Study design and setting:
We conducted a facility-based cross-sectional quantitative study; and a qualitative study at the Regional Office (Centre Region), for a period of 5 months extending from 1st May 2019 to 30th September 2019 in the city of Yaoundé, the regional headquarters of the Centre Region, the capital of Cameroon. Yaoundé is made up of 6 health districts (HDs): Biyem-assi, Cité Verte, Djoungolo, Efoulan, Nkolbisson and Nkolndongo. These districts are made up of 55 health areas harbouring 799 HFs (public and private).
Study variables included socio-professional characteristics of respondents, HF-related characteristics and HF and Community Information System Standards. Socio-professional characteristics were age, sex, professional qualification, years of experience, and function. Health facility-related characteristics included status of the HF (Public, private). Health Facility and Community Information System Standards, defined and grouped into domains and subdomains by WHO and MEASURE Evaluation (17) were:
- Management and Governance (Policies and Planning, Management, Human Resources)
- Data and Decision Support Needs (Data Needs, Data Standards)
- Data Collection and Processing (Data Collection and Management of Individual Client Data; Collection, Management and Reporting of Aggregated Facility Data; Data quality assurance; Information and Communication Technology (ICT))
- Data Analysis, Dissemination, and Use (Analysis, Dissemination, Data Demand and Use
Sample size and sampling
To obtain the minimum sample size (n) of 106 HFs to be visited, we used the formula:
See formula 1 in the supplementary files.
Where Z is the approximate value of the 97.5 percentile point of the standard normal distribution =1.96, P is the proportion of adequately functioning HFs= 10% (19), d is the precision= 0.06 (19), and 10% non-response rate. We then proceed to select the HFs through a stratified sampling using probability proportional to size of HFs in each HD. Stratified variables were HD and HF status (Private, Public).
We included into our study functional public and private HFs of the operational level who gave their consent for participation. One respondent per selected HF was interviewed. The main respondent profile was a person in charge of statistics or responsible of information system. However, since most facilities did not have a RHIS staff, other professionals carried out this function were recommended by the head of the HF (including him/herself) to participate in the study.
Interviewers were recruited and trained to understand the objectives and the methodology of the study. Data was collected using the WHO/MEASURE Evaluation pre-established Rapid Assessment questionnaire (17) that was slightly modified to include the socio-professional characteristics of respondents and HF characteristics. The WHO/MEASURE Evaluation RHIS rapid assessment tool was used for the assessment (17). This tool consists of two Microsoft Excel workbooks: a data entry module and, a data analysis and dashboard module. Firstly, data was entered into the data entry module of the tool. In this module, a checklist of standards for HF and community information systems were grouped into domains and their respective subdomains. Responses were automatically compiled as they were entered into the module. This compilation permitted a rapid and specific analysis of the responses for the concerned HF. There were as many completed copies of the data entry module as respondents.
Each item on the questionnaire was scored as either 0 (no answer/not applicable); 1 (not present, needs to be developed); 2 (needs a lot of strengthening); 3 (needs some strengthening); or 4 (already present, no action needed). Secondly, data was analysed to generate the standard specific results and also results of the RHIS grouped by domain and subdomain.
Statistical data analysis for quantitative study
Data was entered into Microsoft Excel 2013, cleaned and then exported for analyses using IBM- SPSS version 25. Quantitative variables following a normal distribution were presented as mean ± standard deviation; and presented as median (interquartile range) otherwise. Frequencies and percentages (%) were used to describe categorical variables.
Qualitative study, conducted from 16 to 27 September 2019 after quantitative data collection, was primarily designed as a triangulation strategy at the regional level to check for the consistency and convergence of findings generated by data collection through quantitative methods at health facility level for questions related to policy, planning, management, human resources, data needs, standards and system design. Secondary, qualitative study aimed at obtaining proposed strengthening actions for the above mentioned related questions.
In-depth interviews were conducted with eleven key informants aged 25-36 years (6 male and 7 female) that were identified in the various services of the Regional Health Office. There were 6 from Health Information Unit, 3 from Human Resources Unit, and 2 from Planning Unit. All interviews were conducted in a private location and audio-recorded with permission from the interviewee, transcribed, coded; themes and patterns identified, and findings compared with quantitative findings. There were no discrepancies between information provided at the health facility level and that obtained at the regional level.
Broad ideas, themes, concepts, behaviors, or phrases have been identified and codes assigned to them. Once the data coded, for each question, themes, patterns and most common recommendations were identified.
The study received ethical approval 0552-/CRERSHC/2018 from the Regional Ethical Committee for Research and Human Health” (Center Region) and the authorization 0549- /AP/MINSANTE/SG/DRSPC from Regional Delegate of Public Health of the Centre Region.
Recruitment of participants was conducted only after describing the study procedures and obtaining informed consent. During the process of obtaining informed consent, participants were clearly informed that participation is voluntary and that non-participation would have no negative consequences.