Community health workers’ experiences with a digital clinical decision support system for longitudinal hypertension and diabetes care in rural Lesotho: a mixed-methods study

Community health workers (CHWs) are increasingly delivering chronic care in resource-constrained settings but require support to manage complex longitudinal clinical workflows. In the Community-Based chronic Care Lesotho (ComBaCaL) project in rural Lesotho, CHWs provide longitudinal hypertension and diabetes care, supported by the ComBaCaL Community Health Toolkit (CHT) application. The application combines longitudinal participant management and task coordination with clinical decision support for screening, diagnosis, treatment initiation and adjustment, cardiovascular risk management, referral, and follow-up for hypertension and diabetes care. This model of care has demonstrated improved or maintained clinical outcomes compared to facility-based care only. We conducted a mixed-methods study among all 103 participating CHWs to evaluate their experiences with the application. All CHWs completed a 38-item questionnaire, and 22 participated in qualitative interviews or focus group discussions. Overall usability was high, with a mean System Usability Scale score of 75.6 (SD 13.0), and 98 (95%) CHWs were satisfied or very satisfied with the application. General application functions and diagnosis and treatment tasks were rated easy or very easy by 98% of participants. The most frequently reported benefits were task reminders (92%), structured clinical guidance (87%), overview of allocated participants (81%), and retention of participant information (81%). Main challenges were lengthy questionnaires, difficulties charging tablets, and limited internet connectivity. Qualitative findings showed that ease of use increased with experience, supported by training and supervision. Participants described how algorithmic guidance and task reminders supported care delivery, while also identifying tensions between standardized workflows and flexibility in day-to-day care. The ComBaCaL CHT application was highly usable and valued by CHWs. High perceived usability extended from general application functions to complex clinical workflows. CHT demonstrated suitability as a configurable framework for implementing such context-specific workflows for hypertension and diabetes care when accompanied by appropriate workflow design, training, and supervision.