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Table 3 Selected quotes to illustrate qualitative themes

From: Exploring the effect of implementation and context on a stepped-wedge randomised controlled trial of a vital sign triage device in routine maternity care in low-resource settings

Domain Theme Qualitative quote
Fidelity Quality of training Midwife, Tertiary Hospital, Ndola, Zambia: “Sister* who had an opportunity to attend the one-day workshop where the orientation was done (on) how to use the BP machine and she is the one who disseminated the information, orientated myself and other midwives from labour ward on how to use this BP machine … after I got used I have not had any problems and I have also oriented other medical personnel on how to use it. It has been so helpful.”
Midwife, Clinic, Addis Ababa, Ethiopia: “The apparatus is very good. But there was a minor problem. None of us took any training, but instead we just received the apparatus and we started putting it to use. And it had some problems on accuracy.”
Reach Better availability of equipment meant more measurements done and on more women. Clinical Officer, Peripheral Hospital, Zomba, Malawi: “it’s just a matter of having enough resources now, that at least we have a BP machine in the ward and outside to the health centers, and indeed is the easy one, is the fast one. So this is what can take at the same time to listen to the BP. So the things I see at least is that the BP are taking place more often, because the BP machine is always available”
Better availability of equipment reduced time taken to monitor. Midwife, Outpatients, Tertiary Hospital, Freetown Sierra Leone: “… with one referral the pressure was down, it prompted us greatly, to start IV fluids, call a doctor to come back from theatre...(details of clinical management). This machine (VSA) helped us a lot because if it was any other machine where we use stethoscope, we would have needed to run around trying to look for it, but that machine is already there. That morning the machine saved her, because thank god she survived, was discharged, and we are happy about that.”
Increased confidence resulted in increased monitoring in facilities Medical Officer, Primary Health Centre, Gokak, India: “Earlier, because of overload of work our ANMs were not checking the BP with mercury apparatus. Now, after introduction of this machine and after showing this to AHSAs also in a meeting, they are happy with what they are doing. And they are doing more checks than they were doing earlier. Earlier, they were sending pregnant women to the doctor, telling them that the doctor will check the BP. But now they are also checking and then sending the patients to me.”
Task-sharing increased monitoring in communities Registered Nurse, Clinic, Ndola, Zambia: “ … we had a case last month where a SMAG member (Safe Motherhood Action Group volunteer) got BP machine to go and visit a woman in one of the villages and she discovered that BP was high and client referred and managed at Ndola Central Hospital. Without CRADLE that woman would have been left to die in the community. The CRADLE VSA machine is helping us a lot.”
Adoption Ease of use Junior midwife, Clinic, Addis Ababa, Ethiopia: “In our health center, the former device used to fail often. This one measures both the blood pressure and pulse. This means it helps us forecast to the future, about the condition of the woman. Before this, we used to measure only blood pressure, and that’s it. But now since it helps us forecast her pulse. It assesses the condition of the woman, whether she is entering a danger zone or not. It helps us to take care of the mother before the event. Second, since it helps us with the management during the emergency case, it prepares us to take action immediately. So, it guides us, it measures pulse and as long as we follow the rules of positioning, its accuracy is also very good. I like it.”
Improved reliability and champion/research team support Midwife, Clinic, Addis Ababa, Ethiopia: “The devices we used before were very prone to malfunctioning. But if this one malfunctions, it is often due to improper usage. When such problems happen call (the research assistant) and try to solve the problems. In general, it is helpful for our health center.”
Security Midwife, Labour Ward, Tertiary Hospital, Ndola, Zambia: “Yes we had one experience. I think they were just introduced. One blood pressure machine had gone missing … And from that time we learnt a lesson. So each time we are changing shift all the equipment is put on the table and handed over.”
Mechanism of action Cultural change Nursing officer, Clinic, Mbale, Uganda: “it has become a quality issue to monthly charts on how many patients had their BP taken each month since machines are readily available for use. It has increased the work load since every mother has to have her BP taken.”
Alerts trigger increased investigation Maternity Health Assistant, Clinic, Freetown, Sierra Leone “… we check them all when they come and if I see those colours I call my boss. Because when the machine shows those colours it’s a problem and we need to ask her some questions. And if she says she’s not well I can say there is something wrong with her. It will not show this colour if they are well. A person who is well will show a green colour. And if it still persists for two or three times with that colour, we can send them to do tests sometimes to detect anaemia, sometimes (haemoglobin) 9 grams or 8 grams. So we can treat her little by little.”
Alerts aid communication Midwife, Private Labour Ward, Ndola, Zambia: “as a midwife, as nurse you are supposed to know the abnormal so because of that at least it has … I would not say it has changed (management) much but sometimes yes it does help us. When it is red we do the BP we check again, if its red it means the BP is very high we have to inform the doctor immediately. So there are times when you would call the doctor and they not in, you make sure you emphasize because that the patient has to be seen soon..”
Alerts convince women and families Midwife, Clinic, Ndola, Zambia: “if it shows red, I also explain to her even showing her to say “have you seen this colour? Where is this arrow pointing, no it is pointing up. Yes, this means am supposed to refer you to Ndola central” but like before when we were using the digital and the mercury we would just do and even if the patient reads the readings to be high (they) would not understand. But this time around since it has colours, even for somebody who is not learned, it is easy to convince them”
Alerts motivate women Auxillary Nurse Midwife, Community Health Post, Gokak India: “The number of those who come themselves voluntarily has increased and the awareness of getting the BP checked has improved among them. If we show them the reading, they think “Yes, all such things are there in the BP; we need to get checked; if it shows yellow it means this; if it shows red it mean this, there are the signals for us”.”