Perceived barriers and facilitators of implementing a sustained smartphone-based telemonitoring program for pregnant women at high-risk for pre-eclampsia in the public and private sectors in Pakistan

Background: In Pakistan, a smartphone-based telemonitoring (TM) program (Raabta) has been designed to support pregnant women with high risk for preeclampsia (HRPE) in Pakistan. However, implementing TM interventions is often challenging, particularly in low-resource settings, given the complexity of healthcare environments and variations in public and private health sectors. This study explores the potential barriers and facilitators for a sustained implementation of the Raabta program in public and private sector hospitals in Pakistan. Methods: Using a qualitative description design, 57 semi-structured interviews with a diverse group of participants including patients from the public (n = 15) and private sector hospitals (n = 17), obstetricians from the public (n = 5) and private sector hospitals (n = 7), decision-makers (n = 7) and telehealth experts (n = 6). Participants were recruited using purposive and snowball sampling techniques. Interview transcripts were deductively analyzed using the Consolidated Framework for Implementation Research (CFIR) domains. Results: Based on the CFIR domains, the findings included: (1) Raabta being perceived as user-friendly even for patients with low digital and language literacy; (2) Outer settings: Limited health and digital literacy, poor language proficiency, and cultural norms can influence the willingness and ability of public sector patients to use the Raabta; (3) Inner settings: The private health sector is well-equipped for the Raabta implementation, while the public health sector faces challenges related to physical space, limited human and financial resources, and physician resistance; (4) Individual characteristics: Majority participants demonstrated positive attitudes toward the Raabta program and expressed confidence in using it (5) Process: Recommendations included adopting a nurse-led model for the private sector, leveraging paramedics for monitoring the Raabta dashboard, integrating Raabta with existing digital platforms, and establishing an advisory committee for program sustainability. Conclusion: Raabta implementation may be more feasible in the private sector due to patient demographics, health and digital literacy, cultural norms, financial resources, physician readiness, and hospital infrastructure.