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Cited by 12Health Policy Implementation ScienceGlobal Maternal and Child HealthGlobal Health and Surgery

Scale-up of a novel vital signs alert device to improve maternity care in Sierra Leone: a mixed methods evaluation of adoption

Open access
Bright, Sophie, Moses, Francis, Ridout, Alex, Sam, Betty, Momoh, Mariama, Goodhart, Venetia, Smart, Francis, Mannah, Margaret +8 more·2023·Reproductive Health
DOI 10.1186/s12978-022-01551-2PMC PMC9817393
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Abstract

Background: The CRADLE (Community blood pressure monitoring in Rural Africa: Detection of underLying pre-Eclampsia) Vital Signs Alert device—designed specifically to improve maternity care in low resource settings—had varying impact when trialled in different countries. To better understand the contextual factors that may contribute to this variation, this study retrospectively evaluated the adoption of CRADLE, during scale-up in Sierra Leone. Methods: This was a mixed methods study. A quantitative indicator of adoption (the proportion of facilities trained per district) was calculated from existing training records, then focus groups were held with ‘CRADLE Champions’ in each district (n = 32), to explore adoption qualitatively. Template Analysis was used to deductively interpret qualitative data, guided by the NASSS (non-adoption, abandonment, scale-up, spread, sustainability) Framework. Findings: Substantial but non-significant variation was found in the proportion of facilities trained in each district (range 59–90%) [X2 (7, N = 8) = 10.419, p = 0.166]. Qualitative data identified complexity in two NASSS domains that may have contributed to this variation: ‘the technology’ (for example, charging issues, difficulty interpreting device output and concerns about ongoing procurement) and ‘the organisation’ (for example, logistical barriers to implementing training, infighting and high staff turnover). Key strategies mentioned to mitigate against these issues included: transparent communication at all levels; encouraging localised adaptations during implementation (including the involvement of community leaders); and selecting Champions with strong soft skills (particularly conflict resolution and problem solving). Conclusions: Complexity related to the technology and the organisational context were found to influence the adoption of CRADLE in Sierra Leone, with substantial inter-district variation. These findings emphasise the importance of gaining an in-depth understanding of the specific system and context in which a new healthcare technology is being implemented. This study has implications for the ongoing scale-up of CRADLE, and for those implementing or evaluating other health technologies in similar contexts.

AI snapshot

Written from the paper’s full text.

TL;DR

This mixed-methods evaluation of CRADLE Vital Signs Alert scale-up in eight Sierra Leone districts found substantial but non-significant inter-district variation in facility training adoption (59–90%; mean 77.5%). NASSS-guided qualitative analysis identified complexity in “the technology” and “the organisation” as key threats to adoption, with mitigation strategies around transparent communication, localised adaptation, and Champion soft skills.

Key findings

  • The proportion of facilities trained varied from 59% to 90% per district (mean 77.5%), but this variation was not statistically significant [χ² (7, N = 8) = 10.419, p = 0.166].
  • Across four focus groups with 32 CRADLE Champions, all qualitative codes aligned with NASSS domains; the dominant domains were “The Technology” (152 references) and “The Organisation” (127 references), both classified as “complex.”
  • Barriers included charging/battery faults, difficulty interpreting device arrows, concerns about ongoing procurement, infighting, high staff turnover, and logistical/travel difficulties; the proportion of references coded as barriers was greater in low-adoption districts (46%, 40%, 31%, and 33% for Districts A, B, H, and D, respectively).
  • Facilitators and mitigation strategies included transparent communication, localised adaptations such as involving community leaders, and selecting Champions with strong soft skills; Champions unanimously reported the device was desirable and effective, with some reporting perceived reductions in maternal deaths.

Methods

  • Retrospective pragmatic mixed-methods evaluation of CRADLE scale-up in eight of Sierra Leone’s sixteen districts between March 2020 and January 2021, using a training-of-trainers model.
  • Quantitative component used existing training registers to calculate the proportion of facilities trained per district as a proxy for adoption, with a chi-squared goodness-of-fit test for inter-district differences.
  • Qualitative component held four focus group discussions with 32 purposefully selected CRADLE Champions (78% participation; 94% female, 78% midwives), analysed using Template Analysis deductively guided by the NASSS Framework.

Limitations

  • The paper states that focus groups were held in only four districts, social desirability bias was possible, findings are specific to CRADLE and Sierra Leone, and the author was the implementing organisation’s Programmes Manager and White British, increasing risks of investigator bias and power imbalance; mitigations included non-leading questions, reflective analysis, and a Sierra Leonean lead moderator.
  • The text makes evident that the quantitative adoption indicator measured whether facilities were trained, not post-training device use, and the paper notes this differs from the CRCT indicator of “percentage of clinical areas using solely the CRADLE at 12 months.”
  • The paper states data saturation was reached after the third focus group, but the limited number of districts in the qualitative sample still constrains the range of contextual experiences captured.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s12978-022-01551-2

Cites

31 of 31 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

0 of 30 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The proportion of facilities trained varied from 59 to 90% per district (mean 77.5%).

    “The proportion of facilities trained varied from 59 to 90% per district (mean 77.5%; Table 1).”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The existing training registers accurately and completely record the facilities trained in each district.
    • Rests on an assumption: The proportion of facilities trained per district is a valid proxy for adoption of CRADLE by both Champions and facilities.
  • Findingown data

    Transparent communication at all levels was mentioned as a key strategy to mitigate against issues affecting CRADLE adoption.

    “Key strategies mentioned to mitigate against these issues included: transparent communication at all levels; encouraging localised adaptations during implementation (including the involvement of community leaders); and selecting Champions with strong soft skills (particularly conflict resolution and problem solving).”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.
  • Findingown data

    The district with the lowest levels of adoption mentioned power struggles and infighting frequently, and far more than other districts.

    “The district with lowest levels of adoption mentioned power struggles and infighting frequently, and far more than other districts.”
    Quote in the paperSubstantial claim
  • Findingown data

    Doubts about CRADLE accuracy were more common in districts with low adoption (A and B).

    “Doubts about accuracy were more common in districts with low adoption (A and B).”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.
  • Findingreasoning

    Based on quantitative adoption indicators, average adoption levels in this study (77.5%) were lower than those seen in Freetown during the CRCT (96.2%).

    “Based on quantitative adoption indicators, average adoption levels in this study were lower than seen in Freetown during the CRCT (77.5% versus 96.2%).”
    Quote in the paperSubstantial claim
  • May combine two claims. 44
  • Classified as probably not a substantial claim. 19

  • May combine two claims.

    Findingown data

    The inter-district variation in proportion of facilities trained was substantial but not statistically significant [χ2 (7, N = 8) = 10.419, p = 0.166].

    “This variation, although substantial, was not statistically significant [χ2 (7, N = 8) = 10.419, p = 0.166].”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The existing training registers accurately and completely record the facilities trained in each district.
    • Rests on an assumption: The proportion of facilities trained per district is a valid proxy for adoption of CRADLE by both Champions and facilities.

  • May combine two claims.

    Findingown data

    The two most dominant NASSS domains were 'The Technology' (152 references) and 'The Organisation' (127 references).

    “The two most dominant domains were ‘The Technology’ (152 references) and ‘The Organisation’ (127 references).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • May combine two claims.

    Findingown data

    A few participants reported developing a stronger bond with other staff members and improved multi-disciplinary working as a result of the programme.

    “A few reported developing a stronger bond with other staff members and improved multi-disciplinary working as a result of the programme.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Champions reported that pregnant women appreciated having their vital signs taken and the results communicated to them, and this led to increased facility attendance.

    “Champions reported that pregnant women appreciated having their vital signs taken and the results communicated to them, and this led to increased facility attendance.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • May combine two claims.

    Findingown data

    It was hard for Champions to access facilities, particularly during the rainy season, and the associated cost often exceeded the amount of money they had for travel.

    “Firstly, it was hard for Champions to access facilities, particularly during raining season, and the associated cost often exceeded the amount of money they had for travel.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • May combine two claims.

    Findingown data

    Few comments were made relating to the professional, sociocultural and legislative context, but those that were made were supportive of adoption.

    “Few comments were made relating to the professional, sociocultural, and legislative context. However, those made were supportive of adoption.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Concerns about ongoing procurement of spare CRADLE devices and parts (unavailable in Sierra Leone) were raised, and were mentioned more frequently in low-adoption districts.

    “Concerns were also raised about the ongoing procurement of spare devices and parts (unavailable in SL). Participants worried about becoming reliant on a device that may subsequently be withdrawn. These concerns were mentioned more frequently in low-adoption districts.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • May combine two claims.

    Findingcitation

    Respondents generally found the CRADLE device easy to use, but small errors in application (e.g. incorrect positioning) could lead to staff mistrust.

    “In keeping with earlier CRADLE studies [10, 12, 27], respondents generally found the device easy to use, but small errors in application (e.g. incorrect positioning) could lead to staff mistrust.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [10] Nathan H, Boene H, Munguambe K et al. The CRADLE vital signs alert: qualitative evaluation of a novel device designed for use in pregnancy by healthcare workers in low-resource settings. Reprod Health 2018; 15(1). source

      Not checked in the free run.

    • cites [12] Vousden N, Lawley E, Seed PT, et al. Exploring the effect of implementation and context on a stepped-wedge randomised controlled trial of a vital sign triage device in routine maternity care in low-resource settings. Implement Sci. 2019;14:38. source

      Not checked in the free run.

    • cites [27] Vousden N, Lawley E, Nathan HL, et al. Evaluation of a novel vital sign device to reduce maternal mortality and morbidity in low-resource settings: a mixed method feasibility study for the CRADLE-3 trial. BMC Pregnancy Childbirth. 2018;18:115. source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Participants were grateful to have been selected as Champions and expressed a sense of pride and responsibility in the role.

    “Participants were grateful to have been selected as ‘Champions’ and expressed a sense of pride and responsibility in the role.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • May combine two claims.

    Findingown data

    Engaging community leaders supported implementation of CRADLE and promoted community buy-in.

    “In particular, engaging community leaders supported implementation and promoted community buy-in.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Participants across all districts reported that CRADLE was easy to use and improved the accuracy of vital signs recording.

    “Participants across all districts reported that CRADLE was easy to use and improved the accuracy of vital signs recording.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Many Champions felt that expectations of additional payment could be managed with transparent communication and encouragement.

    “Many Champions felt this could be managed with transparent communication and encouragement.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • May combine two claims.

    Findingown data

    Champions in all districts unanimously reported that the CRADLE device was desirable and effective.

    “Champions in all districts unanimously reported that the device was desirable and effective.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • May combine two claims.

    Findingown data

    Power struggles and internal conflicts were mentioned by all districts but primarily by District A, the district with the lowest adoption.

    “These issues were mentioned by all districts but primarily by District A (lowest adoption).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    A clear charging schedule was reported to help, but the task remained burdensome.

    “A clear charging schedule was reported to help, but the task remained burdensome.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • Classified as probably not a substantial claim.

    Findingown data

    Champions reported that, to help avoid professional conflicts, initial consultation with facilities (about the programme, the training plan and the lack of financial incentives) must be communicated transparently and carefully.

    “To help avoid professional conflicts, Champions reported that initial consultation with facilities (e.g. about the programme, the plan for training, and the lack of financial incentives) must be communicated transparently and carefully.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Some participants felt that conflict could be avoided through transparent and sensitive communication with staff prior to training, particularly with the facility in-charges.

    “Some participants felt that conflict could be avoided through transparent and sensitive communication with staff prior to training, particularly with the facility in-charges.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    A few Champions doubted that the Ministry of Health and Sanitation could sustain the use of CRADLE independently, and several commented that continuation of external support was needed, predominantly in District B (low adoption).

    “A few Champions doubted that the MoHS could sustain the use of CRADLE independently and several commented that continuation of external support was needed (predominantly District B—low adoption).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Challenges with charging the CRADLE device were frequently mentioned, including the battery not retaining charge, lack of power supply to facilities and national power cuts.

    “Challenges with charging the device were frequently mentioned, including the battery not retaining charge, lack of power supply to facilities and national power cuts.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • May combine two claims.

    Findingown data

    Staff trained by Champions were reported to be grateful for the device and keen to learn new skills, but often expected additional payment to attend training.

    “Staff trained by Champions were reported to be grateful for the device and keen to learn new skills. However, they often expected additional payment to attend training, even though training was conducted within their routine working hours.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • May combine two claims.

    Findingcitation

    The CRADLE device was reported to support problem identification and management and met an urgent need for blood pressure machines.

    “In keeping with the previous multi-site evaluation [12], the device was reported to support problem identification and management and met an urgent need for blood pressure machines.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] Vousden N, Lawley E, Seed PT, et al. Exploring the effect of implementation and context on a stepped-wedge randomised controlled trial of a vital sign triage device in routine maternity care in low-resource settings. Implement Sci. 2019;14:38. source

      Not checked in the free run.

    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • May combine two claims.

    Findingown data

    Champions were not given funds to travel for in-person follow-up, so many devised alternative strategies to check on trainees.

    “Champions were not given funds to travel for in-person follow-up, so many devised alternative strategies to check on trainees.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    It was widely felt that one-off training was insufficient.

    “It was widely felt that one-off training was insufficient.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • May combine two claims.

    Findingown data

    Some Champions independently engaged community leaders in their area, and these Champions reported that the community leaders assisted them with implementation and enabled them to gain the support of other healthcare providers and the wider community.

    “Some Champions independently took the initiative to engage community leaders in their area. These Champions reported that the community leaders assisted them with implementation and enabled them to gain the support of other healthcare providers and the wider community.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Adoption was not uniform across all districts, with some districts reaching adoption levels of 90%.

    “Furthermore, adoption was not uniform across all districts, with some districts reaching adoption levels of 90%.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Champions reported noticing a reduction in maternal deaths since using the CRADLE device, with several providing personal accounts.

    “A novel finding is that Champions reported noticing a reduction in maternal deaths since using the device, with several providing personal accounts of this.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • May combine two claims.

    Findingown data

    This study identified many barriers to adoption, with substantial complexity identified around the technology and the organisation.

    “In contrast, this study identified many barriers, with substantial complexity identified around the technology and the organisation.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    All qualitative data codes in this study aligned with the NASSS domains, suggesting the framework translates to low-income contexts.

    “All qualitative data codes in this study aligned with the NASSS domains, suggesting the framework translates to low-income contexts.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The mechanisms of the battery faults are as yet unknown.

    “The mechanisms of these faults are yet unknown”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Difficulty charging the CRADLE device was mentioned frequently and could lead to abandonment if not addressed.

    “Difficulty charging the device was mentioned frequently and could lead to abandonment if not addressed.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Concerns were raised about the Ministry of Health and Sanitation's capacity to sustain the programme, particularly in relation to procurement of devices and parts.

    “Finally, concerns were also raised about the MoHS’ capacity to sustain the programme, particularly in relation to procurement of devices and parts.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Barriers to adoption of CRADLE in Sierra Leone included infighting, high staff turnover, charging issues, and concerns about ongoing procurement.

    “barriers to adoption including infighting, high staff turnover, charging issues, and concerns about ongoing procurement.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Participation rate in FGDs was 78%, with at least seven participants per district.

    “Participation rate was 78%, with at least seven participants per district.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The technology domain was considered complex because of reported charging issues (including battery faults), concerns about ongoing procurement, and potential to doubt or misinterpret results if inadequately trained.

    “The technology was considered to be complex because of reported charging issues (including battery faults), concerns about ongoing procurement, and potential to doubt or misinterpret results if inadequately trained.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • Classified as probably not a substantial claim.

    Premisecitation

    If an intervention is found to have complexity in several NASSS domains, it is considered less likely to be adopted and sustained.

    “If an intervention is found to have complexity in several domains (i.e. the domains are dynamic, unpredictable and/or are not easily disaggregated into constituent components) an intervention is considered less likely to be adopted and sustained.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] Greenhalgh T, Wherton J, Papoutsi C, et al. Beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. J Med Internet Res. 2017;19(11): e367. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In Sierra Leone there is a dearth of critical monitoring equipment and senior healthcare staff, inhibiting timely identification and management of complications.

    “However, in SL there is a dearth of critical monitoring equipment and senior healthcare staff, inhibiting timely identification and management of complications [5, 6].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [5] Ministry of Health and Sanitation [Sierra Leone] Sierra Leone National Reproductive, Maternal, Newborn, Child and Adolescent Health Policy. https://www.afro.who.int/publications/sierra-leone-national-reproductive-maternal-newborn-child-and-adolescent-health-policy. (2017, accessed: 20/09/20).

      Not checked in the free run.

    • cites [6] Ministry of Health and Sanitation [Sierra Leone] (2017c) Human Resources for Health Strategy 2017–2021 [online] WHO Available: https://www.afro.who.int/publications/sierra-leone-human-resources-health-strategic-plan-2017-2021 [Accessed: 01/10/20].

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Two NASSS domains-'The Technology' and 'The Organisation'-were classified as 'complex', posing a substantial threat to adoption.

    “Two domains—‘The Technology’ and ‘The Organisation’—were classified as ‘complex’, posing a substantial threat to adoption.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In that previous qualitative evaluation, most healthcare workers reported the CRADLE VSA was easy to use and perceived it to be accurate.

    “Most healthcare workers reported that the device was easy to use and perceived it to be accurate, whilst pregnant women unanimously liked the device, reporting that it increased their understanding of vital signs monitoring [10].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Nathan H, Boene H, Munguambe K et al. The CRADLE vital signs alert: qualitative evaluation of a novel device designed for use in pregnancy by healthcare workers in low-resource settings. Reprod Health 2018; 15(1). source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The technology and organisation domains are interdependent; for example, the need for ongoing training increases the work involved in implementation.

    “These domains are also interdependent, for example, the need for ongoing training increases the work involved in implementation.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In that previous qualitative evaluation, pregnant women unanimously liked the CRADLE VSA and reported it increased their understanding of vital signs monitoring.

    “Most healthcare workers reported that the device was easy to use and perceived it to be accurate, whilst pregnant women unanimously liked the device, reporting that it increased their understanding of vital signs monitoring [10].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Nathan H, Boene H, Munguambe K et al. The CRADLE vital signs alert: qualitative evaluation of a novel device designed for use in pregnancy by healthcare workers in low-resource settings. Reprod Health 2018; 15(1). source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Professional relationships may influence health technology adoption in Sierra Leone, and so should be considered when designing, implementing and evaluating new programmes in this context.

    “This study suggests that professional relationships may influence health technology adoption in Sierra Leone, and so should be considered when designing, implementing, and evaluating new programmes in this context.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Involving community leaders in public health interventions is widely encouraged and was critical in controlling the 2013 Ebola outbreak in Sierra Leone.

    “Involving Community Leaders in Public Health interventions is widely encouraged [25] and was critical in controlling the 2013 Ebola outbreak in SL [26].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [25] Rosato M, Laverack G, Grabman LH, et al. Community participation: lessons for maternal, newborn, and child health. Lancet. 2008;372(9642):962–71. source

      Not checked in the free run.

    • cites [26] Miller NP, Milsom P, Johnson G, et al. Community health workers during the Ebola outbreak in Guinea, Liberia, and Sierra Leone. J Glob Health. 2018;8(2): 020601. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Incorrect use of CRADLE (e.g. poor positioning) could raise doubts about its accuracy, but this is eased with ongoing support.

    “Incorrect use (e.g. poor positioning) could raise doubts about its accuracy. However, this is eased with ongoing support.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Intra- and inter-professional conflicts in healthcare settings have been reported elsewhere in Sub-Saharan Africa in relation to staff burnout, but not previously in relation to implementation of health programmes.

    “Intra- and inter-professional conflicts in healthcare settings have been reported elsewhere in Sub-Saharan Africa in relation to staff burnout [24], but not previously in relation to implementation of health programmes.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [24] Dubale BW, Friedman LE, Chemali Z. Systematic review of burnout among healthcare providers in sub-Saharan Africa. BMC Public Health. 2019;19:1247. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Premisecitation

    Complexity cannot be completely solved and may even increase with time.

    “Potential strategies to manage these are discussed, but it is important to note that complexity cannot be completely solved and may even increase with time [22].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Maylor HR, Turner NW, Murray-Webster R. How hard can it be? Actively managing complexity in technology projects. Res Technol Manag. 2013;56(4):45–51. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Complexity related to the technology and the organisational context influenced the adoption of CRADLE in Sierra Leone, with substantial inter-district variation.

    “Complexity related to the technology and the organisational context were found to influence the adoption of CRADLE in Sierra Leone, with substantial inter-district variation.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The four selected districts are representative of the range of adoption levels across the eight implementation districts.
    • Rests on an assumption: The 8–12 months between initial training and FGDs was adequate implementation time for all districts.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The author is White British, which, in light of the colonial history of Sierra Leone, may have created a power imbalance limiting participants' willingness or ability to voice their opinions.

    “The author is also White British, which in light of the colonial history of SL may have created a power imbalance limiting participants’ willingness or ability to voice their opinions [35].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [35] Scheelbeek PF, Hamza YA, Schellenberg J, et al. Improving the use of focus group discussions in low-income settings. BMC Med Res Methodol. 2020;20:287. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The use of focus group discussions may have increased the risk of social desirability bias.

    “The use of FGDs may have increased the risk of social desirability bias.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    The sustainability concerns may reflect fragmentation in the healthcare system and disparity between those holding decision-making power and resources (central government, external donors) and those responsible for delivering services at district level.

    “This may reflect fragmentation in the healthcare system and disparity between those holding decision-making power and resources (central government, external donors) and those responsible for delivering services at district level [15].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [15] Barr A, Garrett L, Marten R, et al. Health sector fragmentation: three examples from Sierra Leone. Glob Health. 2019;15:8. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Unstable power supplies can limit technological adoption in Sub-Saharan Africa.

    “previous studies have commented that unstable power supplies can limit technological adoption in Sub-Saharan Africa [31].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [31] Manyati T, Mutsau M. A systematic review of the factors that hinder the scale up of mobile health technologies in antenatal care programmes in sub-Saharan Africa. Afr J Sci Technol Innov Dev. 2020;13(1):125. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    To mitigate the potential power imbalance, the lead moderator of the focus group discussions was a Sierra-Leonean midwife known to the Champions.

    “To mitigate this, the lead moderator of FGDs was a Sierra-Leonean Midwife, known to the Champions.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Champions reported many barriers and conflicting opinions were offered within the same focus group discussions, suggesting participants felt able to speak openly.

    “However, Champions reported many barriers, and conflicting opinions were offered within the same FGDs, suggesting participants felt able to speak openly.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The author was the Programmes Manager of the implementing organisation of CRADLE during this phase of scale-up.

    “The author was the Programmes Manager of the implementing organisation of CRADLE during this phase of scale-up.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    'Solar suitcases' are being rolled out in remote maternal health facilities nationally in Sierra Leone and may help mitigate against the charging issue to an extent.

    “Further, ‘Solar suitcases’—easy-to-use solar electric systems that can power small medical devices—are being rolled out in remote maternal health facilities nationally and may help mitigate against this issue to an extent [32].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [32] We Care Solar. Sierra Leone [online]. Accessed: 05/10/22. Available at: https://wecaresolar.org/project/sierra-leone/.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    To mitigate investigator bias, questions were designed to be non-leading and the analysis was reflective of the data.

    “To mitigate this, questions were designed to be non-leading, and the analysis reflective of the data.”
    Quote in the paperNot a substantial claim
55 of 55

  • The paper relies on this without support.

    The existing training registers accurately and completely record the facilities trained in each district.

    “An existing database of training registers, held by the implementing organisation, was used to calculate the proportion of facilities trained per district.”

  • The paper relies on this without support.

    The proportion of facilities trained per district is a valid proxy for adoption of CRADLE by both Champions and facilities.

    “This served as a proxy of adoption (by both the CRADLE Champions and the facilities offered training).”

  • The paper relies on this without support.

    The four selected districts are representative of the range of adoption levels across the eight implementation districts.

    “This information was used to guide the selection of districts for the qualitative evaluation, aiming to choose a sample most representative of the spread of adoption levels.”

  • The paper relies on this without support.

    The 8–12 months between initial training and FGDs was adequate implementation time for all districts.

    “The time between initial training and FGDs was 8–12 months, giving all districts adequate implementation time.”

  • The paper relies on this without support.

    Sierra Leone was the first country to implement CRADLE at scale.

    “Sierra Leone has been the first country to implement CRADLE at scale, providing a unique opportunity to evaluate the adoption of CRADLE outside of a clinical trial setting, where real-world contextual issues may be more apparent.”
5 of 5

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • Consistentχ²(7) = 10.419reported p = .166 · recomputed p = .166

    “X2 (7, N = 8) = 10.419, p = .166”

  • Consistentχ²(7) = 10.419reported p = .166 · recomputed p = .166

    “χ2 (7, N = 8) = 10.419, p = .166”

2 of 2

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • District B's training percentage is incorrect

    Major

    The table reports 50 of 81 targeted facilities trained in District B, which is 61.7%, not 50%. The incorrect entry also conflicts with the stated district range of 59-90%.

    Reported 50 · recomputed 61.728395

  • The list of seven NASSS domains contains only six

    Minor

    The background says the framework has seven domains but names only six. The results include a separate 'The condition' domain that is absent from that list.

2 of 2

Cites

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Cited by

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Related

Authors
Bright, S., Moses, F., Ridout, A., Sam, B., Momoh, M., Goodhart, V., Smart, F., Mannah, M., Issa, S., Herm-Singh, S., Reid, F., Seed, P. T., Bunn, J., Shennan, A., Augustin, K., & Sandall, J.
Affiliations
  • University of Sheffield (GB)
  • Ministry of Health and Sanitation (SL)
  • King's College London (GB)
  • World Health Organization - Sierra Leone (SL)
Corresponding author
Moses, Francis
ORCID
Venue
Reproductive Health
Publisher
Springer Science and Business Media LLC
Published
2023-01-06
Volume
20
Issue
1
Pages
6-6
ISSN
1742-4755 (ISSN-L)
DOI
10.1186/s12978-022-01551-2
PMC
PMC9817393
OpenAlex
W4313640223
Semantic Scholar
2d9089b2c8e7a751ae9f6b3c146021a3b1749e56
Cited by
12
References
31
Citations by year
2026: 2 · 2025: 4 · 2024: 4 · 2023: 2
FWCI
4.25
Type
journal article
Language
en
Open access
Licence
Locations
  • Reproductive Health (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion, other-oa)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Research Portal (King's College London) (submittedVersion, other-oa)
Funders
Foreign, Commonwealth and Development Office
Topics
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Global Health and Surgery
Keywords
cradle, blood pressure monitoring, obstetric care, scale-up, technology adoption, NASSS framework, resource-limited settings, health technology implementation, community health workers, Sierra Leone
MeSH terms
Africa, Female, Humans, Maternal Health Services, Pregnancy, Retrospective Studies, Sierra Leone, Vital Signs

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-07.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-07.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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