Evaluating the Implementation of the Pediatric Acute Care Education (PACE) Program in Northwestern Tanzania: A Mixed-Methods Study Guided by Normalization Process Theory

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To address this, we introduced PACE (Pediatric Acute Care Education), an adaptive e-learning program tailored to enhance provider competency in line with Tanzania’s national guidelines for managing seriously ill children. Adaptive e-learning presents a promising alternative to traditional in-service education, yet optimal strategies for its implementation in LMIC settings remain to be fully elucidated. Objectives This study aimed to ( 1 ) evaluate the initial implementation of PACE in Mwanza, Tanzania, using the constructs of Normalization Process Theory (NPT), and ( 2 ) provide insights into its feasibility, acceptability, and scalability potential. Methods A mixed-methods approach was employed across three healthcare settings in Mwanza: a zonal hospital and two health centers. NPT was utilized to navigate the complexities of implementing PACE. Data collection involved a customized NoMAD survey, focus groups and in-depth interviews with healthcare providers. Results The study engaged 82 healthcare providers through the NoMAD survey and 79 in focus groups and interviews. Findings indicated high levels of coherence and cognitive participation, demonstrating that PACE is well-understood and resonates with existing healthcare goals. Providers expressed a willingness to integrate PACE into their practice, distinguishing it from existing educational methods. However, challenges related to resources and infrastructure, particularly affecting collective action, were noted. The short duration of the study limited the assessment of reflexive monitoring, though early indicators point towards the potential for PACE’s long-term sustainability. Conclusion This study offers vital insights into the feasibility and acceptability of implementing PACE in a Tanzanian context. While PACE aligns well with healthcare objectives, addressing resource and infrastructure challenges is crucial for its successful and sustainable implementation. Furthermore, the study underscores the value of NPT as a framework in guiding implementation processes, with broader implications for implementation science and pediatric acute care in LMICs. Adaptive E-learning Feasibility Acceptability Normalization Process Theory Implementation Science Pediatrics Tanzania Figures Figure 1 Contributions to the Literature Introduces PACE: This study uniquely evaluates the Pediatric Acute Care Education (PACE) program in a low-resource setting, offering initial evidence on its implementation and potential impact on pediatric care. Utilizes NPT Framework: By employing Normalization Process Theory (NPT), the research provides a novel methodological example of how to assess the incorporation of e-learning in LMIC clinical settings. Informs Implementation Strategies: The findings contribute to the design of effective e-learning strategies for healthcare education in LMICs, suggesting practical steps for broader application. Expands Local Capacity: Demonstrates how PACE can build local healthcare capacity, informing ongoing efforts to sustainably improve pediatric care through education in similar environments. Introduction to Results The results section is organized to provide an in-depth analysis of both the implementation and impact of the Pediatric Acute Care Education (PACE) program. Initially, "Provider Demographics and Work Perceptions," offers three layers of data: descriptive statistics that characterize the healthcare providers who took part in the NoMAD survey, comparative analyses that differentiate between providers from a zonal hospital and health centers, and emergent themes from in-depth interviews (IDIs) and focus group discussions (FGDs) that shed light on providers' general perceptions of their roles in pediatric acute care. Following this, "Normalization Process Theory (NPT) Constructs" is bifurcated into an overview of general perceptions regarding PACE implementation and a detailed examination of the four principal NPT constructs—Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring. Each construct is scrutinized through a tripartite lens: descriptive data from the NoMAD survey, comparative analyses across different healthcare settings, and qualitative insights derived from IDIs and FGDs. Finally, "Summary of Feasibility, Acceptability, and Scalability," synthesizes all findings into descriptive and comparative categories to offer a comprehensive evaluation of PACE's potential for normalization within healthcare settings, while deliberately omitting thematic categories for a more focused interpretation. Provider Demographics and Work Perceptions Eighty-two of 272 healthcare providers completed the NoMAD survey, yielding a response rate of 30%. Of the 82 healthcare providers: 59 were from the zonal hospital and 23 from health centers. Median ages were 27 and 29 years for the zonal hospital and health centers, respectively ( Table 2 ). Gender distribution was similar in both settings (39% female in the zonal hospital, 43.5% in health centers). Significant cadre differences existed: the zonal hospital had more medical (47.5% vs. 8.7%) and nursing officers (42.4% vs. 30.4%), while health centers had more clinical officers (30.4% vs. 0%). Clinical experience varied, with medians of 1 year at the zonal hospital and 4 years at health centers (p-value: 0.004). Both settings had over 70% of providers with prior training. Job satisfaction scores were not significantly different between the two groups. IDI and Focus Group demographics. Seventy-nine healthcare providers participated in the study: 24 senior providers were interviewed (18 zonal hospital, 6 health centers) and 13 focus groups were held with junior providers (39 zonal hospital and 16 health centers). The focus group discussions varied in size, with an average of 4 participants per group. All cadres were represented: medical officers ( 26 ), nursing officers ( 19 ), interns ( 16 ), clinical officers ( 12 ), Assistant medical officers ( 3 ), and medical attendants ( 3 ). Clinical experience ranged from 1 to 20 years. Focus group themes for Provider Demographics and Work Perceptions. The overarching theme from the IDIs and FGDs was healthcare providers' active engagement in pediatric care, particularly for seriously ill newborns and children. The quotes elucidate the providers' daily responsibilities and specialized roles across different settings. A provider noted, "I deal with ill children daily. There's always a new transfer or admission." This statement highlights the relentless nature of pediatric care, emphasizing the ongoing attention to both new and existing cases. Another provider said, "I specialize in neonatology but attend to all children as per our country's laws." This underscores the specialized yet comprehensive roles some providers assume, adhering to broader healthcare mandates. A provider added, "I work in the labour ward, treating newborns who fall ill before reaching twenty-eight days." This comment reveals that even those in labour wards have pediatric responsibilities, extending the scope of care to include newborns who become ill. In summary, the quotes collectively depict healthcare providers as deeply committed to pediatric care, each with specialized roles but universally focused on patient well-being. NoMAD General Items Respondents showed high familiarity with PACE, evidenced by a median score of 89 out of 100, although an interquartile range of 76–100 indicates variability (Table 3 , Fig. 1 ) . General satisfaction with PACE in current work had a median of 91 and a similar opinion range, as suggested by an interquartile range of 75–100. Optimism for PACE in future work was highest, with a median of 99 and an interquartile range of 87–100. No significant differences were observed between the zonal hospital and health centers in these variables. Normalization Process Theory (NPT) Constructs Coherence NoMAD data analysis Coherence, a key construct in PACE implementation, and its subconstructs reveal important trends. "Communal Specification" and “Internalization” had median scores of 2 (Agree) and 1 (Strongly Agree), respectively, with interquartile ranges of 1–2 for both indicating strong collective agreement on PACE's purpose and value (Table 3 , Fig. 1 ) . "Differentiation" and "Individual Specification" both had medians of 2 (Agree), suggesting moderate agreement that PACE is distinct, and roles are understood. Interquartile ranges were 1–4 for “Differentiation” and 2–4 for “Individual Specification,” indicating variability within subconstructs. Overall, data suggest strong collective and individual agreement on PACE's differentiation and value. For Coherence subconstructs, there were no significant differences in median scores or IQRs between settings indicating uniform perceptions of purpose, distinctiveness, and valuation of PACE across settings. Coherence Themes from IDI and FGD. Differentiation: Providers value PACE for its detailed guidance on specific pediatric cases, such as difficulty breathing, which was not covered in their basic training. One provider said, "PACE goes beyond basic knowledge, offering detailed steps for managing cases like difficulty breathing. This is a significant advantage." (Table 4) Communal Specification: PACE is seen as a tool for empowering providers to reduce child mortality and improve service quality, aligning with facility goals. One provider remarked, "PACE aims to empower us to reduce child mortality," while another noted, "Its objectives align with our hospital's goals to update healthcare providers' knowledge." Individual Specification: Providers believe PACE has enhanced their understanding and management of seriously ill children. One provider observed, "Before PACE, I relied on existing procedures and guidelines. Now, I've gained new insights that could positively impact our treatment system." Internalization: Providers find that PACE is consistent with Tanzanian and WHO guidelines, useful both in their work and in training medical students. One provider said, "PACE refreshes my memory and aligns with existing guidelines. I use it to educate medical students and junior doctors." Cognitive participation NoMAD data analysis Cognitive Participation, a construct examining collaboration around PACE, reveals strong agreement across its subconstructs. "Activation," measuring ongoing PACE support, had a median of 1, indicating strong agreement (Table 3 , Fig. 1 ) . "Enrolment" and "Initiation," with medians of 1 for both, also showed strong agreement for participation and leadership in PACE. "Legitimation," assessing PACE's work integration, also had a median of 1, suggesting strong agreement. IQRs ranged from 1–1 to 1–2, indicating some dispersion within subconstructs. Overall, data suggest strong agreement on PACE's support, participation, leadership, and legitimacy. There were no significant differences by setting, indicating consistent strong agreement on PACE across settings. Cognitive Participation Themes from IDI and FGD. Initiation: Providers were introduced to PACE by colleagues and supervisors, prompting them to enroll. One provider said, "Specialists introduced us to PACE, and we started learning." Another noted, "After seeing a colleague engage with PACE, I joined too." Some providers find individual initiation beneficial, as one stated, "Starting alone is effective." (Table 4) Legitimation: PACE is seen as empowering providers to enhance their pediatric care. One provider noted, "PACE taught me how to administer oxygen based on a child's age." Another highlighted PACE's flexibility, saying, "You can engage with PACE individually or in groups." Enrolment: Providers mainly use PACE individually but also share modules to spread knowledge. One provider said, "I often use PACE on my phone but also share modules with colleagues." Activation: Despite busy schedules, providers are committed to PACE training. One provider stated, "Our commitment helps translate knowledge into practice." Another emphasized their personal dedication, saying, "I find time to study PACE multiple times a week, showing my commitment." Collective Action NoMAD data analysis In the realm of Collective Action, focusing on collaborative PACE enactment, subconstructs reveal nuanced insights. "Interactional Workability," with a median of 1, suggests work required by PACE is generally manageable (Table 3 , Fig. 1 ) . "Relational Integration" showed strong disagreement that PACE disrupts relationships but agreement that it can be effectively used by peers. "Skill-set Workability" indicated mixed alignment with provider needs but strong consensus on sufficient PACE training. "Contextual Integration" had medians of 2, suggesting strong organizational support. Overall, data suggest varying agreement levels on work manageability, interpersonal relations, task allocation, and organizational support. "Relational Integration" showed a significant difference in one subconstruct (p = 0.02), suggesting higher trust levels in the zonal hospital. There were no other differences by setting. Overall, data suggest consistent Collective Action approaches across settings, with a trust advantage in the zonal hospital. Collective Action Themes from IDI and FGD. Interactional Workability: PACE's digital format allows for individual study and facilitates group discussions. One provider noted, "PACE's digital nature allows for flexible study schedules." Group discussions often occur in the mornings, as another provider said, "We discuss PACE modules early before attending to patients." (Table 4) Relational Integration: Initially, providers engaged with PACE for personal benefit but later saw the value in sharing knowledge. One provider stated, "I initially used PACE for personal growth but later realized the importance of sharing this knowledge." Teamwork and collective benefits were emphasized, with one provider noting, "We work as a team to meet our objectives." Skill-set Workability: Providers value the practical application of PACE knowledge in patient care. One provider said, "After learning, it's crucial to apply this knowledge in treating patients." Contextual Integration: Challenges like inadequate supplies and lack of electricity hinder PACE implementation. One provider stated, "‘’Sometimes we face difficulties such as inadequate supply of medical equipment and supplies. For example, there is a child in need of oxygen while there is no electricity and we do not have standby generator. This becomes a barrier to translating PACE in practice." However, the availability of tools and support from PACE management facilitates implementation, as another provider noted, "Availability of tools and support has eased PACE's translation into practice." Reflexive Monitoring NoMAD data analysis In the context of Reflexive Monitoring, focusing on PACE appraisal, subconstructs reveal varying agreement levels. "Communal Appraisal" had a median of 2, suggesting strong collective agreement on PACE's benefit (Table 3 , Fig. 1 ) . "Individual Appraisal" had a median of 1, indicating strong individual agreement. "Reconfiguration," examining work modifications due to PACE, had a median of 2, showing slight agreement for work adjustments. "Systematization," assessing information access on PACE effects, had a median of 2, leaning towards strong agreement. Overall, data suggest strong agreement on PACE's collective and individual appraisal, work modification, and information access. There were no significant differences by setting, suggesting consistent agreement on PACE appraisal and modification across settings. Reflexive Monitoring Themes from IDI and FGD. Systematization: No quotes directly address this subconstruct, suggesting a need for further exploration within the PACE context. Communal Appraisal: Providers find PACE valuable for educating junior doctors, simplifying complex topics, and boosting confidence. One provider noted, "PACE aids in teaching junior doctors by simplifying complex topics and enhancing my confidence during discussions." (Table 4) Individual Appraisal: Providers believe PACE has enriched their knowledge and confidence in pediatric care. Quotes summarizing this sentiment include, "I've gained confidence and can act quickly in emergencies," and "I can provide timely service with increased courage." Reconfiguration: A notable challenge is the inaccessibility of learned material for future reference, hindering providers' ability to refresh their knowledge. One provider stated, "Once you complete a module, it becomes inaccessible, making it difficult to revisit for future case management." Summary of Feasibility, Acceptability, and Scalability. Overall, PACE is generally feasible across healthcare settings, with providers across settings either agreeing or strongly agreeing that people do the work required by interventions and their components (Interactional Workability), the work of interventions and their components supported by host organizations (Contextual Integration). PACE is also generally acceptable among healthcare providers. Providers collectively agree about the purpose of PACE and its components (Communal Specification), agree that PACE and its components are the right thing to do and should be part of their work (Legitimation), and the collectively and individually agree that PACE is worthwhile (Communal and Individual Appraisal). Lastly, PACE appears to be scalable, with some variability in its adaptability and skill-set alignment. The scalability subconstructs, mapped to NPT, indicate a mean score of 1.23 and a standard deviation of 0.42 for Providers strongly agree that they will continue to support PACE and its components (Activation), that they can modify their work in response to their appraisal of PACE, and feedback can be used to improve it in the future (Reconfiguration). Providers agree or are neutral about the work of PACE and its components being appropriately allocated to people (Skill-set Workability), indicating more work is needed to identify the correct providers to participate in PACE or more support needs to be allocated to those providers to complete PACE. Summary of Main Results Provider Demographics 82 healthcare providers participated in the NoMAD survey and 79 in interviews and discussions, with over 2/3 from the zonal hospital. Profession and years of clinical experience varied between zonal hospital and health centers with more physicians at the zonal hospital and more experienced providers at health centers. Healthcare providers are deeply involved in pediatric care and find value in PACE. NPT Constructs General High levels of familiarity and positive outlook towards the PACE intervention. No significant differences between the zonal hospital and health centers in general perceptions of PACE. Coherence PACE is seen as aligning with facility goals. General agreement on the collective and individual understanding of PACE. No significant differences between settings in understanding and planning for PACE. Cognitive Participation Strong agreement on ongoing support, participation, and legitimacy of PACE. PACE is seen as beneficial for managing specific pediatric cases. Consistent levels of agreement across both zonal hospitals and health centers. Collective Action Varying degrees of agreement on workability, interpersonal confidence, and organizational support. Generally consistent approach across both settings, with a notable difference in relational integration favoring the zonal hospital. Challenges: Inadequate supplies and lack of electricity noted as barriers to PACE implementation. Reflexive Monitoring Strong agreement in the collective and individual appraisal of PACE. Consistent agreement across both settings in the appraisal and modification of PACE. Challenge: Inaccessibility of learned material for future reference. Feasibility, Acceptability, Scalability PACE is generally feasible, acceptable, and potentially scalable across different healthcare settings, with some variability due to challenges and material inaccessibility. Background Context and importance of the study. Healthcare providers’ in-service education in low-and-middle income countries (LMICs) is limited in reach, effectiveness and sustainability, and these limitations contribute to millions of child deaths each year.(1,2) Pneumonia, birth asphyxia, dehydration, malaria, malnutrition, and anaemia collectively cause over 4 million under-five deaths each year, half of those deaths occur in sub-Saharan Africa; and thousands of those deaths occur in Tanzania.(3,4) The government of Tanzania is committed to reducing neonatal mortality from 20 to the sustainable development goals (SDGs) target of 12/100,000 by the year 2030.(5) Brief review of the literature. Provider knowledge and competency are two major drivers of care quality.(2,6) Unfortunately, conventional in-service education methods are often inadequate in coverage and difficult to sustain.(6) Conventional education methods do not systematically adapt to individual providers’ knowledge or convenience,(7,8) target minimal competency, and do not provide long-term increases in knowledge, which limits education effectiveness.(9,10) Adaptive e-learning, characterized by its use of advanced technology such as artificial intelligence and data analytics, offers a promising solution to the limitations of traditional educational methods. This approach tailors the learning experience to each individual by dynamically adjusting content and instructional strategies based on the learner’s unique needs, abilities, and progress. Such personalization not only addresses the challenges of manpower and training resource shortages prevalent in low-and-middle-income countries (LMICs) but also represents a strategic innovation in disseminating knowledge effectively. The World Health Organization (WHO) has underscored the importance of implementing e-learning solutions for healthcare workers globally.(11) Adaptive e-learning, with its capacity to adjust to individual learner needs, holds considerable promise for enhancing the efficiency of training healthcare workers. However, formal studies exploring the use of adaptive e-learning in LMIC contexts are scarce. Identifying and establishing best practices in e-learning and adaptive methodologies presents a significant opportunity to enhance the dissemination and implementation of evidence-based interventions. Such advancements are crucial for improving the quality of care in these regions. To address the existing limitations of current healthcare workers’ education in LMICs, we developed pediatric acute care education (PACE), an adaptive e-learning program focused on pneumonia, birth asphyxia, dehydration, malaria, malnutrition, and anaemia, and Tanzania’s national guidelines for the management of seriously-ill children as source material.(12,13) Prior to large-scale implementation, we undertook a feasibility trial of this curriculum among a cohort of medical interns at a zonal hospital in Tanzania. Then we continued to enroll healthcare providers in 8 health facilities under the Pediatric Association of Tanzania’s Clinical Learning Network facilities in Nyamagana and Ilemela districts of Mwanza region. This research report covers a qualitative pilot study that was conducted in three facilities to explore the feasibility and acceptability PACE. Study aims and objectives. The primary aim of this research is to assess the preliminary implementation of the Pediatric Acute Care E-learning (PACE) intervention across two distinct types of pediatric acute care facilities: zonal hospitals and health centers. The study employs the Normalization Process Theory (NPT) framework in a twofold manner: first, using a tailored NoMAD survey instrument to evaluate the integration of PACE into routine clinical practice; and second, via in-depth interviews and focus group discussions to gain qualitative insights. These dual approaches aim to achieve two principal objectives. The first objective is to utilize the constructs and subconstructs of NPT as evaluative metrics for scrutinizing PACE's implementation. The second objective is to consolidate these findings to provide a comprehensive analysis of the feasibility, acceptability, and scalability of the PACE intervention across the targeted healthcare settings. Methods Study Design This study employed a mixed-methods approach to evaluate the implementation of the Pediatric Acute Care Education (PACE) program in healthcare settings in Northwestern Tanzania. We administered a tailored NoMAD survey post-intervention to healthcare providers in a zonal hospital and two health centers. Additionally, in-depth interviews and focus group discussions were conducted post-intervention to enrich the survey data. The study was guided by two primary objectives: Objective 1: To use Normalization Process Theory (NPT) to assess the initial implementation of PACE. Objective 2: To summarize the findings in terms of feasibility, acceptability, and scalability of PACE. Theoretical Framework Normalization Process Theory (NPT) has been described as a sociological toolkit to help understand the dynamics of implementing, embedding, and integrating new technology, or complex intervention into routine practice.(14) NPT provides a conceptual framework for understanding and evaluating the processes (implementation) by which new health technologies and other complex interventions are routinely operationalized in everyday work (embedding), and sustained in practice (integration).(15–20) The theory is organized around four main constructs, each of which has its own subconstructs.(15) These constructs collectively offer insights into the feasibility, acceptability, and scalability of an intervention or innovation ( Figure 1 ). Each of these constructs and subconstructs offers a unique lens through which the feasibility, acceptability, and scalability of a new practice can be evaluated, thereby aiding in its effective implementation. Study setting The study was conducted between August 2022 and July 2023 at three healthcare facilities in Mwanza, Tanzania: Bugando Medical Centre (BMC), a zonal referral and teaching hospital; Makongoro Health Centre, located in the city center; and Igoma Health Centre, situated a few kilometers from the city center. All three facilities offer newborn and pediatric care among other health services. Providers Eligibility criteria. Providers included physicians (specialist/superspecialist), nursing officers, medical officers, clinical officers, assistant medical officers, medical attendants, or other providers enrolled in PACE or senior facility staff that supervise PACE providers. Recruitment process. Healthcare providers were informed about the study through their facility leaders, and individuals who responded to the survey were not necessarily the same as those who participated in the focus groups or in-depth interviews. Data Collection Tools NoMAD questionnaire. The NoMAD is a 23-item questionnaire based on NPT, designed to assess the social processes influencing the integration of complex interventions.(18,21) It includes 3 general items, and 20 related to specific NPT constructs (4 Coherence, 7 Collective Action, 4 Cognitive Participation, 5 Reflexive Monitoring).The general items were on a scale of 0-100 and NPT construct items were modified to include a five-point Likert scale (1-Strongly Agree, 5-Strongly Disagree)and additional options for respondents to indicate if a question is not relevant to their role, stage, or the intervention itself. NPT subconstruct survey items are listed in Table 1 , with the complete survey in the Supplementary Materials . In-depth interviews (IDIs) and focus group discussions (FGDs). Interview guides were developed based on the previous experience with similar data collection tools. Training and pretesting of tools were conducted by study investigators. Data collection process. NoMAD Survey. All PACE participants received the NoMAD survey invitations via WhatsApp 30 days post-intervention or upon initial learning completion of PACE. Data were collected through REDCap. Focus Group Discussions and In-depth interviews. We employed a purposeful sampling strategy for the qualitative components, selecting senior healthcare providers for in-depth interviews and junior providers for focus group discussions (FGDs). This approach ensured that participants and sites provided valuable insights into the research problem and central phenomenon. The data collection comprised of 24 interviews and 13 FGDs, commenced with a series of field visits and was guided by Normalization Process Theory (NPT) constructs. This ensured thematic consistency across both methods and facilitated methodological triangulation. The focus groups, segregated by sex but including a mix of cadres from each health facility, enriched the diversity of perspectives. The iterative nature of our methodology allowed for continuous refinement of our theoretical framework, methodologies, and sampling strategies, informed by emerging data. Consequently, the guides for both interviews and FGDs were dynamically modified to reflect the evolving study themes. All sessions were conducted in Kiswahili at the providers' work premises, adding contextual depth, and were meticulously audio-recorded, transcribed verbatim, and translated into English for analysis. Data Analysis Quantitative Analysis: Descriptive statistics are reported as frequencies and percentages or medians and interquartile ranges, with comparisons via Fisher’s exact test or Mann-Whitney U test as appropriate. Analyses were conducted using Stata 17.0 (Stata Corp, College Station, TX, USA). Qualitative Analysis: The analysis process, conducted concurrently with data collection, was instrumental in achieving theoretical saturation, marked by the cessation of new information from ongoing interviews and FGDs. To ensure the validity and depth of our findings, we implemented member checking and investigator triangulation, with two independent investigators coding and interpreting the data using NVivo 2020 software (QSR International Pty Ltd., Sydney, Australia). This software facilitated a hybrid coding approach that blended deductive and inductive methods for a comprehensive thematic content analysis. Contextual insights from the interviews and discussions were key to interpreting the findings, with representative quotations included to illustrate identified themes. Data triangulation was achieved using diverse data sources, and the research team's expertise further enhanced the rigor and reflexivity of the analysis. Summarizing for feasibility acceptability and scalability. We used Proctors definition of implementation outcomes and mapped to NPT subconstructs using the definition by May et al.(22,23) Feasibility is concerned with the practical aspects of implementing a new intervention, including resource allocation, training, and ease of integration into existing work. In NPT, this aligns closely with the construct of "Collective Action," which refers to the operational work that people do to enact a set of practices. To assess feasibility, we interpreted responses to “Sufficient training is provided to enable staff to use PACE” (collective action, skill set workability); “Sufficient resources are available to support PACE” and “Management adequately supports PACE” (collective action, contextual integration); and “I can easily integrate PACE into my existing work” (collective action, interactional workability). Acceptability refers to the extent to which the new intervention is agreeable or satisfactory among its users. To assess acceptability, we interpreted responses to “ Staff in this organization have a shared understanding of the purpose of PACE” (coherence: communal specification); “I believe that participating in PACE is a legitimate part of my role” (cognitive participation, legitimation); “The staff agree that PACE is worthwhile” (reflexive monitoring, communal appraisal); and “I value the effects PACE has had on my work” (reflexive monitoring, individual appraisal). In addition, we will compare scores between the zonal hospital and health centers. Scalability involves the ability to expand the intervention to other settings while maintaining its effectiveness. To assess scalability, we interpreted responses to “I will continue to support PACE” (cognitive participation, activation); “Work is assigned to those with skills appropriate to PACE” (collective action, skill set workability); Feedback about PACE can be used to improve it in the future” and “I can modify how I work with PACE” (reflexive monitoring, reconfiguration). Ethical Considerations. All providers provided informed consent, and the study was approved by the relevant ethical review boards. Techniques to enhance trustworthiness. Since processing and analysis of qualitative data was systematic, explicit, and reproducible, the validation and trustworthiness of the findings was established.(24) Reporting Guidelines. This study adheres to the STROBE and SRQR reporting guidelines for comprehensive and explicit reporting of observational and qualitative studies, respectively.(25,26) Results Introduction to Results The results section is organized to provide an in-depth analysis of both the implementation and impact of the Pediatric Acute Care Education (PACE) program. Initially, "Provider Demographics and Work Perceptions," offers three layers of data: descriptive statistics that characterize the healthcare providers who took part in the NoMAD survey, comparative analyses that differentiate between providers from a zonal hospital and health centers, and emergent themes from in-depth interviews (IDIs) and focus group discussions (FGDs) that shed light on providers' general perceptions of their roles in pediatric acute care. Following this, "Normalization Process Theory (NPT) Constructs" is bifurcated into an overview of general perceptions regarding PACE implementation and a detailed examination of the four principal NPT constructs—Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring. Each construct is scrutinized through a tripartite lens: descriptive data from the NoMAD survey, comparative analyses across different healthcare settings, and qualitative insights derived from IDIs and FGDs. Finally, "Summary of Feasibility, Acceptability, and Scalability," synthesizes all findings into descriptive and comparative categories to offer a comprehensive evaluation of PACE's potential for normalization within healthcare settings, while deliberately omitting thematic categories for a more focused interpretation. Provider Demographics and Work Perceptions Eighty-two of 272 healthcare providers completed the NoMAD survey, yielding a response rate of 30%. Of the 82 healthcare providers: 59 were from the zonal hospital and 23 from health centers. Median ages were 27 and 29 years for the zonal hospital and health centers, respectively ( Table 2 ). Gender distribution was similar in both settings (39% female in the zonal hospital, 43.5% in health centers). Significant cadre differences existed: the zonal hospital had more medical (47.5% vs. 8.7%) and nursing officers (42.4% vs. 30.4%), while health centers had more clinical officers (30.4% vs. 0%). Clinical experience varied, with medians of 1 year at the zonal hospital and 4 years at health centers (p-value: 0.004). Both settings had over 70% of providers with prior training. Job satisfaction scores were not significantly different between the two groups. IDI and Focus Group demographics. Seventy-nine healthcare providers participated in the study: 24 senior providers were interviewed (18 zonal hospital, 6 health centers) and 13 focus groups were held with junior providers (39 zonal hospital and 16 health centers). The focus group discussions varied in size, with an average of 4 participants per group. All cadres were represented: medical officers (26), nursing officers (19), interns (16), clinical officers (12), Assistant medical officers (3), and medical attendants (3). Clinical experience ranged from 1 to 20 years. Focus group themes for Provider Demographics and Work Perceptions. The overarching theme from the IDIs and FGDs was healthcare providers' active engagement in pediatric care, particularly for seriously ill newborns and children. The quotes elucidate the providers' daily responsibilities and specialized roles across different settings. A provider noted, "I deal with ill children daily. There's always a new transfer or admission." This statement highlights the relentless nature of pediatric care, emphasizing the ongoing attention to both new and existing cases. Another provider said, "I specialize in neonatology but attend to all children as per our country's laws." This underscores the specialized yet comprehensive roles some providers assume, adhering to broader healthcare mandates. A provider added, "I work in the labour ward, treating newborns who fall ill before reaching twenty-eight days." This comment reveals that even those in labour wards have pediatric responsibilities, extending the scope of care to include newborns who become ill. In summary, the quotes collectively depict healthcare providers as deeply committed to pediatric care, each with specialized roles but universally focused on patient well-being. NoMAD General Items Respondents showed high familiarity with PACE, evidenced by a median score of 89 out of 100, although an interquartile range of 76-100 indicates variability (Table 3, Figure 1). General satisfaction with PACE in current work had a median of 91 and a similar opinion range, as suggested by an interquartile range of 75-100. Optimism for PACE in future work was highest, with a median of 99 and an interquartile range of 87-100. No significant differences were observed between the zonal hospital and health centers in these variables. Normalization Process Theory (NPT) Constructs Coherence NoMAD data analysis Coherence, a key construct in PACE implementation, and its subconstructs reveal important trends. "Communal Specification" and “Internalization” had median scores of 2 (Agree) and 1 (Strongly Agree), respectively, with interquartile ranges of 1-2 for both indicating strong collective agreement on PACE's purpose and value (Table 3, Figure 1) . "Differentiation" and "Individual Specification" both had medians of 2 (Agree), suggesting moderate agreement that PACE is distinct, and roles are understood. Interquartile ranges were 1-4 for “Differentiation” and 2-4 for “Individual Specification,” indicating variability within subconstructs. Overall, data suggest strong collective and individual agreement on PACE's differentiation and value. For Coherence subconstructs, there were no significant differences in median scores or IQRs between settings indicating uniform perceptions of purpose, distinctiveness, and valuation of PACE across settings. Coherence Themes from IDI and FGD. Differentiation: Providers value PACE for its detailed guidance on specific pediatric cases, such as difficulty breathing, which was not covered in their basic training. One provider said, "PACE goes beyond basic knowledge, offering detailed steps for managing cases like difficulty breathing. This is a significant advantage." (Table 4) Communal Specification: PACE is seen as a tool for empowering providers to reduce child mortality and improve service quality, aligning with facility goals. One provider remarked, "PACE aims to empower us to reduce child mortality," while another noted, "Its objectives align with our hospital's goals to update healthcare providers' knowledge." Individual Specification: Providers believe PACE has enhanced their understanding and management of seriously ill children. One provider observed, "Before PACE, I relied on existing procedures and guidelines. Now, I've gained new insights that could positively impact our treatment system." Internalization: Providers find that PACE is consistent with Tanzanian and WHO guidelines, useful both in their work and in training medical students. One provider said, "PACE refreshes my memory and aligns with existing guidelines. I use it to educate medical students and junior doctors." Cognitive participation NoMAD data analysis Cognitive Participation, a construct examining collaboration around PACE, reveals strong agreement across its subconstructs. "Activation," measuring ongoing PACE support, had a median of 1, indicating strong agreement (Table 3, Figure 1) . "Enrolment" and "Initiation," with medians of 1 for both, also showed strong agreement for participation and leadership in PACE. "Legitimation," assessing PACE's work integration, also had a median of 1, suggesting strong agreement. IQRs ranged from 1-1 to 1-2, indicating some dispersion within subconstructs. Overall, data suggest strong agreement on PACE's support, participation, leadership, and legitimacy. There were no significant differences by setting, indicating consistent strong agreement on PACE across settings. Cognitive Participation Themes from IDI and FGD. Initiation: Providers were introduced to PACE by colleagues and supervisors, prompting them to enroll. One provider said, "Specialists introduced us to PACE, and we started learning." Another noted, "After seeing a colleague engage with PACE, I joined too." Some providers find individual initiation beneficial, as one stated, "Starting alone is effective." (Table 4) Legitimation: PACE is seen as empowering providers to enhance their pediatric care. One provider noted, "PACE taught me how to administer oxygen based on a child's age." Another highlighted PACE's flexibility, saying, "You can engage with PACE individually or in groups." Enrolment: Providers mainly use PACE individually but also share modules to spread knowledge. One provider said, "I often use PACE on my phone but also share modules with colleagues." Activation: Despite busy schedules, providers are committed to PACE training. One provider stated, "Our commitment helps translate knowledge into practice." Another emphasized their personal dedication, saying, "I find time to study PACE multiple times a week, showing my commitment." Collective Action NoMAD data analysis In the realm of Collective Action, focusing on collaborative PACE enactment, subconstructs reveal nuanced insights. "Interactional Workability," with a median of 1, suggests work required by PACE is generally manageable (Table 3, Figure 1) . "Relational Integration" showed strong disagreement that PACE disrupts relationships but agreement that it can be effectively used by peers. "Skill-set Workability" indicated mixed alignment with provider needs but strong consensus on sufficient PACE training. "Contextual Integration" had medians of 2, suggesting strong organizational support. Overall, data suggest varying agreement levels on work manageability, interpersonal relations, task allocation, and organizational support. "Relational Integration" showed a significant difference in one subconstruct (p=0.02), suggesting higher trust levels in the zonal hospital. There were no other differences by setting. Overall, data suggest consistent Collective Action approaches across settings, with a trust advantage in the zonal hospital. Collective Action Themes from IDI and FGD. Interactional Workability: PACE's digital format allows for individual study and facilitates group discussions. One provider noted, "PACE's digital nature allows for flexible study schedules." Group discussions often occur in the mornings, as another provider said, "We discuss PACE modules early before attending to patients." (Table 4) Relational Integration: Initially, providers engaged with PACE for personal benefit but later saw the value in sharing knowledge. One provider stated, "I initially used PACE for personal growth but later realized the importance of sharing this knowledge." Teamwork and collective benefits were emphasized, with one provider noting, "We work as a team to meet our objectives." Skill-set Workability: Providers value the practical application of PACE knowledge in patient care. One provider said, "After learning, it's crucial to apply this knowledge in treating patients." Contextual Integration: Challenges like inadequate supplies and lack of electricity hinder PACE implementation. One provider stated, "‘’Sometimes we face difficulties such as inadequate supply of medical equipment and supplies. For example, there is a child in need of oxygen while there is no electricity and we do not have standby generator. This becomes a barrier to translating PACE in practice." However, the availability of tools and support from PACE management facilitates implementation, as another provider noted, "Availability of tools and support has eased PACE's translation into practice." Reflexive Monitoring NoMAD data analysis In the context of Reflexive Monitoring, focusing on PACE appraisal, subconstructs reveal varying agreement levels. "Communal Appraisal" had a median of 2, suggesting strong collective agreement on PACE's benefit (Table 3, Figure 1) . "Individual Appraisal" had a median of 1, indicating strong individual agreement. "Reconfiguration," examining work modifications due to PACE, had a median of 2, showing slight agreement for work adjustments. "Systematization," assessing information access on PACE effects, had a median of 2, leaning towards strong agreement. Overall, data suggest strong agreement on PACE's collective and individual appraisal, work modification, and information access. There were no significant differences by setting, suggesting consistent agreement on PACE appraisal and modification across settings. Reflexive Monitoring Themes from IDI and FGD. Systematization: No quotes directly address this subconstruct, suggesting a need for further exploration within the PACE context. Communal Appraisal: Providers find PACE valuable for educating junior doctors, simplifying complex topics, and boosting confidence. One provider noted, "PACE aids in teaching junior doctors by simplifying complex topics and enhancing my confidence during discussions." (Table 4) Individual Appraisal: Providers believe PACE has enriched their knowledge and confidence in pediatric care. Quotes summarizing this sentiment include, "I've gained confidence and can act quickly in emergencies," and "I can provide timely service with increased courage." Reconfiguration: A notable challenge is the inaccessibility of learned material for future reference, hindering providers' ability to refresh their knowledge. One provider stated, "Once you complete a module, it becomes inaccessible, making it difficult to revisit for future case management." Summary of Feasibility, Acceptability, and Scalability. Overall, PACE is generally feasible across healthcare settings, with providers across settings either agreeing or strongly agreeing that people do the work required by interventions and their components (Interactional Workability), the work of interventions and their components supported by host organizations (Contextual Integration). PACE is also generally acceptable among healthcare providers. Providers collectively agree about the purpose of PACE and its components (Communal Specification), agree that PACE and its components are the right thing to do and should be part of their work (Legitimation), and the collectively and individually agree that PACE is worthwhile (Communal and Individual Appraisal). Lastly, PACE appears to be scalable, with some variability in its adaptability and skill-set alignment. The scalability subconstructs, mapped to NPT, indicate a mean score of 1.23 and a standard deviation of 0.42 for Providers strongly agree that they will continue to support PACE and its components (Activation), that they can modify their work in response to their appraisal of PACE, and feedback can be used to improve it in the future (Reconfiguration). Providers agree or are neutral about the work of PACE and its components being appropriately allocated to people (Skill-set Workability), indicating more work is needed to identify the correct providers to participate in PACE or more support needs to be allocated to those providers to complete PACE. Summary of Main Results Provider Demographics 82 healthcare providers participated in the NoMAD survey and 79 in interviews and discussions, with over 2/3 from the zonal hospital. Profession and years of clinical experience varied between zonal hospital and health centers with more physicians at the zonal hospital and more experienced providers at health centers. Healthcare providers are deeply involved in pediatric care and find value in PACE. NPT Constructs General High levels of familiarity and positive outlook towards the PACE intervention. No significant differences between the zonal hospital and health centers in general perceptions of PACE. Coherence PACE is seen as aligning with facility goals. General agreement on the collective and individual understanding of PACE. No significant differences between settings in understanding and planning for PACE. Cognitive Participation Strong agreement on ongoing support, participation, and legitimacy of PACE. PACE is seen as beneficial for managing specific pediatric cases. Consistent levels of agreement across both zonal hospitals and health centers. Collective Action Varying degrees of agreement on workability, interpersonal confidence, and organizational support. Generally consistent approach across both settings, with a notable difference in relational integration favoring the zonal hospital. Challenges: Inadequate supplies and lack of electricity noted as barriers to PACE implementation. Reflexive Monitoring Strong agreement in the collective and individual appraisal of PACE. Consistent agreement across both settings in the appraisal and modification of PACE. Challenge: Inaccessibility of learned material for future reference. Feasibility, Acceptability, Scalability PACE is generally feasible, acceptable, and potentially scalable across different healthcare settings, with some variability due to challenges and material inaccessibility. Discussion Interpretation of Findings The mixed-methods pilot study was designed to explore the feasibility and acceptability of the PACE intervention among healthcare providers in Mwanza, Tanzania. Utilizing the Normalization Process Theory (NPT) as a guiding framework, the study revealed several key insights. The NoMAD general questions regarding "Familiarity of PACE," "PACE as current work," and "PACE as future work" reveal insights into respondents' perceptions of how well the intervention is being received in their work environment. The higher scores indicate a more positive outlook towards normalization, which can be a useful metric for stakeholders, but the wide variability of responses for familiarity and current work indicate that this optimism is not universal. PACE appears to be well-understood and recognizable among those who are implementing it, already well integrated into routine work, and respondents feel positive that PACE has the potential to become a normalized part of work in the future. Firstly, the high levels of coherence among healthcare providers indicate that PACE is well-understood and aligns with the existing goals and practices of healthcare facilities. This is a crucial factor for the successful implementation of any healthcare intervention, as a clear understanding (i.e., how providers made sense of and accept change) among stakeholders is often the first step towards effective implementation.( 27 ) Secondly, the strong cognitive participation suggests that healthcare providers are not only willing but also eager to engage with PACE. The fact that providers enrolled and rallied behind PACE may indicate that the benefits were clear to them, so they were sufficiently motivated to invest their thoughts and energy into PACE, though at varying levels. This finding is in agreement with what was found by Agreli and colleagues.( 28 ) This is particularly important in the context of pediatric care, where timely and effective interventions can have a significant impact on patient outcomes. The willingness of healthcare providers to engage with PACE is a positive indicator of its long-term sustainability. Thirdly, the study found varying degrees of collective action among healthcare providers. While there was general agreement on the workability and benefits of PACE, some challenges were noted, particularly in terms of resource availability and infrastructural support. However, as pointed out by MacCrorie and colleagues,( 29 ) the extent to which the providers perceived that PACE had prepared them for implementation was influenced by the perceived compatibility of PACE within existing work practice. These challenges need to be addressed to ensure the effective and sustainable implementation of PACE. Lastly, the study was limited in its ability to assess reflexive monitoring due to its short duration. However, the initial findings suggest that healthcare providers find value in PACE and are likely to continue using it, subject to certain improvements. Ample time is needed to allow for reflexive monitoring to mature and be realized. This is consistent with a study by Mishuris and colleagues who found that monitoring domain had the lowest scores due to being a future step in the implementation process.( 30 ) Implications for Implementation Science and Pediatric Acute Care The study's findings have several implications for the fields of implementation science and pediatric acute care. From an implementation science perspective, the study demonstrates the utility of NPT as a conceptual framework for understanding the complexities involved in implementing adaptive e-learnings in LMICs. We observed, like studies reported by May and colleagues,( 18 ) that coherence or sense-making was seen as a necessary precursor to participation, and a degree of cognitive participation was required before collective action-in the form of an actual implementation process-could take place. Sense-making work was also found to be a key to the successful implementation of an enhanced recovery after surgery programme.( 31 ) The use of NPT allowed for a nuanced understanding of the various factors that could influence the implementation of PACE, providing valuable insights that could be applied to other healthcare interventions. In the context of pediatric acute care, the study's findings are particularly significant. The strong agreement among healthcare providers on the benefits of PACE for managing specific pediatric cases suggests that the program could be a valuable addition to pediatric acute care at different facility types to increase provider proficiency. Given the often time-sensitive nature of pediatric cases, the effective and efficient training provided by PACE could lead to improved patient outcomes. Limitations While the study provides valuable insights, it is not without limitations. The most significant limitation is the small sample size, which affects the generalizability of the findings. Another limitation is the potential for response bias, given our response rate. Additionally, the study's short duration did not allow for a comprehensive assessment of all NPT constructs, particularly reflexive monitoring. This limits our understanding of the long-term sustainability and impact of PACE. The study is limited by its reliance on self-reported data, which may introduce social desirability bias. However, the mixed-methods approach and methodological triangulation enhance the robustness of the findings. Recommendations for Future Research Given the limitations and the scope of this pilot study, several avenues for future research are evident. Longitudinal studies are needed to assess the long-term sustainability and impact of PACE on provider proficiency, patient outcomes and quality of care. Such studies could provide insights into how PACE is embedded and integrated into routine healthcare practices over time. Additionally, more rigorous qualitative research designs could be employed to further explore the nuances of each NPT construct. Detailed case studies and ethnographic studies could provide a more in-depth understanding of the challenges and opportunities associated with implementing PACE. Furthermore, future research could focus on the scalability of PACE, exploring how the program could be adapted for different healthcare settings or for healthcare systems in other countries. This could include an assessment of the resource implications of scaling up PACE, as well as an evaluation of the training and support needed for effective implementation in different contexts. Conclusions This study provides valuable insights into the feasibility and acceptability of the PACE program among healthcare providers in Mwanza, Tanzania. The findings suggest that PACE is well-received and aligns well with the goals of healthcare providers, particularly in the context of pediatric care. However, challenges related to resource availability and infrastructural support need to be addressed to ensure the program's effective and sustainable implementation. The study also highlights the utility of NPT as a conceptual framework for understanding the complexities involved in implementing healthcare interventions, providing valuable insights for both implementation science and pediatric acute care. Abbreviations BMC Bugando Medical Centre e learning-Electronic Learning FGD Focus Group Discussion IDI In-Depth Interview LMIC Low-or-Middle-Income Country NPT Normalization Process Theory NoMAD Normalization Measure Development PACE Pediatric Acute Care Education Declarations Ethics approval and consent to participate. The Institutional Review Board of the Tanzania National Institute of Medical Research (NIMR/HO/R.8a/Vol.IX/3990), Stanford University (60379), the ethics committee of the Catholic University of Health and Allied Science (no ID number given), and the Mwanza Regional Medical Officer (Ref. No. AG.52/290/01A/115) approved the study protocol including consent procedures. Data collection procedures were completed in compliance with the guidelines of the Health Insurance Portability and Accountability Act (HIPAA) to ensure subject confidentiality. Informed electronic consent was obtained through REDCap from all providers who participated in PACE. 55 All providers who completed consent were included. All surveys and questionnaires were entered directly by providers into REDCap. This study is reported according to the Consolidated Standards of Reporting Trials (CONSORT) 2010 extension to randomized pilot and feasibility trials. Consent for publication All individual persons' data included in this study are entirely unidentifiable and there are no details on individuals reported within the manuscript. Therefore, consent for publication is not applicable for this study. If there were any identifiable details, images, or videos relating to individual persons, consent would be obtained from those persons or, in the case of children, their parent or legal guardian and noted in this section accordingly. Availability of data and materials Deidentified participant data from this study are available upon reasonable request. Interested researchers may obtain the data by contacting the corresponding author, Dr. Peter Meaney, at [email protected] . Access to the data will be granted following approval by an independent review committee, established to evaluate the scientific validity and ethical justification of the proposed use. Please note that only the deidentified participant data is available, and no additional supporting information, such as study protocols or statistical analysis plans, will be provided. This process ensures that the data is used responsibly and in accordance with ethical research standards. Competing interests BR and MB are compensated by Area 9 Lyceum as Senior Learning Architect and Medical Director, respectively. Funding This study was funded by the Laerdal Foundation for Acute Medicine, Stanford University School of Medicine Maternal and Child Health Research Institute, Stanford Center for Innovation in Global Health, and the Stanford University School of Medicine Division of Pediatric Critical Care Medicine. Funding sources had no role in project design, data collection, analysis, or interpretation; reporting, or the decision to submit results for publication. Stanford CTSA award number UL1 TR001085 from NIH/NCRR. Authors' contributions RM, AH, HN, and PAM contributed to study conception and design, data acquisition, analysis, and interpretation. TM, NC, NPM, and AA contributed to study conception and design, and interpretation of data. FSK, MB, and ZS contributed to study conception and design, and analysis of data. DT, RPM, BR, and CM contributed to the analysis and interpretation of data. ED contributed to the interpretation of data. All authors drafted the work or revised it critically for important intellectual content, approved the final version to be published, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Acknowledgements We are grateful to healthcare providers from Bugando Medical Centre, Makongoro and Igoma Health Centres in Mwanza City Tanzania, who participated in the study for their time, cooperation, and invaluable feedback. The authors would like to thank the Pediatric Association of Tanzania; the Tanzanian Ministry of Health, Regional and Council Health Management Teams for participating in stakeholder meetings. We thank the Catholic University of Health and Allied Sciences, London School of Hygiene and Tropical Medicine, Paediatric Association of Tanzania, and Area 9 for practical support. Additional Declarations REDCap Database. Study data were collected and managed using REDCap electronic data capture tools hosted at Stanford University. 71,72 REDCap (Research Electronic Data Capture) is a secure, web-based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for data integration and interoperability with external sources. The Stanford REDCap platform (http://redcap.stanford.edu) is developed and operated by the Stanford Medicine Research IT team. The REDCap platform services at Stanford are subsidized by a) the Stanford School of Medicine Research Office, and b) the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through grant UL1 TR001085. Area9 Rhapsode™ meets the requirements for full GDPR compliance including encryption, data security, and 'forget me'. Use of ChatGPT: We employed ChatGPT in two ways: 1) to edit and revise manuscripts for clarity, to ensure adherence to writing standards (such as STROBE, SRQR) and to format manuscripts, tables, and figures; and 2) to conduct preliminary data screening/monitoring using de-identified exported from our data from our REDCap databases. All statistical results and conclusions in this manuscript are confirmed by a biostatistician or member of the author group. Patient and public involvement. This research was done without patient involvement. Patients were not invited to comment on the study design and were not consulted to develop patient-relevant outcomes or interpret the results. Patients were not invited to contribute to the writing or editing of this document for readability or accuracy. References Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet. 2018. Lewis TP, Roder-DeWan S, Malata A, Ndiaye Y, Kruk ME. Clinical performance among recent graduates in nine low- and middle-income countries. Trop Med Int Health. 2019;24(5):620–35. Perin J, Mulick A, Yeung D, Villavicencio F, Lopez G, Strong KL, et al. Global, regional, and national causes of under-5 mortality in 2000–19: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet Child Adolesc Health. 2022;6(2):106–15. Sharrow D, Hug L, Lee S, Liu Y, Danzhen You. Levels & Trends in Child Mortality: Report 2021, Estimates developed by the United Nations Inter-agency Group for Child Mortality Estimation. New York: United Nations Children’s Fund; 2021. UNICEF DATA [Internet]. [cited 2023 Jun 11]. United Republic of Tanzania (TZA) - Demographics, Health & Infant Mortality. https://data.unicef.org/country/tza/ . Di Giorgio L, Evans DK, Lindelow M, Nguyen SN, Svensson J, Wane W et al. Analysis of clinical knowledge, absenteeism and availability of resources for maternal and child health: a cross-sectional quality of care study in 10 African countries. BMJ Glob Health. 2020;5(12). Bloom BS. The 2 Sigma Problem: The Search for Methods of Group Instruction as Effective as One-to-One Tutoring. Educ Res. 1984;13(6):4–16. Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D, Rowe AK. A systematic review of the effectiveness of strategies to improve health care provider performance in low- and middle-income countries: Methods and descriptive results. PLoS ONE. 2019;14(5):e0217617. Meaney PA, Sutton RM, Tsima B, Steenhoff AP, Shilkofski N, Boulet JR, et al. Training hospital providers in basic CPR skills in Botswana: acquisition, retention and impact of novel training techniques. Resuscitation. 2012;83(12):1484–90. Meaney PA, Topjian AA, Chandler HK, Botha M, Soar J, Berg RA, et al. Resuscitation training in developing countries: a systematic review. Resuscitation. 2010;81(11):1462–72. WHO. Recommendations on Digital Interventions for Health System Strengthening. Geneva: World Health Organization; 2019 p. Licence: CC BY-NC-SA 3.0 IGO. Meaney PA, Hokororo A, Masenge T, Mwanga J, Kalabamu FS, Berg M, et al. Development of pediatric acute care education (PACE): An adaptive electronic learning (e-learning) environment for healthcare providers in Tanzania. Digit Health. 2023;9:20552076231180471. Meaney P, Hokororo A, Ndosi H, Dahlen A, Jacob T, Mwanga JR et al. Feasibility of an Adaptive E-Learning Environment to Improve Provider Proficiency in Essential and Sick Newborn Care in Mwanza, Tanzania [Internet]. medRxiv; 2023 [cited 2023 Aug 30]. p. 2023.07.11.23292406. https://www.medrxiv.org/content/ 10.1101/2023.07.11.23292406v1 . Finch TL, Girling M, May CR, Mair FS, Murray E, Treweek S, et al. Improving the normalization of complex interventions: part 2 - validation of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT). BMC Med Res Methodol. 2018;18(1):135. May C, Finch T. Implementing, Embedding, and Integrating Practices: An Outline of Normalization Process Theory. Sociology. 2009;43(3):535–54. May C. A rational model for assessing and evaluating complex interventions in health care. BMC Health Serv Res. 2006;6(1):86. May CR, Mair F, Finch T, MacFarlane A, Dowrick C, Treweek S, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci. 2009;4(1):29. May CR, Cummings A, Girling M, Bracher M, Mair FS, May CM, et al. Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implement Sci. 2018;13(1):80. Murray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C, et al. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med. 2010;8(1):63. McEvoy R, Ballini L, Maltoni S, O’Donnell CA, Mair FS, MacFarlane A. A qualitative systematic review of studies using the normalization process theory to research implementation processes. Implement Sci. 2014;9(1):2. Finch TL, Rapley T, Girling M, Mair FS, Murray E, Treweek S, et al. Improving the normalization of complex interventions: measure development based on normalization process theory (NoMAD): study protocol. Implement Sci. 2013;8(1):43. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. Adm Policy Ment Health Ment Health Serv Res. 2011;38(2):65–76. May CR, Albers B, Bracher M, Finch TL, Gilbert A, Girling M, et al. Translational framework for implementation evaluation and research: a normalisation process theory coding manual for qualitative research and instrument development. Implement Sci. 2022;17(1):19. Greenhalgh T, Taylor R. How to read a paper: Papers that go beyond numbers (qualitative research). BMJ. 1997;315(7110):740–3. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335(7624):806–8. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med J Assoc Am Med Coll. 2014;89(9):1245–51. Gould DJ, Hale R, Waters E, Allen D. Promoting health workers’ ownership of infection prevention and control: using Normalization Process Theory as an interpretive framework. J Hosp Infect. 2016;94(4):373–80. Agreli H, Barry F, Burton A, Creedon S, Drennan J, Gould D, et al. Ethnographic study using Normalization Process Theory to understand the implementation process of infection prevention and control guidelines in Ireland. BMJ Open. 2019;9(8):e029514. McCrorie C, Benn J, Johnson OA, Scantlebury A. Staff expectations for the implementation of an electronic health record system: a qualitative study using normalisation process theory. BMC Med Inf Decis Mak. 2019;19(1):222. Mishuris RG, Palmisano J, McCullagh L, Hess R, Feldstein DA, Smith PD, et al. Using normalisation process theory to understand workflow implications of decision support implementation across diverse primary care settings. BMJ Health Care Inf. 2019;26(1):e100088. Sutton E, Herbert G, Burden S, Lewis S, Thomas S, Ness A, et al. Using the Normalization Process Theory to qualitatively explore sense-making in implementation of the Enhanced Recovery After Surgery programme: It’s not rocket science. PLoS ONE. 2018;13(4):e0195890. Tables Tables 1-4 is available in the Supplementary Files section. Additional Declarations Competing interest reported. BR and MB are compensated by Area 9 Lyceum as Senior Learning Architect and Medical Director, respectively. Supplementary Files PACEInitialImplentBMCHSRTable1.docx PACEInitialImplentBMCHSRTable2.docx PACEInitialImplentBMCHSRTable3.docx PACEInitialImplentBMCHSRTable4.docx PACEInitialImplentBMCHSRSupplementaryMaterials.docx Cite Share Download PDF Status: Published Journal Publication published 13 Sep, 2024 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 26 Jun, 2024 Reviews received at journal 25 Jun, 2024 Reviewers agreed at journal 17 Jun, 2024 Reviews received at journal 14 Jun, 2024 Reviewers agreed at journal 04 Jun, 2024 Reviewers invited by journal 02 Jun, 2024 Editor assigned by journal 22 May, 2024 Submission checks completed at journal 19 May, 2024 First submitted to journal 16 May, 2024 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4432440","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":305526894,"identity":"1ee19c14-4cfc-4cf7-8306-54d9ff4f7477","order_by":0,"name":"Joseph R Mwanga","email":"","orcid":"","institution":"Catholic University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"R","lastName":"Mwanga","suffix":""},{"id":305526897,"identity":"c678fe4f-05fc-4021-b2e2-238ccb205b08","order_by":1,"name":"Adolfine Hokororo","email":"","orcid":"","institution":"Catholic University of Health and 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Tanzania","correspondingAuthor":false,"prefix":"","firstName":"Florence","middleName":"S","lastName":"Kalabamu","suffix":""},{"id":305526904,"identity":"3106e546-e996-490c-b37a-84d59002da3b","order_by":5,"name":"Daniel Tawfik","email":"","orcid":"","institution":"Stanford University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Tawfik","suffix":""},{"id":305526907,"identity":"a3d0d3a8-8225-4820-aaac-84591a11af69","order_by":6,"name":"Rishi P Mediratta","email":"","orcid":"","institution":"Stanford University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Rishi","middleName":"P","lastName":"Mediratta","suffix":""},{"id":305526912,"identity":"4db67072-49a4-4567-84ad-932d03334f0d","order_by":7,"name":"Boris Rozenfeld","email":"","orcid":"","institution":"Area9 Lyceum","correspondingAuthor":false,"prefix":"","firstName":"Boris","middleName":"","lastName":"Rozenfeld","suffix":""},{"id":305526915,"identity":"bf79c7dc-4b82-4098-8b47-b892b2421872","order_by":8,"name":"Marc Berg","email":"","orcid":"","institution":"Stanford University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Marc","middleName":"","lastName":"Berg","suffix":""},{"id":305526924,"identity":"35a92f74-7640-41b2-a401-8b5f01f5ee2f","order_by":9,"name":"Zachary H Smith","email":"","orcid":"","institution":"Kaiser Permanente","correspondingAuthor":false,"prefix":"","firstName":"Zachary","middleName":"H","lastName":"Smith","suffix":""},{"id":305526926,"identity":"28bfd114-ed1c-4913-888f-10ef16b54dd4","order_by":10,"name":"Neema Chami","email":"","orcid":"","institution":"Catholic University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Neema","middleName":"","lastName":"Chami","suffix":""},{"id":305526927,"identity":"5d791f1c-d245-499e-ae40-a882df354755","order_by":11,"name":"Namala P Mkopi","email":"","orcid":"","institution":"Pediatric Association of Tanzania","correspondingAuthor":false,"prefix":"","firstName":"Namala","middleName":"P","lastName":"Mkopi","suffix":""},{"id":305526928,"identity":"db4dc49f-26df-43ad-996f-198ad0f21352","order_by":12,"name":"Castory Mwanga","email":"","orcid":"","institution":"Pediatric Association of Tanzania","correspondingAuthor":false,"prefix":"","firstName":"Castory","middleName":"","lastName":"Mwanga","suffix":""},{"id":305526929,"identity":"ba3c4b2c-8857-4673-9db1-57d3dc0d33d1","order_by":13,"name":"Enock Diocles","email":"","orcid":"","institution":"Catholic University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Enock","middleName":"","lastName":"Diocles","suffix":""},{"id":305526931,"identity":"68fe6fc5-b05d-4d66-b333-be2628de0787","order_by":14,"name":"Ambrose Agweyu","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ambrose","middleName":"","lastName":"Agweyu","suffix":""},{"id":305526932,"identity":"250cd750-a1de-4fa0-820d-074772cec9e4","order_by":15,"name":"Peter A Meaney","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBACgwNQBj+YtAFioIgEPi2WMC2SDcxAMo0ILfYwLQYHiNVidrz52YOPbXfkjc+fP/i5IMEmn+8A88HbPPi0nDlmbjiz7ZnhthvJzNIzEtIsZx5gS7bGq+VGgpk0b9thxm03mBmkeX8cNjA4wGMmjU+Lwf3n36T/th2239x/mPk3TwJIC/83/FpuAM1kbDucuIEhmU0aooWHDb+WMzllkj3nniXPuJFsZs2TkGYgeZjN2HIOPi3Hj2+T+FF2x7a//+Dj2zwJNgZ8x5sf3niDRwsYMLIdQOIxE1IOBn8OEFQyCkbBKBgFIxgAACYKVBvpjapCAAAAAElFTkSuQmCC","orcid":"","institution":"Stanford University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Peter","middleName":"A","lastName":"Meaney","suffix":""}],"badges":[],"createdAt":"2024-05-16 16:49:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4432440/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4432440/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-024-11554-3","type":"published","date":"2024-09-13T15:58:25+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":57518760,"identity":"2ecb6327-8195-45c0-848d-9b6c439fc0a4","added_by":"auto","created_at":"2024-05-31 20:37:30","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":253760,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBoxplot of Participant Responses to NoMAD Survey by NPT construct and subconstruct.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4432440/v1/35bcd86fcf1ddb2190cccdfe.jpg"},{"id":64619355,"identity":"2fdd2b90-bff0-4bde-bd1f-95ed130ae7a2","added_by":"auto","created_at":"2024-09-16 16:14:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1343813,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4432440/v1/9953a6b7-841c-42d4-b919-d3c5b58ea9f7.pdf"},{"id":57518764,"identity":"e5c6681c-fe44-4a25-997d-707cf24a2631","added_by":"auto","created_at":"2024-05-31 20:37:30","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24706,"visible":true,"origin":"","legend":"","description":"","filename":"PACEInitialImplentBMCHSRTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4432440/v1/66a845c97311315db5b58513.docx"},{"id":57518761,"identity":"1b60aa8c-4e22-48a0-b4f2-b7d96c50e44a","added_by":"auto","created_at":"2024-05-31 20:37:30","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20374,"visible":true,"origin":"","legend":"","description":"","filename":"PACEInitialImplentBMCHSRTable2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4432440/v1/d524147c2dbf7a2d5ec68462.docx"},{"id":57518763,"identity":"8156c1cc-f0a2-4c59-a579-76af021a424c","added_by":"auto","created_at":"2024-05-31 20:37:30","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":39140,"visible":true,"origin":"","legend":"","description":"","filename":"PACEInitialImplentBMCHSRTable3.docx","url":"https://assets-eu.researchsquare.com/files/rs-4432440/v1/3b128b5ffd9584fdd912cd00.docx"},{"id":57518762,"identity":"fc77129e-ccc9-413e-896b-21ac7e31354d","added_by":"auto","created_at":"2024-05-31 20:37:30","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":30425,"visible":true,"origin":"","legend":"","description":"","filename":"PACEInitialImplentBMCHSRTable4.docx","url":"https://assets-eu.researchsquare.com/files/rs-4432440/v1/5585e854c5fa1e708e20cf23.docx"},{"id":57518766,"identity":"b2dd3ff8-8755-4a7d-a787-b3ff1ea629aa","added_by":"auto","created_at":"2024-05-31 20:37:30","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":295999,"visible":true,"origin":"","legend":"","description":"","filename":"PACEInitialImplentBMCHSRSupplementaryMaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-4432440/v1/ace9ec8071b3f5267bfe28bc.docx"}],"financialInterests":"Competing interest reported. BR and MB are compensated by Area 9 Lyceum as Senior Learning Architect and Medical Director, respectively.","formattedTitle":"Evaluating the Implementation of the Pediatric Acute Care Education (PACE) Program in Northwestern Tanzania: A Mixed-Methods Study Guided by Normalization Process Theory","fulltext":[{"header":"Contributions to the Literature","content":"\u003cp\u003e\u003cstrong\u003eIntroduces PACE:\u003c/strong\u003e This study uniquely evaluates the Pediatric Acute Care Education (PACE) program in a low-resource setting, offering initial evidence on its implementation and potential impact on pediatric care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUtilizes NPT Framework:\u003c/strong\u003e By employing Normalization Process Theory (NPT), the research provides a novel methodological example of how to assess the incorporation of e-learning in LMIC clinical settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInforms Implementation Strategies:\u003c/strong\u003e The findings contribute to the design of effective e-learning strategies for healthcare education in LMICs, suggesting practical steps for broader application.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExpands Local Capacity:\u003c/strong\u003e Demonstrates how PACE can build local healthcare capacity, informing ongoing efforts to sustainably improve pediatric care through education in similar environments.\u003c/p\u003e\n\u003ch3\u003eIntroduction to Results\u003c/h3\u003e\n\u003cp\u003eThe results section is organized to provide an in-depth analysis of both the implementation and impact of the Pediatric Acute Care Education (PACE) program. Initially, \"Provider Demographics and Work Perceptions,\" offers three layers of data: descriptive statistics that characterize the healthcare providers who took part in the NoMAD survey, comparative analyses that differentiate between providers from a zonal hospital and health centers, and emergent themes from in-depth interviews (IDIs) and focus group discussions (FGDs) that shed light on providers' general perceptions of their roles in pediatric acute care. Following this, \"Normalization Process Theory (NPT) Constructs\" is bifurcated into an overview of general perceptions regarding PACE implementation and a detailed examination of the four principal NPT constructs\u0026mdash;Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring. Each construct is scrutinized through a tripartite lens: descriptive data from the NoMAD survey, comparative analyses across different healthcare settings, and qualitative insights derived from IDIs and FGDs. Finally, \"Summary of Feasibility, Acceptability, and Scalability,\" synthesizes all findings into descriptive and comparative categories to offer a comprehensive evaluation of PACE's potential for normalization within healthcare settings, while deliberately omitting thematic categories for a more focused interpretation.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eProvider Demographics and Work Perceptions\u003c/h2\u003e \u003cp\u003eEighty-two of 272 healthcare providers completed the NoMAD survey, yielding a response rate of 30%. Of the 82 healthcare providers: 59 were from the zonal hospital and 23 from health centers. Median ages were 27 and 29 years for the zonal hospital and health centers, respectively (\u003cb\u003eTable\u0026nbsp;2\u003c/b\u003e). Gender distribution was similar in both settings (39% female in the zonal hospital, 43.5% in health centers). Significant cadre differences existed: the zonal hospital had more medical (47.5% vs. 8.7%) and nursing officers (42.4% vs. 30.4%), while health centers had more clinical officers (30.4% vs. 0%). Clinical experience varied, with medians of 1 year at the zonal hospital and 4 years at health centers (p-value: 0.004). Both settings had over 70% of providers with prior training. Job satisfaction scores were not significantly different between the two groups.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIDI and Focus Group demographics.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSeventy-nine healthcare providers participated in the study: 24 senior providers were interviewed (18 zonal hospital, 6 health centers) and 13 focus groups were held with junior providers (39 zonal hospital and 16 health centers). The focus group discussions varied in size, with an average of 4 participants per group. All cadres were represented: medical officers (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), nursing officers (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), interns (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), clinical officers (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), Assistant medical officers (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and medical attendants (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Clinical experience ranged from 1 to 20 years.\u003c/p\u003e \u003cp\u003e \u003cem\u003eFocus group themes for Provider Demographics and Work Perceptions.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe overarching theme from the IDIs and FGDs was healthcare providers' active engagement in pediatric care, particularly for seriously ill newborns and children. The quotes elucidate the providers' daily responsibilities and specialized roles across different settings.\u003c/p\u003e \u003cp\u003eA provider noted, \"I deal with ill children daily. There's always a new transfer or admission.\" This statement highlights the relentless nature of pediatric care, emphasizing the ongoing attention to both new and existing cases.\u003c/p\u003e \u003cp\u003eAnother provider said, \"I specialize in neonatology but attend to all children as per our country's laws.\" This underscores the specialized yet comprehensive roles some providers assume, adhering to broader healthcare mandates.\u003c/p\u003e \u003cp\u003eA provider added, \"I work in the labour ward, treating newborns who fall ill before reaching twenty-eight days.\" This comment reveals that even those in labour wards have pediatric responsibilities, extending the scope of care to include newborns who become ill.\u003c/p\u003e \u003cp\u003eIn summary, the quotes collectively depict healthcare providers as deeply committed to pediatric care, each with specialized roles but universally focused on patient well-being.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eNoMAD General Items\u003c/h2\u003e \u003cp\u003eRespondents showed high familiarity with PACE, evidenced by a median score of 89 out of 100, although an interquartile range of 76\u0026ndash;100 indicates variability \u003cb\u003e(Table\u0026nbsp;3\u003c/b\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. General satisfaction with PACE in current work had a median of 91 and a similar opinion range, as suggested by an interquartile range of 75\u0026ndash;100. Optimism for PACE in future work was highest, with a median of 99 and an interquartile range of 87\u0026ndash;100. No significant differences were observed between the zonal hospital and health centers in these variables.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eNormalization Process Theory (NPT) Constructs\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eCoherence\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section4\"\u003e \u003ch2\u003eNoMAD data analysis\u003c/h2\u003e \u003cp\u003eCoherence, a key construct in PACE implementation, and its subconstructs reveal important trends. \"Communal Specification\" and \u0026ldquo;Internalization\u0026rdquo; had median scores of 2 (Agree) and 1 (Strongly Agree), respectively, with interquartile ranges of 1\u0026ndash;2 for both indicating strong collective agreement on PACE's purpose and value \u003cb\u003e(Table\u0026nbsp;3\u003c/b\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. \"Differentiation\" and \"Individual Specification\" both had medians of 2 (Agree), suggesting moderate agreement that PACE is distinct, and roles are understood. Interquartile ranges were 1\u0026ndash;4 for \u0026ldquo;Differentiation\u0026rdquo; and 2\u0026ndash;4 for \u0026ldquo;Individual Specification,\u0026rdquo; indicating variability within subconstructs. Overall, data suggest strong collective and individual agreement on PACE's differentiation and value.\u003c/p\u003e \u003cp\u003eFor Coherence subconstructs, there were no significant differences in median scores or IQRs between settings indicating uniform perceptions of purpose, distinctiveness, and valuation of PACE across settings.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCoherence Themes from IDI and FGD.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDifferentiation: Providers value PACE for its detailed guidance on specific pediatric cases, such as difficulty breathing, which was not covered in their basic training. One provider said, \"PACE goes beyond basic knowledge, offering detailed steps for managing cases like difficulty breathing. This is a significant advantage.\"\u003cb\u003e(Table\u0026nbsp;4)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCommunal Specification: PACE is seen as a tool for empowering providers to reduce child mortality and improve service quality, aligning with facility goals. One provider remarked, \"PACE aims to empower us to reduce child mortality,\" while another noted, \"Its objectives align with our hospital's goals to update healthcare providers' knowledge.\"\u003c/p\u003e \u003cp\u003eIndividual Specification: Providers believe PACE has enhanced their understanding and management of seriously ill children. One provider observed, \"Before PACE, I relied on existing procedures and guidelines. Now, I've gained new insights that could positively impact our treatment system.\"\u003c/p\u003e \u003cp\u003e Internalization: Providers find that PACE is consistent with Tanzanian and WHO guidelines, useful both in their work and in training medical students. One provider said, \"PACE refreshes my memory and aligns with existing guidelines. I use it to educate medical students and junior doctors.\"\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eCognitive participation\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eNoMAD data analysis\u003c/h2\u003e \u003cp\u003eCognitive Participation, a construct examining collaboration around PACE, reveals strong agreement across its subconstructs. \"Activation,\" measuring ongoing PACE support, had a median of 1, indicating strong agreement \u003cb\u003e(Table\u0026nbsp;3\u003c/b\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. \"Enrolment\" and \"Initiation,\" with medians of 1 for both, also showed strong agreement for participation and leadership in PACE. \"Legitimation,\" assessing PACE's work integration, also had a median of 1, suggesting strong agreement. IQRs ranged from 1\u0026ndash;1 to 1\u0026ndash;2, indicating some dispersion within subconstructs. Overall, data suggest strong agreement on PACE's support, participation, leadership, and legitimacy.\u003c/p\u003e \u003cp\u003eThere were no significant differences by setting, indicating consistent strong agreement on PACE across settings.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCognitive Participation Themes from IDI and FGD.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eInitiation: Providers were introduced to PACE by colleagues and supervisors, prompting them to enroll. One provider said, \"Specialists introduced us to PACE, and we started learning.\" Another noted, \"After seeing a colleague engage with PACE, I joined too.\" Some providers find individual initiation beneficial, as one stated, \"Starting alone is effective.\" \u003cb\u003e(Table\u0026nbsp;4)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eLegitimation: PACE is seen as empowering providers to enhance their pediatric care. One provider noted, \"PACE taught me how to administer oxygen based on a child's age.\" Another highlighted PACE's flexibility, saying, \"You can engage with PACE individually or in groups.\"\u003c/p\u003e \u003cp\u003eEnrolment: Providers mainly use PACE individually but also share modules to spread knowledge. One provider said, \"I often use PACE on my phone but also share modules with colleagues.\"\u003c/p\u003e \u003cp\u003eActivation: Despite busy schedules, providers are committed to PACE training. One provider stated, \"Our commitment helps translate knowledge into practice.\" Another emphasized their personal dedication, saying, \"I find time to study PACE multiple times a week, showing my commitment.\"\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCollective Action\u003c/h2\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eNoMAD data analysis\u003c/h2\u003e \u003cp\u003eIn the realm of Collective Action, focusing on collaborative PACE enactment, subconstructs reveal nuanced insights. \"Interactional Workability,\" with a median of 1, suggests work required by PACE is generally manageable \u003cb\u003e(Table\u0026nbsp;3\u003c/b\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. \"Relational Integration\" showed strong disagreement that PACE disrupts relationships but agreement that it can be effectively used by peers. \"Skill-set Workability\" indicated mixed alignment with provider needs but strong consensus on sufficient PACE training. \"Contextual Integration\" had medians of 2, suggesting strong organizational support. Overall, data suggest varying agreement levels on work manageability, interpersonal relations, task allocation, and organizational support.\u003c/p\u003e \u003cp\u003e\"Relational Integration\" showed a significant difference in one subconstruct (p\u0026thinsp;=\u0026thinsp;0.02), suggesting higher trust levels in the zonal hospital. There were no other differences by setting. Overall, data suggest consistent Collective Action approaches across settings, with a trust advantage in the zonal hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCollective Action Themes from IDI and FGD.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eInteractional Workability: PACE's digital format allows for individual study and facilitates group discussions. One provider noted, \"PACE's digital nature allows for flexible study schedules.\" Group discussions often occur in the mornings, as another provider said, \"We discuss PACE modules early before attending to patients.\" \u003cb\u003e(Table\u0026nbsp;4)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eRelational Integration: Initially, providers engaged with PACE for personal benefit but later saw the value in sharing knowledge. One provider stated, \"I initially used PACE for personal growth but later realized the importance of sharing this knowledge.\" Teamwork and collective benefits were emphasized, with one provider noting, \"We work as a team to meet our objectives.\"\u003c/p\u003e \u003cp\u003eSkill-set Workability: Providers value the practical application of PACE knowledge in patient care. One provider said, \"After learning, it's crucial to apply this knowledge in treating patients.\"\u003c/p\u003e \u003cp\u003eContextual Integration: Challenges like inadequate supplies and lack of electricity hinder PACE implementation. One provider stated, \"\u0026lsquo;\u0026rsquo;Sometimes we face difficulties such as inadequate supply of medical equipment and supplies. For example, there is a child in need of oxygen while there is no electricity and we do not have standby generator. This becomes a barrier to translating PACE in practice.\" However, the availability of tools and support from PACE management facilitates implementation, as another provider noted, \"Availability of tools and support has eased PACE's translation into practice.\"\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eReflexive Monitoring\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eNoMAD data analysis\u003c/h2\u003e \u003cp\u003eIn the context of Reflexive Monitoring, focusing on PACE appraisal, subconstructs reveal varying agreement levels. \"Communal Appraisal\" had a median of 2, suggesting strong collective agreement on PACE's benefit \u003cb\u003e(Table\u0026nbsp;3\u003c/b\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. \"Individual Appraisal\" had a median of 1, indicating strong individual agreement. \"Reconfiguration,\" examining work modifications due to PACE, had a median of 2, showing slight agreement for work adjustments. \"Systematization,\" assessing information access on PACE effects, had a median of 2, leaning towards strong agreement. Overall, data suggest strong agreement on PACE's collective and individual appraisal, work modification, and information access.\u003c/p\u003e \u003cp\u003eThere were no significant differences by setting, suggesting consistent agreement on PACE appraisal and modification across settings.\u003c/p\u003e \u003cp\u003e \u003cem\u003eReflexive Monitoring Themes from IDI and FGD.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSystematization: No quotes directly address this subconstruct, suggesting a need for further exploration within the PACE context.\u003c/p\u003e \u003cp\u003eCommunal Appraisal: Providers find PACE valuable for educating junior doctors, simplifying complex topics, and boosting confidence. One provider noted, \"PACE aids in teaching junior doctors by simplifying complex topics and enhancing my confidence during discussions.\" \u003cb\u003e(Table\u0026nbsp;4)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIndividual Appraisal: Providers believe PACE has enriched their knowledge and confidence in pediatric care. Quotes summarizing this sentiment include, \"I've gained confidence and can act quickly in emergencies,\" and \"I can provide timely service with increased courage.\"\u003c/p\u003e \u003cp\u003eReconfiguration: A notable challenge is the inaccessibility of learned material for future reference, hindering providers' ability to refresh their knowledge. One provider stated, \"Once you complete a module, it becomes inaccessible, making it difficult to revisit for future case management.\"\u003c/p\u003e \u003cp\u003e \u003cb\u003eSummary of Feasibility, Acceptability, and Scalability.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOverall, PACE is generally feasible across healthcare settings, with providers across settings either agreeing or strongly agreeing that people do the work required by interventions and their components (Interactional Workability), the work of interventions and their components supported by host organizations (Contextual Integration).\u003c/p\u003e \u003cp\u003ePACE is also generally acceptable among healthcare providers. Providers collectively agree about the purpose of PACE and its components (Communal Specification), agree that PACE and its components are the right thing to do and should be part of their work (Legitimation), and the collectively and individually agree that PACE is worthwhile (Communal and Individual Appraisal).\u003c/p\u003e \u003cp\u003eLastly, PACE appears to be scalable, with some variability in its adaptability and skill-set alignment. The scalability subconstructs, mapped to NPT, indicate a mean score of 1.23 and a standard deviation of 0.42 for Providers strongly agree that they will continue to support PACE and its components (Activation), that they can modify their work in response to their appraisal of PACE, and feedback can be used to improve it in the future (Reconfiguration). Providers agree or are neutral about the work of PACE and its components being appropriately allocated to people (Skill-set Workability), indicating more work is needed to identify the correct providers to participate in PACE or more support needs to be allocated to those providers to complete PACE.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSummary of Main Results\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eProvider Demographics\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e82 healthcare providers participated in the NoMAD survey and 79 in interviews and discussions, with over 2/3 from the zonal hospital.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eProfession and years of clinical experience varied between zonal hospital and health centers with more physicians at the zonal hospital and more experienced providers at health centers.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHealthcare providers are deeply involved in pediatric care and find value in PACE.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eNPT Constructs\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003eGeneral\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eHigh levels of familiarity and positive outlook towards the PACE intervention.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eNo significant differences between the zonal hospital and health centers in general perceptions of PACE.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCoherence\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePACE is seen as aligning with facility goals.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGeneral agreement on the collective and individual understanding of PACE.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eNo significant differences between settings in understanding and planning for PACE.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eCognitive Participation\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eStrong agreement on ongoing support, participation, and legitimacy of PACE.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePACE is seen as beneficial for managing specific pediatric cases.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eConsistent levels of agreement across both zonal hospitals and health centers.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eCollective Action\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eVarying degrees of agreement on workability, interpersonal confidence, and organizational support.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGenerally consistent approach across both settings, with a notable difference in relational integration favoring the zonal hospital.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eChallenges: Inadequate supplies and lack of electricity noted as barriers to PACE implementation.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eReflexive Monitoring\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eStrong agreement in the collective and individual appraisal of PACE.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eConsistent agreement across both settings in the appraisal and modification of PACE.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eChallenge: Inaccessibility of learned material for future reference.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eFeasibility, Acceptability, Scalability\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePACE is generally feasible, acceptable, and potentially scalable across different healthcare settings, with some variability due to challenges and material inaccessibility.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Background","content":"\u003cp\u003eContext and importance of the study.\u0026nbsp;Healthcare providers\u0026rsquo; in-service education in low-and-middle income countries (LMICs) is limited in reach, effectiveness and sustainability, and these limitations contribute to millions of child deaths each year.(1,2)\u0026nbsp;Pneumonia, birth asphyxia, dehydration, malaria, malnutrition, and anaemia collectively cause over 4 million under-five deaths each year, half of those deaths occur in sub-Saharan Africa; and thousands of those deaths occur in Tanzania.(3,4)\u0026nbsp;The government of Tanzania is committed to reducing neonatal mortality from 20 to the sustainable development goals (SDGs) target of 12/100,000 by the year 2030.(5)\u003c/p\u003e\n\u003cp\u003eBrief review of the literature.\u0026nbsp;Provider knowledge and competency are two major drivers of care quality.(2,6)\u0026nbsp;Unfortunately, conventional in-service education methods are often inadequate in coverage and difficult to sustain.(6)\u0026nbsp;Conventional education methods do not systematically adapt to individual providers\u0026rsquo; knowledge or convenience,(7,8)\u0026nbsp;target minimal competency, and do not provide long-term increases in knowledge, which limits education effectiveness.(9,10)\u003c/p\u003e\n\u003cp\u003eAdaptive e-learning, characterized by its use of advanced technology such as artificial intelligence and data analytics, offers a promising solution to the limitations of traditional educational methods. This approach tailors the learning experience to each individual by dynamically adjusting content and instructional strategies based on the learner\u0026rsquo;s unique needs, abilities, and progress. Such personalization not only addresses the challenges of manpower and training resource shortages prevalent in low-and-middle-income countries (LMICs) but also represents a strategic innovation in disseminating knowledge effectively.\u003c/p\u003e\n\u003cp\u003eThe World Health Organization (WHO) has underscored the importance of implementing e-learning solutions for healthcare workers globally.(11)\u0026nbsp;Adaptive e-learning, with its capacity to adjust to individual learner needs, holds considerable promise for enhancing the efficiency of training healthcare workers. However, formal studies exploring the use of adaptive e-learning in LMIC contexts are scarce. Identifying and establishing best practices in e-learning and adaptive methodologies presents a significant opportunity to enhance the dissemination and implementation of evidence-based interventions. Such advancements are crucial for improving the quality of care in these regions.\u003c/p\u003e\n\u003cp\u003eTo address the existing limitations of current healthcare workers\u0026rsquo; education in LMICs, we developed\u0026nbsp;pediatric\u0026nbsp;acute care education (PACE), an\u0026nbsp;adaptive e-learning\u0026nbsp;program focused on pneumonia, birth asphyxia, dehydration, malaria, malnutrition, and anaemia, and Tanzania\u0026rsquo;s national guidelines for the management of seriously-ill children as source material.(12,13)\u0026nbsp;Prior to large-scale implementation, we undertook a feasibility trial of this curriculum among a cohort of medical interns at a zonal hospital in Tanzania. Then we continued to enroll healthcare providers in 8 health facilities under the\u0026nbsp;Pediatric\u0026nbsp;Association of Tanzania\u0026rsquo;s Clinical Learning Network facilities in Nyamagana and Ilemela districts of Mwanza region. This research report covers a qualitative pilot study that was conducted in three facilities to explore the feasibility and acceptability PACE.\u003c/p\u003e\n\u003cp\u003eStudy aims and objectives. The primary aim of this research is to assess the preliminary implementation of the Pediatric Acute Care E-learning (PACE) intervention across two distinct types of pediatric acute care facilities: zonal hospitals and health centers. The study employs the Normalization Process Theory (NPT) framework in a twofold manner: first, using a tailored NoMAD survey instrument to evaluate the integration of PACE into routine clinical practice; and second, via in-depth interviews and focus group discussions to gain qualitative insights. These dual approaches aim to achieve two principal objectives. The first objective is to utilize the constructs and subconstructs of NPT as evaluative metrics for scrutinizing PACE\u0026apos;s implementation. The second objective is to consolidate these findings to provide a comprehensive analysis of the feasibility, acceptability, and scalability of the PACE intervention across the targeted healthcare settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy Design\u003c/h2\u003e\n\u003cp\u003eThis study employed a mixed-methods approach to evaluate the implementation of the Pediatric Acute Care Education (PACE) program in healthcare settings in Northwestern Tanzania. We administered a tailored NoMAD survey post-intervention to healthcare providers in a zonal hospital and two health centers. Additionally, in-depth interviews and focus group discussions were conducted post-intervention to enrich the survey data. The study was guided by two primary objectives:\u003c/p\u003e\n\u003cp\u003eObjective 1:\u0026nbsp;To use Normalization Process Theory (NPT) to assess the initial implementation of PACE.\u003c/p\u003e\n\u003cp\u003eObjective 2:\u0026nbsp;To summarize the findings in terms of feasibility, acceptability, and scalability of PACE.\u003c/p\u003e\n\u003ch2\u003eTheoretical Framework\u003c/h2\u003e\n\u003cp\u003eNormalization Process Theory (NPT) has been described as a sociological toolkit to help understand the dynamics of implementing, embedding, and integrating new technology, or complex intervention\u0026nbsp;into routine practice.(14)\u0026nbsp;NPT provides a conceptual framework for understanding and evaluating the processes (implementation) by which new health technologies and other complex interventions are routinely operationalized in everyday work (embedding), and sustained in practice (integration).(15\u0026ndash;20)\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe theory is organized around four main constructs, each of which has its own subconstructs.(15)\u0026nbsp;These constructs collectively offer insights into the feasibility, acceptability, and scalability of an intervention or innovation (\u003cstrong\u003eFigure 1\u003c/strong\u003e). Each of these constructs and subconstructs offers a unique lens through which the feasibility, acceptability, and scalability of a new practice can be evaluated, thereby aiding in its effective implementation.\u003c/p\u003e\n\u003ch2\u003eStudy setting\u003c/h2\u003e\n\u003cp\u003eThe study was conducted between August 2022 and July 2023 at three healthcare facilities in Mwanza, Tanzania: Bugando Medical Centre (BMC), a zonal referral and teaching hospital; Makongoro Health Centre, located in the city center; and Igoma Health Centre, situated a few kilometers from the city center. All three facilities offer newborn and pediatric care among other health services.\u003c/p\u003e\n\u003ch2\u003eProviders\u003c/h2\u003e\n\u003cp\u003eEligibility criteria.\u003cem\u003e\u0026nbsp;\u003c/em\u003eProviders included physicians (specialist/superspecialist), nursing officers, medical officers, clinical officers, assistant medical officers, medical attendants, or other providers enrolled in PACE or senior facility staff that supervise PACE providers.\u003c/p\u003e\n\u003cp\u003eRecruitment process.\u003cem\u003e\u0026nbsp;\u003c/em\u003eHealthcare providers were informed about the study through their facility leaders, and individuals who responded to the survey were not necessarily the same as those who participated in the focus groups or in-depth interviews.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData Collection Tools\u003c/h2\u003e\n\u003cp\u003eNoMAD questionnaire.\u003cem\u003e\u0026nbsp;\u003c/em\u003eThe NoMAD is a 23-item questionnaire based on NPT, designed to assess the social processes influencing the integration of complex interventions.(18,21)\u0026nbsp;It includes 3 general items, and 20 related to specific NPT constructs (4 Coherence, 7 Collective Action, 4 Cognitive Participation, 5 Reflexive Monitoring).The general items were on a scale of 0-100 and NPT construct items were modified to include a five-point Likert scale (1-Strongly Agree, 5-Strongly Disagree)and additional options for respondents to indicate if a question is not relevant to their role, stage, or the intervention itself. NPT subconstruct survey items are listed in \u003cstrong\u003eTable 1\u003c/strong\u003e, with the complete survey in the \u003cstrong\u003eSupplementary Materials\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn-depth interviews (IDIs) and focus group discussions (FGDs).\u0026nbsp;Interview guides were developed based on the previous experience with similar data collection tools. Training and pretesting of tools were conducted by study investigators.\u003c/p\u003e\n\u003ch2\u003eData collection process.\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eNoMAD Survey.\u0026nbsp;All PACE participants received the NoMAD survey\u0026nbsp;invitations via WhatsApp 30 days post-intervention or upon initial learning completion of PACE. Data were collected through REDCap.\u003c/p\u003e\n\u003cp\u003eFocus Group Discussions and In-depth interviews.\u003cem\u003e\u0026nbsp;\u003c/em\u003eWe employed a purposeful sampling strategy for the qualitative components, selecting senior healthcare providers for in-depth interviews and junior providers for focus group discussions (FGDs). This approach ensured that participants and sites provided valuable insights into the research problem and central phenomenon. The data collection comprised of 24 interviews and 13 FGDs, commenced with a series of field visits and was guided by Normalization Process Theory (NPT) constructs. This ensured thematic consistency across both methods and facilitated methodological triangulation. The focus groups, segregated by sex but including a mix of cadres from each health facility, enriched the diversity of perspectives. The iterative nature of our methodology allowed for continuous refinement of our theoretical framework, methodologies, and sampling strategies, informed by emerging data. Consequently, the guides for both interviews and FGDs were dynamically modified to reflect the evolving study themes. All sessions were conducted in Kiswahili at the providers\u0026apos; work premises, adding contextual depth, and were meticulously audio-recorded, transcribed verbatim, and translated into English for analysis.\u003c/p\u003e\n\u003ch2\u003eData Analysis\u003c/h2\u003e\n\u003cp\u003eQuantitative Analysis:\u0026nbsp;Descriptive statistics are reported as frequencies and percentages or medians and interquartile ranges, with comparisons via Fisher\u0026rsquo;s exact test or Mann-Whitney U test as appropriate. Analyses were conducted using Stata 17.0 (Stata Corp, College Station, TX, USA).\u003c/p\u003e\n\u003cp\u003eQualitative Analysis:\u0026nbsp;The analysis process, conducted concurrently with data collection, was instrumental in achieving theoretical saturation, marked by the cessation of new information from ongoing interviews and FGDs. To ensure the validity and depth of our findings, we implemented member checking and investigator triangulation, with two independent investigators coding and interpreting the data using NVivo 2020 software (QSR International Pty Ltd., Sydney, Australia). This software facilitated a hybrid coding approach that blended deductive and inductive methods for a comprehensive thematic content analysis. Contextual insights from the interviews and discussions were key to interpreting the findings, with representative quotations included to illustrate identified themes. Data triangulation was achieved using diverse data sources, and the research team\u0026apos;s expertise further enhanced the rigor and reflexivity of the analysis.\u003c/p\u003e\n\u003cp\u003eSummarizing for feasibility acceptability and scalability.\u003cem\u003e\u0026nbsp;\u003c/em\u003eWe used Proctors definition of implementation outcomes and mapped to NPT subconstructs using the definition by May et al.(22,23)\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFeasibility\u0026nbsp;is concerned with the practical aspects of implementing a new intervention, including resource allocation, training, and ease of integration into existing work. In NPT, this aligns closely with the construct of \u0026quot;Collective Action,\u0026quot; which refers to the operational work that people do to enact a set of practices. To assess feasibility, we interpreted responses to \u0026ldquo;Sufficient training is provided to enable staff to use PACE\u0026rdquo; (collective action, skill set workability); \u0026ldquo;Sufficient resources are available to support PACE\u0026rdquo; and \u0026ldquo;Management adequately supports PACE\u0026rdquo; (collective action, contextual integration); and \u0026ldquo;I can easily integrate PACE into my existing work\u0026rdquo; (collective action, interactional workability).\u003c/p\u003e\n\u003cp\u003eAcceptability\u0026nbsp;refers to the extent to which the new intervention is agreeable or satisfactory among its users. To assess acceptability, we interpreted responses to\u003cstrong\u003e\u0026nbsp;\u0026ldquo;\u003c/strong\u003eStaff in this organization have a shared understanding of the purpose of PACE\u0026rdquo; (coherence: communal specification); \u0026ldquo;I believe that participating in PACE is a legitimate part of my role\u0026rdquo; (cognitive participation, legitimation); \u0026ldquo;The staff agree that PACE is worthwhile\u0026rdquo; (reflexive monitoring, communal appraisal); and \u0026ldquo;I value the effects PACE has had on my work\u0026rdquo; (reflexive monitoring, individual appraisal). In addition, we will compare scores between the zonal hospital and health centers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eScalability\u0026nbsp;involves the ability to expand the intervention to other settings while maintaining its effectiveness. To assess scalability, we interpreted responses to \u0026ldquo;I will continue to support PACE\u0026rdquo; (cognitive participation, activation); \u0026ldquo;Work is assigned to those with skills appropriate to PACE\u0026rdquo; (collective action, skill set workability); Feedback about PACE can be used to improve it in the future\u0026rdquo; and \u0026ldquo;I can modify how I work with PACE\u0026rdquo; (reflexive monitoring, reconfiguration).\u003c/p\u003e\n\u003cp\u003eEthical Considerations. All providers provided informed consent, and the study was approved by the relevant ethical review boards.\u003c/p\u003e\n\u003cp\u003eTechniques to enhance trustworthiness.\u0026nbsp;Since processing and analysis of qualitative data was systematic, explicit, and reproducible, the validation and trustworthiness of the findings was established.(24)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eReporting Guidelines. This study adheres to the STROBE and SRQR reporting guidelines for comprehensive and explicit reporting of observational and qualitative studies, respectively.(25,26)\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eIntroduction to Results\u003c/h2\u003e\n\u003cp\u003eThe results section is organized to provide an in-depth analysis of both the implementation and impact of the Pediatric Acute Care Education (PACE) program. Initially, \u0026quot;Provider Demographics and Work Perceptions,\u0026quot; offers three layers of data: descriptive statistics that characterize the healthcare providers who took part in the NoMAD survey, comparative analyses that differentiate between providers from a zonal hospital and health centers, and emergent themes from in-depth interviews (IDIs) and focus group discussions (FGDs) that shed light on providers\u0026apos; general perceptions of their roles in pediatric acute care. Following this, \u0026quot;Normalization Process Theory (NPT) Constructs\u0026quot; is bifurcated into an overview of general perceptions regarding PACE implementation and a detailed examination of the four principal NPT constructs\u0026mdash;Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring. Each construct is scrutinized through a tripartite lens: descriptive data from the NoMAD survey, comparative analyses across different healthcare settings, and qualitative insights derived from IDIs and FGDs. Finally, \u0026quot;Summary of Feasibility, Acceptability, and Scalability,\u0026quot; synthesizes all findings into descriptive and comparative categories to offer a comprehensive evaluation of PACE\u0026apos;s potential for normalization within healthcare settings, while deliberately omitting thematic categories for a more focused interpretation.\u003c/p\u003e\n\u003ch2\u003eProvider Demographics and Work Perceptions\u003c/h2\u003e\n\u003cp\u003eEighty-two of 272 healthcare providers completed the NoMAD survey, yielding a response rate of 30%. Of the 82 healthcare providers: 59 were from the zonal hospital and 23 from health centers. Median ages were 27 and 29 years for the zonal hospital and health centers, respectively (\u003cstrong\u003eTable 2\u003c/strong\u003e). Gender distribution was similar in both settings (39% female in the zonal hospital, 43.5% in health centers). Significant cadre differences existed: the zonal hospital had more medical\u0026nbsp;(47.5% vs. 8.7%) and nursing officers (42.4% vs. 30.4%), while health centers had more clinical officers\u0026nbsp;(30.4% vs. 0%). Clinical experience varied, with medians of 1 year at the zonal hospital and 4 years at health centers (p-value: 0.004). Both settings had over 70% of providers with prior training. Job satisfaction scores were not significantly different between the two groups.\u003c/p\u003e\n\u003ch3\u003eIDI and Focus Group demographics.\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eSeventy-nine healthcare providers participated in the study: 24 senior providers were interviewed (18 zonal hospital, 6 health\u0026nbsp;centers) and 13 focus groups were held with junior providers (39 zonal hospital and 16 health centers).\u0026nbsp;The focus group discussions varied in size, with an average of 4 participants per group.\u0026nbsp;All cadres were represented: medical officers (26), nursing officers (19), interns (16), clinical officers (12), Assistant medical officers (3), and medical attendants (3). Clinical experience ranged from 1 to 20 years.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ch4\u003e\u0026nbsp;\u003c/h4\u003e\n\u003ch4\u003eFocus group themes for Provider Demographics and Work Perceptions.\u003c/h4\u003e\n\u003cp\u003eThe overarching theme from the IDIs and FGDs was healthcare providers\u0026apos; active engagement in pediatric care, particularly for seriously ill newborns and children. The quotes elucidate the providers\u0026apos; daily responsibilities and specialized roles across different settings.\u003c/p\u003e\n\u003cp\u003eA provider noted, \u0026quot;I deal with ill children daily. There\u0026apos;s always a new transfer or admission.\u0026quot; This statement highlights the relentless nature of pediatric care, emphasizing the ongoing attention to both new and existing cases.\u003c/p\u003e\n\u003cp\u003eAnother provider said, \u0026quot;I specialize in neonatology but attend to all children as per our country\u0026apos;s laws.\u0026quot; This underscores the specialized yet comprehensive roles some providers assume, adhering to broader healthcare mandates.\u003c/p\u003e\n\u003cp\u003eA provider added, \u0026quot;I work in the labour ward, treating newborns who fall ill before reaching twenty-eight days.\u0026quot; This comment reveals that even those in labour wards have pediatric responsibilities, extending the scope of care to include newborns who become ill.\u003c/p\u003e\n\u003cp\u003eIn summary, the quotes collectively depict healthcare providers as deeply committed to pediatric care, each with specialized roles but universally focused on patient well-being.\u003c/p\u003e\n\u003ch4\u003eNoMAD General Items\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eRespondents showed high familiarity with PACE, evidenced by a median score of 89 out of 100, although an interquartile range of 76-100 indicates variability (Table 3, Figure 1). General satisfaction with PACE in current work had a median of 91 and a similar opinion range, as suggested by an interquartile range of 75-100. Optimism for PACE in future work was highest, with a median of 99 and an interquartile range of 87-100. No significant differences were observed between the zonal hospital and health centers in these variables.\u003c/p\u003e\n\u003ch2\u003eNormalization Process Theory (NPT) Constructs\u0026nbsp;\u003c/h2\u003e\n\u003ch3\u003eCoherence\u003c/h3\u003e\n\u003ch4\u003eNoMAD data analysis\u003c/h4\u003e\n\u003cp\u003eCoherence, a key construct in PACE implementation, and its subconstructs reveal important trends. \u0026quot;Communal Specification\u0026quot; and \u0026ldquo;Internalization\u0026rdquo; had median scores of 2 (Agree) and 1 (Strongly Agree), respectively, with interquartile ranges of 1-2 for both indicating strong collective agreement on PACE\u0026apos;s purpose and value \u003cstrong\u003e(Table 3, Figure 1)\u003c/strong\u003e. \u0026quot;Differentiation\u0026quot; and \u0026quot;Individual Specification\u0026quot; both had medians of 2 (Agree), suggesting moderate agreement that PACE is distinct, and roles are understood. Interquartile ranges were 1-4 for \u0026ldquo;Differentiation\u0026rdquo; and 2-4 for \u0026ldquo;Individual Specification,\u0026rdquo; indicating variability within subconstructs. Overall, data suggest strong collective and individual agreement on PACE\u0026apos;s differentiation and value.\u003c/p\u003e\n\u003cp\u003eFor Coherence subconstructs, there were no significant differences in median scores or IQRs between settings indicating uniform perceptions of purpose, distinctiveness, and valuation of PACE across settings.\u003c/p\u003e\n\u003ch4\u003eCoherence Themes from IDI and FGD.\u003c/h4\u003e\n\u003cp\u003eDifferentiation:\u0026nbsp;Providers value PACE for its detailed guidance on specific pediatric cases, such as difficulty breathing, which was not covered in their basic training. One provider said, \u0026quot;PACE goes beyond basic knowledge, offering detailed steps for managing cases like difficulty breathing. This is a significant advantage.\u0026quot;\u003cstrong\u003e(Table 4)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCommunal Specification:\u0026nbsp;PACE is seen as a tool for empowering providers to reduce child mortality and improve service quality, aligning with facility goals. One provider remarked, \u0026quot;PACE aims to empower us to reduce child mortality,\u0026quot; while another noted, \u0026quot;Its objectives align with our hospital\u0026apos;s goals to update healthcare providers\u0026apos; knowledge.\u0026quot;\u003c/p\u003e\n\u003cp\u003eIndividual Specification:\u0026nbsp;Providers believe PACE has enhanced their understanding and management of seriously ill children. One provider observed, \u0026quot;Before PACE, I relied on existing procedures and guidelines. Now, I\u0026apos;ve gained new insights that could positively impact our treatment system.\u0026quot;\u003c/p\u003e\n\u003cp\u003eInternalization:\u0026nbsp;Providers find that PACE is consistent with Tanzanian and WHO guidelines, useful both in their work and in training medical students. One provider said, \u0026quot;PACE refreshes my memory and aligns with existing guidelines. I use it to educate medical students and junior doctors.\u0026quot;\u003c/p\u003e\n\u003ch3\u003eCognitive participation\u003c/h3\u003e\n\u003ch4\u003eNoMAD data analysis\u003c/h4\u003e\n\u003cp\u003eCognitive Participation, a construct examining collaboration around PACE, reveals strong agreement across its subconstructs. \u0026quot;Activation,\u0026quot; measuring ongoing PACE support, had a median of 1, indicating strong agreement \u003cstrong\u003e(Table 3, Figure 1)\u003c/strong\u003e. \u0026quot;Enrolment\u0026quot; and \u0026quot;Initiation,\u0026quot; with medians of 1 for both, also showed strong agreement for participation and leadership in PACE. \u0026quot;Legitimation,\u0026quot; assessing PACE\u0026apos;s work integration, also had a median of 1, suggesting strong agreement. IQRs ranged from 1-1 to 1-2, indicating some dispersion within subconstructs. Overall, data suggest strong agreement on PACE\u0026apos;s support, participation, leadership, and legitimacy.\u003c/p\u003e\n\u003cp\u003eThere were no significant differences by setting, indicating consistent strong agreement on PACE across settings.\u003c/p\u003e\n\u003ch4\u003eCognitive Participation Themes from IDI and FGD.\u003c/h4\u003e\n\u003cp\u003eInitiation:\u0026nbsp;Providers were introduced to PACE by colleagues and supervisors, prompting them to enroll. One provider said, \u0026quot;Specialists introduced us to PACE, and we started learning.\u0026quot; Another noted, \u0026quot;After seeing a colleague engage with PACE, I joined too.\u0026quot; Some providers find individual initiation beneficial, as one stated, \u0026quot;Starting alone is effective.\u0026quot;\u003cstrong\u003e\u0026nbsp;(Table 4)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLegitimation:\u0026nbsp;PACE is seen as empowering providers to enhance their pediatric care. One provider noted, \u0026quot;PACE taught me how to administer oxygen based on a child\u0026apos;s age.\u0026quot; Another highlighted PACE\u0026apos;s flexibility, saying, \u0026quot;You can engage with PACE individually or in groups.\u0026quot;\u003c/p\u003e\n\u003cp\u003eEnrolment:\u0026nbsp;Providers mainly use PACE individually but also share modules to spread knowledge. One provider said, \u0026quot;I often use PACE on my phone but also share modules with colleagues.\u0026quot;\u003c/p\u003e\n\u003cp\u003eActivation:\u0026nbsp;Despite busy schedules, providers are committed to PACE training. One provider stated, \u0026quot;Our commitment helps translate knowledge into practice.\u0026quot; Another emphasized their personal dedication, saying, \u0026quot;I find time to study PACE multiple times a week, showing my commitment.\u0026quot;\u003c/p\u003e\n\u003ch3\u003eCollective Action\u003c/h3\u003e\n\u003ch4\u003eNoMAD data analysis\u003c/h4\u003e\n\u003cp\u003eIn the realm of Collective Action, focusing on collaborative PACE enactment, subconstructs reveal nuanced insights. \u0026quot;Interactional Workability,\u0026quot; with a median of 1, suggests work required by PACE is generally manageable \u003cstrong\u003e(Table 3, Figure 1)\u003c/strong\u003e. \u0026quot;Relational Integration\u0026quot; showed strong disagreement that PACE disrupts relationships but agreement that it can be effectively used by peers. \u0026quot;Skill-set Workability\u0026quot; indicated mixed alignment with provider needs but strong consensus on sufficient PACE training. \u0026quot;Contextual Integration\u0026quot; had medians of 2, suggesting strong organizational support. Overall, data suggest varying agreement levels on work manageability, interpersonal relations, task allocation, and organizational support.\u003c/p\u003e\n\u003cp\u003e\u0026quot;Relational Integration\u0026quot; showed a significant difference in one subconstruct (p=0.02), suggesting higher trust levels in the zonal hospital. There were no other differences by setting. Overall, data suggest consistent Collective Action approaches across settings, with a trust advantage in the zonal hospital.\u003c/p\u003e\n\u003ch4\u003eCollective Action Themes from IDI and FGD.\u003c/h4\u003e\n\u003cp\u003eInteractional Workability:\u0026nbsp;PACE\u0026apos;s digital format allows for individual study and facilitates group discussions. One provider noted, \u0026quot;PACE\u0026apos;s digital nature allows for flexible study schedules.\u0026quot; Group discussions often occur in the mornings, as another provider said, \u0026quot;We discuss PACE modules early before attending to patients.\u0026quot; \u003cstrong\u003e(Table 4)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRelational Integration:\u0026nbsp;Initially, providers engaged with PACE for personal benefit but later saw the value in sharing knowledge. One provider stated, \u0026quot;I initially used PACE for personal growth but later realized the importance of sharing this knowledge.\u0026quot; Teamwork and collective benefits were emphasized, with one provider noting, \u0026quot;We work as a team to meet our objectives.\u0026quot;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSkill-set Workability:\u0026nbsp;Providers value the practical application of PACE knowledge in patient care. One provider said, \u0026quot;After learning, it\u0026apos;s crucial to apply this knowledge in treating patients.\u0026quot;\u003c/p\u003e\n\u003cp\u003eContextual Integration:\u0026nbsp;Challenges like inadequate supplies and lack of electricity hinder PACE implementation. One provider stated, \u0026quot;\u0026lsquo;\u0026rsquo;Sometimes we face difficulties such as inadequate supply of medical equipment and supplies. For example, there is a child in need of oxygen while there is no electricity and we do not have standby generator. This becomes a barrier to translating PACE in practice.\u0026quot; However, the availability of tools and support from PACE management facilitates implementation, as another provider noted, \u0026quot;Availability of tools and support has eased PACE\u0026apos;s translation into practice.\u0026quot;\u003c/p\u003e\n\u003ch3\u003eReflexive Monitoring\u003c/h3\u003e\n\u003ch4\u003eNoMAD data analysis\u003c/h4\u003e\n\u003cp\u003eIn the context of Reflexive Monitoring, focusing on PACE appraisal, subconstructs reveal varying agreement levels. \u0026quot;Communal Appraisal\u0026quot; had a median of 2, suggesting strong collective agreement on PACE\u0026apos;s benefit \u003cstrong\u003e(Table 3, Figure 1)\u003c/strong\u003e. \u0026quot;Individual Appraisal\u0026quot; had a median of 1, indicating strong individual agreement. \u0026quot;Reconfiguration,\u0026quot; examining work modifications due to PACE, had a median of 2, showing slight agreement for work adjustments. \u0026quot;Systematization,\u0026quot; assessing information access on PACE effects, had a median of 2, leaning towards strong agreement. Overall, data suggest strong agreement on PACE\u0026apos;s collective and individual appraisal, work modification, and information access.\u003c/p\u003e\n\u003cp\u003eThere were no significant differences by setting, suggesting consistent agreement on PACE appraisal and modification across settings.\u003c/p\u003e\n\u003ch4\u003eReflexive Monitoring Themes from IDI and FGD.\u003c/h4\u003e\n\u003cp\u003eSystematization:\u0026nbsp;No quotes directly address this subconstruct, suggesting a need for further exploration within the PACE context.\u003c/p\u003e\n\u003cp\u003eCommunal Appraisal:\u0026nbsp;Providers find PACE valuable for educating junior doctors, simplifying complex topics, and boosting confidence. One provider noted, \u0026quot;PACE aids in teaching junior doctors by simplifying complex topics and enhancing my confidence during discussions.\u0026quot;\u003cstrong\u003e\u0026nbsp;(Table 4)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIndividual Appraisal:\u0026nbsp;Providers believe PACE has enriched their knowledge and confidence in pediatric care. Quotes summarizing this sentiment include, \u0026quot;I\u0026apos;ve gained confidence and can act quickly in emergencies,\u0026quot; and \u0026quot;I can provide timely service with increased courage.\u0026quot;\u003c/p\u003e\n\u003cp\u003eReconfiguration:\u0026nbsp;A notable challenge is the inaccessibility of learned material for future reference, hindering providers\u0026apos; ability to refresh their knowledge. One provider stated, \u0026quot;Once you complete a module, it becomes inaccessible, making it difficult to revisit for future case management.\u0026quot;\u003c/p\u003e\n\u003ch2\u003eSummary of Feasibility, Acceptability, and Scalability.\u003c/h2\u003e\n\u003cp\u003eOverall, PACE is generally feasible across healthcare settings, with providers across settings either agreeing or strongly agreeing that people do the work required by interventions and their components (Interactional Workability), the work of interventions and their components supported by host organizations (Contextual Integration).\u003c/p\u003e\n\u003cp\u003ePACE is also generally acceptable among healthcare providers. Providers collectively agree about the purpose of PACE and its components (Communal Specification), agree that PACE and its components are the right thing to do and should be part of their work (Legitimation), and the collectively and individually agree that PACE is worthwhile (Communal and Individual Appraisal).\u003c/p\u003e\n\u003cp\u003eLastly, PACE appears to be scalable, with some variability in its adaptability and skill-set alignment. The scalability subconstructs, mapped to NPT, indicate a mean score of 1.23 and a standard deviation of 0.42 for Providers strongly agree that they will continue to support PACE and its components (Activation), that they can modify their work in response to their appraisal of PACE, and feedback can be used to improve it in the future (Reconfiguration). \u0026nbsp; Providers agree or are neutral about the work of PACE and its components being appropriately allocated to people (Skill-set Workability), indicating more work is needed to identify the correct providers to participate in PACE or more support needs to be allocated to those providers to complete PACE.\u003c/p\u003e\n\u003ch2\u003eSummary of Main Results\u003c/h2\u003e\n\u003ch3\u003eProvider Demographics\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003e82 healthcare providers participated in the NoMAD survey and 79 in interviews and discussions, with over 2/3 from the zonal hospital.\u003c/li\u003e\n \u003cli\u003eProfession and years of clinical experience varied between zonal hospital and health centers with more physicians at the zonal hospital and more experienced providers at health centers.\u003c/li\u003e\n \u003cli\u003eHealthcare providers are deeply involved in pediatric care and find value in PACE.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003eNPT Constructs\u003c/h3\u003e\n\u003ch4\u003eGeneral\u003c/h4\u003e\n\u003cul\u003e\n \u003cli\u003eHigh levels of familiarity and positive outlook towards the PACE intervention.\u003c/li\u003e\n \u003cli\u003eNo significant differences between the zonal hospital and health centers in general perceptions of PACE.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003eCoherence\u003c/h4\u003e\n\u003cul\u003e\n \u003cli\u003ePACE is seen as aligning with facility goals.\u003c/li\u003e\n \u003cli\u003eGeneral agreement on the collective and individual understanding of PACE.\u003c/li\u003e\n \u003cli\u003eNo significant differences between settings in understanding and planning for PACE.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003eCognitive Participation\u003c/h4\u003e\n\u003cul\u003e\n \u003cli\u003eStrong agreement on ongoing support, participation, and legitimacy of PACE.\u003c/li\u003e\n \u003cli\u003ePACE is seen as beneficial for managing specific pediatric cases.\u003c/li\u003e\n \u003cli\u003eConsistent levels of agreement across both zonal hospitals and health centers.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003eCollective Action\u003c/h4\u003e\n\u003cul\u003e\n \u003cli\u003eVarying degrees of agreement on workability, interpersonal confidence, and organizational support.\u003c/li\u003e\n \u003cli\u003eGenerally consistent approach across both settings, with a notable difference in relational integration favoring the zonal hospital.\u003c/li\u003e\n \u003cli\u003eChallenges: Inadequate supplies and lack of electricity noted as barriers to PACE implementation.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003eReflexive Monitoring\u003c/h4\u003e\n\u003cul\u003e\n \u003cli\u003eStrong agreement in the collective and individual appraisal of PACE.\u003c/li\u003e\n \u003cli\u003eConsistent agreement across both settings in the appraisal and modification of PACE.\u003c/li\u003e\n \u003cli\u003eChallenge: Inaccessibility of learned material for future reference.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003eFeasibility, Acceptability, Scalability\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003ePACE is generally feasible, acceptable, and potentially scalable across different healthcare settings, with some variability due to challenges and material inaccessibility.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eInterpretation of Findings\u003c/h2\u003e \u003cp\u003eThe mixed-methods pilot study was designed to explore the feasibility and acceptability of the PACE intervention among healthcare providers in Mwanza, Tanzania. Utilizing the Normalization Process Theory (NPT) as a guiding framework, the study revealed several key insights.\u003c/p\u003e \u003cp\u003eThe NoMAD general questions regarding \"Familiarity of PACE,\" \"PACE as current work,\" and \"PACE as future work\" reveal insights into respondents' perceptions of how well the intervention is being received in their work environment. The higher scores indicate a more positive outlook towards normalization, which can be a useful metric for stakeholders, but the wide variability of responses for familiarity and current work indicate that this optimism is not universal. PACE appears to be well-understood and recognizable among those who are implementing it, already well integrated into routine work, and respondents feel positive that PACE has the potential to become a normalized part of work in the future.\u003c/p\u003e \u003cp\u003eFirstly, the high levels of coherence among healthcare providers indicate that PACE is well-understood and aligns with the existing goals and practices of healthcare facilities. This is a crucial factor for the successful implementation of any healthcare intervention, as a clear understanding (i.e., how providers made sense of and accept change) among stakeholders is often the first step towards effective implementation.(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSecondly, the strong cognitive participation suggests that healthcare providers are not only willing but also eager to engage with PACE. The fact that providers enrolled and rallied behind PACE may indicate that the benefits were clear to them, so they were sufficiently motivated to invest their thoughts and energy into PACE, though at varying levels. This finding is in agreement with what was found by Agreli and colleagues.(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) This is particularly important in the context of pediatric care, where timely and effective interventions can have a significant impact on patient outcomes. The willingness of healthcare providers to engage with PACE is a positive indicator of its long-term sustainability.\u003c/p\u003e \u003cp\u003eThirdly, the study found varying degrees of collective action among healthcare providers. While there was general agreement on the workability and benefits of PACE, some challenges were noted, particularly in terms of resource availability and infrastructural support. However, as pointed out by MacCrorie and colleagues,(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) the extent to which the providers perceived that PACE had prepared them for implementation was influenced by the perceived compatibility of PACE within existing work practice. These challenges need to be addressed to ensure the effective and sustainable implementation of PACE.\u003c/p\u003e \u003cp\u003eLastly, the study was limited in its ability to assess reflexive monitoring due to its short duration. However, the initial findings suggest that healthcare providers find value in PACE and are likely to continue using it, subject to certain improvements. Ample time is needed to allow for reflexive monitoring to mature and be realized. This is consistent with a study by Mishuris and colleagues who found that monitoring domain had the lowest scores due to being a future step in the implementation process.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Implementation Science and Pediatric Acute Care\u003c/h2\u003e \u003cp\u003e The study's findings have several implications for the fields of implementation science and pediatric acute care. From an implementation science perspective, the study demonstrates the utility of NPT as a conceptual framework for understanding the complexities involved in implementing adaptive e-learnings in LMICs. We observed, like studies reported by May and colleagues,(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) that coherence or sense-making was seen as a necessary precursor to participation, and a degree of cognitive participation was required before collective action-in the form of an actual implementation process-could take place. Sense-making work was also found to be a key to the successful implementation of an enhanced recovery after surgery programme.(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) The use of NPT allowed for a nuanced understanding of the various factors that could influence the implementation of PACE, providing valuable insights that could be applied to other healthcare interventions.\u003c/p\u003e \u003cp\u003eIn the context of pediatric acute care, the study's findings are particularly significant. The strong agreement among healthcare providers on the benefits of PACE for managing specific pediatric cases suggests that the program could be a valuable addition to pediatric acute care at different facility types to increase provider proficiency. Given the often time-sensitive nature of pediatric cases, the effective and efficient training provided by PACE could lead to improved patient outcomes.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eWhile the study provides valuable insights, it is not without limitations. The most significant limitation is the small sample size, which affects the generalizability of the findings. Another limitation is the potential for response bias, given our response rate. Additionally, the study's short duration did not allow for a comprehensive assessment of all NPT constructs, particularly reflexive monitoring. This limits our understanding of the long-term sustainability and impact of PACE. The study is limited by its reliance on self-reported data, which may introduce social desirability bias. However, the mixed-methods approach and methodological triangulation enhance the robustness of the findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eRecommendations for Future Research\u003c/h2\u003e \u003cp\u003eGiven the limitations and the scope of this pilot study, several avenues for future research are evident. Longitudinal studies are needed to assess the long-term sustainability and impact of PACE on provider proficiency, patient outcomes and quality of care. Such studies could provide insights into how PACE is embedded and integrated into routine healthcare practices over time.\u003c/p\u003e \u003cp\u003eAdditionally, more rigorous qualitative research designs could be employed to further explore the nuances of each NPT construct. Detailed case studies and ethnographic studies could provide a more in-depth understanding of the challenges and opportunities associated with implementing PACE.\u003c/p\u003e \u003cp\u003eFurthermore, future research could focus on the scalability of PACE, exploring how the program could be adapted for different healthcare settings or for healthcare systems in other countries. This could include an assessment of the resource implications of scaling up PACE, as well as an evaluation of the training and support needed for effective implementation in different contexts.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study provides valuable insights into the feasibility and acceptability of the PACE program among healthcare providers in Mwanza, Tanzania. The findings suggest that PACE is well-received and aligns well with the goals of healthcare providers, particularly in the context of pediatric care. However, challenges related to resource availability and infrastructural support need to be addressed to ensure the program's effective and sustainable implementation. The study also highlights the utility of NPT as a conceptual framework for understanding the complexities involved in implementing healthcare interventions, providing valuable insights for both implementation science and pediatric acute care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBugando Medical Centre\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ee\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elearning-Electronic Learning\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFGD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFocus Group Discussion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIDI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIn-Depth Interview\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow-or-Middle-Income Country\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNPT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNormalization Process Theory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNoMAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNormalization Measure Development\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePACE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePediatric Acute Care Education\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate.\u003c/h2\u003e\n\u003cp\u003eThe Institutional Review Board of the Tanzania National Institute of Medical Research (NIMR/HO/R.8a/Vol.IX/3990), Stanford University (60379), the ethics committee of the Catholic University of Health and Allied Science (no ID number given), and the Mwanza Regional Medical Officer (Ref. No. AG.52/290/01A/115) approved the study protocol including consent procedures. \u0026nbsp;Data collection procedures were completed in compliance with the guidelines of the Health Insurance Portability and Accountability Act (HIPAA) to ensure subject confidentiality. Informed electronic consent was obtained through REDCap from all providers who participated in PACE.\u003csup\u003e55\u003c/sup\u003e All providers who completed consent were included. All surveys and questionnaires were entered directly by providers into REDCap. This study is reported according to the Consolidated Standards of Reporting Trials (CONSORT) 2010 extension to randomized pilot and feasibility trials.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eAll individual persons\u0026apos; data included in this study are entirely unidentifiable and there are no details on individuals reported within the manuscript. Therefore, consent for publication is not applicable for this study. If there were any identifiable details, images, or videos relating to individual persons, consent would be obtained from those persons or, in the case of children, their parent or legal guardian and noted in this section accordingly.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eDeidentified participant data from this study are available upon reasonable request. Interested researchers may obtain the data by contacting the corresponding author, Dr. Peter Meaney, at [email protected]. Access to the data will be granted following approval by an independent review committee, established to evaluate the scientific validity and ethical justification of the proposed use. Please note that only the deidentified participant data is available, and no additional supporting information, such as study protocols or statistical analysis plans, will be provided. This process ensures that the data is used responsibly and in accordance with ethical research standards.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eBR and MB are compensated by Area 9 Lyceum as Senior Learning Architect and Medical Director, respectively.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003col\u003e\n \u003cli\u003eThis study was funded by the Laerdal Foundation for Acute Medicine, Stanford University School of Medicine Maternal and Child Health Research Institute, Stanford Center for Innovation in Global Health, and the Stanford University School of Medicine Division of Pediatric Critical Care Medicine.\u003c/li\u003e\n \u003cli\u003eFunding sources had no role in project design, data collection, analysis, or interpretation; reporting, or the decision to submit results for publication.\u003c/li\u003e\n \u003cli\u003eStanford CTSA award number UL1 TR001085 from NIH/NCRR.\u003c/li\u003e\n\u003c/ol\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eRM, AH, HN, and PAM contributed to study conception and design, data acquisition, analysis, and interpretation. TM, NC, NPM, and AA contributed to study conception and design, and interpretation of data. FSK, MB, and ZS contributed to study conception and design, and analysis of data. DT, RPM, BR, and CM contributed to the analysis and interpretation of data. ED contributed to the interpretation of data. All authors drafted the work or revised it critically for important intellectual content, approved the final version to be published, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe are grateful to healthcare providers from Bugando Medical Centre, Makongoro and Igoma Health Centres in Mwanza City Tanzania, who participated in the study for their time, cooperation, and invaluable feedback. The authors would like to thank the Pediatric Association of Tanzania; the Tanzanian Ministry of Health, Regional and Council Health Management Teams for participating in stakeholder meetings. We thank the Catholic University of Health and Allied Sciences, London School of Hygiene and Tropical Medicine, Paediatric Association of Tanzania, and Area 9 for practical support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional Declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eREDCap Database.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eStudy data were collected and managed using REDCap electronic data capture tools hosted at Stanford University.\u003csup\u003e71,72\u003c/sup\u003e REDCap (Research Electronic Data Capture) is a secure, web-based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for data integration and interoperability with external sources. The Stanford REDCap platform (http://redcap.stanford.edu) is developed and operated by the Stanford Medicine Research IT team. The REDCap platform services at Stanford are subsidized by a) the Stanford School of Medicine Research Office, and b) the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through grant UL1 TR001085. Area9 Rhapsode\u0026trade; meets the requirements for full GDPR compliance including encryption, data security, and \u0026apos;forget me\u0026apos;.\u003c/p\u003e\n\u003cp\u003eUse of ChatGPT:\u0026nbsp;We employed ChatGPT in two ways: 1) to edit and revise manuscripts for clarity, to ensure adherence to writing standards (such as STROBE, SRQR) and to format manuscripts, tables, and figures; and 2) to conduct preliminary data screening/monitoring using de-identified exported from our data from our REDCap databases. All statistical results and conclusions in this manuscript are confirmed by a biostatistician or member of the author group.\u003c/p\u003e\n\u003cp\u003ePatient and public involvement.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThis research was done without patient involvement. Patients were not invited to comment on the study design and were not consulted to develop patient-relevant outcomes or interpret the results. Patients were not invited to contribute to the writing or editing of this document for readability or accuracy.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKruk ME, Gage AD, Joseph NT, Danaei G, Garc\u0026iacute;a-Sais\u0026oacute; S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis TP, Roder-DeWan S, Malata A, Ndiaye Y, Kruk ME. Clinical performance among recent graduates in nine low- and middle-income countries. Trop Med Int Health. 2019;24(5):620\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerin J, Mulick A, Yeung D, Villavicencio F, Lopez G, Strong KL, et al. Global, regional, and national causes of under-5 mortality in 2000\u0026ndash;19: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet Child Adolesc Health. 2022;6(2):106\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharrow D, Hug L, Lee S, Liu Y, Danzhen You. Levels \u0026amp; Trends in Child Mortality: Report 2021, Estimates developed by the United Nations Inter-agency Group for Child Mortality Estimation. New York: United Nations Children\u0026rsquo;s Fund; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF DATA [Internet]. [cited 2023 Jun 11]. United Republic of Tanzania (TZA) - Demographics, Health \u0026amp; Infant Mortality. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.unicef.org/country/tza/\u003c/span\u003e\u003cspan address=\"https://data.unicef.org/country/tza/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Giorgio L, Evans DK, Lindelow M, Nguyen SN, Svensson J, Wane W et al. Analysis of clinical knowledge, absenteeism and availability of resources for maternal and child health: a cross-sectional quality of care study in 10 African countries. BMJ Glob Health. 2020;5(12).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBloom BS. The 2 Sigma Problem: The Search for Methods of Group Instruction as Effective as One-to-One Tutoring. Educ Res. 1984;13(6):4\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D, Rowe AK. A systematic review of the effectiveness of strategies to improve health care provider performance in low- and middle-income countries: Methods and descriptive results. PLoS ONE. 2019;14(5):e0217617.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeaney PA, Sutton RM, Tsima B, Steenhoff AP, Shilkofski N, Boulet JR, et al. Training hospital providers in basic CPR skills in Botswana: acquisition, retention and impact of novel training techniques. Resuscitation. 2012;83(12):1484\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeaney PA, Topjian AA, Chandler HK, Botha M, Soar J, Berg RA, et al. Resuscitation training in developing countries: a systematic review. Resuscitation. 2010;81(11):1462\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Recommendations on Digital Interventions for Health System Strengthening. Geneva: World Health Organization; 2019 p. Licence: CC BY-NC-SA 3.0 IGO.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeaney PA, Hokororo A, Masenge T, Mwanga J, Kalabamu FS, Berg M, et al. Development of pediatric acute care education (PACE): An adaptive electronic learning (e-learning) environment for healthcare providers in Tanzania. Digit Health. 2023;9:20552076231180471.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeaney P, Hokororo A, Ndosi H, Dahlen A, Jacob T, Mwanga JR et al. Feasibility of an Adaptive E-Learning Environment to Improve Provider Proficiency in Essential and Sick Newborn Care in Mwanza, Tanzania [Internet]. medRxiv; 2023 [cited 2023 Aug 30]. p. 2023.07.11.23292406. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.medrxiv.org/content/\u003c/span\u003e\u003cspan address=\"https://www.medrxiv.org/content/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1101/2023.07.11.23292406v1\u003c/span\u003e\u003cspan address=\"10.1101/2023.07.11.23292406v1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFinch TL, Girling M, May CR, Mair FS, Murray E, Treweek S, et al. Improving the normalization of complex interventions: part 2 - validation of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT). BMC Med Res Methodol. 2018;18(1):135.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMay C, Finch T. Implementing, Embedding, and Integrating Practices: An Outline of Normalization Process Theory. Sociology. 2009;43(3):535\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMay C. A rational model for assessing and evaluating complex interventions in health care. BMC Health Serv Res. 2006;6(1):86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMay CR, Mair F, Finch T, MacFarlane A, Dowrick C, Treweek S, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci. 2009;4(1):29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMay CR, Cummings A, Girling M, Bracher M, Mair FS, May CM, et al. Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implement Sci. 2018;13(1):80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C, et al. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med. 2010;8(1):63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcEvoy R, Ballini L, Maltoni S, O\u0026rsquo;Donnell CA, Mair FS, MacFarlane A. A qualitative systematic review of studies using the normalization process theory to research implementation processes. Implement Sci. 2014;9(1):2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFinch TL, Rapley T, Girling M, Mair FS, Murray E, Treweek S, et al. Improving the normalization of complex interventions: measure development based on normalization process theory (NoMAD): study protocol. Implement Sci. 2013;8(1):43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. Adm Policy Ment Health Ment Health Serv Res. 2011;38(2):65\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMay CR, Albers B, Bracher M, Finch TL, Gilbert A, Girling M, et al. Translational framework for implementation evaluation and research: a normalisation process theory coding manual for qualitative research and instrument development. Implement Sci. 2022;17(1):19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenhalgh T, Taylor R. How to read a paper: Papers that go beyond numbers (qualitative research). BMJ. 1997;315(7110):740\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335(7624):806\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med J Assoc Am Med Coll. 2014;89(9):1245\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGould DJ, Hale R, Waters E, Allen D. Promoting health workers\u0026rsquo; ownership of infection prevention and control: using Normalization Process Theory as an interpretive framework. J Hosp Infect. 2016;94(4):373\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgreli H, Barry F, Burton A, Creedon S, Drennan J, Gould D, et al. Ethnographic study using Normalization Process Theory to understand the implementation process of infection prevention and control guidelines in Ireland. BMJ Open. 2019;9(8):e029514.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCrorie C, Benn J, Johnson OA, Scantlebury A. Staff expectations for the implementation of an electronic health record system: a qualitative study using normalisation process theory. BMC Med Inf Decis Mak. 2019;19(1):222.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMishuris RG, Palmisano J, McCullagh L, Hess R, Feldstein DA, Smith PD, et al. Using normalisation process theory to understand workflow implications of decision support implementation across diverse primary care settings. BMJ Health Care Inf. 2019;26(1):e100088.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSutton E, Herbert G, Burden S, Lewis S, Thomas S, Ness A, et al. Using the Normalization Process Theory to qualitatively explore sense-making in implementation of the Enhanced Recovery After Surgery programme: It\u0026rsquo;s not rocket science. PLoS ONE. 2018;13(4):e0195890.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1-4 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adaptive E-learning, Feasibility, Acceptability, Normalization Process Theory, Implementation Science, Pediatrics, Tanzania","lastPublishedDoi":"10.21203/rs.3.rs-4432440/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4432440/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn low- and -middle-income countries (LMICs) like Tanzania, the competency of healthcare providers critically influences the quality of pediatric care. To address this, we introduced PACE (Pediatric Acute Care Education), an adaptive e-learning program tailored to enhance provider competency in line with Tanzania\u0026rsquo;s national guidelines for managing seriously ill children. Adaptive e-learning presents a promising alternative to traditional in-service education, yet optimal strategies for its implementation in LMIC settings remain to be fully elucidated.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis study aimed to (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) evaluate the initial implementation of PACE in Mwanza, Tanzania, using the constructs of Normalization Process Theory (NPT), and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) provide insights into its feasibility, acceptability, and scalability potential.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods approach was employed across three healthcare settings in Mwanza: a zonal hospital and two health centers. NPT was utilized to navigate the complexities of implementing PACE. Data collection involved a customized NoMAD survey, focus groups and in-depth interviews with healthcare providers.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study engaged 82 healthcare providers through the NoMAD survey and 79 in focus groups and interviews. Findings indicated high levels of coherence and cognitive participation, demonstrating that PACE is well-understood and resonates with existing healthcare goals. Providers expressed a willingness to integrate PACE into their practice, distinguishing it from existing educational methods. However, challenges related to resources and infrastructure, particularly affecting collective action, were noted. The short duration of the study limited the assessment of reflexive monitoring, though early indicators point towards the potential for PACE\u0026rsquo;s long-term sustainability.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study offers vital insights into the feasibility and acceptability of implementing PACE in a Tanzanian context. While PACE aligns well with healthcare objectives, addressing resource and infrastructure challenges is crucial for its successful and sustainable implementation. Furthermore, the study underscores the value of NPT as a framework in guiding implementation processes, with broader implications for implementation science and pediatric acute care in LMICs.\u003c/p\u003e","manuscriptTitle":"Evaluating the Implementation of the Pediatric Acute Care Education (PACE) Program in Northwestern Tanzania: A Mixed-Methods Study Guided by Normalization Process Theory","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-31 20:37:25","doi":"10.21203/rs.3.rs-4432440/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-26T13:45:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-25T21:44:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54807797466270625047694047215626136194","date":"2024-06-17T14:11:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-14T06:34:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"18731312423909834867168076186032892837","date":"2024-06-04T08:09:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-02T14:12:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-22T09:24:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-20T01:20:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-05-16T16:47:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"222aa44c-6911-4a2c-b4e5-c9199662ba00","owner":[],"postedDate":"May 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-16T16:06:16+00:00","versionOfRecord":{"articleIdentity":"rs-4432440","link":"https://doi.org/10.1186/s12913-024-11554-3","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2024-09-13 15:58:25","publishedOnDateReadable":"September 13th, 2024"},"versionCreatedAt":"2024-05-31 20:37:25","video":"","vorDoi":"10.1186/s12913-024-11554-3","vorDoiUrl":"https://doi.org/10.1186/s12913-024-11554-3","workflowStages":[]},"version":"v1","identity":"rs-4432440","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4432440","identity":"rs-4432440","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}