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Using the Normalization Process Theory to study facilitators and barriers to sustainable implementation of artificial
Wanjiku Mathenge1,2, Olivier Uwizeye1, Noelle Whitestone2
1Rwanda International Institute of Ophthalmology, Kigali, Rwanda.
Background:
The rising incidence of diabetes and its complications, particularly diabetic retinopathy (DR), in sub-Saharan Africa presents a significant public health challenge, compounded by a lack of skilled human resources. Artificial intelligence (AI)-based screening offers a promising way to address this burden. Understanding the integration of such complex interventions from research to routine clinical practice is crucial for sustainability.
Methods:
A qualitative study design was employed using the Normalization Process Theory (NPT) framework, which supports the evaluation of whether an innovation will be sustainable in everyday practice by analysing how new practices become embedded into routine work. Clinical staff and patients involved in AI-based DR screening at three clinics in Kigali, Rwanda were interviewed using an NPT-based questionnaire through semi-structured interviews and focus groups. Verbal consent was obtained for recording and transcription. Interview data were thematically analysed, with codes generated to align with the four NPT constructs: coherence, cognitive participation, collective action, and reflexive monitoring.
Findings:
In total, nine clinical staff members and 67 patient participants were interviewed. Participants reported a coherent understanding of the program's purpose, value, and benefits. They valued the technology for its ability to address the gap between the scarcity of competent healthcare providers and the growing burden of DR. Challenges identified related to workload, division of labour, initial patient distrust of AI, and restrictive organizational policies regarding operator access.
Interpretation:
The NPT framework proved valuable for analysing the implementation of this complex intervention, providing insights into user perceptions and generating actionable recommendations for enhancement. While positive adoption was observed, further research is needed to fully understand the intervention's long-term impact on health outcomes such as visual preservation and treatment success.
Funding:
Fundus cameras were donated by Topcon. The company had no input into the design and/or analysis of the study.
