Application of ICT in Strengthening Health Information Systems in Developing Countries in the Wake of Globalisation.

Information Communication Technology (ICT) revolution brought opportunities and challenges to developing countries in their efforts to strengthen the Health Management Information Systems (HMIS). In the wake of globalisation, developing countries have no choice but to take advantage of the opportunities and face the challenges. The last decades saw developing countries taking action to strengthen and modernise their HMIS using the existing ICT. Due to poor economic and communication infrastructure, the process has been limited to national and provincial/region levels leaving behind majority of health workers living in remote/rural areas. Even those with access do not get maximum benefit from ICT advancements due to inadequacies in data quality and lack of data utilisation. Therefore, developing countries need to make deliberate efforts to address constraints threatening to increase technology gap between urban minority and rural majority by setting up favourable policies and appropriate strategies. Concurrently, strategies to improve data quality and utilisation should be instituted to ensure that HMIS has positive impact on people's health. Potential strength from private sector and opportunities for sharing experiences among developing countries should be utilised. Short of this, advancement in ICT will continue to marginalise health workers in developing countries especially those living in remote areas

Adherence to artemether/lumefantrine treatment in children under real-life situations in rural Tanzania.

A follow-up study was conducted to determine the magnitude of and factors related to adherence to artemether/lumefantrine (ALu) treatment in rural settings in Tanzania. Children in five villages of Kilosa District treated at health facilities were followed-up at their homes on Day 7 after the first dose of ALu. For those found to be positive using a rapid diagnostic test for malaria and treated with ALu, their caretakers were interviewed on drug administration habits. In addition, capillary blood samples were collected on Day 7 to determine lumefantrine concentrations. The majority of children (392/444; 88.3%) were reported to have received all doses, in time. Non-adherence was due to untimeliness rather than missing doses and was highest for the last two doses. No significant difference was found between blood lumefantrine concentrations among adherent (median 286 nmol/l) and non-adherent [median 261 nmol/l; range 25 nmol/l (limit of quantification) to 9318 nmol/l]. Children from less poor households were more likely to adhere to therapy than the poor [odds ratio (OR)=2.45, 95% CI 1.35-4.45; adjusted OR=2.23, 95% CI 1.20-4.13]. The high reported rate of adherence to ALu in rural areas is encouraging and needs to be preserved to reduce the risk of emergence of resistant strains. The age-based dosage schedule and lack of adherence to ALu treatment guidelines by health facility staff may explain both the huge variability in observed lumefantrine concentrations and the lack of difference in concentrations between the two groups

Managing malaria in under-fives : Prompt access, adherence to treatment and referral in rural Tanzania

Background: Nearly a million people die of malaria each year, the majority are children in rural African settings. These deaths could be reduced if children had prompt access to artemisinin-based combination therapy (ACTs), demonstrated adherence to treatment and to referral advice for severe malaria. However, health systems are weak to deliver the interventions. Although many African countries, including Tanzania, changed malaria treatment policy to ACTs in the last decade, few children reportedly get prompt access to ACTs. Main aim: To determine factors influencing prompt access to effective antimalarials; adherence to treatment schedules and to referral advice among children under five, in rural settings. Methods: Community-based studies were conducted in rural villages in Kilosa (I,II) and Mtwara rural (II,IV) districts, in Tanzania. Study I and II were prospective designed while study III and IV were nested in a community-based rectal-artesunate deployment intervention study. In study I, a total of 1,235 children from 12 randomly selected villages were followed up for six months. Caretakers of children reported to have fever were interviewed at home about the type and source of treatment using a questionnaire. In study II, all children (3918) in five selected villages were followed-up for 12 months, to determine adherence to treatment when they had malaria, diagnosed using Rapid Diagnostic Test (RDT) and treated with artemether-lumefantrine (ALu). In study III, 587 children who received pre-referral rectal artesunate during the deployment study were traced home and caretakers interviewed on a number of factors likely to influence adherence to referral advice, using a questionnaire. Study IV was qualitative, 12 focus group discussions were conducted in three purposively selected villages to explore reasons for non-adherence to referral advice. Results: Only one-third (37.6%) of febrile children had prompt access to ALu, the recommended ACTs in Tanzania, mainland (I). Lack of prompt access was mostly (>80 percent) attributed to receiving non-recommended drugs. Less than half of the febrile children were taken to government facilities, where they were 17-times more likely to have prompt access compared to those who went elsewhere. Less than 10% (41/607) of febrile children had access to ALu (I) from faith-based organisation facilities and accredited drug dispensing outlets, despite having subsidized ALu. Reported adherence to treatment schedules was high (>80 percent) and non-adherence was attributed mainly to untimely dosing, rather than taking a fewer number of doses (II). While social economic status influenced prompt access to ALu and adherence to treatment, basic education did not (I, II). Caretakers of children with altered consciousness and convulsion were almost 4-times more likely to adhere to referral advice than those whose children had less severe symptoms (III). They seemed to weigh child condition against obstacles to accessing care at health facilities, if the condition was less severe prior to or improved after rectal artesunate dose, caretakers were likely to be deterred from adhering to referral advice (IV). Detailed understanding of provider’s advice was likely to lead to adherence to the treatment schedule (II) and to referral advice (III, IV). Conclusion: This thesis has shown that once a child had access to ALu, caretakers were likely to adhere to treatment schedule; and to referral advice, if child had severe symptoms or not improved after pre-referral treatment. More efforts should therefore be directed towards increasing access to ALu by strengthening the public health sector to reach rural remote areas. A wide coverage in prompt access to ALu will also reduce the need for the rectal artesunate strateg

Primacy of effective communication and its influence on adherence to artemether-lumefantrine treatment for children under five years of age: a qualitative study.

BACKGROUND\ud \ud Prompt access to artemesinin-combination therapy (ACT) is not adequate unless the drug is taken according to treatment guidelines. Adherence to the treatment schedule is important to preserve efficacy of the drug. Although some community based studies have reported fairly high levels of adherence, data on factors influencing adherence to artemether-lumefantrine (AL) treatment schedule remain inadequate. This study was carried-out to explore the provider's instructions to caretakers, caretakers' understanding of the instructions and how that understanding was likely to influence their practice with regard to adhering to AL treatment schedule.\ud \ud METHODS\ud \ud A qualitative study was conducted in five villages in Kilosa district, Tanzania. In-depth interviews were held with providers that included prescribers and dispensers; and caretakers whose children had just received AL treatment. Information was collected on providers' instructions to caretakers regarding dose timing and how to administer AL; and caretakers' understanding of providers' instructions.\ud \ud RESULTS\ud \ud Mismatch was found on providers' instructions as regards to dose timing. Some providers' (dogmatists) instructions were based on strict hourly schedule (conventional) which was likely to lead to administering some doses in awkward hours and completing treatment several hours before the scheduled time. Other providers (pragmatists) based their instruction on the existing circumstances (contextual) which was likely to lead to delays in administering the initial dose with serious treatment outcomes. Findings suggest that, the national treatment guidelines do not provide explicit information on how to address the various scenarios found in the field. A communication gap was also noted in which some important instructions on how to administer the doses were sometimes not provided or were given with false reasons.\ud \ud CONCLUSIONS\ud \ud There is need for a review of the national malaria treatment guidelines to address local context. In the review, emphasis should be put on on-the-job training to address practical problems faced by providers in the course of their work. Further research is needed to determine the implication of completing AL treatment prior to scheduled time

Understanding caretakers' dilemma in deciding whether or not to adhere with referral advice after pre-referral treatment with rectal artesunate

BACKGROUND: Malaria kills. A single rectal dose of artesunate before referral can reduce mortality and prevent permanent disability. However, the success of this intervention depends on caretakers' adherence to referral advice for follow-up care. This paper explores the dilemma facing caretakers when they are in the process of deciding whether or not to transit their child to a health facility after pre-referral treatment with rectal artesunate. METHODS: Four focus group discussions were held in each of three purposively selected villages in Mtwara rural district of Tanzania. Data were analysed manually using latent qualitative content analysis. RESULTS: The theme "Caretakers dilemma in deciding whether or not to adhere with referral advice after pre-referral treatment with rectal artesunate" depicts the challenge they face. Caretakers' understanding of the rationale for going to hospital after treatment--when and why they should adhere--influenced adherence. Caretakers, whose children did not improve, usually adhered to referral advice. If a child had noticeably improved with pre-referral treatment however, caretakers weighed whether they should proceed to the facility, balancing the child's improved condition against other competing priorities, difficulties in reaching the health facilities, and the perceived quality of care at the health facility. Some misinterpretation were found regarding the urgency and rationale for adherence among some caretakers of children who improved which were attributed to be possibly due to their prior understanding. CONCLUSION: Some caretakers did not adhere when their children improved and some who adhered did so without understanding why they should proceed to the facility. Successful implementation of the rectal artesunate strategy depends upon effective communication regarding referral to clinic

FACTORS INFLUENCING QUALITY of HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS) DATA: THE CASE OF KINONDONI DISTRICT IN DAR ES SALAAM REGION, TANZANIA

Objective: A study was done in Kinondoni Municipality, Tanzania, to assess quality of data collected through the HMIS and explore possible associated factors. Method: Using a structured questionnaire, health facility in-charges were interviewed. Attributes of data quality were recorded from health facility data using an observation schedule. A total of 69 health facilities were involved in the study including all (21) public health facilities and 25% (41/164) private facilities. Completion rate of health facility data was used as a proxy for measuring quality of data. Results: Although knowledge on HMIS basic concept was found to be associated with improved quality of data, training in HMIS did not seem to correspond with improved quality of data. Regardless of duration, supervision had no relationship with quality of data thus raising serious doubts on its quality. Presence of a focal person, responsible for day to day HMIS activities, had a positive influence on the quality of data where facilities with a focal person had a higher data completion rate (69.9%) compared to those without (44.7%). Accountability as measured by queries reportedly made by Municipal authorities on data inaccuracies was associated with better quality of data. However, queries on delay in sending report had no influence in quality of data. Conclusion: The study concludes that training, followed by supervision in HMIS, did not result into a significant improvement of the quality of HMIS. There is need to re-examine the current approaches used in training and supervision to focus on actual needs of health workers. As a long- term goal, creation of demand for processed data will serve to enhance ownership of the system by health workers, hence improve data qualit

Le bénévolat chez les éducateurs de pairs qui ne fréquentent plus l’école et qui sont chargés de la santé de reproduction : Est-ce une stratégie durable dans les pays ayant des ressources limitées?

Out-of-school peer educators [PE] are resourceful in transmitting reproductive health information but their retention remains a contentious issue. This study aimed to assess motivation and sustainability of out-of-school PEs in disseminating reproductive health information among adolescents. A structured questionnaire was used to interview 406 PEs in Mbeya region, Tanzania. Focus Group Discussions [FGDs] were also conducted with the PEs and other relevant stakeholders. Most PEs had hopes for future employment and allowances through continuous training. The fact that majority of PEs had primary level education [89%] and were either peasants or self employed [92%] posed a serious question as to whether voluntary work is for the less educated, peasants and self-employed. Sustenance of PEs needs to be a continuous activity aimed at increasing the number of trained adolescents from their own social and economic groups. Otherwise, provision of transport and compensation for time spent should be considered (Afr J Reprod Health 2009; 13[3]:99-110).Les éducateurs de pairs qui ne fréquentent plus l’école (EPs) sont ingénieux en matière de la transmission de l’information concernant la santé de reproduction, mais le problème reste de savoir si l’on doit les retenir ou non. C’est-a-dire, il faut évaluer la motivation et la viabilité des EPs qui ne fréquentent plus l’école par rapport à la dissemination de l’information sur la santé de reproduction chez les adolescents. Nous avons interviewé 406 EPs dans la région de Mbeya en Tanzanie à l’aide d’un questionnaire structuré. Il y a eu aussi des discussions à groupe cible (DGC) avec les EPs et les autres intéressés appropriés. Le fait que la majorité des EPs avaient reçu l’éducation primaire (89%) et qu’ils étaient soit des paysans soit des auto-employés (92%) a soulevé une question importante de savoir si le bénévolat est destiné au gens moins scolarisés, aux paysans et aux auto-employés. Il faut que le maintien des besoins des EPs soit régulier pour les rendre une activité qui visent à l’augmentation de nombre des adolescents formés à partir de leurs groupes sociaux et économiques. Sinon, il faut tenir en compte l’assurance du transport et de la recompensation pour le temps qu’on a passé (Afr J Reprod Health 2009; 13[3]:99-110)

Referral Pattern of Patients Received at the National Referral Hospital: Challenges in Low Income Countries

Objective: To examine the medical referral pattern of patients received at the Muhimbili National Hospital (MNH) in order to inform the process of strengthening the referral system. Methods: The study design was a prospective study conducted at MNH during a 10-week study period from January to March 2004. The study sample consisted of patients referred to MNH Results: Of the 11,412 patients seen, 72.5% were self-referrals. More than 70% of the patients seen required admission, though not necessarily at tertiary level. Only 0.8% came from outside the Dar es Salaam region. More than 70% of the patients seen required admission. Surgical services were required by 66.8% of patients, with obstetric conditions being most prominent (24.6% of all patients). For those who were formally referred from other health services, lack of expertise and equipment were the most common reasons given for referral (96.3%). Conclusion: Efforts to improve referral systems in low-income countries require that the primary and secondary level hospitals services be strengthened and increased so as to limit inappropriate use of national referral hospitals