Health workers' use of routine health information and related factors at public health institutions in Illubabor Zone, Western Ethiopia

A health information system (HIS) is one of the six building blocks of a health system that interacts with the remaining blocks. An effective HIS produces reliable and real-time evidence on the health status of a population, determinants of health and health system performance. It provides information that aids in the direction of activities in all other components of the health system, such as the health workforce, service delivery, access to essential medicines, finance, and health system leadership and governance. Beyond health system management, the routine health information system can be a sources of data for research purposes [1‐8].

Proper information utilization is considered the foundation for effective health system performance and a strategy to attain health-related targets in the Sustainable Development Goal (SDG) era. Despite this fact, the narrow scope and weaknesses of the existing information systems coupled with a low culture of information use are hindering the progress made towards health goals. The major determinants of information use are categorized as technical factors, behavioral factors, and organizational factors. Low access to quality health data, influenced by a lack of data management and analysis capacity, a lack of information promotion culture at organizations, and an unfavorable attitude toward data, continue to be the main challenges to information utilization in low and middle income countries’ health system [9‐14].

The government of Ethiopia has considered strengthening the health information system as a mechanism to enable effective monitoring and evaluation of health policies, programs, projects and strategies since 2006. However, until the fourth health sector development plan (HSDP IV), little emphasis has been given to evidence based decision-making. In Ethiopia, the main source of evidence for routine health decisions is the health management information system, and policy-level decisions are made based on evidence generated through national surveys, censuses and planned operational research. Following the introduction of the health sector transformation agenda, data-driven decision making has taken due consideration as it is reflected in one of the agendas, ‘Information Revolution’ [15, 16].

Though Ethiopia has implemented routine health information systems for more than a decade, the progress made in terms of information utilization is steady. Information utilization among health workers stands at 57.42% [17]. Whereas cross-sectional studies revealed that information utilization among health workers in Ethiopia ranged from 37.3 to 78.5% [18, 19]. Weak information utilization at the point of data generation is attributed to various factors, mainly grouped under technical, organizational, and behavioral factors. Health worker’s characteristics, availability of HIS focused training and supportive supervision, good perceived culture of health information, having a standard set of indicators, competence of health workers on health information tasks, and good governance were the determinants of information use [17, 19, 20]. Understanding the factors affecting of health information use at the point of data generation by taking into consideration the broader determinants has paramount importance for improving the health information system. Therefore, this study aimed to determine the level of information utilization and factors associated with it among health workers and health care managers at various levels of the health system in Illubabor zone, Oromia regional state, Ethiopia.

According to this study, two-thirds of health workers had good information usage practices. Two-thirds (67.1%) of health workers rated the organizational decision-making climate and information use promotion by facility managers or supervisors (65.5%) as favorable. The facility's information use promotion measures were rated positively by seven out of ten (71.9%) health workers.

Regarding RHIS data and its management, over half (57.0%) of health workers had a favorable perception. More than eight out of ten (85.8%) health workers believed that they had high self-efficacy in data analysis, interpretation, and use. However, only about two-thirds (65.5%) of health workers actually had high competency in data analysis and interpretation. Information utilization among health workers was predicted by service experience, title or position, work place, RHI training, knowledge of data quality, self-efficacy and competency in data analysis and interpretation, organizational decision making climate, and information promotion by department staff. The sexes had marginal associations with good information utilization and utilization.

Information use practices in the study area were comparable to a study done in Kenya (69.6%), East Wollega zone, Western Ethiopia (66%), and Hadiya zone, Southern Ethiopia (62.7%) [20, 25, 26]. This is better than studies done in the East Gojam zone, Northern Ethiopia (45.8%) [27] Diredawa, Eastern Ethiopia (53.1%) [28], Addis Ababa (37.3%) [18], Western Amhara (38.4%) [29], Oromia special zone (52.8%) [30], hospitals of Oromia regional state (56%) [31], and Southwest Ethiopia (57.3%) [32]. The finding was also better than a study conducted in selected districts of Amhara region (46%) [33], estimated pooled prevalence of information use at the national level (57.4%) [17], a study conducted in Tanzania [34] and another study conducted in Kenya among health care providers (34%) [35]. The current study's finding, on the other hand, was lower than that of a study conducted in North Gondar, Northwest Ethiopia (78.5%) [19], and the North Shewa zone of the Oromia region (71.6%) [36]. The possible explanation for the variations in study findings might be contextual differences, differences in the period of assessments, and scope of the study. However, the current level of information use at the point of data generation and supervisory level was unacceptably low in the study area. This has a considerable impact on the performance of the health system.

The majority of health workers have utilized health information to observe health service trends in their catchment area, identify and manage epidemics, drug supply and management, disease prioritization, and plan with an information utilization rate ranging from 72.8 to 81.8%. Only over half (56.3%) of health workers have utilized health data for day-to-day management of health services. That is a finding lower than a study conducted at health centers in Oromia special zone (77.5%) and public health centers in North Gondar (89.6%) [19, 30]. The good practice of information use by healthcare providers and managers helps to improving primary health care and achieve universal health coverage [37].

Two-thirds of health workers believe a favorable culture of health information use promotion exist in their organization, and managers or supervisors have a positive attitude towards information use. This finding was better than a study conducted in Southern Ethiopia in which 58.8% of health workers had a good perceived culture of health information [20] and that of Northern Ethiopia, where 48.1% of health workers had a good perceived culture of health information [19]. Besides, the majority of health workers had a favorable attitude towards data management, including data collection, organization, analysis, and reporting. It is believed that these organizational and behavioral factors enhance the proper utilization of health data in health institutions. Many barriers to information use are linked to organizational and behavioral factors, and as such strengthening routine information systems involves building an information culture where information is valued at all health system levels [10].

Though most health workers had high self-efficacy in data analysis and interpretation, the study revealed that only two-thirds of them were competent in data analysis and interpretation. In terms of RHI task competency, the findings of this study outperformed the findings of a study conducted in Northwest Ethiopia (East Gojam (51.5%) and North Gondar (29.9%) [19, 24], as well as a study conducted in Southern Ethiopia (Hadiya zone (56.7%) [20]. The variations in health workers’ RHI skills might be due to contextual differences, differences in the scope of the study, and differences in supports in terms of training and supervision. In comparison to other research regions, the majority of health workers in the study area have been trained (88.7%) and supervised (92.9%) with an emphasis on RHI tasks [19, 20, 27].

In the study area, proper information use practices were predicted by service experience, title or position held by health workers, trainings, the existence of a favorable organizational decision-making climate, information use practices by department staff, and self-efficacy and competency in data analysis and interpretation. In support of this, insufficient skill in information use core competencies, poor data quality, insufficient data availability, system design, relationships between actors who produce and use data, decision making autonomy and authority structures, information use leadership, information use culture, and low individual commitment and motivations are all barriers to information use in low and middle-income countries [38]. Similarly, another study revealed that awareness gaps, lack of motivating incentives, irregularity of supportive supervision, lack of community engagement in health report verification, and poor technical capacity of health professionals were found to be the major barriers to information use [39]. The presence of competent professionals in data analysis and interpretations remains a critical factor to improve information use practices at health care setting [40].

Proper information use practice was positively associated with health workers’ service experience, title or position possessed by health workers, and work place. Good health information utilization was four times more likely among health workers having service experience of greater than 10 years compared to those with less than 5 years. Moreover, health information utilization was more likely among head health workers than experts and health workers at admin units compared to health facilities. Experienced health workers had the knowledge and motivation to manage data and utilize information compared to less experienced ones as they felt more responsibility. Most health decisions are made by people in positions located at administrative units rather than health facilities.

In this study, information use practice was less likely among trained health workers compared to untrained health workers. This finding was in contradiction to other studies that found RHI training was positively associated with proper information utilization [17, 20, 27, 29, 30, 32]. In the study area, the majority of health workers were trained, with a higher proportion of them having received training before the 12 months of survey period and most had received RHI training with a component of data management and quality assurance. Training may be one factor influencing data management and information utilization, but so may changes in health workers' knowledge, attitude, motivation, and competency, and, in turn, information utilization may be influenced by supervision, mentorships and other interventions [41]. Besides coverage of RHI training, the of quality of delivery in terms of content, duration and frequency is critical to influence positive changes in information usage behavior [42].

Health workers’ knowledge of health data quality improving measures was positively associated with information use practices in that information use practice were two times more likely among health workers with good RHI knowledge. Health workers who have a better knowledge of data quality and its measures have a high probability of generating good quality data. Access to good quality data in turn influences better utilization of information. This finding was supported by other studies that showed health workers’ knowledge of RHI management was associated with good information utilization [17, 20].

Health workers’ self-efficacy in data analysis and interpretation was positively associated with good information use among health workers in that high self-efficacy health workers utilized information 2.5 times more than their counterparts. Likewise, health workers’ skill in data analysis and interpretation also showed a positive association, in which good information utilization was three times more likely among competent health workers in data analysis and interpretation. This finding was consistent with other studies [19, 20, 27, 30, 32]. Lack of skills to analyze, interpret, and use data among health workers impedes real-time decision making in organizations.

The existence of a favorable organizational decision-making climate and information promotion by department staff was positively associated with information use among health workers. Information use is about three times more likely among health workers’ in organizations with a favorable decision making climate and among health workers in organizations where information is promoted by department staff. Information use promotion culture in an organization is identified as an important factor in the effective utilization of information by its workers and managers. This finding was supported by other studies [18‐20, 27]. The presence of regular supervision and managerial support, and provision of feedback is important to improve health workers’ commitment to information use [43] and enhance primary healthcare service delivery [44]. On the contrary, the social and political dynamics (such as political conflict, interest of significant others etc..) in decision making process hinders better information use practice [45].

In the bivariate analysis, variables such as sex of health workers, existence of supportive supervision, type of health institution, knowledge of collecting and using aggregated health data (disease, age and sex), and dimensions of data quality, and information use promotion by department managers or supervisors were shown to have an association. However, the association was not maintained when adjusted for other confounding variables. In other studies, these variables were statistically associated with good information utilization among health workers [17‐20, 27‐30, 32]. The organizational determinants, including feedback mechanisms, supportive supervision and resource availability in the health information system, were predictors of information use among health workers [46].

This study has assessed information use practices and associated factors guided by validated framework (PRISM framework) and by considering both organizational and individual factors comprehensively. Both healthcare providers and healthcare managers were included in the study. The assessment was conducted based on a representative district in the zonal administration and, hence, the findings have the possibility of generalizability. The study was not without limitations. Information use is measured based on the perception of health workers and this might obscure the actual practice. As the assessment was conducted at facility level, information bias might be introduced because the data collection setting is the same as the working environment. The health workers might be afraid to give the correct information. Since we have used data collectors outside of the study settings and adequate explanations were provided about the aim of the study to respondents, this bias might be minimized.

Informed decision-making in primary health care (PHC) is a foundation of universal health coverage. This study concluded that about two thirds of health professionals practice proper information utilization, however the routine information usage at public health institutions remains lower than the regional and national expectations. This might impede efforts towards improving health system performance at the primary health care level. The study also revealed that health workers’ knowledge on health data quality, and their self-efficacy and skills of data analysis and interpretations, existence of information use promotion culture at organizations, among health care managers and department staffs were positively associated with information use practices among health workers. Therefore, efforts should be made to improve the organizational decision making climate, and health workers knowledge towards health data management and use. The value of data should be advocated and promoted at all levels of the health system.