often creates difficulties when trying to switch to digital systems. Many interviewees noted that the existing paper systems lead to compatibility issues with digital databases, which can make users hesitant to adopt new technologies and reduce their satisfaction with the system (Table 5: Section C, Construct 24). Health workers believe that having a system capable of accessing all recorded data, monitoring children's growth, obtaining statistical insights on measurements, and tracking the number of children in rehabilitation would significantly improve their efficiency.
Furthermore, while various stakeholders in the nutrition program support the idea of replacing paper systems with digital data entry at the point of care, success in this transition requires teamwork among all parties involved. The government of Rwanda is backing initiatives like the FBF tracker system and the monthly HMIS reports, which health workers believe could help them manage heavy workloads and address competing resource challenges.
However, some participants highlighted difficulties with technology adoption. Many colleagues, especially the nutritionists, struggle with basic technologies, hindering their effective performance (Table 5: Section C, Construct 23). There is also concern that even that overseeing nutrition at the district level may not fully understand the importance of accurate data recording in their roles.
Table 5
Main findings and illustrative quotes
| Construct number | Main findings | Example quotes |
| Section A: Technology |
| System quality |
| 1 | The digital system is easy to learn and use for skilled users | “…it is easy to use when someone has advanced skills; and “one-stop, easy and quick information access or retrieval” (Data manager 008). |
| 2 | The tracker system is not easy to learn for nonskilled users | “…the digital system is not user friendly; it is cumbersome and difficult to understand, it is complex and contains too much data elements which cannot be calculated into information as well as unnecessary features and functions” (Nutritionist 009). |
| 3 | Paper registries affect data security and privacy | “…the security and privacy of data [in paper] is lost when new registers are introduced and the existing ones become invalid” (CHWs 012). |
| 4 | Low speed internet connectivity | “the [internet] is slow because they usually give us 2GB data packages to be shared with other services and by noon it runs out” (Data manager, 004). |
| 5 | Shortage of IT resources. | “…certain health centers, data managers often use outdated machines, whereas some nutritionists may not have any at all” (Data Manager 009). |
| Information quality |
| 6 | Paper-based formats reduce availability, usefulness, and security | “…. when the big register book is lost, all clients’ data gets lost too;” “[paper] registers are not the safest way of keeping clinical data. [What if] the archive room … burned down” (Nutritionist 004). |
| 7 | Low data reliability and more documentation | “…the more data is taken from the CHWs to the nutritionists to the data managers, the more they are likely to make errors on paper” “[data] must be entered in the computer when the information is first collected at the point of contact” (Data manager 009). |
| 8 | Susceptibility to errors due to community data misalignment | “…. based on the information chain from a village to cell and then to the health center, many errors can be made along the journey” (CHW 016). |
| Service quality |
| 9 | Delays in technical support | “…. it is difficult for technical issues to be quickly responded to, as it is the central level that provide such assistance […] if the problem is an easy to fix, [it] can be done on a phone call to the District Hospital but certain technical issues take time” (Data manager 002) |
| 10 | Communication routes | “…I just call my superior at the district hospital, and he or she forwarded the case to the central level technical team, … the team is competent and the quicker the reply, the quicker it comes back to me” (Data Manager 001). |
| Section B: Human |
| System use |
| 11 | A secure area | “…the technology is a backup and reporting system that records children's status and their caregivers so that if the manual records are lost, we can get that very information”. (Nutritionist 002) |
| 12 | The system helps users speed up work | “…the new technologies could help us to collect data on time and to speed up reporting” (Nutritionist 007). |
| 13 | Scheduling appointments | “a digital system is needed to record all information related to the health status of children including notification of next visits and health center programs events” (CHW 011). |
| 14 | A better system that stores data and is secure | “…the new technology may store information with proper security and honestly for us it is possible for data and information to get lost using the current nondigital system” (Nutritionist 003). |
| User satisfaction |
| 15 | Fairly satisfied with the system in making corrective measures | “…when it is observed that there are some errors in the data, the system helps to communicate easily in an electronic format and issues are settled in a given timeframe without lots of face-to-face meetings” (Data Manager 009). |
| Section C: Organization |
| Structure |
| 16 | Cumbersome patient data transfer between levels | “…the current paper-based and FBF tracker system does not record transferred cases immediately […] data transfer from one level to another is difficult and may take weeks – which hinders clinical outcomes” (Nutritionist 006). |
| 17 | Users prefer a more efficient system | “…we require a system that assists in timely data collection, identifies missed appointments, accelerates reporting for caregivers, and provides alerts for upcoming nutrition and growth-related events at the health center” Nutritionist 008). |
| 18 | Digital literacy | “…many of our colleagues, especially the nutritionists, struggle with even basic technologies. This barrier hinders their effective performance. Surprisingly, even that overseeing nutrition at the district level seem unaware, despite the necessity for them to record data from their specific roles” (Data Manager 003). |
| 19 | Lack of outreach programs & IT tools | “…We do not have sufficient outreach initiatives or portable digital tools for remote villages. However, running such outreach efforts might result in certain services being unavailable at the health center since a team comprising a nutritionist, CEHO, and nurse is essential to conduct them” Nutritionist 001). |
| Environment |
| 20 | Communication gaps in the systems serving the same child | “...a single child might appear in the FBF, rehabilitation, growth tracking, vaccination, and community program initiatives, each with distinct documents and structures. This entire data input falls on a sole data manager who also supports various departments within the healthcare center” (Data manager 006). |
| Section D: Net Benefits |
| 21 | Impact on clinical care & decision-making | “...without the system, manually finalizing the FBF beneficiaries' report would take months. However, with its help, we can analyze and promptly share results with authorities, ensuring timely orders of food supplements and incentives” Data Manager 004). |
| 22 | A digital system catering to a specific group of stakeholders and sponsors | "…when stakeholders with access to the nutrition data notice a discrepancy, it can be electronically communicated and addressed within a specific period. While face-to-face meetings are not always necessary, they can be arranged if there's a need for further consolidation” (Data Manager 005). |
| 23 | Continuous learning is needed | “…many of our colleagues, especially the nutritionists, struggle with even basic technologies. This barrier hinders their effective performance. Surprisingly, even that overseeing nutrition at the district level seem unaware, despite the necessity for them to record data from their specific roles” (Data Manager 003). |
| 24 | “Users” description of what they need (but lack) | “...A system that is able to access all the recorded data, be reminded of a child's growth monitoring, obtain statistical insights on a child’s measurements, view the count of children in rehabilitation services per village, and observe the treatments and guidance provided” (Nutritionist 002). |