Sustainability and normalization of an intervention to improve evidence-based myocardial infarction care in Tanzania

Abstract

BACKGROUND: The Multicomponent Intervention to Improve Acute Myocardial Infarction Care (MIMIC) was developed to address gaps in AMI diagnosis and treatment in northern Tanzania. Although initial implementation was promising, many quality improvement interventions are not sustained after research support ends, especially in resource-limited settings. Few studies in sub-Saharan Africa have prospectively assessed organizational capacity for sustainability or normalization after external support concludes, limiting understanding of longer-term implementation trajectories in emergency care. Evaluating sustainability capacity and normalization is essential for understanding the long-term impact of implementation research. We evaluated these outcomes for the MIMIC intervention in a Tanzanian emergency department following a pilot implementation trial. METHODS: We conducted a cross-sectional survey of all full-time emergency department clinicians (n = 35) at Kilimanjaro Christian Medical Centre (KCMC) using two validated implementation science tools: the Clinical Sustainability Assessment Tool (CSAT) and the Normalization MeAsure Development (NoMAD) questionnaire. The CSAT assesses seven domains, with higher scores reflecting greater perceived sustainability capacity. The NoMAD measures four constructs, with higher scores indicating stronger normalization. For each domain, scores were summarized descriptively (means, standard deviations) and compared across provider type (doctors vs. nurses) and role (champions vs. users) using Welch's t-tests or Mann-Whitney U tests as appropriate based on normality. RESULTS: All 35 eligible clinicians (100%) completed the survey. Mean CSAT domain scores ranged from 5.81 (SD 1.04) for Organizational Context and Capacity to 6.73 (SD 0.47) for Outcomes and Effectiveness (scale 1-7). Mean NoMAD scores were uniformly high and clustered within a narrow range from 4.26 (SD 0.51) for Collective Action to 4.69 (SD 0.42) for Cognitive Participation (scale 1-5). Domains related to perceived clinical benefit, individual engagement, and feedback scored highest, whereas organizational context and financial support scored comparatively lower. In subgroup analyses, no statistically significant differences were observed by provider type (doctors vs. nurses) on either instrument; similarly, champions and routine users did not differ significantly across CSAT or NoMAD domains. CONCLUSIONS: This study is among the first to apply the CSAT and NoMAD tools to evaluate a quality improvement intervention in sub-Saharan Africa. Findings indicate high capacity to sustain MIMIC and strong normalization at KCMC, as reflected by consistently high mean domain scores across both instruments, although formal thresholds for these measures have not yet been established. Strengthening organizational capacity and long-term support, particularly financing and team coordination, may further enhance capacity for ongoing implementation.