IMPROVING FIDELITY OF SELF-ADMINISTERED PULSE OXIMETRY AND REMOTE PATIENT MONITORING IMPLEMENTATION IN HONDURAS DURING THE COVID-19 PANDEMIC

Abstract During the COVID-19 pandemic, Honduras’ Secretariat of Health was eager to understand whether self-administered pulse oximetry could improve clinical outcomes of high risk COVID-19 patients. While these interventions show promise for expanding healthcare access in lower- and middle-income countries, evidence about contextual implementation fidelity and effectiveness remains limited. We conducted a retrospective fidelity of implementation analysis of phone-based patient monitoring with or without self-administered pulse oximetry in Tegucigalpa and Comayagüela, Honduras. Using Carroll’s Conceptual Framework for Implementation Fidelity, we analyzed adherence (content, coverage, frequency, duration), delivery quality, participant responsiveness, and implementation strategies through trial data, acceptability assessments, and implementation documentation. The intervention achieved high fidelity: 97.9% coverage (1,821/1,860 eligible patients), 97.7% daily monitoring call completion calls, and 97.8% pulse oximeter utilization. Implementation strategies including culturally-adapted education materials and communication styles, and multi-disciplinary team engagement. Participant satisfaction was 99.7%, with minimal withdrawal (0.1%) and loss to follow-up (2.0%). However, only 28% of participants sought additional care when referred for warning signs. Unexpected benefits included reported positive impacts on participants’ mental health during isolation. This analysis demonstrates that remote patient monitoring and self-administered pulse oximetry implementation can achieve high fidelity in a lower-middle-income setting, including during a health emergency and where such interventions are novel. This challenges concerns about technology access and adoption in resource-limited environments. Future research should focus on hybrid effectiveness-implementation trials and strategies to improve referral adherence. These findings suggest that expanding implementation of these approaches may enhance healthcare access during emergencies and routine circumstances. Competing Interest Statement The authors have declared no competing interest. Clinical Trial NCT04886414 Funding Statement The U.S. Centers for Disease Control and Prevention funded the trial and supported design, interpretation, and review. All decisions were taken by the primary investigator. Roche SARS-CoV-2 Rapid Antigen Tests were donated by Roche Diagnostics, Ltd, which had no additional involvement. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This activity was determined to meet the definition of research [45 CFR 46.102(l)] involving human subjects [45 CFR 46.102 (e)(1)] and Institutional Review Board (IRB) review and was approved by Massachusetts General Brigham Institutional Review Board (2021P001143), the Autonomous University of Honduras (00003070), and SESAL. Secondary data analysis was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board (Approval No. 24586). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability Data belong to the Secretariat of Health of Honduras and will be shared upon reasonable request.