Positive attitudes toward MIMIC.

All participants across all stakeholder groups expressed positive affective attitudes towards the MIMIC intervention. However, perceptions of individual intervention components varied across stakeholder groups. For example, as discussed below, patients expressed strong positive feelings about the educational pamphlets, while feelings towards the pamphlets among administrators were more mixed. Nonetheless, all participants expressed an overall positive attitude toward MIMIC.

“Yeah. I would frown filling in a death certificate but not MIMIC.”

[…]

I have never seen a frown face when it comes to MIMIC.” (Physician, M)

“I liked MIMIC. Not only liked it but I loved it! And I still love it!

[…] Everyone that I met thinks it is a very good intervention.” (Physician, F)

Patients who only engaged with the educational pamphlet component of MIMIC also reported uniformly positive feelings towards this intervention.

I: “In general, how do you feel about this educational pamphlet?”

R: “The pamphlet is good […]. They gave me that pamphlet, it helped me, and I received it because I knew that I already had MI and what was required for me to do, and at what time.” (Patient, M)

Minimal implementation effort.

Participants generally viewed MIMIC as minimally burdensome to implement because improving quality of care was considered to be a core professional responsibility. The intervention was perceived as simple, easy to understand, and requiring little additional time or effort.

Moreover, providers felt that MIMIC, which was co-designed by KCMC ED staff and tailored to the Tanzanian context, fit within existing workflows. For example, participants cited the way in which the “MI Suspect” red triage cards could be integrated seamlessly into the existing card-based triage system without creating additional tasks for staff. Furthermore, as MIMIC became normalized, participants reported that it became part of routine ED operations.

“I really don’t see the burden because it is not something completely new. We are using triage cards that we also had before. We have other cards that show if the patient has been seen, if they are awaiting responses and so on. Doing ECG and other tests are part of the doctor’s consultation. Doing troponin in the ED has also made things easier for us. Pocket cards do not give the doctors a burden but rather reminds them on what they are supposed to do. At the emergency we also have charts that remind us on different other diseases so it’s just similar. I don’t think they are a burden I think they are just part of normal routine.” (Administrator, F)

“MIMIC is not a hard thing to do. It is not burdensome. It doesn’t demand a lot from you, you just need to remember a few things. Do this, do that, remember the red tag and follow the protocol. Just a few things that don’t consume your time and energy.” (Physician, F)

Time and connectivity barriers.

Although participants felt that MIMIC was minimally burdensome overall, some considered the online module somewhat burdensome to complete. A concern shared by nurses, administrators, and doctors was that an additional online training course was a burden because a busy clinical schedule necessitated the course to be completed on one’s own time outside of the hospital. Because no protected work time was allocated, providers often completed the course at home using a personal internet bundle, which raised concerns about cost and internet access. Although no participant reported personally being unable to access internet to complete the module, many expressed concern that limited internet access or smartphone availability could pose barriers for other staff.

“This is dependent on the overlapping of tasks. You find that you have had a busy day at work, and you have been asked to do an online module. When you get home, you are exhausted, and all you want to do is just rest and say that you will do it on the next day. And that is the beginning of procrastination. Sometimes you cannot do it because of data and internet issues. When you ask some people to do it, they tell you that they do not have data and internet, or their phones are faulty. Those are some of the barriers” (Nurse, M)

Alignment with staff values.

All groups interviewed believed that the MIMIC intervention aligned with both hospital and professional values. When discussing hospital values, participants emphasized that as a tertiary care center, KCMC has a responsibility to provide evidence-based AMI care, and MIMIC helped achieve this goal. In terms of professional ethics, both nurses and physicians noted that MIMIC enhanced their core responsibility to save lives.

“I: Do you think the MIMIC intervention aligns with your values?

R: Yes, it does completely because our aim in providing care is to get quality care. How is quality care described? Have we been able to follow the requirements to get quality care? So, I see it aligns with my values.” (Administrator, F)

Divergent views on ED pamphlet distribution.

Providers and patients had notably different perspectives on the appropriateness of distributing educational pamphlets to patients in the ED. Many providers felt that patients with suspected AMI were too acutely ill and distressed to benefit from written educational materials. Instead, they advocated for pamphlet distribution later in the hospitalization or in community settings such as markets, churches, or mosques. This sentiment was particularly common among departmental administrators. Providers also noted that ED doctors were focused on delivering life-saving care, which limited their ability to distribute pamphlets consistently. These participants suggested pamphlet distribution in lower-acuity settings such as inpatient wards or outpatient clinics.

“You know in the case of emergencies, relatives or the patients are mostly in shock and unsettled. If you give them something to read, they keep it in their bags, they don’t read it. That’s my observation.” (Administrator, F)

“As I mentioned earlier, most patients that come here are very old, very sick, in pain and uncooperative. So, we need to improve because we need to deal with the society that is caring for that patient and the population of society that is healthy, so that when they get that education, they may bring their patients early before they reach the end stage of AMI. Also, when the healthy society is educated, they will know how to prevent and control AMI. Not wait until when they reach that [end] stage” (Administrator, F)

In contrast, patients expressed uniformly positive views regarding the timing and location of pamphlet distribution. Several described the pamphlet as an important educational tool, stating that they helped them understand their disease and contributed to a sense of self-efficacy. Many referenced inadequate doctor-patient communication throughout their hospital stay and felt that the pamphlets helped fill gaps in the information they received.

“[receiving the pamphlet in the hospital] matched my value because I received that pamphlet because I was diagnosed of a certain disease. After realizing that I had a certain a problem, the doctor explained it to me, I received the news and understood. Afterwards, he gave me that pamphlet which was like an addition to what he had already explained to me. I received the news verbally and in written form and it is better to have it in writing because you can keep that.” (Patient, M)

“[Providing the pamphlet] is important. It is helpful, it gives people awareness regarding cardiovascular issues. I have been very sick and since I noted it as a problem, I have been hearing from people with MI that they are experiencing challenges like difficulty in breathing, or they have been hospitalized. It is very important and would be helpful if they continued providing them.” (Patient, M)

Clear understanding of MIMIC.

Participants consistently demonstrated a clear understanding of MIMIC and its individual components, with most able to describe the intervention and its purpose without prompting. They understood both the overall goal of improving AMI diagnosis and treatment, as well as the role of MIMIC in achieving this goal. Several participants also noted their involvement in MIMIC’s participatory co-design process. Both the patient pamphlet and provider pocket card were described as clear and easy to understand by both patients and providers because of their simple language and use of Swahili.

“MIMIC is an intervention that helps us identify and manage patients with myocardial infarction. Mostly identification of patients is done once they come into the ED with a red card, so we stay alert that this patient is a suspected case of MI. We also did an online course that helped us gain knowledge on myocardial infarction. We were also given pocket cards which reminded us of the management and diagnosis of myocardial infarction. Most of us have them in our pockets and phones. We also have patient education pamphlets that we give to the patients’ relatives which help shorten the explanation that you need to give to the patient or their relatives. After giving out those pamphlets, the doctor’s job is just to clarify on the things that they did not understand from the pamphlet. This will help increase patients’ knowledge on this disease. Champions also motivate us to ensure that we provide the appropriate management to MI patients and to remind the students and interns on the proper management of MI.

[…]

“I don’t think that it’s a very difficult thing to understand” (Physician, F)

“Honestly, the part that I understood really well is the [Patient education pamphlet] which discusses what MI is and how to prevent it for people without MI. How to avoid MI for example looking at the foods we eat, tobacco use and weight. It has really helped me as an MI patient. If someone asks me what causes MI, it’s easy for me to explain.” (Patient, M)

MIMIC did not compete with clinical responsibilities.

Participants stated that MIMIC did not detract from other important clinical tasks. Because AMI was viewed as life-threatening, its diagnosis and management were viewed as the highest clinical priority. Participants also emphasized that implementing MIMIC was simply a part of their responsibility to provide high-quality care and required minimal additional time or effort.

“So, it can`t distract me from important work, there is nothing that is as important to me, as the patients during my shift. So as long as I am at the emergency department and patient comes in with acute coronary syndrome, I have to go through and adhere to MIMIC. It’s not a distraction, it just draws attention.” (Physician, F)

“I: Have you ever thought that the MIMIC intervention may distract you from other important work?

R: As I mentioned earlier, it is part of my work, so it doesn’t affect anything. Not only for me but also for my colleagues.” (Administrator, F)

Improved AMI care.

Perceived effectiveness was the most frequently discussed domain of MIMIC acceptability among participants. Physicians, nurses, and administrators agreed that the intervention substantially improved AMI care quality in the KCMC ED. Participants noted enhanced uptake of ECG and troponin testing, reduced missed AMI diagnoses, and increased use of evidence-based therapies like aspirin and clopidogrel. Perceived effectiveness was also a major driver of overall intervention acceptability. Staff expressed pride in observable improvements in clinical practice, including an improved ability to rapidly recognize AMI symptoms, greater confidence in using diagnostic tools, and more timely treatment decisions, such as transfers to specialized centers or thrombolytic administration. Several also noted a cultural shift in the ED, with AMI now recognized as a time-sensitive emergency requiring immediate attention, directly contributing to better long-term survival outcomes.

“Honestly, I see that we have gone a step ahead because some patients were mismanaged. People didn’t think it was important to give them Aspirin and Clopidogrel, let’s just give them one. But when you have [MIMIC], you can see. Is it important to do an ECG again? But [MIMIC] reminded us. I think now we are more able to identify the patients with this diagnosis compared to the previous years. […] So, it has given us a wider knowledge on how to manage and exclude other things that limited our management.” (Administrator, F)

“I would say it effectively improved the care because yes, sometimes we miss [AMI cases] but now it’s very very few times. We recognize the cases super-fast and they get referred early and they get saved. Most of the cases.” (Physician, F)

“It is good because it helps in identifying patients with AMI, which accounts for many lives. This problem was there and was hurting many people and many people died for that reason. Patients with AMI were coming to the emergency department and there were formerly many delays including delays in sending the patient to the ward. Now, we have reduced those delays and patients are rushed to [specialty cardiology hospital] with an ambulance and receive treatment on time. Of course, it helps because if MIMIC wasn’t there then we would be missing these diagnoses.” (Nurse, F)

Improved provider knowledge.

All physicians, nurses, and administrators described improved AMI knowledge and awareness following MIMIC implementation. Participants attributed these gains primarily to the online training module and provider pocket cards, which reinforced AMI recognition and evidence-based management. Participants thought MIMIC was particularly effective in dispelling common misconceptions, refreshing knowledge among experienced clinicians, and educating new providers.

“I like MIMIC because it increases my awareness on this because initially, I did not know about AMI. It has explained AMI to me, and it still sharpens me. I can even educate community members on this now.” (Nurse, M)

“For me, I am happy because it increases my knowledge. Let’s say I go and work in another hospital where such things have not arrived, I can act as a role model. If someone comes with a chest pain on the left side and it is radiating, I can tell them let’s start with this coming from the few things that I know.”

(Nurse, F)

“I: How about improvement of provider awareness? Do you think MIMIC has been effective at that?

R: I’d personally say yes. If you compare the knowledge I had before this intervention and after, there’s a big gap.” (Physician, F)

Support for continued implementation.

Providers strongly supported continued implementation of MIMIC in the KCMC ED beyond the study period’s completion. Staff members described the intervention as essential to improving awareness, recognition, and management of AMI; some even expressed concern that discontinuing the intervention would lead to patient harm. Participants also reported actively maintaining components of MIMIC, as well as introducing new staff to intervention practices.

“Please don’t stop this project, please don’t because we have only done it here at KCMC and we have realized that it is a leading cause of death. If you implement it in all hospitals in Tanzania, you will realize that many people die of myocardial infarction.” (Administrator, F)

“I: Do you think the MIMIC intervention can continue in the KCMC emergency department later on?

R: Absolutely! We have seen that this is a good system. We are celebrating good behavior. We are maintaining it with both hands.” (Administrator, M)

“I would like to thank you for this program because it has made a huge positive impact, something which we wish to continue. As I already mentioned, it shouldn’t end here but we should create an environment for those around us to understand this intervention so as to improve care for all patients.” (Nurse, M)

“The major thing we are thinking about in the MIMIC intervention is for this project to continue because it reminds us on how to care for these patients. If you are a provider and have the ability and skills to care for these patients quickly, it will be a stable carrier full of success. Many of us want this to continue for many years.” (Physician, M)

“It is important. Apart from personally liking the pamphlet, it is important to continue distributing it. It is helpful, it gives people awareness regarding cardiovascular issues. … It is very important and would be helpful if KCMC continued providing them.” (Patient, M)

Support for intervention scale-up.

In addition to stating that MIMIC should continue at KCMC, participants expressed a desire to implement the MIMIC intervention at emergency departments and health facilities throughout Tanzania. Many felt that implementation at local district hospitals and community clinics could reduce delays in diagnosis and eliminate the need for referral to larger hospitals, ultimately improving patient outcomes. Some also advocated for broader pamphlet distribution to facilitate community education regarding AMI.

“Many people will be helped. So many! Imagine people travelling from the villages to KCMC! How many hospitals have they skipped? How many hospitals have they been attended? They come here in the late stage. So MIMIC is something very nice, they should not stop. Please continue working on it.” (Administrator, F)

“We are now aware of MI, and we need others to be aware. Tanzania is big, and we wish for patients to be diagnosed as soon as possible if they experience those symptoms. It is very important for this education to be taken to other emergency departments. Not only emergency rooms because some hospitals do not have an emergency department; those are the primary facilities that are attended by many patients who are poor. It should be provided to all facility levels and not only to the big hospitals.” (Physician, F)

“I am happy to be part of this intervention. If where we are planning to go [to other emergency departments] we will be received with open arms and then we will get more patients and we will reach more people.” (Administrator, M)

“You should give pamphlets anywhere patients can be given them. Print out more copies and give the pamphlet to more people. This will help in reducing this problem. People will get to know the symptoms, the type and the numbers [of MI cases] will reduce.” (Patient, M)

Pamphlet as a patient and community education tool.

Patients widely described the educational pamphlet as an effective tool for improving understanding of AMI among not only themselves but also their friends, neighbors, and families. Participants reported learning about AMI symptoms, etiologies, prevention, and treatment while also utilizing the pamphlet to teach fellow community members, including those with lower health literacy. Some even described the pamphlet as prompting them to seek emergent care for a loved one with suspected AMI.

“It has improved [things for me] because I didn’t know anything about that disease. When I was given the pamphlet, I read about the symptoms and causes, and I understood that there is a disease of this kind.” (Patient, F)

“The pamphlet is important. It is very important because the more you read it the more you remember. It reminds you the of symptoms, what to do, what to avoid to prevent another heart attack.” (Patient, M)

“Honestly, I read this pamphlet with my children when it was given to me at KCMC. Everybody wanted to know what it was.” (Patient, M)

“All the people that I have shared it with them were eager to read it. Some of them were eager to change because there are some things that they have seen there that cause MI. Some people have seen the need to reduce or stop for instance the smokers. I can see that some are trying to stop. Sometimes they fail but they are trying. The issue of obesity as well because I have spoken to many people and I see that they can understand. People like it, it is nice and some people have partners with this problem, so they understand.” (Patient, M)

Red triage card as a visual cue.

The red triage card was identified as a clear visual cue for suspected AMI, immediately prompting ED physicians to consider this diagnosis in their workups. Staff appreciated its visually distinctive appearance, commenting that they could identify the card clearly in a crowded ED and initiate the appropriate diagnostic workup for AMI. Physicians, nurses, and administrators all felt that AMI was commonly overlooked in the KCMC ED prior to MIMIC implementation, primarily due to physicians failing to consider the diagnosis. They believed the red triage card substantially reduced missed cases by keeping AMI at the forefront of providers’ minds

“Basically, the card is unique, when someone sees it, it draws attention that there is something that needs to be done quickly or at a particular time.” (Nurse, M)

“…the red card draws attention and even if you don’t explain it to providers, they already know that it is associated with MI. They are all focused on getting the ECG, Troponin, et cetera.” (Nurse, M)

“The red card is a priority especially for providers working in the emergency department. That is like a visual language, before you say anything, there is already something in their minds to know that the particular patient might have MI.” (Nurse, M)

Provider pocket card as a clinical reminder.

The provider pocket cards were lauded by the staff as a practical reference that reinforced information they learned previously during training. Most providers were familiar with the overall approach to AMI diagnosis and treatment, but utilized the pocket card for a quick reminder of medication dosing and diagnostic thresholds. Although the pocket cards were provided both as physical laminated cards and digital copies, most providers preferred using the digital version on their phones. The pocket card was also noted to be a particularly useful educational resource for newer providers, including rotating interns.

“Pocket card is good because it is a small card with everything and makes things easier for us. It tells us what to do and what to prescribe. It helps even in reminding the new doctors that will come as well as the online training.” (Administrator, F)

“The pocket cards, they really remind us. For me I usually confuse the doses for Aspirin and Clopidogrel. There is 300 or 600, so every time I will be peeping at the card and remember. Sometimes I forget to prescribe Heparin, I will peep here again and [chuckles] then I will remember.” (Physician, F)

Champions facilitated evidence-based AMI care and MIMIC implementation.

Across all stakeholder groups, champions were viewed as effective in promoting adherence to MIMIC protocols and evidence-based AMI care overall. Several participants reported that champions encouraged completion of more burdensome tasks, such as the online training module, while also providing regular reminders during morning report and follow-up on individual patient cases. Participants particularly valued champions’ roles in promoting use of intervention components (such as triage cards, online training module, educational pamphlets), auditing MI care, providing regular feedback to providers, and openly recognizing high-quality clinical performance. Many providers thought the fact that the champions were already trusted colleagues and friends made them particularly effective in this role.

” They [the champions] are working well. We have different cases in the emergency department so sometimes it’s hard to remember all protocols, like doing an ECG and troponin in the first hour and again after three hours. It’s not easy if you don’t have someone who can remind you. You may find patients stay for more than three hours and are admitted with only a single ECG and troponin. So, it’s important for the champions to continue being there.” (Physician, M)

“Because the champions were supervising the implementation of all the other components. So, without champions the rest probably couldn’t be implemented well. The champions were the ones following up on placing the cards, doing an ECG, reminding that when the troponin results come out to give Aspirin, do not be afraid of giving Aspirin to patients with CKD. Reminding us to do online module. I believe the champions were very important.” (Administrator, F)

Online training-enhanced provider competency.

Despite concerns regarding time and internet access, participants consistently regarded the online training module as improving providers’ ability to diagnose and treat AMI. Many participants valued the module for providing straightforward direction on diagnostic test interpretation, reinforcing medication recommendations, and addressing common misconceptions, such as concerns regarding aspirin use in patients with chronic kidney disease (CKD). The online module was also noted to be beneficial for providing constructive feedback to participants.

“There are some medicines that we were so scared to prescribe but the online module assisted us in clearing those doubts.” (Nurse, F)

“It (online module) updates us for instance, you usually submit your work, so they give us feedback on what we have done. What we have achieved, what needs improvement, and the like; so, it really helps us to know where we are, and we are going. We put effort on the points that we need to improve. It is really helpful.” (Nurse, F)

“Because the online module has touched well on misconceptions, it ensures providers diagnose MI at an earlier stage. It also explains how to diagnose it from the ECG and troponin readings. It also explains what medicines to prescribe, at what dosage and at which time.” (Physician, M)

Inconsistent pamphlet distribution.

Participants reported that patient education pamphlets were sometimes not given to patients, which limited their overall effectiveness. Most attributed inconsistent distribution to the busy workload inherent to the ED. ED staff also commented on the pamphlet’s storage location being out of sight and therefore difficult to consistently locate and remember. Although several providers questioned whether the ED was the appropriate setting for pamphlet distribution, none cited this concern as a reason they had not given a pamphlet to a patient.

“There are two issues. You find that a person is too focused in providing care to give the pamphlet. The second thing is where they are stored. It becomes somewhat challenging to access them anytime. People don’t know where they are stored and by the time they know where the cards are the patient may have left. If it was kept in a place where everyone can see it would be easy to pick. At the emergency we have new doctors and nurses, we have new students, you understand. It becomes challenging to identify such things at that time. But if the cards are in an open space where everyone can see, When the student comes there, they will be asking what is this? They will be told that MI patients are given the pamphlet, so they know that if they get such patients, they need to give them.” (Nurse, M)

“The first hassle is in looking for them because there are many files in there. We need to keep the educational pamphlets elsewhere please. You might look and miss them sometimes.” (Physician, F)

Provider empowerment in AMI management.

Many participants stated that the MIMIC intervention effectively boosted their confidence in their ability to manage patients with AMI. This confidence stemmed from a stronger knowledge base gained through training materials such as the online module and pocket card, which helped them recognize pertinent signs and symptoms and interpret diagnostic results. After MIMIC implementation, staff noted a significant improvement in their confidence to treat AMI, particularly in administering lifesaving medications. Prior to the intervention, guidelines were often not followed; however, afterward, participants expressed a clearer understanding of the importance of each medication. They also felt comfortable prescribing these treatments and teaching others to do the same.

“I have proof, some patients I sent to [cardiac referral center] are still alive to this day. Most of my patients, all of them. I can say most of my patients they are doing good. I was able to diagnose them, give them the medication and send them for PCI and normal I make follow-up to them. I did that.” (Physician, F)

“I: After meeting the MIMIC training intervention, all the five parts, were you able to perform your part?

R: Definitely! It has been like a wake-up call for everybody that MI is a serious thing. I can perform everything to ensure that everything is there, medication is there and investigations.” (Nurse, M)

“Because one of a doctor’s values is being competent and objective. MIMIC intervention has been able to assist me with identifying these patients and channeling them to the appropriate places. It has increased something in my capacity to treat.” (Physician, M)

Patient self-management confidence.

Patients stated that they had more confidence in their ability to manage their heart disease after they left the hospital due to the information provided in the patient education pamphlet. They repeatedly credited the pamphlet for clearly explaining red flag symptoms and return precautions. They also emphasized that it described the medication regimen they should maintain after discharge, including when and how to take medications, as well as the timing of follow-up visits. Patients described the pamphlet as an excellent source of information and felt that it helped them manage their condition more effectively.

“Because I want to know, what did they say on the pamphlet? When I felt the chest pain-like symptoms, I said what did they say here. I liked it because I know if I experience any problem, I will go back to the pamphlet to see what it says about that problem. For instance, if I get a headache I check to see if they mentioned headache as a symptom of heart attacks.” (Patient, M)

“It has motivated me to continue using my medicines to cure this disease. If I use my medicines, it won’t be easy for that problem to recur.

[…]

It has encouraged me to go to the clinic for follow up. That is why initially I was attending the monthly clinics, but I am now only having to go after every two months. I attend the clinics and do all tests. I do ECHO, ECG, every time that I go there I do all the tests. They check my progress and prescribe me medications, so it causes me to continue receiving care, like using the medicines, and preventing another heart attack. My health will become better, and I will be doing very fine.” (Patient, M)