Implementation of a clinical decision support tool for acute diarrhea management in Tanzania and the United States: A Qualitative study using the Consolidated Framework for Implementation Research

Background

In two large studies conducted in Bangladesh, our recently developed artificial intelligence (AI)-based models for assessing dehydration severity in children under five years (DHAKA models) and patients over age five (NIRUDAK models) were significantly more accurate and reliable than the WHO IMCI and IMAI guidelines for diarrhea management. We incorporated these models into a novel mobile health (mHealth) clinical decision support tool (CDST), called “FluidCalc”, with the potential to improve acute diarrhea management by frontline health workers worldwide. Our objective was to assess the barriers and facilitators to uptake and use of our mHealth CDST in both a low-resource setting (Tanzania) and high-resource setting (United States (US)) among healthcare providers and stakeholders.

Methods

Qualitative data were collected through focus group discussions (FGDs) with healthcare providers and in-depth interviews (IDIs) with stakeholders and policymakers from February - July 2025 in Tanzania and February - March 2026 in the US. The Consolidated Framework for Implementation Research (CFIR) was used to guide discussions and elicit participant feedback. Audio recordings were transcribed and translated from Swahili to English where applicable, and data were analyzed using framework matrix analysis.

Results

35 providers from different cadres participated in FGDs, and 13 stakeholders participated in IDIs. Facilitators to implementation included FluidCalc’s simplicity, ease of use, and offline functionality. Participants reported that the app could streamline clinical workflows, promote adherence to diarrhea management guidelines, facilitate task shifting, support antibiotic stewardship, and reduce errors in fluid rehydration calculations. FluidCalc was also viewed as a valuable teaching tool, and for supporting less experienced healthcare providers and trainees, and as useful during diarrheal disease outbreaks. Perceived barriers included the need for reliable digital infrastructure, including access to mobile devices, internet connectivity, and dependable electricity and lengthy institutional approval processes. Endorsement and approval from the Ministry of Health and health facility leadership were perceived as essential for successful implementation.

Conclusion

Healthcare providers and stakeholders believe FluidCalc has the potential to improve care for patients with acute diarrhea in both high- and low-resource settings. Addressing identified barriers and ensuring reliable digital health infrastructure are needed to support effective integration into patient care.

Contributions to literature

• FluidCalc is a clinical decision support tool (CDST) for managing acute diarrhea.

• Few implementation studies have examined CDSTs for diarrhea management across both high-resource and low-resource settings. This study provides comparative insights into factors influencing implementation in two distinct health system contexts.

• Beyond technical performance and usefulness, CDST uptake depends on clinicians’ perceptions of the tool’s impact on workflow, workload, clinical autonomy, and compatibility with existing health systems.

• Additionally, organizational context shapes perceptions of digital innovations, helping explain why a tool may be perceived as an opportunity to improve care or as an added implementation burden.