field report 4.2

8/8/2019 Field Report 4.2

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FIELD REPORT

FACTORS INFLUENCING REGULAR REPORTING OF

MATERNAL AND CHILD HEALTH INFORMATION FROM

PRIVATE MATERNITY UNITS IN MUKONO DISTRICT

BY

DR. JANET OOLA(MB. Ch,B(MUK), MPH(MUK), DTBCE, PGDPAM, Crt PPM)

INSTITUTE OF PUBLIC HEALTH

MAKERERE UNIVERSITY, KAMPALA

FIELD SUPERVISOR: DR. E.K. TUMUSHABE

DDHS, MUKONO

AUGUST 2000

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ACKNOWLEDGEMENTS

I acknowledge the following people and institutions for the help, support and guidance

they offered that enabled the conduction and completion of the study:

1. The District Director of Health Services, Mukono for the support and guidance.

2. The District Health Services Project and IPH for the financial assistance.

3. The members of the District Health Team who helped in the data collection process.

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TABLE OF CONTENTS ITEM PAGE

ACKNOWLEDGEMENTS..

TABLE OF CONTENTS..

LIST OF TABLES AND FIGURES....

LIST OF ACRONYMS.

ABSTRACT...

CHAPTER ONE1.0 INTRODUCTION..1.1 STATEMENT OF THE PROBLEM.....

1.2 JUSTIFICATION...

CHAPTER TWO...2.0 STUDY OBJECTIVES......2.1 GENERAL OBJECTIVES.

2.2 SPECIFIC OBJECTIVES..

CHAPTER THREE...3.0 METHODOLOGY.....

3.1 STUDY AREA..

3.2 STUDY POPULATION....

3.3 STUDY UNITS..

3.4 STUDY DESIGN...3.5 SAMPLE SIZE AND SAMPLE DETERMINATION..

3.6 STUDY VARIABLES AND INDICATORS....

3.7 DATA COLLECTION INSTRUMENTS..

3.8 QUALITY CONTROL..

3.9 ETHICAL CONSIDERATIONS...3.10 DATA MANAGEMENT AND ANALYSIS..

3.11 STUDY LIMITATIONS..

3.12 DISSEMINATION OF RESULTS..

CHAPTER FOUR.....4.0 RESULTS..

CHAPTER FIVE...5.0 DISCUSSION....

CHAPTER SIX......6.0 CONCLUSIONS AND RECOMMENDATIONS.....

6.1 CONCLUSIONS.....

6.2 RECOMMENDATIONS........

REFERENCES..

APPENDICES......

APPENDIX 1.APPENDIX 2.....

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vi

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LIST OF TABLES AND FIGURES

TABLES

Table 1: Relationship between gender and qualification..10

Table 2: Use of the records by respondents..13

Table 3: Knowledge on the HMIS14

Table 4: Relationship between qualificationand having heard of the HMIS...14

Table 5: Knowledge of importance of the HMIS.15

Table 6: Problems faced by respondents in reporting .15

Table 7: Suggestions for improving the reporting system16

FIGURES

Figure 1: Distribution of respondents by qualification9

Figure 2: Types of services offered by the private maternity units10

Figure 3: Antenatal care utilization.11

Figure 4: Number of deliveries conducted..12

Figure 5: Utilization of Family Planning services...12

Figure 6: Attendance for immunization...13

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LIST OF ACRONYMS

HMIS : Health Management Information System

WHO : World Health Organization

UDHS : Uganda Demographic Health Survey

MOH : Ministry Of Health

MCH : Maternal and Child Health

ANC : Antenatal Care

NIDS : National Immunization Days

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ABSTRACT

Setting: The study was conducted in 23 private maternity units in Mukono district found

in the South-east of Uganda.

Objective: To identify the factors influencing regular reporting of maternal and child

health information from the private maternity homes in order to generate data which

could help in improving the reporting system.

Design: A cross sectional study carried out in July 2000 in 23 private maternity units in

Mukono district.

Results: The mean age of the respondents was 42.5 (sd=12). Twenty one (21, 91.3%)

were female and 2 (8.7%) were male. Of these, 74% were enrolled midwives. Most (12,

52.2%) units had been operational for more than 10 years. All units offered Antenatal

care and conducted deliveries, while the units despite very good attendance rates for the

services available did not all offer other important Maternal and Child Health services.

Records were used mainly (15, 65.2%) for the management of accounts and few (2,

8.7%) mentioned using it for compiling returns. Only 4 in-charges had heard of the

HMIS, and being a clinical officer was associated with having heard of the HMIS

(p=0.024). All 4 who had heard of the HMIS had a positive attitude towards it. Lack of

forms for reporting was the main (5, 52.2%) problem faced, as well as incomplete records

and no feedbacks got on the reports sent to the DDHSs office. Most (18, 78.3%)

suggested being provided reporting forms and being oriented (13, 56.5%) on the HMIS as

a way of improving the reporting system.

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Conclusions: Lack of adequate awareness on the HMIS, lack of reporting forms, poor

record keeping and no feedback from the DDHSs office on the returns sent there were

the factors that promoted irregular reporting to the office of the DDHS. However, all

units provide Antenatal care and delivery services, while the other maternal and child

health services are not provided by all private units, despite good attendance rates at these

units. The main use of data was for the management of accounts. The private midwives

had no knowledge of the HMIS.

Recommendations: The owners of the private maternity homes be oriented on the

HMIS. HMIS registers and forms be provided for the private maternity homes to aid

complete and comprehensive reporting to the office of the DDHS.

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CHAPTER 1

1.0 INTRODUCTION

Managing effectively requires relevant and reliable information on which to base

management decisions, and the Health Management Information system can do this

effectively for the manager in the health system (Manual of District Health System in

Uganda, 1995).

On that note, health information is thus a very important management tool which should

be comprehensive and also collected from all units providing health care, whether private

or government in order to give one a better overview of existing situations.

The basic indicators of maternal and child health in Uganda remain among the poorest in

the region. Maternal mortality rate in Uganda is estimated at 506/100 000 live births and

the major obstetric causes are haemorrhage, sepsis, ruptured uterus, eclampsia and unsafe

abortion (UDHS, 1995). Maternal mortality among among women 15-49 years can be

reduced substantially by providing adequate maternal services (MOH, MCH/FP 5 year

strategic plan, 1997). Adequate maternal services also considers the four pillars of safe

motherhood as Family planning, Ante-natal Care, Clean and safe deliveries and Essential

Obstetric care (WHO Mother Baby Package, 1994).

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Maternal and Child Health/Family Planning is a component of the national strategy to

improve the health status of the population (MOH National Policy guidelines for Family

Planning and Maternal Health service delivery, 1992). A number of programs to improve

maternal services have been implemented, but few if any private units are involved. One

of the key problems that mothers face is access to contraceptives and high quality

reproductive health care services. Providing this access could prevent some of the

millions of unwanted pregnancies that occur each year and save the lives of millions of

mothers and children. High quality reproductive health programs are needed that are

sustainable, appropriate to local cultures and sensitive to client needs. According to the

Midwifery Association Partnerships for Sustainability (MAPS), private midwives serve

existing needs and reduce the public sector burden. Involving them in the routine

reporting system can thus shed better light on existing trends as regards reproductive

health status of the population.

Mukono district is situated in the South East of Uganda. It is approximately 20 km east of

Kampala and is bordered by the districts of Kamuli in the North East, Jinja in the East,

Iganga in the South East, Lira in the North, Luwero and Nakasongola in the North West,

Mpigi in the West and the republic of Tanzania in the South. Mukono district has a total

of 6 counties, 37 subcounties and 207 parishes.

The district occupies 14 635 sq.km of land. The climate is equatorial and modified by an

altitude of 1 060- 1 220 meters above sea level, and a temperature range of 160C-270C.

The total projected population for the year 2000 now stands at 1,088, 755 (Projection

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from Housing and population census of 1991), with an annual growth rate of 2.4%.

Women of childbearing age constitute 23% of the total population with a fertility rate of

6.8 children per woman. There are 29 private maternity units registered in the year 1999

and who are offering Maternal and Child Health services (MCH). The Maternal and

Child health performance indicators in the district are as outlined below:

TYPE OF SERVICE INDICATOR

1.Maternal and child health services Infant mortality rate 88/1000 live births

Maternal mortality rate 500/100 000

births

ANC offered in 40 units out of 56(71%)

Delivery services and nutrition

education offered in 38 units(68%)

NIDS coverage for polio eradication

1998 Aug 94%

Sept 96%1999 Aug 99%

Sept 108%

Routine immunization coverage for all

antigens 80%-90% coverage

12 out of 37 Subcounties haveCommunity based Distributors program

1.1 STATEMENT OF THE PROBLEM

Twenty-nine (29) private units in Mukono district report to the District Health

Directorate. However, it is noted that not all units report regularly. The services offered

by these units are not also known. Since the beginning of the year, 6 out of the 29 units

have reported monthly to date. The rest report irregularly. It is also not known whether

the private midwives have any knowledge on the Health Management Information

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System (HMIS) and its importance and whether they have a positive attitude towards it.

The reasons for irregular reporting also need to be identified.

1.2 JUSTIFICATION

Identifying the factors affecting the regular reporting to the office of the DDHS will aid

in identifying the gaps that need to be bridged for improvement in the smooth running of

the HMIS. Knowing the services offered by these private maternity homes as well as the

utilisation of these services can also help to update the records already available. The

gaps identified in as far as their knowledge and attitude on the HMIS is concerned can

help to identify interventions by the DHT to improve the reporting system. Many

programs have been implemented to improve the health of mothers and children in

Mukono district. It is known that the population prefers private units for care as they

value courteous services, convenience, accessibility and ready availability of drugs, and

yet these programs hardly involve the private maternity homes. The data generated from

this study is thus vital for adequate planning and implementation of Reproductive Health

programmes; and also for the DHT to improve the reporting system by the private

midwives.

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CHAPTER 2

2.0 STUDY OBJECTIVES

2.1 General objective

To identify the loop holes in the smooth running of the HMIS and to obtain maternal and

child health information from the private maternity homes in order to generate data which

could help in improving the reporting system and thus the provision of these services.

2.2 Specific objectives

1. To determine the Maternal and Child Health services offered in the private units.

2. To determine the utilisation of these services.

3. To determine the use of the information on attendances to the units.

4. To assess the knowledge and attitude of the in-charges on the Health Management and

Information System.

5. To get the midwives, views on the factors affecting the regular reporting of health

information from their private units.

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CHAPTER 3

3.0 METHODOLOGY

3.1 Study area

Mukono district

3.2 Study units

Private maternity homes

3.3 Study population

In-charges of the units

3.4 Study design

Cross sectional study employing quantitative methods of data collection..

3.5 Study variables

Types of maternal and child health services available

Number of deliveries conducted

Number of still births

Number of maternal deaths

Number of referrals

Number of family planning acceptors

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Number of antenatal care attendances

Use of information

Knowledge and attitude towards HMIS

Factors affecting regular reporting to the DDHSs office

3.6 Data collection instruments

Semi-structured questionnaire for the in-charges.

Check list for the services offered and deliveries and other attendances

Review of available records

3.7 Data management and analysis

Data was analyzed using the Epi-Info 6 computer software package. Results were

presented as proportions, frequencies and in the form of tables, graphs and pie charts

were appropriate.

3.8 Quality control

Research assistants were trained in data collection methods. Questionnaires were pre-

tested prior to actual data collection. Data was field edited and there were daily debrief

meetings.

3.9 Ethical issues

Informed consent was obtained from the respondents. Permission to carry out the study

was obtained from the DDHSs office.

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3.10 Study limitations

Incomplete records

Lack of records

3.11 Data dissemination

Data will be disseminated to the Institute of Public Health for evaluation and the District

Health Directorate.

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CHAPTER 4

4.0 RESULTS

23 of the 29 private maternity homes were involved in the study. In three units, the in-

charges were not available and 3 units were found to be no longer operational since the

year begun.

4.0.1 Background characteristics

Age : Their mean age was 42.5 years (sd=12) and ranged from 20 to 63 years.

Sex : 21 (91.3%) were female and 2 (8.7%) were male.

Figure 1 shows the distribution of the respondents by their qualification

Figure 1: Distribution of respondents by qualification

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Enrolled midwife74%

Double trained

13%

Clinical Officer

9%

Registered

midwife

4%


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Most respondents were Enrolled midwives.

The respondents had been in practice for a range of 2 to 38 years with a mean of 19.3

years. Most (12, 52.2%) of the units had been operational for more than 10 years.

There was a noted relationship between sex and qualification as depicted in Table 1

below:

Table 1: Relationship between gender and qualification

Male Female

Midwife/double trained 0 21

Clinical officer 2 0

TOTAL 2 21

________________________________________________________________________

The Fishers exact test gave a p-value of 0.004. Thus being a female was associated with

a greater likelihood of being a midwife.

4.1 Types of services offered. Figure 2 shows the type of services offered by the units

Figure 2: Types of services offered by the private maternity homes

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23 2321

12

9 8 7

0

5

10

15

20

25

ANC

Deliveries

Family

Planning

Postnatal

STD

Adolescent

Health

Immunisation

SERVICES OFFERED

FREQUEN

CY


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4.2.2 Figure 4: Number of deliveries conducted

4.2.3 Figure 5: Utilisation of Family planning services

More new acceptors of family planning methods have been recorded from January to

June 2000. Most units did not record use of condoms.

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Deliveries

Stillbirths

BBAs

Neonataldeaths

Maternaldeaths

1999

Jan-Jun '000

500

1000

1500

2000

2500

FREQU

ENC

1999 2182 26 8 4 1

Jan-Jun '00 1027 5 5 3 1

Deliveries Still births BBAsNeonatal

deathsMaternal deaths

0

200

400

600

800

1000

1200

14001600

1800

FREQUENC

1999 918 744 873 130 1458 267 1171 168

J an-J un '00 1694 1161 478 55 1026 129 749 148

New

acceptors

New clients

OPs

New clients

DEPO

New clients

CondomsRevisits Revisits Ops Revisits DEPO

Revisits

Condoms


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4.2.4 Figure 6: Attendances for Immunisation

Many mothers and children are immunised at these units. All these are, however, reported

to the DDHSs office.

4.3 Use of records

Table 2: Use of records by respondents

Use Frequency(n=23) Percentage

Management of accounts 15 65.2

For monitoring and evaluation of services 14 60.9

Follow up of patients 13 56.5

For compiling returns 2 8.7

Few in-charges of the units used the records for compiling returns.

All respondents recorded their attendances in hard covered books. Most (14, 60.9%) also

20

0

200

400

600

800

1000

1200

1400

1600

FREQUENCY

1999 465 182 477 378 380 412 344 354 397 716

J an-J un 2000 537 285 575 469 553 612 569 491 553 1473

BCG Polio 0 Polio 1 Polio 2 Polio 3 DPT 1 DPT 2 DPT 3 Measles TT


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stored these books in a cupboard, 6 (26.1%) stored them in desk drawers and 3 (13%)

stored them on shelves.

4.4 Knowledge and attitude on the Health Management Information System (HMIS)

Table 3 shows the responses when asked whether they had heard of the HMIS.

Table 3: Knowledge on the HMIS

Heard of the HMIS Frequency Percentage

Yes 4 17.4

No 19

TOTAL 23 100

Very few had heard of the HMIS.

Table 4 shows the relationship between qualification and having heard of the HMIS:

Table 4: Relationship between qualification and having heard of the HMIS

Heard Not heard TOTAL_______________________________________________________________________

_

Midwife/double trained 2 19 21

Clinical Officer 2 0 2

TOTAL 4 19 23

Fishers exact 2-tailed test gave a p-value of 0.024. Therefore being a Clinical Officer

was associated with having heard of the HMIS.

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4.5 Importance of the HMIS

Table 5 shows what the respondents thought were the importances of the HMIS.

Table 5: Knowledge of importance of HMIS by respondents

Importance of the HMIS Frequency (n=4) Percentage

For surveillance of diseases 4 100

Assists in planning 3 75

The four who had heard of the HMIS had good knowledge of its importance.

4.6 Attitude of respondents towards the HMIS

All four viewed the HMIS as a good system.

4.7 Factors affecting regular reporting to the DDHSs office

Table 6 shows the problems the respondents faced in reporting to the DDHS,s office.

Table 6: Problems faced by respondents in reporting

Problems faced Frequency (n=12) Percentage

Forms for reporting not available 5 41.6

Records are incomplete 4 33.3

Fares for travelling high 2 16.6

No feedback got on the returns sent 2 16.6

Too many forms to fill 1 8.3

Lack of forms for returns affects the smooth reporting system. Table 7 shows the

responses when asked what their suggestions were for improving the reporting system.

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Table 7: Suggestions for improving the reporting system

Suggestions Frequency (n=23) Percentage

To be provided forms for returns 18 78.3

To be oriented on the HMIS 13 56.5

Provide regular support supervision 11 47.8

Forms for returns be short 2 8.7

Provide feedback on returns sent 1 4.3

Most of the respondents were interested in being oriented on the HMIS as a way of

improving the reporting system.

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CHAPTER 5

5.0 DISCUSSION

Services provided and their utilisation

The private maternity units do offer a cross section of maternal and child health services.

The main activities are Antenatal care and conducting deliveries which is done by all the

units which were involved in the study. These services are also well attended by mothers.

This study did not cover 6 units, but the figures got still showed a very high attendance

rate for these units. It is known that the private units are more receptive to patients thus

attracting more patients. The government units could borrow a leaf from these private

practitioners. Considering that mothers still pay even higher fees than that paid in

government units, the major factors attracting more mothers to these units as was found

by Odoi et al, 1996 includes courteous services, convenience, accessibility and ready

availability of drugs.

Mothers in the community are noted to prefer using DEPO Provera as a means of

contraception. Records for condoms are not necessarily kept by the private practitioners.

Use of the records

All units had good record keeping habits and recorded their attendances in hard covered

books. Their storage habits were also good with most storing their records in cupboards.

This is as a result of the private midwives association to which they belong. It encourages

recording data as well as reporting the data to relevant authorities. This is a good starting

point for improving the reporting system. The main use of the records by these private

practitioners is connected with the proper management of their units as regards making

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profit and sustaining their businesses. Regarding that they are mostly private workers and

dependant on sustenance from the very businesses, it is understandable that they should

get their businesses running well. Use of records for compiling returns was hardly

conceived as an important reason for keeping records. One thing noted about the record

keeping is that it was not well organised. Getting information from those records was

quite a task. Infact it was also mentioned by one respondent that there was too much to

record and how to organise their recording was the main problem. The private midwives

had hardly heard of the HMIS, but they were willing to be informed about it. This could

be a major step in ensuring regular and up-to-date reporting.

Factors influencing irregular reporting to the office of the DDHS

Lack of forms for reporting was cited as a problem faced in reporting to the DDHSs

office. These forms were printed from the private midwives association but did not

include all the Reproductive Health Services as they now stand. Developing reporting

forms for these private midwives could help in facilitating a more comprehensive

reporting system for the district. Most of these units also provide laboratory and curative

services. Providing them the HMIS registers and forms would assist them in reporting

more comprehensively on the services they are offering in their units. A similar finding

was reported by the MAPS initiative report which noted that Primary Health Care service

delivery points (like private maternity homes) are incomplete without minor curative

services and immunisation capabilities. The paucity of knowledge on the HMIS by these

private midwives who serve a big number of the underserved population calls for their

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orientation on the HMIS to ensure better recording and reporting practices by these

midwives.

CHAPTER 6

6.0 CONCLUSIONS AND RECOMMENDATIONS

6.1 CONCLUSIONS

All units provide Antenatal care and delivery services while the other maternal and

child health services are not provided by all private units despite good utilisation of

the services.

The main use of data was for the management of accounts.

The private midwives had no knowledge of the HMIS.

Lack of forms for reporting was the main factor causing irregular reporting.

6.1 RECOMMENDATIONS

The owners of the private maternity homes be oriented on the HMIS.

HMIS registers and forms be provided for the private maternity homes to aid

comprehensive reporting to the office of the DDHS.

Support supervision could include the supervision of these private units as well.

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References

Manual of District Health Management for Uganda, 1995.

Ministry of Health, maternal Child Health/Family planning five year strategic plan 1997-2000.

Ministry of Health, Maternal Child Health/Family Planning Safe Motherhood strategicplan 1997-2000.

Ministry of Health, National Policy guidelines for family Planning and Maternal health

service delivery, 1992.

Population and housing census, 1991.

Uganda Demographic Health Survey, 1995.

World Health Organization (1994) Mother Baby Package: Implementing SafeMotherhood in countries.

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7.0 APPENDICES

Appendix 1: Check listUnit no.------------------ County------------------------

Service(Tick where appropriate) Attendance in1999

Attendance in2000

J F M A M J

Ante-natal Care

- New clients-Re-attendances

-Referrals

Deliveries

Post natal care

Family planning

New acceptors -Oral pills

-IUDS

-DEPO-Condomns

-Natural methods

-Foaming tablets,creams,jellies

FP Counselling with no

Acceptance

Revisitors -Oral pills

-IUDS-DEPO

-Condomns

-Natural methods

-Foaming tablets,creams,jellies

STD services

Immunization -BCG

-Polio 0-Polio 1-Polio 2

-Polio 3

-DPT 1

-DPT 2

-DPT 3

-Measles

Health education

Adolescent health services

-Counseling-Contraception

-STD services

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Number of deliveries in 1999

Number of deliveries in January 2000

Number of deliveries in February 2000

Number of deliveries in March 2000

Number of deliveries in April 2000

Number of deliveries in May 2000

Number of deliveries in June 2000

Number of still births in 1999

Number of neonatal deaths in 1999

Number of maternal deaths in 1999

Number of still births from January to June 2000

Number of neonatal deaths from January to June

2000

Number of maternal deaths from January to June

2000

Number of mothers referred for further care in 1999

Number of mothers referred for further care from

January to June 2000

Appendix 2: Questionnaire for in-charges/assistant

Number---------------------- Interviewer------------------------ Date------------------------

1. Age-----------

2. Sex------------

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3. Qualifications:

(a) Registered nurse

(b) Double trained

(c) Public health nurse

(d) Other(specify)-------------------------------

4. Years of practice?----------------

5. How long has the unit been operational;

(a) 3 years

6. How many staff work in this unit?---------------

7. What are their qualifications?----------------------------------------------------------------

8. What services do you offer in your unit?(Tick)

(a) Deliveries

(b) ANC

(c) Family planning

(d) Post-natal services

(e) STD services

(f) Other(specify)-----------------------------------------------

9. Do you have records for your patients and clients? Y/N

10. Where is the information recorded?

(a) Hard covered books

(b) Exercise books

(c) Other(specify)---------------------------------------------

11. Where do you store these records?-------------------------------

12. What do you use these records

for?--------------------------------------------------------------------------------------------------

------------------------------------------------------------------

13. Have you had any deaths in your unit? Y/N

14. What are the causes of the deaths?(Give the causes and the number of deaths against

each)-------------------------------------------------------------------------------------------------

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-------------------------------------------------------------------------------------------------------

---------------------------------------------------------------------------------------------------

15. Have you heard of the Health Management Information System(HMIS)? Y/N

16. If yes, what is/are the importance of the

system?---------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------------

-------------------------------------------------------

17. What are your views on the

HMIS?----------------------------------------------------------------------------------------------

---------------------------------------------------------------

18. Have you reported monthly since January of this year to May to the DDHSs office?

Y/N

19. If not, what are your reasons for not reporting

regularly?-------------------------------------------------------------------------------------------

-----------------------------------------------

20. Do you have standardized forms for reporting? Y/N

21. Are you supervised/ Y/N

22. Who supervises you and how often?-----------------------------------------------------------

23. What problems do you face in reporting to the DDHSs

office?-----------------------------------------------------------------------------------------------

-----------------------------------

24. What are your suggestions for improving the reporting

system?---------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------------

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field report 4.2

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