CFIR Model for Exploring the Role of Co-creation in the Implementation of Electronic Community Health Information System (eCHIS) in Kenya 

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This study explores the role of co-creation in the implementation of eCHIS, focusing on achieving adaptability, interoperability, and standardization. We employed semi-structured interviews with key informants, including policymakers, implementing partners, and end users. The Consolidated Framework for Implementation Research (CFIR) guided our thematic analysis. Key findings indicate that co-creation facilitated consensus and synergy among stakeholders. The construct of adaptability was highlighted through the customization of eCHIS to meet diverse needs, as reflected in the stakeholders' emphasis on real-time data access and policy-driven evidence. Interoperability was achieved through collaborative efforts to integrate eCHIS with existing health systems, supported by unified standards and protocols. Standardization efforts were underscored by the establishment of uniform data collection and reporting practices across all counties. Stakeholders perceived strong political support and leadership as critical to overcoming implementation challenges. Effective collaboration, continuous training, and capacity building were identified as essential for sustaining the system. The study also revealed that end users, including community health assistants and promoters, felt confident in their ability to utilize eCHIS, attributing this to comprehensive training and support structures. The co-creation approach significantly contributed to the successful implementation of eCHIS in Kenya by fostering adaptability, interoperability, and standardization. These findings underscore the importance of collaborative frameworks in health information system deployments, aligning with broader literature on co-creation and health systems strengthening. Co-creation eCHIS CFIR Adaptability Interoperability Standardization Leadership and Governance Introduction Health information systems (HIS) play a role in enhancing healthcare services streamlining data management and improving decision-making processes on a global scale. In Kenya, the Electronic Community Health Information System (eCHIS) is being implemented to incorporate technology in healthcare to tackle issues like scattered data, inefficiencies in care and the absence of real-time health data [ 1 ]. However, the introduction of HIS in developing nations like Kenya has encountered obstacles and often failed due to disjointed efforts from various stakeholders such as government bodies, donor groups and non-governmental organizations. This has led to challenges related to sustainability like data and inefficient resource utilization [ 2 , 3 ]. Despite the benefits of HIS systems developing countries encounter notable barriers during implementation including limited infrastructure, insufficient training for healthcare professionals and resistance to change from stakeholders [ 4 ]. Ensuring interoperability, standardization and adaptability, to contexts remains a complex task [ 5 ]. Often these HIS initiatives lack coordination resulting in incompatible systems that collect data differently making it challenging to effectively aggregate and analyze information. Inconsistencies in data entry, errors and a decrease in healthcare delivery efficiency are outcomes of this situation [ 6 ]. Relying heavily on donor funding for setting up and running HIS can lead to sustainability issues, especially when donors change their priorities or stop funding many systems struggle to operate or are abandoned. This worsens the fragmentation of healthcare systems and results in resource wastage [ 7 , 8 ]. To tackle these issues effectively a unified and standardized approach is needed that stresses collaboration and co-creation among all stakeholders. This will help develop sustainable systems that optimize resource utilization and enhance healthcare services in Kenya. Co-creation within HIS emphasizes the importance of efforts among stakeholders to create, implement and enhance technology solutions that cater to diverse healthcare needs. Co-creation entails involvement, from policymakers, implementers and end users to ensure that the system is robust technologically user friendly and aligned with local healthcare practices [ 9 ]. This strategy promotes innovation boosts user engagement levels and enhances the effectiveness of HIS implementation [ 10 ]. In developing nations where resource limitations and varying user demands pose challenges, collaborative creation holds significant relevance [ 11 ]. Past research on HIS implementation underscores the significance of incorporating user feedback and local context in the design and rollout process. For example, when eCHIS systems were introduced in middle-income nations those that took stakeholder input into account were found to have better acceptance and longevity. The adoption of the District Health Information Software (DHIS2) improved data management and decision-making. However, it also highlighted challenges related to user training and system customization [ 12 ]. Similar observations in African countries stress the importance of involving stakeholders and having adaptable systems [ 4 ]. Training, support and iterative development processes are vital for addressing evolving obstacles and meeting user requirements [ 13 , 14 ]. The Consolidated Framework for Implementation Research (CFIR) offers a basis for examining implementation elements. Various CFIR constructs—such as intervention characteristics, external environment, internal environment, individual traits and process— align with co-creation principles. CFIR aids in understanding how co-creation impacts adaptability, interoperability and standardization. Adaptability involves tailoring systems to suit needs—an essential aspect considering Kenyan diverse healthcare landscape. Interoperability ensures integration with other HIS, for seamless data exchange. Creating protocols and data collection practices is important for ensuring reliability and uniformity as highlighted by Damschroder et al. (2009) [ 15 ]. The literature emphasizes the role of collaborative efforts in designing and implementing HIS. Incorporating the CFIR offers a perspective for improving the implementation process, especially in achieving flexibility, compatibility and standardization. Effective leadership and governance are crucial, in navigating the complexities of deploying eCHIS to ensure that the system aligns with its objectives and contributes to enhancing healthcare outcomes in Kenya. Purpose of the Study This study aims to investigate the role of co-creation in the successful implementation of eCHIS in Kenya. Co-creation, which involves collaborative efforts among various stakeholders, has been identified as a crucial factor in overcoming implementation challenges and achieving sustainable HISs [ 9 ]. By examining the processes and outcomes of co-creation in the eCHIS project, this research seeks to provide insights into how consensus and synergy were achieved among stakeholders. Research Questions 1. What are the key components of co-creation utilized in the eCHIS implementation? 2. How did these components influence consensus and synergy among stakeholders? 3. What role did leadership and governance play in the implementation process? Significance of the Study Understanding the dynamics of co-creation in the context of HIS can inform future initiatives, ensuring more effective and sustainable implementations. This study contributes to the growing body of knowledge on HIS in developing countries and offers practical recommendations for policymakers, healthcare providers, and other stakeholders involved in similar projects. Methods Research Design This study employs a qualitative research design, specifically utilizing semi-structured interviews to gather in-depth insights from various stakeholders involved in the implementation of the eCHIS in Kenya. A qualitative approach was chosen to capture the complex, contextual, and nuanced perspectives of different stakeholders, which are essential for understanding the co-creation process and its impact on the eCHIS implementation [ 16 ]. Participants The study included a diverse group of respondents categorized into policymakers, implementers, and end users. Policymakers comprised representatives from national and county governments and development partners, and donor organizations. Implementers included members of county health teams and implementing partners who were directly involved in the operational aspects of the eCHIS deployment. End users were composed of CHAs, CHPs, and health managers who actively utilized the eCHIS in their day-to-day activities. This comprehensive inclusion ensured a holistic understanding of the implementation process from various stakeholder perspectives. This diverse group of participants was selected to reflect the multi-faceted nature of the co-creation process and to provide a holistic view of the eCHIS implementation [ 17 ]. Data Collection Methods Data were collected through semi-structured interviews, which allowed for flexibility in probing deeper into specific areas of interest while ensuring that all relevant topics were covered consistently across interviews [ 18 ]. The semi-structured interview guides were designed to explore various themes including, the role and contributions of each stakeholder in the eCHIS implementation; experiences and challenges faced during the co-creation process; perceptions towards adaptability, interoperability, and standardization of eCHIS; the influence of leadership and governance on the implementation process. Interviews were conducted either in-person or via virtual communication platforms, depending on the availability and preferences of the participants. Each interview lasted approximately 20 to 40 minutes and was audio-recorded with the consent of the participants to ensure accuracy in data capture. Data Analysis Thematic analysis was employed to analyze the qualitative data obtained from the interviews. The process involved several steps to ensure a rigorous and systematic analysis [ 19 ]. All audio recordings were transcribed verbatim to create textual data for analysis, codes were generated based on significant statements and recurring themes, codes were grouped into themes that represented broader patterns in the data and finally, the themes were reviewed in relation to the coded extracts and the entire data set to ensure coherence and consistency. Ethical Considerations Ethical approval for the study was obtained from the relevant institutional review board. Informed consent was obtained from all participants before conducting the interviews. Participants were assured of the confidentiality of their responses and were informed that they could withdraw from the study at any time without any consequences. Data were anonymized to protect the identity of the participants and ensure privacy. Results The results of this study utilizing CFIR, elucidate the multifaceted role of co-creation in implementing the eCHIS in Kenya. The study categorizes its findings according to CFIR elements demonstrating how working together supported adaptability, interoperability and standardization. Innovation Characteristics To ensure the quality design, functionality, and packaging of eCHIS stakeholders collaborated in brainstorming ideation and developing features that met criteria. The co-creation process stressed the importance of building a standardized system that could adapt to different county contexts while also being interoperable with other HIS. Together stakeholders created a platform that met broader health system requirements and seamlessly integrated with existing systems. "We are not customizing it for counties. Instead we are introducing an approach for additional systems that can be utilized while ensuring compatibility with other systems." The implementation of eCHIS showed improvements over traditional paper based systems especially in terms of efficiency, data accuracy and real time access. This transition was crucial, for making evidence based decisions and formulating policies across levels of healthcare management. This illustrates the relative advantage of using eCHIS over traditional manual paper systems and the challenges of integrating data from various disconnected digital systems, which hindered decision making. "The real-time access to information makes planning easier... Analyzing this information facilitates policy decisions.” Outer Setting External policies and incentives have been shown to impact the success of implementing and scaling up eCHIS. Strong governmental support and political commitment played a role in driving the initiative forward. The eCHIS project was a priority on the agenda ensuring high-level backing and streamlining resource allocation and priorities across government levels. "The implementation and scale-up were largely influenced by political will... It was a focus for our president. There was pressure from the leadership." The need for a standardized system across counties created peer pressure among regions to adopt the unified eCHIS platform. This collective effort, toward consistency proved vital in achieving interoperability and minimizing system fragmentation. The peer pressure from neighboring counties also motivated them to introduce eCHIS in order to enjoy the advantages as those who had previously embraced it. "Our partners were in sync with our goals and everyone worked towards that" and “Most counties were eager to be on-boarded onto eCHIS to also enjoy its benefits.” Inner Setting The implementation climate for eCHIS was influenced by the collective attitudes, perceptions and actions of the various stakeholders involved in the project. Many stakeholders viewed the implementation climate as supportive and cooperative. This positive setting was cultivated through communication, active engagement of all parties and shared objectives. The collaborative approach ensured that stakeholders felt their contributions were valued and they were part of an endeavor to enhance healthcare services through digital methods. "The government is considering a pathway... Ensuring guidance and a clear path from national to county levels to prevent disjointed systems." Readiness for implementation was bolstered by planning, including readiness evaluations and structured training initiatives. This guaranteed that counties were well prepared for launching the system making adoption smoother and minimizing resistance. "We had the resources we needed, from funding to training programs. It was all there to support us through the implementation and ongoing operations of eCHIS." Characteristics of Individuals The implementation of eCHIS revealed a variety of opinions and beliefs among the varied stakeholders. These viewpoints were influenced by their interactions with the systems design, training procedures, and operational efficiency underscoring the importance of user understanding and confidence in the success of eCHIS. The positive attitudes and trust that stakeholders had towards eCHIS played a role in its successful deployment. Engaging users and providing thorough training and a co-creation process fostered a sense of ownership and dedication to the new system. "Initially people generally viewed eCHIS positively as it aligned with the government's push for digitalization and was perceived as a tool to improve healthcare services." The effective implementation of eCHIS heavily hinged on the self-efficacy of its users. Their self-efficacy stemmed from their experiences with training programs assistance provided and operational obstacles faced while using the system. Empowering community health workers through training sessions and capacity building was crucial, in enhancing their ability to utilize the platform effectively. The empowerment played a role in ensuring continuous engagement and effective utilization of the system. "The training boosted our confidence. Now, I feel capable of using eCHIS effectively in my daily tasks... There was a learning curve, but I've moved from hesitant to skilled user of eCHIS " Implementation Process A collaborative approach was adopted, involving planning and coordination among all stakeholders. Regular meetings, technical working groups, and ongoing communication were key to keeping everyone aligned and adhering closely to the implementation plan. "Planning was key. We had a clear roadmap, which helped everyone stay on track and meet our goals." Stakeholder engagement was at the core of the process. By involving a range of stakeholders such as government departments, county health teams, community health workers and development partners’ various viewpoints were considered to design a system that addresses users' needs. "There's an eCHIS Technical working group (TWG), run headed by digital health and digital Division of Community Health. They have a WhatsApp group..." The collaborative method proved essential in overcoming technical hurdles encountered during the execution phase such as delays in smartphone deliveries required efforts, from all stakeholders involved in deploying the eCHIS system. "I think that the technology organization is making great. We don't consider ourselves a vendor for technology. Consider ourselves a partner to the Ministry of Health." The reflecting and evaluation phase of implementing eCHIS played a role in evaluating the system's impact identifying areas for enhancement and ensuring its long-term viability. Implementers utilized strategies to collect feedback assess performance and collectively refine the system. "Continuous improvement... while the main rollout is nearly complete, there is a focus on management, maintenance, and improvements." The CFIR framework offered a foundation for analyzing the collaborative process during eCHIS implementation. The active engagement of stakeholders at all stages backed by political commitment, thorough planning, and ongoing evaluation played a key role in achieving adaptability, interoperability and standardization objectives. These results highlight the importance of collaboration in health system interventions and offer a blueprint for similar endeavors, in different settings. Discussion The implementation of eCHIS in Kenya, analyzed through the lens of the CFIR model, offers key insights into the role of co-creation in achieving adaptability, interoperability, and standardization. This synthesis compares the findings with existing research on HIS (HIS) and co-creation in healthcare. The co-creation process in eCHIS implementation highlighted the importance of designing interventions that are both evidence-based and adaptable, aligning with [ 20 ], who emphasize the need for adaptability in digital health interventions. Active involvement of various stakeholders ensured the system was grounded in practical knowledge and flexible enough to accommodate different county needs. Strong political will and government support were critical for the rapid implementation, scale-up, and standardization of eCHIS. This finding is consistent with studies by [ 21 ], indicating that political support and alignment with national health objectives are crucial for successful HIS implementation. Top-down pressure and aligned priorities helped streamline efforts and resources toward a unified goal. Similar outcomes have been observed in other contexts where political support and policy frameworks significantly influenced HIS success [ 22 ]. The implementation climate, characterized by strong leadership and a clear vision, fostered a conducive environment for eCHIS adoption. Damschroder et al. [ 15 ] highlight the significance of a supportive implementation climate and readiness for implementation as key factors in successful deployment. Extensive training and capacity-building initiatives ensured stakeholders were well-prepared, facilitating smoother implementation and enhanced system sustainability. Stakeholder engagement and empowerment were crucial in building positive perceptions and confidence in the system, resonating with [ 23 ], who highlight the importance of involving users in the design and implementation process to enhance acceptance and effectiveness. By involving and training end-users like community health workers, the co-creation process bolstered their self-efficacy and commitment to the system. Effective planning, engagement, execution, and continuous evaluation were critical components of the co-creation process. [ 24 ] emphasize iterative planning and stakeholder engagement in the implementation process. Regular communication through platforms like WhatsApp groups and technical working groups ensured all stakeholders were consistently informed and involved, facilitating collaborative problem-solving and decision-making. This iterative refinement based on stakeholder feedback is supported by implementation science literature [ 25 ]. The findings align with existing literature on HIS and co-creation in healthcare as [ 26 ] underscore the role of stakeholder engagement and political support in successful HIS implementations, while [ 27 ] highlight the importance of co-creation in designing user-friendly and effective health interventions. Similarly, [ 28 ] on EHR implementation emphasized collaborative approaches in overcoming barriers. The success of eCHIS in achieving interoperability and standardization parallels findings from the European Union's eHealth initiatives, where co-creation and stakeholder engagement were pivotal [ 29 ]. Moreover, the emphasis on real-time data access and utilization in eCHIS is consistent with [ 30 ], who discuss the transformative potential of real-time health data in improving healthcare delivery and policy-making. The ability to make data-driven decisions and enhance service delivery at the community level was a notable outcome of the eCHIS implementation, reflecting broader trends in the digital health field. This study contributes to the co-creation literature by providing empirical evidence on its effectiveness in a nationwide HIS implementation. The findings reinforce principles such as stakeholder engagement, iterative development, and shared decision-making as essential for successful health interventions. The positive impact of co-creation on system adaptability, interoperability, and standardization in eCHIS underscores its potential as a viable strategy for other large-scale health implementations, aligning with [ 31 ], who argues that co-creation enhances the relevance and sustainability of health services by aligning them with user needs and contextual realities. Conclusion This study underscores the vital role of co-creation in the successful design and implementation of the eCHIS in Kenya. Utilizing the Consolidated Framework for Implementation Research (CFIR) as an analytical lens, the study highlights how stakeholder engagement at multiple levels facilitated the achievement of key implementation goals, such as adaptability, interoperability, and standardization. By actively involving diverse stakeholders, including government officials, healthcare providers, and community health workers, the co-creation process ensured that the system was tailored to meet the specific needs of various users, leading to widespread acceptance and effective utilization. The findings align with existing literature on health information systems, reaffirming that stakeholder involvement and collaborative approaches are crucial for overcoming implementation barriers. This study adds to the body of knowledge by providing empirical evidence on the importance of a supportive policy environment, continuous capacity building, and adaptive planning in the success of health informatics projects. The positive perceptions and trust developed through co-creation were pivotal in fostering a conducive implementation climate, highlighting the significance of user-centered design in health technology initiatives. The eCHIS project in Kenya exemplifies how co-creation and collaborative efforts can lead to the successful deployment of complex HIS. The insights gained from this study provide valuable guidance for future health informatics projects, emphasizing the need for inclusive stakeholder engagement, robust policy support, and adaptive implementation strategies. As eCHIS continues to evolve, the principles of co-creation will remain essential for ensuring that these systems are not only technically sound but also user-friendly and sustainable in diverse healthcare contexts. Declarations The authors declare no competing interests. Corresponding author Correspondence to Michael Anindo. Author information Michael Anindo Adjunct lecturer, University of Nairobi, Department of Computing and Informatics, Nairobi, Kenya Peter Waiganjo Professor, University of Nairobi, Department of Computing and Informatics, Nairobi, Kenya Daniel Orwa Professor, University of Nairobi, Department of Computing and Informatics, Nairobi, Kenya Maureen Adoyo Lecturer, Rongo University, Faculty of Health Sciences, Migori, Kenya Michael Kagiri Adjunct lecturer, University of Nairobi, Department of Computing and Informatics, Nairobi, Kenya Salome Ireri Adjunct lecturer, University of Nairobi, Department of Computing and Informatics, Nairobi, Kenya Rachael Wanjiru Digital Health Lead, University of Nairobi, HealthIT Project, Nairobi, Kenya Joan Kirui Project Coordinator, University of Nairobi, HealthIT Project, Nairobi, Kenya Raphael Pundo Chief of Party, University of Nairobi, HealthIT Project, Nairobi, Kenya Maureen Kimani Head of Community Health Division, Ministry of Health, Nairobi, Kenya Ethics Declarations The protocol was reviewed and approved by the Chuka University Ethical Review Committee on 20th September, 2023. The Protocol approval number is NACOSTI/NBC/AC-0812. Informed consent was obtained from all individual participants included in the study. Funding This study was funded by HealthIT USAID Project. Author Contribution All authors have made substantial contributions to the completion of this manuscript. M.A. conceived, designed and wrote the main manuscript text and was responsible for the operationalization of the project and performed data extraction. All authors participated actively in the interpretation of data. This manuscript was initially prepared by M.A. and critically reviewed by the other co-authors. All the authors have revised and approved the final version of the manuscript. Acknowledgement We would like to acknowledge the Ministry of Health-Kenya, HealthIT, Lwala Community Alliance, MEDIC, Living Goods, and AMREF for facilitating access to the data for analysis. Data Availability Data will be available upon request References Ministry of Health, Kenya. (2018). 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Palumbo, R. (2016). Contextualizing co-production of health care: A systematic literature review. International Journal of Public Sector Management, 29(1), 72–90. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-4479712","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":312816243,"identity":"963c2f6e-4de7-492c-be93-6d3caca13a27","order_by":0,"name":"Michael Anindo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYFACxgYGHgYbIIOH4QCIL0GkljSStIAVHwaTDERp4Z/d3PbgTcX5xH7p3oMHGGrsGCTbG/BrkbhzsN1wzpnbiTPnnEs4wHAsmUGa5wABa24ktknztt1O3HAjx+AAA9sBBjmJBPw65CFazkG1/ANqkX+AX4sBRMsBiBbGtgMM0oT8bwjUIjnnTLLxzBl5CQcS+5J5JHsIOEzuRvoziTcVdrL9ErmHP3z4ZicncfwAAWtQQAI8dkbBKBgFo2AUUAQAJO9GS5efS7QAAAAASUVORK5CYII=","orcid":"","institution":"University of Nairobi","correspondingAuthor":true,"prefix":"","firstName":"Michael","middleName":"","lastName":"Anindo","suffix":""},{"id":312816244,"identity":"1e8aba14-b650-43f2-b5e2-4f6362dbfc41","order_by":1,"name":"Peter Waiganjo","email":"","orcid":"","institution":"University of Nairobi","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Waiganjo","suffix":""},{"id":312816245,"identity":"1b32b575-d83c-4091-97b2-bea9ee6df7fc","order_by":2,"name":"Daniel Orwa","email":"","orcid":"","institution":"University of Nairobi","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Orwa","suffix":""},{"id":312816246,"identity":"8c246b79-7021-4483-bf18-ed40ce908bd0","order_by":3,"name":"Michael Kagiri","email":"","orcid":"","institution":"University of Nairobi","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Kagiri","suffix":""},{"id":312816247,"identity":"a41ad9bf-d61a-41e9-99b6-4f5bac2d7241","order_by":4,"name":"Salome Ireri","email":"","orcid":"","institution":"University of Nairobi","correspondingAuthor":false,"prefix":"","firstName":"Salome","middleName":"","lastName":"Ireri","suffix":""},{"id":312816248,"identity":"6d03e5cb-751e-4576-be96-d826232f00b7","order_by":5,"name":"Maureen Adoyo","email":"","orcid":"","institution":"Rongo University","correspondingAuthor":false,"prefix":"","firstName":"Maureen","middleName":"","lastName":"Adoyo","suffix":""},{"id":312816249,"identity":"0a054aa6-ffdc-45c4-9c78-04405d92d6cb","order_by":6,"name":"Rachael Wanjiru","email":"","orcid":"","institution":"HealthIT","correspondingAuthor":false,"prefix":"","firstName":"Rachael","middleName":"","lastName":"Wanjiru","suffix":""},{"id":312816250,"identity":"63827d28-5562-4662-8d54-5281c140facd","order_by":7,"name":"Joan Kirui","email":"","orcid":"","institution":"HealthIT","correspondingAuthor":false,"prefix":"","firstName":"Joan","middleName":"","lastName":"Kirui","suffix":""},{"id":312816251,"identity":"aed99b02-c071-41ea-ad08-414323bfa94e","order_by":8,"name":"Raphael Pundo","email":"","orcid":"","institution":"HealthIT","correspondingAuthor":false,"prefix":"","firstName":"Raphael","middleName":"","lastName":"Pundo","suffix":""},{"id":312816252,"identity":"aca596c0-baf2-4ac0-af45-17fe94442782","order_by":9,"name":"Maureen Kimani","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Maureen","middleName":"","lastName":"Kimani","suffix":""}],"badges":[],"createdAt":"2024-05-26 10:46:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4479712/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4479712/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60916832,"identity":"a5b7acb9-6d95-4bec-984b-1e8967abe9f2","added_by":"auto","created_at":"2024-07-23 13:52:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":390029,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4479712/v1/56bd1c30-1423-4a80-9875-e7279397a5af.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":" CFIR Model for Exploring the Role of Co-creation in the Implementation of Electronic Community Health Information System (eCHIS) in Kenya ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealth information systems (HIS) play a role in enhancing healthcare services streamlining data management and improving decision-making processes on a global scale. In Kenya, the Electronic Community Health Information System (eCHIS) is being implemented to incorporate technology in healthcare to tackle issues like scattered data, inefficiencies in care and the absence of real-time health data [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, the introduction of HIS in developing nations like Kenya has encountered obstacles and often failed due to disjointed efforts from various stakeholders such as government bodies, donor groups and non-governmental organizations. This has led to challenges related to sustainability like data and inefficient resource utilization [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the benefits of HIS systems developing countries encounter notable barriers during implementation including limited infrastructure, insufficient training for healthcare professionals and resistance to change from stakeholders [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Ensuring interoperability, standardization and adaptability, to contexts remains a complex task [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Often these HIS initiatives lack coordination resulting in incompatible systems that collect data differently making it challenging to effectively aggregate and analyze information. Inconsistencies in data entry, errors and a decrease in healthcare delivery efficiency are outcomes of this situation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRelying heavily on donor funding for setting up and running HIS can lead to sustainability issues, especially when donors change their priorities or stop funding many systems struggle to operate or are abandoned. This worsens the fragmentation of healthcare systems and results in resource wastage [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. To tackle these issues effectively a unified and standardized approach is needed that stresses collaboration and co-creation among all stakeholders. This will help develop sustainable systems that optimize resource utilization and enhance healthcare services in Kenya.\u003c/p\u003e \u003cp\u003eCo-creation within HIS emphasizes the importance of efforts among stakeholders to create, implement and enhance technology solutions that cater to diverse healthcare needs. Co-creation entails involvement, from policymakers, implementers and end users to ensure that the system is robust technologically user friendly and aligned with local healthcare practices [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This strategy promotes innovation boosts user engagement levels and enhances the effectiveness of HIS implementation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In developing nations where resource limitations and varying user demands pose challenges, collaborative creation holds significant relevance [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePast research on HIS implementation underscores the significance of incorporating user feedback and local context in the design and rollout process. For example, when eCHIS systems were introduced in middle-income nations those that took stakeholder input into account were found to have better acceptance and longevity. The adoption of the District Health Information Software (DHIS2) improved data management and decision-making. However, it also highlighted challenges related to user training and system customization [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Similar observations in African countries stress the importance of involving stakeholders and having adaptable systems [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Training, support and iterative development processes are vital for addressing evolving obstacles and meeting user requirements [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Consolidated Framework for Implementation Research (CFIR) offers a basis for examining implementation elements. Various CFIR constructs\u0026mdash;such as intervention characteristics, external environment, internal environment, individual traits and process\u0026mdash; align with co-creation principles. CFIR aids in understanding how co-creation impacts adaptability, interoperability and standardization. Adaptability involves tailoring systems to suit needs\u0026mdash;an essential aspect considering Kenyan diverse healthcare landscape. Interoperability ensures integration with other HIS, for seamless data exchange. Creating protocols and data collection practices is important for ensuring reliability and uniformity as highlighted by Damschroder et al. (2009) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe literature emphasizes the role of collaborative efforts in designing and implementing HIS. Incorporating the CFIR offers a perspective for improving the implementation process, especially in achieving flexibility, compatibility and standardization. Effective leadership and governance are crucial, in navigating the complexities of deploying eCHIS to ensure that the system aligns with its objectives and contributes to enhancing healthcare outcomes in Kenya.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003ePurpose of the Study\u003c/h2\u003e \u003cp\u003eThis study aims to investigate the role of co-creation in the successful implementation of eCHIS in Kenya. Co-creation, which involves collaborative efforts among various stakeholders, has been identified as a crucial factor in overcoming implementation challenges and achieving sustainable HISs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. By examining the processes and outcomes of co-creation in the eCHIS project, this research seeks to provide insights into how consensus and synergy were achieved among stakeholders.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResearch Questions\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e1. What are the key components of co-creation utilized in the eCHIS implementation?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e2. How did these components influence consensus and synergy among stakeholders?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e3. What role did leadership and governance play in the implementation process?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSignificance of the Study\u003c/h2\u003e \u003cp\u003eUnderstanding the dynamics of co-creation in the context of HIS can inform future initiatives, ensuring more effective and sustainable implementations. This study contributes to the growing body of knowledge on HIS in developing countries and offers practical recommendations for policymakers, healthcare providers, and other stakeholders involved in similar projects.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eResearch Design\u003c/h2\u003e \u003cp\u003eThis study employs a qualitative research design, specifically utilizing semi-structured interviews to gather in-depth insights from various stakeholders involved in the implementation of the eCHIS in Kenya. A qualitative approach was chosen to capture the complex, contextual, and nuanced perspectives of different stakeholders, which are essential for understanding the co-creation process and its impact on the eCHIS implementation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe study included a diverse group of respondents categorized into policymakers, implementers, and end users. Policymakers comprised representatives from national and county governments and development partners, and donor organizations. Implementers included members of county health teams and implementing partners who were directly involved in the operational aspects of the eCHIS deployment. End users were composed of CHAs, CHPs, and health managers who actively utilized the eCHIS in their day-to-day activities. This comprehensive inclusion ensured a holistic understanding of the implementation process from various stakeholder perspectives. This diverse group of participants was selected to reflect the multi-faceted nature of the co-creation process and to provide a holistic view of the eCHIS implementation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Methods\u003c/h2\u003e \u003cp\u003eData were collected through semi-structured interviews, which allowed for flexibility in probing deeper into specific areas of interest while ensuring that all relevant topics were covered consistently across interviews [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The semi-structured interview guides were designed to explore various themes including, the role and contributions of each stakeholder in the eCHIS implementation; experiences and challenges faced during the co-creation process; perceptions towards adaptability, interoperability, and standardization of eCHIS; the influence of leadership and governance on the implementation process.\u003c/p\u003e \u003cp\u003e Interviews were conducted either in-person or via virtual communication platforms, depending on the availability and preferences of the participants. Each interview lasted approximately 20 to 40 minutes and was audio-recorded with the consent of the participants to ensure accuracy in data capture.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThematic analysis was employed to analyze the qualitative data obtained from the interviews. The process involved several steps to ensure a rigorous and systematic analysis [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. All audio recordings were transcribed verbatim to create textual data for analysis, codes were generated based on significant statements and recurring themes, codes were grouped into themes that represented broader patterns in the data and finally, the themes were reviewed in relation to the coded extracts and the entire data set to ensure coherence and consistency.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e for the study was obtained from the relevant institutional review board. Informed consent was obtained from all participants before conducting the interviews. Participants were assured of the confidentiality of their responses and were informed that they could withdraw from the study at any time without any consequences. Data were anonymized to protect the identity of the participants and ensure privacy.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe results of this study utilizing CFIR, elucidate the multifaceted role of co-creation in implementing the eCHIS in Kenya. The study categorizes its findings according to CFIR elements demonstrating how working together supported adaptability, interoperability and standardization.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInnovation Characteristics\u003c/h2\u003e \u003cp\u003eTo ensure the quality design, functionality, and packaging of eCHIS stakeholders collaborated in brainstorming ideation and developing features that met criteria. The co-creation process stressed the importance of building a standardized system that could adapt to different county contexts while also being interoperable with other HIS. Together stakeholders created a platform that met broader health system requirements and seamlessly integrated with existing systems.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"We are not customizing it for counties. Instead we are introducing an approach for additional systems that can be utilized while ensuring compatibility with other systems.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe implementation of eCHIS showed improvements over traditional paper based systems especially in terms of efficiency, data accuracy and real time access. This transition was crucial, for making evidence based decisions and formulating policies across levels of healthcare management. This illustrates the relative advantage of using eCHIS over traditional manual paper systems and the challenges of integrating data from various disconnected digital systems, which hindered decision making.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"The real-time access to information makes planning easier... Analyzing this information facilitates policy decisions.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOuter Setting\u003c/h2\u003e \u003cp\u003eExternal policies and incentives have been shown to impact the success of implementing and scaling up eCHIS. Strong governmental support and political commitment played a role in driving the initiative forward. The eCHIS project was a priority on the agenda ensuring high-level backing and streamlining resource allocation and priorities across government levels.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"The implementation and scale-up were largely influenced by political will... It was a focus for our president. There was pressure from the leadership.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe need for a standardized system across counties created peer pressure among regions to adopt the unified eCHIS platform. This collective effort, toward consistency proved vital in achieving interoperability and minimizing system fragmentation. The peer pressure from neighboring counties also motivated them to introduce eCHIS in order to enjoy the advantages as those who had previously embraced it.\u003c/p\u003e \u003cp\u003e\u003cem\u003e \"Our partners were in sync with our goals and everyone worked towards that\" and \u0026ldquo;Most counties were eager to be on-boarded onto eCHIS to also enjoy its benefits.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eInner Setting\u003c/h2\u003e \u003cp\u003eThe implementation climate for eCHIS was influenced by the collective attitudes, perceptions and actions of the various stakeholders involved in the project. Many stakeholders viewed the implementation climate as supportive and cooperative. This positive setting was cultivated through communication, active engagement of all parties and shared objectives. The collaborative approach ensured that stakeholders felt their contributions were valued and they were part of an endeavor to enhance healthcare services through digital methods.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"The government is considering a pathway... Ensuring guidance and a clear path from national to county levels to prevent disjointed systems.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eReadiness for implementation was bolstered by planning, including readiness evaluations and structured training initiatives. This guaranteed that counties were well prepared for launching the system making adoption smoother and minimizing resistance.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"We had the resources we needed, from funding to training programs. It was all there to support us through the implementation and ongoing operations of eCHIS.\"\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of Individuals\u003c/h2\u003e \u003cp\u003eThe implementation of eCHIS revealed a variety of opinions and beliefs among the varied stakeholders. These viewpoints were influenced by their interactions with the systems design, training procedures, and operational efficiency underscoring the importance of user understanding and confidence in the success of eCHIS. The positive attitudes and trust that stakeholders had towards eCHIS played a role in its successful deployment. Engaging users and providing thorough training and a co-creation process fostered a sense of ownership and dedication to the new system.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Initially people generally viewed eCHIS positively as it aligned with the government's push for digitalization and was perceived as a tool to improve healthcare services.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe effective implementation of eCHIS heavily hinged on the self-efficacy of its users. Their self-efficacy stemmed from their experiences with training programs assistance provided and operational obstacles faced while using the system. Empowering community health workers through training sessions and capacity building was crucial, in enhancing their ability to utilize the platform effectively. The empowerment played a role in ensuring continuous engagement and effective utilization of the system.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"The training boosted our confidence. Now, I feel capable of using eCHIS effectively in my daily tasks... There was a learning curve, but I've moved from hesitant to skilled user of eCHIS \"\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eImplementation Process\u003c/h2\u003e \u003cp\u003eA collaborative approach was adopted, involving planning and coordination among all stakeholders. Regular meetings, technical working groups, and ongoing communication were key to keeping everyone aligned and adhering closely to the implementation plan.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Planning was key. We had a clear roadmap, which helped everyone stay on track and meet our goals.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eStakeholder engagement was at the core of the process. By involving a range of stakeholders such as government departments, county health teams, community health workers and development partners\u0026rsquo; various viewpoints were considered to design a system that addresses users' needs.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"There's an eCHIS Technical working group (TWG), run headed by digital health and digital Division of Community Health. They have a WhatsApp group...\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe collaborative method proved essential in overcoming technical hurdles encountered during the execution phase such as delays in smartphone deliveries required efforts, from all stakeholders involved in deploying the eCHIS system.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I think that the technology organization is making great. We don't consider ourselves a vendor for technology. Consider ourselves a partner to the Ministry of Health.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe reflecting and evaluation phase of implementing eCHIS played a role in evaluating the system's impact identifying areas for enhancement and ensuring its long-term viability. Implementers utilized strategies to collect feedback assess performance and collectively refine the system.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Continuous improvement... while the main rollout is nearly complete, there is a focus on management, maintenance, and improvements.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe CFIR framework offered a foundation for analyzing the collaborative process during eCHIS implementation. The active engagement of stakeholders at all stages backed by political commitment, thorough planning, and ongoing evaluation played a key role in achieving adaptability, interoperability and standardization objectives. These results highlight the importance of collaboration in health system interventions and offer a blueprint for similar endeavors, in different settings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe implementation of eCHIS in Kenya, analyzed through the lens of the CFIR model, offers key insights into the role of co-creation in achieving adaptability, interoperability, and standardization. This synthesis compares the findings with existing research on HIS (HIS) and co-creation in healthcare. The co-creation process in eCHIS implementation highlighted the importance of designing interventions that are both evidence-based and adaptable, aligning with [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], who emphasize the need for adaptability in digital health interventions. Active involvement of various stakeholders ensured the system was grounded in practical knowledge and flexible enough to accommodate different county needs.\u003c/p\u003e \u003cp\u003eStrong political will and government support were critical for the rapid implementation, scale-up, and standardization of eCHIS. This finding is consistent with studies by [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], indicating that political support and alignment with national health objectives are crucial for successful HIS implementation. Top-down pressure and aligned priorities helped streamline efforts and resources toward a unified goal. Similar outcomes have been observed in other contexts where political support and policy frameworks significantly influenced HIS success [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe implementation climate, characterized by strong leadership and a clear vision, fostered a conducive environment for eCHIS adoption. Damschroder et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] highlight the significance of a supportive implementation climate and readiness for implementation as key factors in successful deployment. Extensive training and capacity-building initiatives ensured stakeholders were well-prepared, facilitating smoother implementation and enhanced system sustainability. Stakeholder engagement and empowerment were crucial in building positive perceptions and confidence in the system, resonating with [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], who highlight the importance of involving users in the design and implementation process to enhance acceptance and effectiveness. By involving and training end-users like community health workers, the co-creation process bolstered their self-efficacy and commitment to the system.\u003c/p\u003e \u003cp\u003eEffective planning, engagement, execution, and continuous evaluation were critical components of the co-creation process. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] emphasize iterative planning and stakeholder engagement in the implementation process. Regular communication through platforms like WhatsApp groups and technical working groups ensured all stakeholders were consistently informed and involved, facilitating collaborative problem-solving and decision-making. This iterative refinement based on stakeholder feedback is supported by implementation science literature [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe findings align with existing literature on HIS and co-creation in healthcare as [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] underscore the role of stakeholder engagement and political support in successful HIS implementations, while [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] highlight the importance of co-creation in designing user-friendly and effective health interventions. Similarly, [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] on EHR implementation emphasized collaborative approaches in overcoming barriers. The success of eCHIS in achieving interoperability and standardization parallels findings from the European Union's eHealth initiatives, where co-creation and stakeholder engagement were pivotal [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMoreover, the emphasis on real-time data access and utilization in eCHIS is consistent with [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], who discuss the transformative potential of real-time health data in improving healthcare delivery and policy-making. The ability to make data-driven decisions and enhance service delivery at the community level was a notable outcome of the eCHIS implementation, reflecting broader trends in the digital health field.\u003c/p\u003e \u003cp\u003eThis study contributes to the co-creation literature by providing empirical evidence on its effectiveness in a nationwide HIS implementation. The findings reinforce principles such as stakeholder engagement, iterative development, and shared decision-making as essential for successful health interventions. The positive impact of co-creation on system adaptability, interoperability, and standardization in eCHIS underscores its potential as a viable strategy for other large-scale health implementations, aligning with [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], who argues that co-creation enhances the relevance and sustainability of health services by aligning them with user needs and contextual realities.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study underscores the vital role of co-creation in the successful design and implementation of the eCHIS in Kenya. Utilizing the Consolidated Framework for Implementation Research (CFIR) as an analytical lens, the study highlights how stakeholder engagement at multiple levels facilitated the achievement of key implementation goals, such as adaptability, interoperability, and standardization. By actively involving diverse stakeholders, including government officials, healthcare providers, and community health workers, the co-creation process ensured that the system was tailored to meet the specific needs of various users, leading to widespread acceptance and effective utilization.\u003c/p\u003e \u003cp\u003eThe findings align with existing literature on health information systems, reaffirming that stakeholder involvement and collaborative approaches are crucial for overcoming implementation barriers. This study adds to the body of knowledge by providing empirical evidence on the importance of a supportive policy environment, continuous capacity building, and adaptive planning in the success of health informatics projects. The positive perceptions and trust developed through co-creation were pivotal in fostering a conducive implementation climate, highlighting the significance of user-centered design in health technology initiatives.\u003c/p\u003e \u003cp\u003eThe eCHIS project in Kenya exemplifies how co-creation and collaborative efforts can lead to the successful deployment of complex HIS. The insights gained from this study provide valuable guidance for future health informatics projects, emphasizing the need for inclusive stakeholder engagement, robust policy support, and adaptive implementation strategies. As eCHIS continues to evolve, the principles of co-creation will remain essential for ensuring that these systems are not only technically sound but also user-friendly and sustainable in diverse healthcare contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Michael Anindo.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMichael Anindo\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdjunct lecturer, University of Nairobi, Department of Computing and Informatics, Nairobi, Kenya\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePeter Waiganjo\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eProfessor, University of Nairobi, Department of Computing and Informatics, Nairobi, Kenya\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDaniel Orwa\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eProfessor, University of Nairobi, Department of Computing and Informatics, Nairobi, Kenya\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMaureen Adoyo\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLecturer, Rongo University, Faculty of Health Sciences, Migori, Kenya\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMichael Kagiri\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdjunct lecturer, University of Nairobi, Department of Computing and Informatics, Nairobi, Kenya\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSalome Ireri\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdjunct lecturer, University of Nairobi, Department of Computing and Informatics, Nairobi, Kenya\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRachael Wanjiru\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDigital Health Lead, University of Nairobi, HealthIT Project, Nairobi, Kenya\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eJoan Kirui\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eProject Coordinator, University of Nairobi, HealthIT Project, Nairobi, Kenya\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRaphael Pundo\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eChief of Party, University of Nairobi, HealthIT Project, Nairobi, Kenya\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMaureen Kimani\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHead of Community Health Division, Ministry of Health, Nairobi, Kenya\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003eEthics Declarations\u003c/h2\u003e\n\u003cp\u003eThe protocol was reviewed and approved by the Chuka University Ethical Review Committee on 20th September, 2023. The Protocol approval number is NACOSTI/NBC/AC-0812. Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was funded by HealthIT USAID Project.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAll authors have made substantial contributions to the completion of this manuscript. M.A. conceived, designed and wrote the main manuscript text and was responsible for the operationalization of the project and performed data extraction. All authors participated actively in the interpretation of data. This manuscript was initially prepared by M.A. and critically reviewed by the other co-authors. All the authors have revised and approved the final version of the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eWe would like to acknowledge the Ministry of Health-Kenya, HealthIT, Lwala Community Alliance, MEDIC, Living Goods, and AMREF for facilitating access to the data for analysis.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eData will be available upon request\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health, Kenya. (2018). Kenya Health Information System (KHIS) Strategic Plan.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlaya, J. A., Fraser, H. S. F., \u0026amp; Holt, B. (2010). E-health technologies show promise in developing countries. Health Affairs, 29(2), 244\u0026ndash;251.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraa, J., Monteiro, E., \u0026amp; Sahay, S. (2007). 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(2002). The key to success in innovation part I: The art of interessement. International Journal of Innovation Management, 6(2), 187\u0026ndash;206.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRenedo, A., \u0026amp; Marston, C. (2015). Spaces for citizen involvement in healthcare: An ethnographic study. Sociology, 49(3), 488\u0026ndash;504.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFraser, H. S. F., Biondich, P., Moodley, D., Choi, S., Mamlin, B. W., \u0026amp; Szolovits, P. (2012). Implementing electronic medical record systems in developing countries. Informatics in Primary Care, 13(2), 83\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGordon, S., Cass, C., Finch, M., Liu, M., Owen, C., Hu, W., \u0026amp; Smith, K. (2017). Implementation science and the evaluation of healthcare innovations: A case study of eHealth innovations. 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Qualitative Research and Evaluation Methods (3rd ed.). Thousand Oaks, CA: Sage Publications.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKvale, S., \u0026amp; Brinkmann, S. (2009). InterViews: Learning the Craft of Qualitative Research Interviewing (2nd ed.). Thousand Oaks, CA: Sage Publications.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun, V., \u0026amp; Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenhalgh, T., Koh, G. C., \u0026amp; Car, J. (2017). Health information systems: overcoming challenges to improving healthcare. The BMJ, 358.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheikh, A., Sood, H. S., \u0026amp; Bates, D. W. (2011). Leveraging health information technology to achieve the \u0026ldquo;triple aim\u0026rdquo; of healthcare reform. 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BMC Medical Informatics and Decision Making, 11(1), 76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMolfenter, T., Boyle, M., Holloway, D., Zwick, J., \u0026amp; Moyer, A. (2015). Trends in electronic health record implementation in addiction treatment settings. Journal of Addiction Medicine, 9(2), 104\u0026ndash;110.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLupi\u0026aacute;\u0026ntilde;ez-Villanueva, F., Hardey, M., Torrent, J., \u0026amp; Ficapal, P. (2012). The integration of information and communication technology into medical practice. International Journal of Medical Informatics, 81(11), 850\u0026ndash;861.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones, S. S., Rudin, R. S., Perry, T., \u0026amp; Shekelle, P. G. (2014). Health information technology: An updated systematic review with a focus on meaningful use. Annals of Internal Medicine, 160(1), 48\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalumbo, R. (2016). Contextualizing co-production of health care: A systematic literature review. International Journal of Public Sector Management, 29(1), 72\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Co-creation, eCHIS, CFIR, Adaptability, Interoperability, Standardization, Leadership and Governance","lastPublishedDoi":"10.21203/rs.3.rs-4479712/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4479712/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe successful implementation of an Electronic Community Health Information System (eCHIS) in Kenya is pivotal for enhancing healthcare delivery. This study explores the role of co-creation in the implementation of eCHIS, focusing on achieving adaptability, interoperability, and standardization. We employed semi-structured interviews with key informants, including policymakers, implementing partners, and end users. The Consolidated Framework for Implementation Research (CFIR) guided our thematic analysis. Key findings indicate that co-creation facilitated consensus and synergy among stakeholders. The construct of adaptability was highlighted through the customization of eCHIS to meet diverse needs, as reflected in the stakeholders' emphasis on real-time data access and policy-driven evidence. Interoperability was achieved through collaborative efforts to integrate eCHIS with existing health systems, supported by unified standards and protocols. Standardization efforts were underscored by the establishment of uniform data collection and reporting practices across all counties. Stakeholders perceived strong political support and leadership as critical to overcoming implementation challenges. Effective collaboration, continuous training, and capacity building were identified as essential for sustaining the system. The study also revealed that end users, including community health assistants and promoters, felt confident in their ability to utilize eCHIS, attributing this to comprehensive training and support structures. The co-creation approach significantly contributed to the successful implementation of eCHIS in Kenya by fostering adaptability, interoperability, and standardization. These findings underscore the importance of collaborative frameworks in health information system deployments, aligning with broader literature on co-creation and health systems strengthening.\u003c/p\u003e","manuscriptTitle":" CFIR Model for Exploring the Role of Co-creation in the Implementation of Electronic Community Health Information System (eCHIS) in Kenya ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-12 08:59:12","doi":"10.21203/rs.3.rs-4479712/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3d7a3cad-c19c-49f2-b08c-622d4e737cd5","owner":[],"postedDate":"June 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-23T13:44:15+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-12 08:59:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4479712","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4479712","identity":"rs-4479712","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}