Acceptability of an intervention to improve uptake of evidence-based emergency myocardial infarction care in Tanzania: A qualitative study

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Abstract
Acute myocardial infarction (AMI) is an increasing cause of morbidity and mortality in Sub-Saharan Africa (SSA) but is often underdiagnosed and undertreated. To address this gap, the Multicomponent Intervention to Improve Myocardial Infarction Care (MIMIC) was developed and implemented in the emergency department (ED) of a regional referral center in northern Tanzania. We conducted in-depth interviews with 20 key stakeholders (physicians, nurses, administrators, and patients) who participated in MIMIC during the first year of implementation. Purposive sampling was used to recruit a broad range of participants. Interviews were guided by a semi-structured interview guide informed by the Theoretical Framework of Acceptability (TFA). Interview transcripts were thematically analyzed by a team of coders using an inductive, grounded theory approach guided by the seven TFA domains. Nineteen major themes emerged across all TFA domains. Overall, participants described MIMIC as highly acceptable, minimally burdensome, and well-aligned with professional and ethical values. Perceived effectiveness was most emphasized, with staff citing improvements in AMI recognition, ECG and troponin testing, and use of evidence-based therapies. All components were highlighted as effective and easily integrated into existing workflows. Patients valued the educational pamphlet for improving knowledge and self-efficacy, though staff expressed concerns about distributing it during acute care, contributing to inconsistent delivery. Champions were viewed as key in promoting adherence and sustaining implementation of the intervention. MIMIC was widely acceptable in all seven TFA domains among ED providers and patients, with perceived effectiveness driving positive attitudes across stakeholder groups. Use of a co-design approach in MIMIC development likely contributed to high intervention acceptability. Patient education strategies may require adaptation to improve fidelity. These findings suggest that continued implementation and future adaptation of MIMIC may be feasible.

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