Acceptability, Usability, and Perceived Quality of Care of a Digital Decision Support System in Tele-Primary Health Care in Sindh, Pakistan: Sequential Explanatory Mixed Methods Pilot Study.

Background: Primary health care (PHC) delivery in Pakistan is constrained by persistent workforce shortages, which are further exacerbated by the attrition of trained female physicians following marriage or childbirth. Telehealth platforms, such as Sehat Kahani, have emerged as one response to this gap, enabling female physicians to provide remote primary care from home. Within this model, a digital decision support system (DDSS) was recently piloted for selected febrile illnesses to strengthen clinical decision-making. However, evidence on how such systems are perceived by female PHC providers in low-income and middle-income country settings remains limited. In particular, there is limited understanding of how perceived usefulness, ease of use, and perceived impact on quality of care shape the early adoption of DDSS within tele-PHC workflows. Objective: This pilot study aimed to explore the acceptability, perceived ease of use, and perceived quality of care associated with a DDSS among female PHC providers delivering teleconsultations through a large-scale telehealth platform in Sindh, Pakistan. Methods: An exploratory pilot study using a sequential explanatory mixed methods design was conducted. Quantitative data were collected through an online survey of female health care providers (N=30) across 5 telehealth clinics using the DDSS. The survey assessed experiences related to DDSS utilization, usability, technical facilitation, satisfaction, and perceived diagnostic and treatment accuracy. This was followed by 3 focus group discussions to further examine facilitators and barriers to DDSS use. Survey data were analyzed descriptively, and qualitative data were analyzed thematically. Qualitative findings were used to explain and contextualize quantitative patterns. Results: Survey findings indicated frequent integration of DDSS into routine teleconsultation practice, with 43.3% (n=13) of providers using the system multiple times per day. DDSS was primarily used alongside clinical judgment (n=16, 53.3%) rather than as a standalone decision-making tool. Half (n=15, 50%) of participants reported confidence in the accuracy of DDSS-supported recommendations, while 46.7% (n=14) reported occasional reassessment of system outputs. Usability perceptions were generally positive, with 50% (n=15) reporting moderate satisfaction and 46.7% (n=14) finding the system easy to navigate. Qualitative findings contextualized these patterns, highlighting that DDSS enhanced decision-making confidence, supported care in unfamiliar clinical domains, and promoted standardized practice, while also revealing concerns about algorithm completeness and workflow burden. Conclusions: This pilot study suggests that DDSS embedded within telehealth platforms is acceptable to female PHC providers and can support clinical decision-making in resource-constrained PHC settings. By providing early implementation evidence from a real-world tele-PHC setting in a low- or middle-income country, this study contributes context-specific insights to inform iterative refinement and responsible scale-up of DDSS-enabled care models.