Introduction Hypoxemia is an important contributor to child mortality, particularly in low-resource settings where diagnostic tools are scarce. The AIRE project introduced pulse oximeters (POs) into 202 primary healthcare centres (PHCs) in Burkina Faso, Guinea, Mali, and Niger, integrating them into the Integrated Management of Childhood Illness (IMCI) guidelines. This initiative aimed to strengthen diagnostic capacities for identifying hypoxemia and to improve care management for critically ill children under five. This study examined how healthcare workers (HCWs) adopted POs and explored the contexts and mechanisms influencing their adoption. Methods We conducted a realist evaluation to analyse adoption patterns, focusing on interactions between the Intervention, Contexts, Actors, Mechanisms, and Outcomes (ICAMO configurations). Data collection included 299 interviews with HCWs, patients' families, and institutional actors, conducted in 16 selected PHCs, at the institutional level, and in district hospitals, complemented by site observations. Analysis was performed using NVivo software, identifying ICAMO configurations as demi-regularities to explain variations in PO use and adoption. Results Training enabled HCWs to recognize the utility of POs, further motivating their use. Support-focused supervision fostering a sense of support, while control-focused approaches sometimes resulted in mechanical use driven by external pressure. In contexts of high workloads and children's agitation, difficulties in using POs were observed. In settings with limited diagnostic tools, POs increased HCWs' diagnostic confidence, encouraging adoption and improving decision-making. Observing or knowing the benefits of POs on children's health provided HCWs with a sense of relief and pride, further reinforcing PO adoption. However, structural barriers and challenges related to institutional adoption may threaten long-term use. Conclusion This study highlights the necessary conditions for adopting POs in PHCs. While widely used by healthcare workers, addressing challenges related to training, supply chain logistics, and referral systems to hospitals is essential to ensure long-term sustainability and improve child health outcomes.

The authors have declared no competing interest.

https://pubmed.ncbi.nlm.nih.gov/36566173/

The AIRE project is funded by UNITAID, with in-kind support from Inserm and IRD. UNITAID was not involved in the design of the study, the collection, analysis and interpretation of the data, nor in the writing of the manuscript.

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:

Comite d'Ethique pour la Recherche en Sante (CERS) Burkina Faso n.2020-4-070 ; Comite National d'Ethique pour la Recherche en Sante (CNERS) Guinea n.169/CNERS/21 ; Comite National d'Ethique pour la Sante et les Sciences de la vie (CNESS) Mali n.127/MSDS-CNESS ; Comite National d'Ethique pour la Recherche en Sante (CNERS) Niger n.67/2020/CNERS ; Inserm IEEC n.20-720 ; and WHO-ERC n.ERC.0003364 gave ethical approval for this work

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

The datasets generated and analysed during the current study are not publicly available. Access to processed deidentified participant data will be made available to any third Party after the publication of the main AIRE results stated in the Pan African Clinical Trial Registry Study statement (PACTR202206525204526, registered on 06/15/2022), upon a motivated request (concept sheet), and after the written consent of the AIRE research coordinator (Valeriane Leroy, valeriane.leroy@inserm.fr, Inserm U1295 Toulouse, France, orcid.org/0000-0003-3542-8616) obtained after the approval of the AIRE publication committee, if still active.