Perception of mothers and male partners of the use of an electronic health data recording system while attending reproductive and child health clinics in Kilimanjaro, Tanzania: A qualitative study

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Olomi, Blandina T. Mmbaga, Charles Makasi, Karen Yeates, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8134388/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction : Electronic health record systems (EHRSs) can promote maternal and perinatal healthcare through timely data capture, data accuracy, continuity of care, and service efficiency. It is unclear how clients to whom the data are collected perceive the process or understand its use. This study investigated the perception of the use of EHRSs during the perinatal period among mothers and male partners attending reproductive and child health (RCH) clinics in the Kilimanjaro Region. Methods : A qualitative study was conducted between April and June 2024 via focus group discussions and in-depth interviews within reproductive and child health clinics around the communities of the Moshi District Council (rural) and the Moshi Municipal Council (urban). The research involved mothers who gave birth in the past 12 months before this study and male escorting partners attending RCH clinics. The data were collected via Sem-structured interview guides and analyzed thematically via NVivo 15 software. Data triangulation, reflexivity, and adherence to qualitative research standards were observed, ensuring that the study met ethical and methodological rigor. To address these components, our study established a trustworthy and robust system. Results : A total of 39 participants were recruited for the study, i.e., 29 mothers who gave birth between March 2023 and March 2024 and 10 male partners attending RCH clinics. The findings revealed that most participants had positive opinions of EHRS due to its efficacy and safety, ability to reduce access time, ensure continuity of care, increase trust through confidentiality, increase data storage, and simplify work. However, limited client awareness, privacy concerns, infrastructure problems, and financial limitations are some of the obstacles that might affect its adoption. Systems integrating healthcare facilities with training for clients and healthcare providers and creating policy documents to ensure sustainability and efficacy were proposed. Conclusion : Our study reflects a representative range in the transition of EHRSs. Although some concerns around understanding, privacy issues, infrastructure, and technical capabilities were revealed, the positive outcomes indicate significant opportunities in improving quality-of-care delivery through the EHRS. Resolving these challenges is crucial for smoother transitions and building trust in EHRSs over time. Maternal & Fetal Medicine Electronic health record systems paper records perinatal care maternal care reproductive health Tanzania Figures Figure 1 Introduction In 2019, maternal and neonatal disorders ranked among the top 10 causes of the global burden of disease [ 1 ]. Better access to maternal and perinatal healthcare might help reduce unnecessary morbidity associated with pregnancy and, therefore, improve pregnancy outcomes [ 2 ]. Pregnant and parent EHRSs are being used by women worldwide at a growing rate to the point that they are practically expected during pregnancy [ 3 ]. The growing use of smartphones offers a remarkable chance to change and enhance the way pregnant women track their health, particularly for those who live in rural areas, ensuring equitable health services [ 4 ]. Moreover, the COVID-19 pandemic has highlighted the need for more effective EHRS interventions, improved data collection, and continuity of care [ 5 , 6 ]. Given the potential of EHRS in improving maternal and perinatal care from a global perspective, what is surprising is the limited evidence supporting the use of this intervention in low- and middle-income countries (LMICs) in maternal and perinatal care, and even then, there is evidence of positive outcomes of using EHRs [ 7 , 8 ]. Universal mHealth has been identified as a potential healthcare tool for delivering quality healthcare services, according to the WHO [ 9 ]. Numerous contexts in the healthcare industry have seen the usage of mobile phones, including telemedicine, public and primary healthcare, disease surveillance, epidemics, and adherence to treatment for chronic diseases [ 7 ]. Many lives may be saved if citizens' mobile phones are outfitted with basic healthcare information on first aid, maternity and child health, and other subjects [ 10 ]. Healthcare providers (HCPs) have also reported similar positive experiences, such as reduced consultation times, lower travel expenses, simple client referrals and follow-ups, ease of confidential health information communication, and the capacity to remotely consult groups of clients instead of in person [ 11 ]. EHRS tools could facilitate better communication between healthcare providers and patients by maintaining permanent and accessible patient medical records [ 12 ]. Despite these favorable findings, mHealth applications lack personalization, particularly with respect to symptom tracking [ 6 ]. Pregnant women interacting with mHealth technology interventions face several obstacles, including financial difficulties in supporting a backup generator, poor mobile network access, inadequate power supply in some remote regions, a low household literacy rate among women, and cultural hurdles [ 10 , 11 ]. Similar challenges have also been observed by healthcare providers in LMICs [ 11 ]. Pregnant women have positive opinions regarding the use of EHRS tools during prenatal care, but they believe that these technologies should be introduced concurrently with structural improvements to service delivery, such as the availability of testing required as part of their prenatal care [ 12 ]. The purpose of this study was to ascertain the awareness, attitudes, and experiences of mothers and male partners visiting the RCH clinic during the perinatal period in relation to the collection of health data through EHRSs in the Kilimanjaro region. The potential of this study is to generate local evidence from the community to inform decision makers of what can be done to the beneficiaries of EHRS in improving maternal and perinatal healthcare delivery during planning to shift from paper-based data collection to the EHRS. Furthermore, the EHRS can provide good support for better clinical decision-making and data-driven interventions, potentially by strengthening health systems by reducing preventable maternal and perinatal complications and deaths. Materials and methods Study design This was a purely qualitative study conducted between April and June 2024. In this study, we employed qualitative methods to explore the perceptions, attitudes and lived experiences of mothers and male partners with respect to the use of EHRS in health facilities while obtaining perinatal care in the Kilimanjaro region [ 13 , 14 ]. Our data analysis was performed through a reflexive thematic analysis approach [ 15 , 16 ]. Study area The participants in this study were recruited from two districts: the Moshi Municipal Council (MC), which represents the urban community, and the Moshi District Council (DC), which represents the rural community. The study sites were two out of seven districts in the Kilimanjaro region: Moshi MC, Moshi, Siha, Hai, Rombo, and Same. Four wards (two wards from each district) participated, and the selection was based on the catchment areas being served by health facilities via the EHRS. Study population Our study population involved two distinct groups: mothers who had given birth between March 2023 and March 2024 and male partners attending reproductive health clinics in facilities utilizing the EHRS. The male partners were not necessarily the spouses of the enrolled mothers but different men who had escorted their partners in accessing reproductive health services during the perinatal period. Eligibility for recruitment Inclusion criteria: Women who gave birth in the past 12 months before this study and who attended the RCH clinic at the time of the study data collection (April to June 2024), male partners attending the RCH clinic where the EHRS was implemented, and male participants were partners who attended clinics regularly with supporting their female partners were not necessarily required to be the partners of each enrolled mother; rather, they could have been men who were seeking reproductive health services with partners at the time of study enrollment. Able to communicate in English or Swahili, and those who consented to be involved in the study. Exclusion criteria Participants who were unable to cooperate due to illness or physical challenges and individuals not living in the study area. Sampling and sample size We used a purposive sampling technique to select participants in focus group discussions (FGDs) and in-depth interviews (IDIs) [ 17 ]. A total of 39 participants were recruited: 29 across three FGDs and 10 in IDIs. Among the health facilities using the EHRS in Moshi District (15 total), three facilities (1 hospital, 1 health center, and 1 dispensary) were selected on the basis of participant availability and accessibility. Similarly, in Moshi municipality (14 facilities), three were selected (1 hospital, 2 health centers) using the same criteria. A list of eligibility criteria was generated by healthcare workers (HCWs) from facility records and provided to community healthcare workers (CHWs), who invited participants for the sessions. FGD sessions were held at health facilities as preferred by participants. Three FGDs were conducted, two from Moshi municipality and one from Moshi District, with 9–10 participants per group, while IDIs were conducted in the community. FGDs and IDIs were both utilized because the FGD aimed to capture collective perspectives of the group dynamic; therefore, it provided room for participants to debate and negotiate. It also builds each other’s ideas, revealing shared beliefs, contradictions and community-level perspectives that may not emerge from IDIs. On the other hand, the IDIs were used to provide a comfortable environment for participants to express their views freely, given the sensitivity of maternal health, EHRS use and gendered perceptions. Data collection tools Semi-structured interview guides were developed for IDIs (male partners) and FGDs (mothers). It allows flexibility in probing emerging ideas while ensuring that key topics such as usability, trust and data privacy are consistently explored across interviews. All the questions were open ended to encourage rich and detailed narratives: “The semi-structured interview guides for FGDs and IDIs are provided in additional file 1 & 2”. The guiding questions explored participants’ awareness, experiences, perceived benefits, challenges, and suggestions regarding EHRS. The guides were developed through a review of the relevant literature and refined through expert consultation to ensure content validity and alignment with the study objectives. The guides were developed in English, translated into the Kiswahili language, and back-translated to ensure accuracy. The interviews were conducted in Kiswahili. Data collection procedure Two methods of data collection were used in this study: FGDs with mothers and IDIs with male partners. The IDIs lasted approximately 30 minutes and were conducted in a private community setting, and audio recordings were made via encrypted devices to guarantee data security. The researcher intended to extend the IDIs to more than ten people, but after observing no more emergent themes, stopped at the tenth person owing to data saturation [ 18 ]. The FGD was moderated by the lead researcher (GAO), with a note-taker present. Sessions began with an explanation of the study, answering any questions raised by the participants, obtaining consent procedures, and assuring confidentiality. Three FGDs were conducted, involving two groups from Moshi Municipal and one group from Moshi District, each lasting 60–90 minutes. Data saturation was reached after these sessions[ 19 ]; see the COREQ checklist; 32 items for reporting qualitative studies are provided in “Additional file 3”. Data management and analysis Two researchers (ACM and GAO) independently coded the initial transcripts (2IDIs and 1FGD) to develop a coding framework. The coding process followed Braun and Clarke’s reflexive thematic analysis framework [ 20 ]. A computer software program known as NVivo version 15 was used to manage the data coding and retrieval. Codes were generated inductively and grouped into categories, subthemes and themes through an iterative reflective process. Discrepancies were resolved through discussion. Thematic interpretation was performed in relation to the sociocultural context of the study area to ensure relevance and rigor. Consent and Confidentiality Individual participants provided written informed consent in their local language (Swahili). This was done after the study objectives, confidentiality and voluntary participation rights were explained, which allowed the participants to withdraw at any time without penalty. Although there were no physical hazards associated with this study, emotional sensitivity was guaranteed during data collection, particularly regarding personal experiences with maternity healthcare. Results Demographic characteristics of the participants A study recruited 39 participants, comprising 29 mothers involved in three FGDs and 10 male partners in IDIs. Most participants were aged 25–34 years, with the majority from urban areas. The participants frequently visited the RCH clinic more than five times (as shown in Table 1 ). Table 1 Demographic characteristics of the study participants (N = 39) Characteristics Total (n = 39) Female (n = 29) Male (n = 10) Age group 18–24 8 (20.5%) 8 (27.6%) 0 (0.0%) 25–34 21 (53.8%) 14 (48.3%) 7 (70.0%) 35–44 9 (23.1%) 7 (24.1%) 2 (20.0%) ≥45 1 (2.6%) 0 (0.0%) 1 (10.0%) Residence Rural 15 (38.5) 10 (34.5%) 5 (50.0%) Urban 24 (61.5) 19 (65.5%) 5 (50.0%) Education level No formal education 0 (0.0) 0 (0.0) 0 (0.0) Primary education 9 (23.1) 7 (24.1%) 2 (20.0%) Secondary education 22 (56.4) 17 (58.6%) 5 (50.0%) Postsecondary education 8 (20.5) 5 (17.2%) 3 (30.0%) Occupation House wife 9 (23.1) 9 (31.0%) 0 (0.0%) Farmer 6 (15.4) 3 (10.3%) 3 (30.0%) Formal employment 7 (17.9) 4(13.8%) 3(30.0%) Business 17 (43.6) 13 (44.8%) 4 (40.0%) Number of attendances at RCH Clinic 3–4 times 4 (10.3) 1 (3.4%) 3 (30.0%) ≥ 5 times 35 (89.7) 28 (96.6%) 7 (70.0%) The study identified four main themes: preferences for EHRSs over paper-based systems, perceived benefits of the EHRS, challenges in implementing EHRSs, and suggestions for improvement. “Themes and subthemes are shown in Fig. 1 ”. Description of the themes The document provides descriptions of the main themes and subthemes derived from reflexive thematic analysis, intended to contextualize the interviews and create a framework for discussing the results: “A coding framework is provided in additional file 4”. Theme 1: Preferences for EHR systems over paper-based systems This theme examined the differing perspectives of mothers and male partners regarding the use of EHRSs compared with paper-based systems in RCH services. It focused on how these views might affect their preferences for EHRS adoption, particularly in relation to the perceived quality of patient care, continuity of care, and timely service delivery. It also highlights how important efficient data collection is for system improvements, strategic healthcare planning, and tailored interventions. Subtheme 1 (i): Knowledge and awareness of the EHRS In this subtheme, the findings reflect the importance of raising awareness in the community about the benefits of using EHRS for data collection during facility visits, as it contributes to the improvement of proper diagnosis and management: “I think the computers or tablets are more efficient in hospital visits, as they streamline the process of registering names, visiting doctors, and performing tests in the lab, resulting in a more accurate diagnosis and treatment” (mother, 24 years, Moshi DC). From the male partners’ perspective, the need to raise awareness in the community toward the benefits of EHRS was raised, as it seems that the community that is among the beneficiaries of expected changes is left behind: “Our service providers understand well how to use EHRS, but the challenge comes to us, benefiters of this information, as we do not have enough understanding/awareness of the uses of EHRS (male partner, 30 years, Moshi MC). Subtheme 1(ii): EHR systems as the preferred option The use of paper-based records in healthcare settings has historically been the norm, providing a simple and tangible way of documenting patient information. However, the limitations of this system, such as the risk of data loss and lack of privacy, pose significant challenges to efficient healthcare delivery. Most participants expressed concern that their information may occasionally be entered by health providers in large paper ledgers. However, they were apprehensive that someone could misplace or access their information. The participants raised concerns about the confidentiality and security of the paper records: “For me, my opinions concerning the EHR system I think it should be going on being used because it does not waste time and the information is stored safely and kept there for a long time, unlike in papers where the papers might get wet and the information get destroyed, so the EHR system is good, it must be used” (male partner, 33 years, Moshi MC). Some participants mentioned the advantages of utilizing EHRSs, such as the reduction of confidentiality concerns, time management, and service delivery, which led them to value and advocate for the use of EHRSs in healthcare facilities: “For me, I think the right system to be used is the electronic system because first it helps to keep the records; second, it helps to keep the confidential information between the customer and the service provider; third, it saves time, as it is simple to obtain the services faster when you go to the hospital” (mother, 28 years, Moshi DC). The participants reported consistent questions during clinic visits, believing that EHRSs would improve timely service provision and care management: “ I think the system that is going to be used is good so that even if I go to Dar es salaam am not going to start afresh, after I just enter my details, they just see where the services ended, so it will be easy for the continuation of service because they have that information (male partner, 30 years, Moshi MC). Theme 2: Perceived benefits of EHRSs The adoption of the EHRS in healthcare settings is seen as a significant step toward enhancing patient and provider experiences through efficiency and convenience. Subtheme 2(i). Enhanced confidentiality and privacy The participants emphasized the privacy benefits of electronic health records (EHRSs) over paper-based systems, which are easily accessible by unauthorized individuals, thereby promoting ethical medical record storage: “ When our information is stored electronically, there’s confidentiality [...] while on the other hand, if I lose the paper, anyone could read it." (mother, 26 years, Moshi MC). Compared with paper records, the use of patient identification numbers to access medical records stored in the EHRS is perceived to increase confidentiality: “For the papers, the confidentiality is low; a person can access other people’s information very easily […] However, in the EHRS, no one can easily access other people’s information unless she has my identification information or my identification number, which is found on my card” (male partner, 36 years, Moshi DC); “For me, am concerned about the privacy of our personal information, as they store it in books, clinics, and at home, and am not sure of its storage duration” (mothers attending RCH clinic, 27 years old and 24 years old from urban areas, FGDs). Subtheme 2(ii). Improved efficiency, continuity of care, and time management The participants found the repetition of their details at health facilities, particularly in paper-based systems, to be time-consuming. In contrast, EHRSs were viewed as more efficient and service streamlined: “[…] for me, I prefer the EHR system to be used because it simplifies the work; writing in papers takes time, but in the EHR system, your information is just recorded, stored and accessed easily” (male partner, 28 years, Moshi MC). One participant noted that EHRSs could save time and enhance continuity of care if there were better linkages between health facilities: “For example, last year I got problems here, I had given birth and the baby did not cry, they referred me to KCMC as I was leaving the facility where I was receiving services; my information could be sent through EHRS to KCMC, which could simplify care continuity between facilities” (mother, 36 years, Moshi MC). Using EHRS has been associated with an increase in the attendance of male partners at ANC visits, thereby saving time: “ First, it saves time, for example, I have come now in just ten minutes, I have already gotten the services, this convinces me to come again because I do not stay for a long time […]” (male partner, 29 years, Moshi DC). One participant noted that providing their details once and having access to each service department enhanced the continuum of care: “[…] the benefit of the EHR system it simplifying the service provided since when you get there you can just give the explanation and obtain services within a short time, it is different from the paper-based system where you have to take papers from here and there and sometimes a lot of time is used sorting the papers” (male partner, 50 years, Moshi DC ) Subtheme 2(iii). Storage durability and accessibility “ The computer system keeps records safe and helps avoid losing information” (mother, 23 years, Moshi MC). Other participants valued the government's initiatives to transition health services from analog to digital, which were seen as simplifying the health-seeking process: “Currently, the health system is transitioning from analogy to EHR systems, replacing paper systems. This eliminates the need for individuals to visit the hospital for medical treatment with exercise books. EHR systems allow for direct visits wherever you feel to seek medical attention, allowing doctors to quickly access patient information and potentially avoiding retesting for previously treated diseases” (male partner, 32 years, Moshi MC). Long-term data storage via EHRSs is more reliable than paper-based systems, according to participant explanations: “First, I would like to say the EHR system is better than the paper system because, in the EHR system, the information is not easy to get lost, and its storage is very long compared with the paper system” (male partner, 33 years, Moshi MC). Theme 3: Challenges of implementing EHRS When planning to move from a paper-based system to an EHRS, several challenges must be overcome, such as power outages, inconsistent network connectivity, the expense of internet access and backup generators, and barriers related to literacy and culture. Subtheme 3(i). Infrastructure and resource limitations The challenges of deploying EHRSs in rural regions were emphasized by the participants, who emphasized how issues such as power outages and erratic internet could make it more difficult to use them: “ The system is good, but when they go to hospitals in cities, there will be no problem; however, in interior villages, there might be challenges related to internet and electricity issues, which occur mostly in villages” (male partners, 30 years, Moshi MC) ; “They should improve the infrastructure of electricity and the internet in the villages so that even when these services are brought there, it is easier to use” (mother, 35 years, Moshi MC). Financial limitations affecting support for internet bundles and electricity backup for the sustainability of EHRSs were another issue: “The cost must be needed for the generators as a backup of electricity availability, or if it is internet, it must be paid for it to be accessed (male partner, 32 years, Moshi MC). Irregular power supply issues that could have a long-term impact on EHRS use were reported to the government by an IDI participant: “If the electricity is there, everything will go well; but to some hospitals which do not have backup generators, it will become a challenge, imagine if there is no electricity for three days, how is that going to be […] we will go back to paper recording” (male partner, 28 years, Moshi MC). Subtheme 3(ii). Cultural barriers and literacy rates Although the participants identified literacy rates and cultural customs as obstacles to the adoption of the EHRS, the results revealed no cultural problems with its use. However, there is still a need to address community awareness of the system: “On the side of our traditions and customs, there is no challenge with the knowledge of using EHRSs during services. Most people in the community are educated, so even if elderly clients have gone to the hospital and have been told that they want to put their information in the system, they know. No one says that we used to this and not to that system, people understand” (mother, 24 years, Moshi DC). To allay worries about using EHRSs, the participants expressed confidence in their security and suggested that successful integration with mobile money would signify dependable performance in medical facilities: “Although using EHR systems has been linked to fraudsters in our areas, they are safe and effective since they work well with mobile money. Therefore, with time, people will understand and trust the system” (male partner, 28 years, Moshi MC). The participants stated that their opinions of literacy rates are influenced by the community's historical reliance on paper systems. To encourage the use and upkeep of EHRSs in healthcare facilities, the government prompted the organization of educational sessions for community members and healthcare providers: “[…] the government would give more education on the use of EHR systems because other clients from the community have insufficient understanding of the EHR system; this is because they are used in the paper system for quite long and not experienced with EHRS, so the society may handle those devices carelessly and damage them and become a challenge and repair of that equipment is costly” (mother, 21 years, Moshi DC). Damage and repair issues were brought up, emphasizing the necessity for people with the know-how to fix any harm to EHRS devices: “The challenge will occur if the equipment storing information becomes damaged with no one equipped with the skills of how to repair it” (mother, 29 years, Moshi MC) . Theme 4: Suggestions for improvement of the EHRS To address the present infrastructure issues in healthcare, the participants discussed the necessity of enhancing EHRSs. They discussed the importance of streamlining procedures and improving care quality by developing and scaling the EHRS. Additionally, they highlighted the importance of understanding patient perspectives to identify areas needing reform. Subtheme 4(i). Training and staffing enhancements The participants suggested that the government address challenges in transitioning from paper-based systems to the EHRS. They emphasize the importance of increasing education for both healthcare providers and the community concerning EHRS usage: “Let me say that the computer system is the best, the education should be provided so that we can change if we want to move forward” (male partner, 32 years, Moshi MC). Other participants highlighted the importance of transparency in hospital bill payments to prevent unnecessary cost increases while utilizing the system: “In building the understanding of the system, service providers should be well educated and we as mothers we should be educated as well on how the system operates so that if there is a need for any payment, it should be well known rather than being told by the doctor as he may increase the cost” (mother, 25 years, Moshi MC). The participants noted that EHRSs enhance health governance and accountability by strengthening connections among the country, health facilities, and healthcare workers: “ The EHR system creates direct connections between the central government and hospitals, health centers, and dispensaries. Therefore, it helps the government obtain information on the weaknesses and strengths of service provisions and helps staff obtain fairness based on their work” (male partner, 28 years, Moshi MC). Another participant perceived the EHRS as a staff shortage problem solver: “If an electronic system is used for all health facilities, it can help reduce the problem of inadequate health service providers, as it simplifies service provision (male partner, 36 years, Moshi DC). Subtheme 4(ii). Integration with existing practices The participants recommended the integration of various EHRSs across different health facility levels to enhance referral management through electronic services: “If I am given a referral to other center(s), the benefit is that my information will be there; rather than if I was given the paper-based referral and maybe it happen to rain, I may be needed to go back for another referral paper, but in the case of the EHRS, I am sure that my information will be accessed at the referral point once my identification is entered” (male partner, 29 years, Moshi DC) . Integration of the existing system enhances patient management and ensures a continuous continuum of care: “It helps; even if you go to a different hospital, so long as they use an EHR system and it reads other systems, the services become better since they know where to continue. Let’s say the patient has gone to the hospital in a bad condition; once they access his information, they will know where to start” (male partner, 36 years, Moshi DC). The participants recommended the implementation of EHRSs across various health facility levels because of their ability to maintain a comprehensive memory: “I advise that they should improve the use of EHRS as it is a good one, it helps to keep our memories, so, in my opinion, they should install that system for us at all healthcare facility levels and hospitals in Tanzania” (mother, 26 years; Male partner, 50 years, Moshi MC). Subtheme 4 (iii). Policy dialog on EHRS implementation The participants in the study highlighted the importance of the nationwide rollout of the EHRS to enhance the referral system and ensure timely service delivery: “Implementing the system all over the country will enhance efficiency and ensure timely service delivery” (male partner, 29 years, Moshi MC); “The EHRS has to be implemented at all levels of health-care service delivery to support referrals” (mother, 30 years, Moshi MC) ; “there should be a linkage between one hospital and another as there is no meaning if these systems will operate independently or in a limited health facility levels only” (male partner, 28 years, Moshi DC). The participants suggested the use of mobile EHRS devices for convenience outside health facilities while stressing the need for restricted access to patient information to safeguard confidentiality: “I think this digital equipment should not be fixed in hospitals only; rather, they should be mobile in a way that a person can move with them easily, like laptops and tablets and that their systems should have limited access to clients’ information[...]” (male partner, 28 years, Moshi MC). A reliable power supply is critical for the successful implementation of Electronic Health Record Systems (EHRSs): “The government has to ensure the availability of a stable power supply to support healthcare services without disruption for twenty-four hours, seven days a week” (male partner, 32 years, Moshi DC). Discussion The study explored the perspectives of mothers and male partners attending reproductive and child health clinics in Kilimanjaro, Tanzania, regarding their experience with and readiness to use electronic health recording systems during the perinatal period. Generally, there were no significant differences in their views between urban and rural areas or in terms of gender. These findings suggest that the Kilimanjaro community shares a common experience and perspective on EHRSs, demonstrating readiness and openness to EHRS health innovations, which highlights the potential for equitable adoption across genders and locations. Communities favor the use of the EHRS, highlighting benefits such as reduced redundant information, faster service delivery, better coordination across healthcare providers, and enhanced data privacy. The community believes that by strengthening privacy protection, the EHRS enhances the quality of healthcare and fosters trust. They value systems that reduce waiting times and ensure continuity of care, and they anticipate that the EHRS will lead to more equitable, patient-centered services by allowing healthcare professionals to focus less on administrative tasks. These perceptions also highlight a change in mindset toward recognizing EHRS as a means to enhance healthcare services. These results are in line with findings from other low- and middle-income contexts, highlighting that the success of implementing EHRSs depends on technological readiness and community awareness and trust [ 2 , 11 ]. Patient confidentiality in EHRSs can be maintained through limited access for unauthorized individuals. Previous studies indicate that EHRSs enhance data security [ 7 , 8 , 21 ]. Despite the general community's positive perspectives toward the introduction of EHRSs, several barriers might hinder their successful implementation. The main challenges include limited awareness and understanding of their purpose, data storage duration, and access control mechanisms among community members. These challenges are not far from what has been reported in related geographical setting studies, where limited EHRS literacy and inadequate understanding of patients’ information privacy have contributed to the failure of other EHRS initiatives [ 2 , 5 , 22 – 24 ]. As far as the importance of clarity in any new electronic systems initiatives. Infrastructure issues, particularly in rural settings, include unreliable power, poor internet connectivity, and insufficient technical capacity to repair hardware/software, which could hinder the implementation of EHRSs [ 25 , 26 ]. To sustain the system backup generator and allocated a budget for the internet bundle and device repairs perceived to mitigate the challenge. Additionally, skilled information technology (IT) personnel are necessary to address hardware and software challenges. Findings from other studies conducted across sub-Saharan nations highlighted similar issues of insufficient IT expertise, as it contributed to hindering the scaling-up of EHRSs [ 2 , 5 , 22 , 23 ]. The participants’ acknowledgment of the perceived barriers indicates a general willingness or openness to adopt and maintain EHRS use, provided that technical and infrastructural challenges are properly addressed. Healthcare workers’ lack of EHRS literacy, particularly among elderly individuals, makes it difficult to navigate effectively with EHRSs. This challenge also impacts community beneficiaries, as they lack a fundamental understanding of how these devices operate, which makes them uncomfortable and may lead to a lack of trust during service when visiting clinics. Therefore, enhancing EHRS literacy for both providers and patients is crucial for improving EHRS adoption, usability, and trust. In LMIC settings, users’ acceptance of the EHRS is significantly influenced by their comfort and familiarity with the technology [ 8 , 9 ]. To address these issues, participants suggested conducting user education sessions during antenatal visits to increase community awareness and foster wider acceptance. Additionally, to guarantee continuity of care and improve referral systems, integration across all health facility levels is crucial for the successful implementation of EHRSs, which has a wider range of advantages. This includes infrastructural investment by the government through capacitating healthcare professionals and the creation of explicit policy guidelines that support system interoperability and prioritize data privacy protection [ 4 , 7 , 11 ]. Interestingly, EHRSs were viewed as clinical instruments to increase governance accountability. The participants indicated that EHRSs would enable the sharing of data in real time across health facilities and respective authorities to improve healthcare management, monitoring, planning, and resource allocation. However, this would depend on sustained funding, trustworthy data protection policies, and a technological partnership of both the EHRSs and digital strategies. This finding relates to Vos et al. (2020), who noted EHRSs' potential for improving clinical coordination but cautioned against risks such as reduced face‒to-face interactions, fragmented departmental communication, and increased administrative burdens[ 27 – 29 ]. Strengths of the study This research provides an informative and contextually rich perspective on how clients, such as mothers and male partners, experience and their views on the transition to electronic health data recording systems within RCH clinics. It also provides views from urban and rural contexts, which may offer a more comprehensive representation of community perspectives. We used multiple data collection methods in which both FGD and IDI were applied appropriately. Through this approach, it was possible to explore participants’ personal experiences, beliefs and attitudes toward the EHRS in a confidential setting through one-to-one interviews as well as group or community perspectives during FGDs. Therefore, using both FGDs and IDIs enriched the understanding of both the personal and social dimensions of EHRS adoption. Involving more than one researcher in coding and theme development as well as peer debriefing within the research team minimized individual bias. Field notes and reflexive memos were maintained to ensure the confirmability and dependability of the findings. The findings provide evidence for local and national health system planning agencies regarding the potential benefits and challenges of implementing the EHRS and offer suggestions to address notable gaps. Limitations of the study As with a qualitative study relying on purposive sampling, the study findings are not generalizable beyond the specific sites in Tanzania or other lower-middle-income country contexts. However, the findings have the potential for understanding readiness and community perspectives on the EHRS as a new health record system and share their views and expectations for transitioning from a paper base to the EHRS. While reflexivity, transparency, and validation through dual coding were operationalized, there remains an element of interpretation, possible cultural and/or contextual bias, in a study of this nature. Conclusion The study participants recognized that EHRSs could enhance care efficiency, data security, and service continuity among populations with higher EHRS literacy. However, they also expressed concerns about the usability of EHRSs, infrastructure, and data privacy. To support long-term implementation, it is essential to develop policies that address and overcome barriers, provide training for both users and healthcare providers, and improve infrastructure. Importantly, participants highlighted the importance of system-wide integration of EHRSs across the health and social care sectors while ensuring that approaches are tailored and user-centered. Recommendation Given that this study was conducted in Kilimanjaro, a relatively advantaged region in terms of infrastructure and literacy, it is recommended that similar studies be conducted in more underserved or remote regions to assess transferability and generate broader insights. Future studies employing longitudinal or mixed method designs may also provide stronger evidence on the long-term impact and scalability of EHRSs across different health system levels. Abbreviations CHWs Community health workers EHRSs Electronic health record systems EHR Electronic Health Record FGDs Focus Group Discussions HCWs Healthcare Workers IDIs In-depth interviews KCMC Kilimanjaro Christian Medical Centre LMIC Low Middle-Income Countries RCH Reproductive and Child Health NatHREC National Health Research Ethics Review Committee NIMR National Institute for Medical Research Declarations Ethical approval and consent to participate Ethical clearance to conduct this study was obtained from the Research and Ethical Committee of the University of KCMC (No 2644) and the National Health Research Ethics Review Committee (NatHREC) of Tanzania’s National Institute for Medical Research (NIMR) (No NIMR/HQ/R.8a/Vol. IX/4075). Permissions letters were also granted from local authorities (President’s Office, Regional Administration and Local Government (PO-RALG), Tanzania; the Kilimanjaro region and District Authorities) and their respective health facilities. Individual participants provided written informed consent in their local language (Swahili). This was done after the study objectives, confidentiality and voluntary participation rights were explained, which allowed the participants to withdraw at any time without penalty. Although there were no physical hazards associated with this study, emotional sensitivity was guaranteed during data collection, particularly regarding personal experiences with maternity healthcare. Consent for publication All the participants provided consent for their direct quotes to be used in this manuscript. Data availability statement The data underlying the results of this qualitative study originate from the authors, other relevant details are within the manuscript, and others can be found here: DOI. https://doi.org/10.6084/m9.figshare.30152938 and for more details, please contact the Head of the Data Management Unit at Kilimanjaro Clinical Research Institute (KCRI), email: [email protected] . Competing interests The authors declare that they have no competing interests. Funding information The project was partly funded by an Irish Research Council (IRC), Department of Foreign Affairs COALESCE Award (COALESCE/2021/51). I received mentorship and supervision from the project team and data collection support, but there was no special fund allocated for publication. Author contributions The study was conceptualized by GAO, BTM, ASK, SW and RM. The FGDs and IDIs conducted by GAO. GAO, CM and RM conducted the data analysis, and GAO, BTM, CM, KY, SW, ASK and RM contributed to the methodology, validation, visualization, and drafted the manuscript. All the authors provided feedback on multiple drafts of the manuscript before approving the final manuscript for publication. Acknowledgment For their dedicated assistance in making this study successful, we would like to thank the Regional Health Management, Moshi Municipal and Moshi district health management teams, staff and participants from the involved health facilities. GAO acknowledges Prof. Karen Yeates’ personal assistance with tuition fees, ULTRA team support on supervision and data collection, and Dr. Agnes Msoka's technical support provided during the production of the manuscript and thematic analysis. References Dahab R, Sakellariou D. Barriers to Accessing Maternal Care in Low Income Countries in Africa: A Systematic Review. International journal of environmental research and public health. 2020;17(12). 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World Journal of Advanced Research and Reviews. 2024;21:1446-55. doi: 10.30574/wjarr.2024.21.2.0592. Madanian S, Nakarada-Kordic I, Reay S, Chetty T. Patients' perspectives on digital health tools. PEC Innov. 2023;2:100171. Epub 20230526. doi: 10.1016/j.pecinn.2023.100171. PubMed PMID: 37384154; PubMed Central PMCID: PMCPMC10294099. Creswell JW, Creswell JD. Research design: Qualitative, quantitative, and mixed methods approaches: Sage publications; 2017. Patton MQ. Qualitative research & evaluation methods: Integrating theory and practice. (No Title). 2015. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77-101. doi: 10.1191/1478088706qp063oa. Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative research in psychology. 2021;18(3):328-52. Alhammad N, Alajlani M, Abd-Alrazaq A, Epiphaniou G, Arvanitis T. Patients' Perspectives on the Data Confidentiality, Privacy, and Security of mHealth Apps: Systematic Review. Journal of medical internet research. 2024;26:e50715. Epub 20240531. doi: 10.2196/50715. PubMed PMID: 38820572; PubMed Central PMCID: PMCPMC11179037. Guest G, Bunce A, Johnson L. How Many Interviews Are Enough?:An Experiment with Data Saturation and Variability. Field Methods. 2006;18(1):59-82. doi: 10.1177/1525822x05279903. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007;19(6):349-57. doi: 10.1093/intqhc/mzm042. Brandão C. P. Bazeley and K. Jackson, Qualitative Data Analysis with NVivo (2nd ed.). Qualitative Research in Psychology. 2015;12:492-4. doi: 10.1080/14780887.2014.992750. Alzghaibi H, Hutchings H. Barriers to the implementation of large-scale electronic health record systems in Primary Healthcare centers2024. Obasola OI, Mabawonku I, Lagunju I. A Review of e-Health Interventions for Maternal and Child Health in Sub-Sahara Africa. Matern Child Health J. 2015;19(8):1813-24. doi: 10.1007/s10995-015-1695-0. PubMed PMID: 25652059. Angst C, Block E, D’Arcy J, Kelley K. When Do IT Security Investments Matter? Accounting for the Influence of Institutional Factors in the Context of Healthcare Data Breaches. MIS Quarterly. 2017;41:893-916. doi: 10.25300/MISQ/2017/41.3.10. Kiberu VM, Matovu JK, Makumbi F, Kyozira C, Mukooyo E, Wanyenze RK. Strengthening district-based health reporting through the district health management information software system: the Ugandan experience. BMC medical informatics and decision making. 2014;14(1):40. MoHCDGEC. Tanzania digital health strategy 2019-2024 2020 [12 November 2025]. Available from: https://www.path.org/our-impact/resources/tanzania-digital-health-strategy-2019-2024/. Odekunle FF, Odekunle RO, Shankar S. Why sub-Saharan Africa lags in electronic health record adoption and possible strategies to increase its adoption in this region. International journal of health sciences. 2017;11(4):59. Vos JFJ, Boonstra A, Kooistra A, Seelen M, van Offenbeek M. The influence of electronic health record use on collaboration among medical specialties. BMC health services research. 2020;20(1):676. doi: 10.1186/s12913-020-05542-6. Attah AO. Implementing the Electronic Health Record in a Nigerian Secondary Healthcare Facility: Prospects and Challenges. 2017 [27/04/2025]. Available from: https://munin.uit.no/bitstream/handle/10037/12245/thesis.pdf?sequence=2&isAllowed=y. Ogaji D, Anyanwu C. Implementing electronic healthcare record in a public health facility in Nigeria: awareness, acceptance and concerns among critical stakeholders. International Journal of Electronic Healthcare. 2021;11:364. doi: 10.1504/IJEH.2021.117830. Additional Declarations The authors declare no competing interests. Supplementary Files Additionalfile1FDGinterviewguide.docx Additional file 1: FGD Intherview guide Additionalfile2.IDIguide.docx Additional file 1: IDI Intherview guide Additionalfile3.COREQchecklist.docx Additional file 3: COREQ checklist summary Addtionalfile4Coding.docx Additional file 4: Coding book Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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10:09:36","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":18170,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 4: Coding book\u003c/p\u003e","description":"","filename":"Addtionalfile4Coding.docx","url":"https://assets-eu.researchsquare.com/files/rs-8134388/v1/10b76336cc95f69f5ef52b36.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003ePerception of mothers and male partners of the use of an electronic health data recording system while attending reproductive and child health clinics in Kilimanjaro, Tanzania: A qualitative study\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn 2019, maternal and neonatal disorders ranked among the top 10 causes of the global burden of disease [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Better access to maternal and perinatal healthcare might help reduce unnecessary morbidity associated with pregnancy and, therefore, improve pregnancy outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Pregnant and parent EHRSs are being used by women worldwide at a growing rate to the point that they are practically expected during pregnancy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The growing use of smartphones offers a remarkable chance to change and enhance the way pregnant women track their health, particularly for those who live in rural areas, ensuring equitable health services [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Moreover, the COVID-19 pandemic has highlighted the need for more effective EHRS interventions, improved data collection, and continuity of care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGiven the potential of EHRS in improving maternal and perinatal care from a global perspective, what is surprising is the limited evidence supporting the use of this intervention in low- and middle-income countries (LMICs) in maternal and perinatal care, and even then, there is evidence of positive outcomes of using EHRs [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Universal mHealth has been identified as a potential healthcare tool for delivering quality healthcare services, according to the WHO [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Numerous contexts in the healthcare industry have seen the usage of mobile phones, including telemedicine, public and primary healthcare, disease surveillance, epidemics, and adherence to treatment for chronic diseases [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Many lives may be saved if citizens' mobile phones are outfitted with basic healthcare information on first aid, maternity and child health, and other subjects [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHealthcare providers (HCPs) have also reported similar positive experiences, such as reduced consultation times, lower travel expenses, simple client referrals and follow-ups, ease of confidential health information communication, and the capacity to remotely consult groups of clients instead of in person [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. EHRS tools could facilitate better communication between healthcare providers and patients by maintaining permanent and accessible patient medical records [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Despite these favorable findings, mHealth applications lack personalization, particularly with respect to symptom tracking [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Pregnant women interacting with mHealth technology interventions face several obstacles, including financial difficulties in supporting a backup generator, poor mobile network access, inadequate power supply in some remote regions, a low household literacy rate among women, and cultural hurdles [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Similar challenges have also been observed by healthcare providers in LMICs [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Pregnant women have positive opinions regarding the use of EHRS tools during prenatal care, but they believe that these technologies should be introduced concurrently with structural improvements to service delivery, such as the availability of testing required as part of their prenatal care [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The purpose of this study was to ascertain the awareness, attitudes, and experiences of mothers and male partners visiting the RCH clinic during the perinatal period in relation to the collection of health data through EHRSs in the Kilimanjaro region. The potential of this study is to generate local evidence from the community to inform decision makers of what can be done to the beneficiaries of EHRS in improving maternal and perinatal healthcare delivery during planning to shift from paper-based data collection to the EHRS. Furthermore, the EHRS can provide good support for better clinical decision-making and data-driven interventions, potentially by strengthening health systems by reducing preventable maternal and perinatal complications and deaths.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThis was a purely qualitative study conducted between April and June 2024. In this study, we employed qualitative methods to explore the perceptions, attitudes and lived experiences of mothers and male partners with respect to the use of EHRS in health facilities while obtaining perinatal care in the Kilimanjaro region [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Our data analysis was performed through a reflexive thematic analysis approach [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy area\u003c/h3\u003e\n\u003cp\u003eThe participants in this study were recruited from two districts: the Moshi Municipal Council (MC), which represents the urban community, and the Moshi District Council (DC), which represents the rural community. The study sites were two out of seven districts in the Kilimanjaro region: Moshi MC, Moshi, Siha, Hai, Rombo, and Same. Four wards (two wards from each district) participated, and the selection was based on the catchment areas being served by health facilities via the EHRS.\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eOur study population involved two distinct groups: mothers who had given birth between March 2023 and March 2024 and male partners attending reproductive health clinics in facilities utilizing the EHRS. The male partners were not necessarily the spouses of the enrolled mothers but different men who had escorted their partners in accessing reproductive health services during the perinatal period.\u003c/p\u003e\n\u003ch3\u003eEligibility for recruitment\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eInclusion criteria:\u003c/h2\u003e\u003cp\u003eWomen who gave birth in the past 12 months before this study and who attended the RCH clinic at the time of the study data collection (April to June 2024), male partners attending the RCH clinic where the EHRS was implemented, and male participants were partners who attended clinics regularly with supporting their female partners were not necessarily required to be the partners of each enrolled mother; rather, they could have been men who were seeking reproductive health services with partners at the time of study enrollment. Able to communicate in English or Swahili, and those who consented to be involved in the study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eExclusion criteria\u003c/h2\u003e\u003cp\u003eParticipants who were unable to cooperate due to illness or physical challenges and individuals not living in the study area.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSampling and sample size\u003c/h3\u003e\n\u003cp\u003eWe used a purposive sampling technique to select participants in focus group discussions (FGDs) and in-depth interviews (IDIs) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A total of 39 participants were recruited: 29 across three FGDs and 10 in IDIs. Among the health facilities using the EHRS in Moshi District (15 total), three facilities (1 hospital, 1 health center, and 1 dispensary) were selected on the basis of participant availability and accessibility. Similarly, in Moshi municipality (14 facilities), three were selected (1 hospital, 2 health centers) using the same criteria. A list of eligibility criteria was generated by healthcare workers (HCWs) from facility records and provided to community healthcare workers (CHWs), who invited participants for the sessions. FGD sessions were held at health facilities as preferred by participants. Three FGDs were conducted, two from Moshi municipality and one from Moshi District, with 9\u0026ndash;10 participants per group, while IDIs were conducted in the community. FGDs and IDIs were both utilized because the FGD aimed to capture collective perspectives of the group dynamic; therefore, it provided room for participants to debate and negotiate. It also builds each other\u0026rsquo;s ideas, revealing shared beliefs, contradictions and community-level perspectives that may not emerge from IDIs. On the other hand, the IDIs were used to provide a comfortable environment for participants to express their views freely, given the sensitivity of maternal health, EHRS use and gendered perceptions.\u003c/p\u003e\n\u003ch3\u003eData collection tools\u003c/h3\u003e\n\u003cp\u003eSemi-structured interview guides were developed for IDIs (male partners) and FGDs (mothers). It allows flexibility in probing emerging ideas while ensuring that key topics such as usability, trust and data privacy are consistently explored across interviews. All the questions were open ended to encourage rich and detailed narratives: \u0026ldquo;The semi-structured interview guides for FGDs and IDIs are provided in additional file 1 \u0026amp; 2\u0026rdquo;.\u003c/p\u003e\u003cp\u003e The guiding questions explored participants\u0026rsquo; awareness, experiences, perceived benefits, challenges, and suggestions regarding EHRS.\u003c/p\u003e\u003cp\u003eThe guides were developed through a review of the relevant literature and refined through expert consultation to ensure content validity and alignment with the study objectives. The guides were developed in English, translated into the Kiswahili language, and back-translated to ensure accuracy. The interviews were conducted in Kiswahili.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData collection procedure\u003c/h2\u003e\u003cp\u003eTwo methods of data collection were used in this study: FGDs with mothers and IDIs with male partners. The IDIs lasted approximately 30 minutes and were conducted in a private community setting, and audio recordings were made via encrypted devices to guarantee data security. The researcher intended to extend the IDIs to more than ten people, but after observing no more emergent themes, stopped at the tenth person owing to data saturation [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The FGD was moderated by the lead researcher (GAO), with a note-taker present. Sessions began with an explanation of the study, answering any questions raised by the participants, obtaining consent procedures, and assuring confidentiality. Three FGDs were conducted, involving two groups from Moshi Municipal and one group from Moshi District, each lasting 60\u0026ndash;90 minutes. Data saturation was reached after these sessions[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]; see the COREQ checklist; 32 items for reporting qualitative studies are provided in \u0026ldquo;Additional file 3\u0026rdquo;.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eData management and analysis\u003c/h2\u003e\u003cp\u003eTwo researchers (ACM and GAO) independently coded the initial transcripts (2IDIs and 1FGD) to develop a coding framework. The coding process followed Braun and Clarke\u0026rsquo;s reflexive thematic analysis framework [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A computer software program known as NVivo version 15 was used to manage the data coding and retrieval. Codes were generated inductively and grouped into categories, subthemes and themes through an iterative reflective process. Discrepancies were resolved through discussion. Thematic interpretation was performed in relation to the sociocultural context of the study area to ensure relevance and rigor.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eConsent and Confidentiality\u003c/h2\u003e\u003cp\u003e Individual participants provided written informed consent in their local language (Swahili). This was done after the study objectives, confidentiality and voluntary participation rights were explained, which allowed the participants to withdraw at any time without penalty. Although there were no physical hazards associated with this study, emotional sensitivity was guaranteed during data collection, particularly regarding personal experiences with maternity healthcare.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eDemographic characteristics of the participants\u003c/h2\u003e\u003cp\u003eA study recruited 39 participants, comprising 29 mothers involved in three FGDs and 10 male partners in IDIs. Most participants were aged 25\u0026ndash;34 years, with the majority from urban areas. The participants frequently visited the RCH clinic more than five times (as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of the study participants (N\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMale (n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u0026ndash;24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8 (20.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8 (27.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25\u0026ndash;34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e21 (53.8%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e14 (48.3%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e7 (70.0%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e35\u0026ndash;44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9 (23.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (24.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2 (20.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (2.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1 (10.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15 (38.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10 (34.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e24 (61.5)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e19 (65.5%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e5 (50.0%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo formal education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9 (23.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (24.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2 (20.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e22 (56.4)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e17 (58.6%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e5 (50.0%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostsecondary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8 (20.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5 (17.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3 (30.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHouse wife\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9 (23.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (31.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFarmer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (15.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3 (10.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3 (30.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFormal employment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7 (17.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4(13.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3(30.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBusiness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17 (43.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13 (44.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4 (40.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of attendances at RCH Clinic\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u0026ndash;4 times\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (10.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (3.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3 (30.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge; 5 times\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e35 (89.7)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e28 (96.6%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e7 (70.0%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe study identified four main themes: preferences for EHRSs over paper-based systems, perceived benefits of the EHRS, challenges in implementing EHRSs, and suggestions for improvement. \u0026ldquo;Themes and subthemes are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026rdquo;.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eDescription of the themes\u003c/h2\u003e\u003cp\u003eThe document provides descriptions of the main themes and subthemes derived from reflexive thematic analysis, intended to contextualize the interviews and create a framework for discussing the results: \u0026ldquo;A coding framework is provided in additional file 4\u0026rdquo;.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eTheme 1: Preferences for EHR systems over paper-based systems\u003c/h2\u003e\u003cp\u003eThis theme examined the differing perspectives of mothers and male partners regarding the use of EHRSs compared with paper-based systems in RCH services. It focused on how these views might affect their preferences for EHRS adoption, particularly in relation to the perceived quality of patient care, continuity of care, and timely service delivery. It also highlights how important efficient data collection is for system improvements, strategic healthcare planning, and tailored interventions.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eSubtheme 1 (i): Knowledge and awareness of the EHRS\u003c/h2\u003e\u003cp\u003eIn this subtheme, the findings reflect the importance of raising awareness in the community about the benefits of using EHRS for data collection during facility visits, as it contributes to the improvement of proper diagnosis and management:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think the computers or tablets are more efficient in hospital visits, as they streamline the process of registering names, visiting doctors, and performing tests in the lab, resulting in a more accurate diagnosis and treatment\u0026rdquo; (mother, 24 years, Moshi DC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFrom the male partners\u0026rsquo; perspective, the need to raise awareness in the community toward the benefits of EHRS was raised, as it seems that the community that is among the beneficiaries of expected changes is left behind:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Our service providers understand well how to use EHRS, but the challenge comes to us, benefiters of this information, as we do not have enough understanding/awareness of the uses of EHRS (male partner, 30 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eSubtheme 1(ii): EHR systems as the preferred option\u003c/h2\u003e\u003cp\u003eThe use of paper-based records in healthcare settings has historically been the norm, providing a simple and tangible way of documenting patient information. However, the limitations of this system, such as the risk of data loss and lack of privacy, pose significant challenges to efficient healthcare delivery.\u003c/p\u003e\u003cp\u003eMost participants expressed concern that their information may occasionally be entered by health providers in large paper ledgers. However, they were apprehensive that someone could misplace or access their information. The participants raised concerns about the confidentiality and security of the paper records:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For me, my opinions concerning the EHR system I think it should be going on being used because it does not waste time and the information is stored safely and kept there for a long time, unlike in papers where the papers might get wet and the information get destroyed, so the EHR system is good, it must be used\u0026rdquo; (male partner, 33 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome participants mentioned the advantages of utilizing EHRSs, such as the reduction of confidentiality concerns, time management, and service delivery, which led them to value and advocate for the use of EHRSs in healthcare facilities:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For me, I think the right system to be used is the electronic system because first it helps to keep the records; second, it helps to keep the confidential information between the customer and the service provider; third, it saves time, as it is simple to obtain the services faster when you go to the hospital\u0026rdquo; (mother, 28 years, Moshi DC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe participants reported consistent questions during clinic visits, believing that EHRSs would improve timely service provision and care management:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI think the system that is going to be used is good so that even if I go to Dar es salaam am not going to start afresh, after I just enter my details, they just see where the services ended, so it will be easy for the continuation of service because they have that information (male partner, 30 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eTheme 2: Perceived benefits of EHRSs\u003c/h2\u003e\u003cp\u003eThe adoption of the EHRS in healthcare settings is seen as a significant step toward enhancing patient and provider experiences through efficiency and convenience.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eSubtheme 2(i). Enhanced confidentiality and privacy\u003c/h2\u003e\u003cp\u003eThe participants emphasized the privacy benefits of electronic health records (EHRSs) over paper-based systems, which are easily accessible by unauthorized individuals, thereby promoting ethical medical record storage:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWhen our information is stored electronically, there\u0026rsquo;s confidentiality [...] while on the other hand, if I lose the paper, anyone could read it.\" (mother, 26 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eCompared with paper records, the use of patient identification numbers to access medical records stored in the EHRS is perceived to increase confidentiality:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For the papers, the confidentiality is low; a person can access other people\u0026rsquo;s information very easily [\u0026hellip;] However, in the EHRS, no one can easily access other people\u0026rsquo;s information unless she has my identification information or my identification number, which is found on my card\u0026rdquo; (male partner, 36 years, Moshi DC); \u0026ldquo;For me, am concerned about the privacy of our personal information, as they store it in books, clinics, and at home, and am not sure of its storage duration\u0026rdquo; (mothers attending RCH clinic, 27 years old and 24 years old from urban areas, FGDs).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eSubtheme 2(ii). Improved efficiency, continuity of care, and time management\u003c/h2\u003e\u003cp\u003e The participants found the repetition of their details at health facilities, particularly in paper-based systems, to be time-consuming. In contrast, EHRSs were viewed as more efficient and service streamlined:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] for me, I prefer the EHR system to be used because it simplifies the work; writing in papers takes time, but in the EHR system, your information is just recorded, stored and accessed easily\u0026rdquo; (male partner, 28 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOne participant noted that EHRSs could save time and enhance continuity of care if there were better linkages between health facilities:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For example, last year I got problems here, I had given birth and the baby did not cry, they referred me to KCMC as I was leaving the facility where I was receiving services; my information could be sent through EHRS to KCMC, which could simplify care continuity between facilities\u0026rdquo; (mother, 36 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eUsing EHRS has been associated with an increase in the attendance of male partners at ANC visits, thereby saving time:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eFirst, it saves time, for example, I have come now in just ten minutes, I have already gotten the services, this convinces me to come again because I do not stay for a long time [\u0026hellip;]\u0026rdquo; (male partner, 29 years, Moshi DC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOne participant noted that providing their details once and having access to each service department enhanced the continuum of care:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] the benefit of the EHR system it simplifying the service provided since when you get there you can just give the explanation and obtain services within a short time, it is different from the paper-based system where you have to take papers from here and there and sometimes a lot of time is used sorting the papers\u0026rdquo; (male partner, 50 years, Moshi DC\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eSubtheme 2(iii). Storage durability and accessibility\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe computer system keeps records safe and helps avoid losing information\u0026rdquo; (mother, 23 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOther participants valued the government's initiatives to transition health services from analog to digital, which were seen as simplifying the health-seeking process:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Currently, the health system is transitioning from analogy to EHR systems, replacing paper systems. This eliminates the need for individuals to visit the hospital for medical treatment with exercise books. EHR systems allow for direct visits wherever you feel to seek medical attention, allowing doctors to quickly access patient information and potentially avoiding retesting for previously treated diseases\u0026rdquo; (male partner, 32 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eLong-term data storage via EHRSs is more reliable than paper-based systems, according to participant explanations:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;First, I would like to say the EHR system is better than the paper system because, in the EHR system, the information is not easy to get lost, and its storage is very long compared with the paper system\u0026rdquo; (male partner, 33 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3: Challenges of implementing EHRS\u003c/h2\u003e\u003cp\u003eWhen planning to move from a paper-based system to an EHRS, several challenges must be overcome, such as power outages, inconsistent network connectivity, the expense of internet access and backup generators, and barriers related to literacy and culture.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eSubtheme 3(i). Infrastructure and resource limitations\u003c/h2\u003e\u003cp\u003eThe challenges of deploying EHRSs in rural regions were emphasized by the participants, who emphasized how issues such as power outages and erratic internet could make it more difficult to use them:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe system is good, but when they go to hospitals in cities, there will be no problem; however, in interior villages, there might be challenges related to internet and electricity issues, which occur mostly in villages\u0026rdquo; (male partners, 30 years, Moshi MC)\u003c/em\u003e; \u003cem\u003e\u0026ldquo;They should improve the infrastructure of electricity and the internet in the villages so that even when these services are brought there, it is easier to use\u0026rdquo; (mother, 35 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFinancial limitations affecting support for internet bundles and electricity backup for the sustainability of EHRSs were another issue:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The cost must be needed for the generators as a backup of electricity availability, or if it is internet, it must be paid for it to be accessed (male partner, 32 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIrregular power supply issues that could have a long-term impact on EHRS use were reported to the government by an IDI participant:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If the electricity is there, everything will go well; but to some hospitals which do not have backup generators, it will become a challenge, imagine if there is no electricity for three days, how is that going to be [\u0026hellip;] we will go back to paper recording\u0026rdquo; (male partner, 28 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eSubtheme 3(ii). Cultural barriers and literacy rates\u003c/h2\u003e\u003cp\u003eAlthough the participants identified literacy rates and cultural customs as obstacles to the adoption of the EHRS, the results revealed no cultural problems with its use. However, there is still a need to address community awareness of the system:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;On the side of our traditions and customs, there is no challenge with the knowledge of using EHRSs during services. Most people in the community are educated, so even if elderly clients have gone to the hospital and have been told that they want to put their information in the system, they know. No one says that we used to this and not to that system, people understand\u0026rdquo; (mother, 24 years, Moshi DC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo allay worries about using EHRSs, the participants expressed confidence in their security and suggested that successful integration with mobile money would signify dependable performance in medical facilities:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Although using EHR systems has been linked to fraudsters in our areas, they are safe and effective since they work well with mobile money. Therefore, with time, people will understand and trust the system\u0026rdquo; (male partner, 28 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe participants stated that their opinions of literacy rates are influenced by the community's historical reliance on paper systems. To encourage the use and upkeep of EHRSs in healthcare facilities, the government prompted the organization of educational sessions for community members and healthcare providers:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] the government would give more education on the use of EHR systems because other clients from the community have insufficient understanding of the EHR system; this is because they are used in the paper system for quite long and not experienced with EHRS, so the society may handle those devices carelessly and damage them and become a challenge and repair of that equipment is costly\u0026rdquo; (mother, 21 years, Moshi DC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDamage and repair issues were brought up, emphasizing the necessity for people with the know-how to fix any harm to EHRS devices:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The challenge will occur if the equipment storing information becomes damaged with no one equipped with the skills of how to repair it\u0026rdquo; (mother, 29 years, Moshi MC)\u003c/em\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eTheme 4: Suggestions for improvement of the EHRS\u003c/h2\u003e\u003cp\u003eTo address the present infrastructure issues in healthcare, the participants discussed the necessity of enhancing EHRSs. They discussed the importance of streamlining procedures and improving care quality by developing and scaling the EHRS. Additionally, they highlighted the importance of understanding patient perspectives to identify areas needing reform.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eSubtheme 4(i). Training and staffing enhancements\u003c/h2\u003e\u003cp\u003eThe participants suggested that the government address challenges in transitioning from paper-based systems to the EHRS. They emphasize the importance of increasing education for both healthcare providers and the community concerning EHRS usage:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Let me say that the computer system is the best, the education should be provided so that we can change if we want to move forward\u0026rdquo; (male partner, 32 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOther participants highlighted the importance of transparency in hospital bill payments to prevent unnecessary cost increases while utilizing the system:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In building the understanding of the system, service providers should be well educated and we as mothers we should be educated as well on how the system operates so that if there is a need for any payment, it should be well known rather than being told by the doctor as he may increase the cost\u0026rdquo; (mother, 25 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe participants noted that EHRSs enhance health governance and accountability by strengthening connections among the country, health facilities, and healthcare workers:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe EHR system creates direct connections between the central government and hospitals, health centers, and dispensaries. Therefore, it helps the government obtain information on the weaknesses and strengths of service provisions and helps staff obtain fairness based on their work\u0026rdquo; (male partner, 28 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnother participant perceived the EHRS as a staff shortage problem solver:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If an electronic system is used for all health facilities, it can help reduce the problem of inadequate health service providers, as it simplifies service provision (male partner, 36 years, Moshi DC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eSubtheme 4(ii). Integration with existing practices\u003c/h2\u003e\u003cp\u003eThe participants recommended the integration of various EHRSs across different health facility levels to enhance referral management through electronic services:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If I am given a referral to other center(s), the benefit is that my information will be there; rather than if I was given the paper-based referral and maybe it happen to rain, I may be needed to go back for another referral paper, but in the case of the EHRS, I am sure that my information will be accessed at the referral point once my identification is entered\u0026rdquo; (male partner, 29 years, Moshi DC)\u003c/em\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIntegration of the existing system enhances patient management and ensures a continuous continuum of care:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It helps; even if you go to a different hospital, so long as they use an EHR system and it reads other systems, the services become better since they know where to continue. Let\u0026rsquo;s say the patient has gone to the hospital in a bad condition; once they access his information, they will know where to start\u0026rdquo; (male partner, 36 years, Moshi DC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe participants recommended the implementation of EHRSs across various health facility levels because of their ability to maintain a comprehensive memory:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I advise that they should improve the use of EHRS as it is a good one, it helps to keep our memories, so, in my opinion, they should install that system for us at all healthcare facility levels and hospitals in Tanzania\u0026rdquo; (mother, 26 years; Male partner, 50 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSubtheme 4 (iii). Policy dialog on EHRS implementation\u003c/h3\u003e\n\u003cp\u003eThe participants in the study highlighted the importance of the nationwide rollout of the EHRS to enhance the referral system and ensure timely service delivery:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Implementing the system all over the country will enhance efficiency and ensure timely service delivery\u0026rdquo; (male partner, 29 years, Moshi MC); \u0026ldquo;The EHRS has to be implemented at all levels of health-care service delivery to support referrals\u0026rdquo; (mother, 30 years, Moshi MC)\u003c/em\u003e; \u003cem\u003e\u0026ldquo;there should be a linkage between one hospital and another as there is no meaning if these systems will operate independently or in a limited health facility levels only\u0026rdquo; (male partner, 28 years, Moshi DC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe participants suggested the use of mobile EHRS devices for convenience outside health facilities while stressing the need for restricted access to patient information to safeguard confidentiality:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think this digital equipment should not be fixed in hospitals only; rather, they should be mobile in a way that a person can move with them easily, like laptops and tablets and that their systems should have limited access to clients\u0026rsquo; information[...]\u0026rdquo; (male partner, 28 years, Moshi MC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA reliable power supply is critical for the successful implementation of Electronic Health Record Systems (EHRSs):\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The government has to ensure the availability of a stable power supply to support healthcare services without disruption for twenty-four hours, seven days a week\u0026rdquo; (male partner, 32 years, Moshi DC).\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study explored the perspectives of mothers and male partners attending reproductive and child health clinics in Kilimanjaro, Tanzania, regarding their experience with and readiness to use electronic health recording systems during the perinatal period. Generally, there were no significant differences in their views between urban and rural areas or in terms of gender. These findings suggest that the Kilimanjaro community shares a common experience and perspective on EHRSs, demonstrating readiness and openness to EHRS health innovations, which highlights the potential for equitable adoption across genders and locations.\u003c/p\u003e\u003cp\u003eCommunities favor the use of the EHRS, highlighting benefits such as reduced redundant information, faster service delivery, better coordination across healthcare providers, and enhanced data privacy. The community believes that by strengthening privacy protection, the EHRS enhances the quality of healthcare and fosters trust. They value systems that reduce waiting times and ensure continuity of care, and they anticipate that the EHRS will lead to more equitable, patient-centered services by allowing healthcare professionals to focus less on administrative tasks. These perceptions also highlight a change in mindset toward recognizing EHRS as a means to enhance healthcare services.\u003c/p\u003e\u003cp\u003eThese results are in line with findings from other low- and middle-income contexts, highlighting that the success of implementing EHRSs depends on technological readiness and community awareness and trust [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Patient confidentiality in EHRSs can be maintained through limited access for unauthorized individuals. Previous studies indicate that EHRSs enhance data security [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the general community's positive perspectives toward the introduction of EHRSs, several barriers might hinder their successful implementation. The main challenges include limited awareness and understanding of their purpose, data storage duration, and access control mechanisms among community members. These challenges are not far from what has been reported in related geographical setting studies, where limited EHRS literacy and inadequate understanding of patients\u0026rsquo; information privacy have contributed to the failure of other EHRS initiatives [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. As far as the importance of clarity in any new electronic systems initiatives.\u003c/p\u003e\u003cp\u003eInfrastructure issues, particularly in rural settings, include unreliable power, poor internet connectivity, and insufficient technical capacity to repair hardware/software, which could hinder the implementation of EHRSs [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. To sustain the system backup generator and allocated a budget for the internet bundle and device repairs perceived to mitigate the challenge.\u003c/p\u003e\u003cp\u003eAdditionally, skilled information technology (IT) personnel are necessary to address hardware and software challenges. Findings from other studies conducted across sub-Saharan nations highlighted similar issues of insufficient IT expertise, as it contributed to hindering the scaling-up of EHRSs [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The participants\u0026rsquo; acknowledgment of the perceived barriers indicates a general willingness or openness to adopt and maintain EHRS use, provided that technical and infrastructural challenges are properly addressed.\u003c/p\u003e\u003cp\u003eHealthcare workers\u0026rsquo; lack of EHRS literacy, particularly among elderly individuals, makes it difficult to navigate effectively with EHRSs. This challenge also impacts community beneficiaries, as they lack a fundamental understanding of how these devices operate, which makes them uncomfortable and may lead to a lack of trust during service when visiting clinics. Therefore, enhancing EHRS literacy for both providers and patients is crucial for improving EHRS adoption, usability, and trust.\u003c/p\u003e\u003cp\u003eIn LMIC settings, users\u0026rsquo; acceptance of the EHRS is significantly influenced by their comfort and familiarity with the technology [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. To address these issues, participants suggested conducting user education sessions during antenatal visits to increase community awareness and foster wider acceptance.\u003c/p\u003e\u003cp\u003eAdditionally, to guarantee continuity of care and improve referral systems, integration across all health facility levels is crucial for the successful implementation of EHRSs, which has a wider range of advantages. This includes infrastructural investment by the government through capacitating healthcare professionals and the creation of explicit policy guidelines that support system interoperability and prioritize data privacy protection [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInterestingly, EHRSs were viewed as clinical instruments to increase governance accountability. The participants indicated that EHRSs would enable the sharing of data in real time across health facilities and respective authorities to improve healthcare management, monitoring, planning, and resource allocation. However, this would depend on sustained funding, trustworthy data protection policies, and a technological partnership of both the EHRSs and digital strategies. This finding relates to Vos et al. (2020), who noted EHRSs' potential for improving clinical coordination but cautioned against risks such as reduced face‒to-face interactions, fragmented departmental communication, and increased administrative burdens[\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003eStrengths of the study\u003c/h2\u003e\u003cp\u003eThis research provides an informative and contextually rich perspective on how clients, such as mothers and male partners, experience and their views on the transition to electronic health data recording systems within RCH clinics. It also provides views from urban and rural contexts, which may offer a more comprehensive representation of community perspectives.\u003c/p\u003e\u003cp\u003eWe used multiple data collection methods in which both FGD and IDI were applied appropriately. Through this approach, it was possible to explore participants\u0026rsquo; personal experiences, beliefs and attitudes toward the EHRS in a confidential setting through one-to-one interviews as well as group or community perspectives during FGDs. Therefore, using both FGDs and IDIs enriched the understanding of both the personal and social dimensions of EHRS adoption.\u003c/p\u003e\u003cp\u003eInvolving more than one researcher in coding and theme development as well as peer debriefing within the research team minimized individual bias. Field notes and reflexive memos were maintained to ensure the confirmability and dependability of the findings.\u003c/p\u003e\u003cp\u003eThe findings provide evidence for local and national health system planning agencies regarding the potential benefits and challenges of implementing the EHRS and offer suggestions to address notable gaps.\u003c/p\u003e\u003cdiv id=\"Sec33\" class=\"Section3\"\u003e\u003ch2\u003eLimitations of the study\u003c/h2\u003e\u003cp\u003eAs with a qualitative study relying on purposive sampling, the study findings are not generalizable beyond the specific sites in Tanzania or other lower-middle-income country contexts. However, the findings have the potential for understanding readiness and community perspectives on the EHRS as a new health record system and share their views and expectations for transitioning from a paper base to the EHRS. While reflexivity, transparency, and validation through dual coding were operationalized, there remains an element of interpretation, possible cultural and/or contextual bias, in a study of this nature.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study participants recognized that EHRSs could enhance care efficiency, data security, and service continuity among populations with higher EHRS literacy. However, they also expressed concerns about the usability of EHRSs, infrastructure, and data privacy. To support long-term implementation, it is essential to develop policies that address and overcome barriers, provide training for both users and healthcare providers, and improve infrastructure. Importantly, participants highlighted the importance of system-wide integration of EHRSs across the health and social care sectors while ensuring that approaches are tailored and user-centered.\u003c/p\u003e\n\u003ch3\u003eRecommendation\u003c/h3\u003e\n\u003cp\u003eGiven that this study was conducted in Kilimanjaro, a relatively advantaged region in terms of infrastructure and literacy, it is recommended that similar studies be conducted in more underserved or remote regions to assess transferability and generate broader insights. Future studies employing longitudinal or mixed method designs may also provide stronger evidence on the long-term impact and scalability of EHRSs across different health system levels.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCHWs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Community health workers\u003c/p\u003e\n\u003cp\u003eEHRSs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Electronic health record systems\u003c/p\u003e\n\u003cp\u003eEHR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Electronic Health Record\u003c/p\u003e\n\u003cp\u003eFGDs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Focus Group Discussions\u003c/p\u003e\n\u003cp\u003eHCWs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Healthcare Workers\u003c/p\u003e\n\u003cp\u003eIDIs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;In-depth interviews\u003c/p\u003e\n\u003cp\u003eKCMC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Kilimanjaro Christian Medical Centre\u003c/p\u003e\n\u003cp\u003eLMIC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Low Middle-Income Countries\u003c/p\u003e\n\u003cp\u003eRCH \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Reproductive and Child Health\u003c/p\u003e\n\u003cp\u003eNatHREC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;National Health Research Ethics Review Committee\u003c/p\u003e\n\u003cp\u003eNIMR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;National Institute for Medical Research\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance to conduct this study was obtained from the Research and Ethical Committee of the University of KCMC (No 2644) and the National Health Research Ethics Review Committee (NatHREC) of Tanzania’s National Institute for Medical Research (NIMR) (No NIMR/HQ/R.8a/Vol. IX/4075). Permissions letters were also granted from local authorities (President’s Office, Regional Administration and Local Government (PO-RALG), Tanzania; the Kilimanjaro region and District Authorities) and their respective health facilities. Individual participants provided written informed consent in their local language (Swahili). This was done after the study objectives, confidentiality and voluntary participation rights were explained, which allowed the participants to withdraw at any time without penalty. Although there were no physical hazards associated with this study, emotional sensitivity was guaranteed during data collection, particularly regarding personal experiences with maternity healthcare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the participants provided consent for their direct quotes to be used in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data underlying the results of this qualitative study originate from the authors, other relevant details are within the manuscript, and others can be found here: DOI. https://doi.org/10.6084/m9.figshare.30152938 and for more details, please contact the Head of the Data Management Unit at Kilimanjaro Clinical Research Institute (KCRI), email: [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project was partly funded by an Irish Research Council (IRC), Department of Foreign Affairs COALESCE Award (COALESCE/2021/51). I received mentorship and supervision from the project team and data collection support, but there was no special fund allocated for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u003c/strong\u003e\u003cstrong\u003e contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conceptualized by GAO, BTM, ASK, SW and RM. The FGDs and IDIs conducted by GAO. GAO, CM and RM conducted the data analysis, and GAO, BTM, CM, KY, SW, ASK and RM contributed to the methodology, validation, visualization, and drafted the manuscript. All the authors provided feedback on multiple drafts of the manuscript before approving the final manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor their dedicated assistance in making this study successful, we would like to thank the Regional Health Management, Moshi Municipal and Moshi district health management teams, staff and participants from the involved health facilities. GAO acknowledges Prof. Karen Yeates’ personal assistance with tuition fees, ULTRA team support on supervision and data collection, and Dr. Agnes Msoka's technical support provided during the production of the manuscript and thematic analysis.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDahab R, Sakellariou D. Barriers to Accessing Maternal Care in Low Income Countries in Africa: A Systematic Review. International journal of environmental research and public health. 2020;17(12). 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Why sub-Saharan Africa lags in electronic health record adoption and possible strategies to increase its adoption in this region. International journal of health sciences. 2017;11(4):59.\u003c/li\u003e\n\u003cli\u003eVos JFJ, Boonstra A, Kooistra A, Seelen M, van Offenbeek M. The influence of electronic health record use on collaboration among medical specialties. BMC health services research. 2020;20(1):676. doi: 10.1186/s12913-020-05542-6.\u003c/li\u003e\n\u003cli\u003eAttah AO. Implementing the Electronic Health Record in a Nigerian Secondary Healthcare Facility: Prospects and Challenges. 2017 [27/04/2025]. Available from: https://munin.uit.no/bitstream/handle/10037/12245/thesis.pdf?sequence=2\u0026amp;isAllowed=y.\u003c/li\u003e\n\u003cli\u003eOgaji D, Anyanwu C. Implementing electronic healthcare record in a public health facility in Nigeria: awareness, acceptance and concerns among critical stakeholders. International Journal of Electronic Healthcare. 2021;11:364. doi: 10.1504/IJEH.2021.117830.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Electronic health record, systems, paper records, perinatal care, maternal care, reproductive health, Tanzania","lastPublishedDoi":"10.21203/rs.3.rs-8134388/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8134388/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction\u003c/b\u003e: Electronic health record systems (EHRSs) can promote maternal and perinatal healthcare through timely data capture, data accuracy, continuity of care, and service efficiency. It is unclear how clients to whom the data are collected perceive the process or understand its use. This study investigated the perception of the use of EHRSs during the perinatal period among mothers and male partners attending reproductive and child health (RCH) clinics in the Kilimanjaro Region.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e: A qualitative study was conducted between April and June 2024 via focus group discussions and in-depth interviews within reproductive and child health clinics around the communities of the Moshi District Council (rural) and the Moshi Municipal Council (urban). The research involved mothers who gave birth in the past 12 months before this study and male escorting partners attending RCH clinics.\u003c/p\u003e\u003cp\u003eThe data were collected via Sem-structured interview guides and analyzed thematically via NVivo 15 software. Data triangulation, reflexivity, and adherence to qualitative research standards were observed, ensuring that the study met ethical and methodological rigor. To address these components, our study established a trustworthy and robust system.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e: A total of 39 participants were recruited for the study, i.e., 29 mothers who gave birth between March 2023 and March 2024 and 10 male partners attending RCH clinics. The findings revealed that most participants had positive opinions of EHRS due to its efficacy and safety, ability to reduce access time, ensure continuity of care, increase trust through confidentiality, increase data storage, and simplify work. However, limited client awareness, privacy concerns, infrastructure problems, and financial limitations are some of the obstacles that might affect its adoption. Systems integrating healthcare facilities with training for clients and healthcare providers and creating policy documents to ensure sustainability and efficacy were proposed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e: Our study reflects a representative range in the transition of EHRSs. Although some concerns around understanding, privacy issues, infrastructure, and technical capabilities were revealed, the positive outcomes indicate significant opportunities in improving quality-of-care delivery through the EHRS. Resolving these challenges is crucial for smoother transitions and building trust in EHRSs over time.\u003c/p\u003e","manuscriptTitle":"Perception of mothers and male partners of the use of an electronic health data recording system while attending reproductive and child health clinics in Kilimanjaro, Tanzania: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 12:11:08","doi":"10.21203/rs.3.rs-8134388/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"405657df-2fa8-4a90-af57-0d06e2f1708f","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":58109396,"name":"Maternal \u0026 Fetal Medicine"}],"tags":[],"updatedAt":"2025-11-19T12:11:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-19 12:11:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8134388","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8134388","identity":"rs-8134388","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}