Routine health information utilization and associated factors among health care workers in Ethiopia: A systematic review and meta-analysis

Birye Dessalegn Mekonnen; Senafekesh Biruk Gebeyehu

doi:10.1371/journal.pone.0254230

. 2021 Jul 7;16(7):e0254230. doi: 10.1371/journal.pone.0254230

Routine health information utilization and associated factors among health care workers in Ethiopia: A systematic review and meta-analysis

Birye Dessalegn Mekonnen ^1,^*, Senafekesh Biruk Gebeyehu ²

Editor: Frank T Spradley³

PMCID: PMC8263267 PMID: 34234370

Abstract

Background

Utilization of routine health information plays a vital role for the effectiveness of routine and programed decisions. A proper utilization of routine health information helps to make decisions based on evidence. Considerable studies have been done on the utilization of routine health information among health workers in Ethiopia, but inconsistent findings were reported. Thus, this study was conducted to determine the pooled utilization of routine health information and to identify associated factors among health workers in Ethiopia.

Methods

Search of PubMed, HINARI, Global Health, Scopus, EMBASE, web of science, and Google Scholar was conducted to identify relevant studies from October 24, 2020 to November 18, 2020. The Newcastle-Ottawa scale tool was used to assess the quality of included studies. Two reviewers extracted the data independently using a standardized data extraction format and exported to STATA software version 11 for meta-analysis. Heterogeneity among studies was checked using Cochrane Q and I² test statistics. The pooled estimate of utilization of routine health information was executed using a random effect model.

Results

After reviewing 22924 studies, 10 studies involving 4054 health workers were included for this review and meta-analysis. The pooled estimate of routine health information utilization among health workers in Ethiopia was 57.42% (95% CI: 41.48, 73.36). Supportive supervision (AOR = 2.25; 95% CI: 1.80, 2.82), regular feedback (AOR = 2.86; 95% CI: 1.60, 5.12), availability of standard guideline (AOR = 2.53; 95% CI: 1.80, 3.58), data management knowledge (AOR = 3.04; 95% CI: 1.75, 5.29) and training on health information (AOR = 3.45; 95% CI: 1.96, 6.07) were identified factors associated with utilization of routine health information.

Conclusion

This systematic review and meta-analysis found that more than two-fifth of health workers did not use their routine health information. This study suggests the need to conduct regular supportive supervision, provision of training and capacity building, mentoring on competence of routine health information tasks, and strengthening regular feedback at all health facilities. In addition, improving the accessibility and availability of standard set of indicators is important to scale-up information use.

Background

Health information is the processed and generated data that an individual, group or institution use to support their decisions in the health care system [1]. It is essential for the entire health system by providing the right information for evidence-based health practices and improving managerial decisions [2,3].

Routine health information utilization is vital for the day-to-day patient management, disease prioritization, health education, resource allocation, and decision making as well as for the planning, monitoring, and evaluation of health care service activities [4]. A properly functioning of routine health information system helps to get the right information at the right time into the right hands, which supporting policymakers, managers, and service providers to make decisions based on evidence [5,6].

In developing countries, the utilization of routine data for decision making remains very weak mainly due to inadequate data analysis and health information systems [7,8]. Though most health care providers report routine health data, understanding the benefits of routine health information and utilization remains low in low income countries [9–11]. As a result, data usually sat on shelves, cabinets without sufficiently processed and utilized for program and policy improvements [12,13]. This leads to challenges and difficulties to the efficiency and effectiveness of health care delivery [14].

In Ethiopia, Information Revolution is one of the four transformation agendas in the Health Sector Transformation Plan (HSTP), which involves an important shift from old methods of information utilization to practical use of information [15,16]. Information Revolution, as transformation agenda sets a priority for the generation and utilization of health information [17]. In addition, the Ethiopian federal ministry of health has been incorporating new initiatives which are more comprehensive and focused on strengthening the standardization process [16]. Even with these efforts, the utilization of routine health information in Ethiopia is still a big challenge [18,19].

The identified factors that prevent utilization of routine health information including, analysis skills, organizational infrastructure and training, lack of culture of information use, lack of supervision and regular feedback, availability of human resources, knowledge, computer skill, work load, computer access, availability of guidelines and formats, and data quality [5,9,20–22]. Furthermore, a limited use of routine health data was observed in health care workers who lack training on computer software and data management [22,23].

Despite the fact utilization of routine health information is important for operational, tactical and strategic decision-making, poor data quality and limited use remain the major concerns [16]. Thus, for the effective intervention of routine health information utilization and its factors, determination of the level of utilization and identifications of associated factors is important.

In this study, literature on utilization of routine health information among health workers in Ethiopia were reviewed. However, the studies show a difference in routine health information utilization and associated factors, and to the authors knowledge, the literatures have not been examined systematically. Therefore, this systematic review and meta-analysis was aimed to estimate the pooled utilization of routine health information and to identify associated factors among health workers in Ethiopia. The findings of this meta-analysis will help for policy-makers, and other stakeholders to effectively implement different health sector strategies and programs, social and community health insurances, and health care financing. The finding from this study will also help health workers to design suitable intervention to improve evidence-based practice and to understand their routine health information utilization level.

Methods

This systematic review and meta-analysis was prepared and presented based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist (S1 Checklist).

Eligibility criteria

Original research studies reporting the utilization of routine health information and/or associated factors among health workers in Ethiopia were included in the study. Observational studies with no restrictions on publication year were considered. Both published and unpublished articles, but written only in English language were considered for inclusion. All publications reported up to November 18, 2020 were considered.

Studies that did not clearly report the utilization of routine health information among health workers in Ethiopia were excluded. In addition, articles without full text, and abstract, editorial reports, letters, reviews, and commentaries were excluded from the study.

Search strategy and information sources

A comprehensive and systematic search of literature was carried out through electronic databases including PubMed, HINARI, Global Health, Scopus, EMBASE, web of science, African journal online (AJOL), and Google Scholar from October 24, 2020 to November 18, 2020. The search was done using the following keywords and Medical Subject Headings (MeSH) terms: “utilization” OR “practice” AND “health communication” OR “health information” AND “associated factors” OR “determinants” AND “health professionals” OR “health care workers” OR “healthcare facilities” AND “Ethiopia”. The search focused on studies with epidemiological data on the utilization of routine health information and associated factors among health workers in Ethiopia.

Data extraction

After screening of titles, abstracts and the full texts of each included original studies, data were extracted using a standardized data extraction tool which was adapted from the Joanna Briggs Institute (JBI). Two reviewers (BDM & SBG) extracted the data independently, and reviewed all the included articles. Any disagreement between reviewers were resolved through discussion.

The study characteristics, such as the name of first author, study region and setting, year of publication, study design, study participants, sampling technique, data source, sample size, and response rate were extracted. Prevalence (utilization) of routine health information and risk factors with 95% confidence intervals were also extracted.

Risk of bias (quality) assessment

The quality of each original studies was assessed by using the Newcastle-Ottawa scale (NOS) tool adapted for cross-sectional studies quality assessments. The assessment tool contains three main parts. The first part of the tool has five-stars, and assesses the methodological quality of each study (i.e., sampling technique, sample size, response rate, and ascertainment of the risk factor or exposure). The second part of the tool assesses the comparability of the study with a possibility of two stars to be gained. The last component of the instrument measures the outcomes and statistical tests of the primary study with a possibility of three stars to be gained. Finally, studies included in this systematic review and meta-analysis have medium (5–6 out of 10 stars) to high quality scores (>6 out of 10 stars). Two authors (BDM & SBG) independently assessed the quality of studies included in the review. Disagreements between reviewers during quality assessment were handled through discussion.

Outcome measurement

The primary outcome measure of this meta-analysis and systematic review is utilization of routine health information. Utilization of routine health information was assessed using the Performance of Routine Information System Management (PRISM) assessment tool. It was defined as the use of routine health information for monitoring day to day health service activities, developing weekly plan, service delivery improvement, displaying updated information, drug procurement, resource mobilization, facilitating community mobilization, detecting the cause of health problem in the community, prediction of outbreaks, and disease prioritization. For this study, utilization of routine health information was computed by dividing the number of health workers who had a good level of routine health information utilization by the total number of health workers in the study (sample size) multiplied by 100. The second outcome variable of the study was to identify factors associated with utilization of routine health information among health workers in Ethiopia, which were measured in the form of the odds ratio (OR). Odds ratio was calculated for each identified factor based on the binary outcome data reported by each primary study.

Data synthesis and analysis

The data were extracted using a Microsoft Excel spreadsheet and then imported into STATA version 14 for further analysis. The primary studies were described and summarized using tables, figures, and forest plots. The pooled estimate of utilization of routine health information was executed using a random effect model with 95% confidence interval (CI). The measure of association for factors that determine utilization of routine health information among health workers was estimated using odds ratio with 95% CI. Random effect model was computed during meta-analysis as heterogeneity was exhibited among the included studies. Heterogeneity among the recorded prevalence of studies has been assessed with Cochran’s Q statistic and the I² statistics. Furthermore, subgroup analysis was done to reduce the random variations among the point estimates of the primary studies. Visual inspection of asymmetry in funnel plots, and Egger regression tests were employed to assess the existence of publication bias.

Result

Search results

A total of 22924 articles regarding the utilization of routine health information and/or associated factors among health workers in Ethiopia were retrieved. Among the total retrieved studies, 237 studies were removed due to duplication. After assessing the articles based on their titles and abstracts, 22656 articles were excluded. The remaining 31 full-text articles were assessed for eligibility criteria, which resulted in the further exclusion of 21 articles mainly because of variation in the study population and unreported outcome of interest. As a result, 10 studies were included to undergo the final meta-analysis (Fig 1).

Characteristics of the included studies

All included studies used facility based cross-sectional study design to estimate utilization of routine health information. All the studies included for this review were published from 2011 up to 2020. Five of the studies included in this review used purposive sampling technique, two used systematic random sampling, two used cluster sampling technique, and one used multi-stage sampling technique. Of the included studies, four studies used self-administered and observation, four studies used only self-administered, and two studies used interviewer-administered method to select study participants. From an estimated 4144 health care workers, a total of 4054 participants were involved with an estimated sample size range from 239 [24] up to720 [21]. The included studies reported that the utilization of routine health information among health workers ranged from 32.9% [25] to 97.1% [9]. Five of the studies included in this review were conducted from Amhara region [9,21,26–28], two were from Southern Nations Nationalities and People’s Region (SNNPR) [29,30], two were from Oromia region [25,31], and the remaining one was from Dire Dawa administrative city [24] (Table 1).

Table 1. Descriptive summary of primary studies included in the meta-analysis of utilization of routine health information and associated factors among health workers in Ethiopia, 2020.

First author, publication year	Region	Study area	Study design	Study population	Sampling technique	Data collection method	Sample size	Response rate (%)	Prevalence (%)
Asemahagn MA [27], 2017	Amhara	East Gojjam zone	IBCSS	Health Center and unit heads	Systematic random sampling	Self-administered and observation	250	100	38.4
Shiferaw AM et al [26], 2017	Amhara	East Gojjam zone	IBCSS	Health workers	Cluster sampling technique	Self-administered	668	97.8	45.7
Dagnew E et al [21], 2018	Amhara	North Gondar	IBCSS	Health care professional	Multi-stage sampling technique	Self-administered and observation	720	100	78.5
Wude H et al [29], 2020	SNNPR	Hadiya zone	IBCSS	Health workers	Systematic random sampling	Self-administered	490	98	62.7
Yitayew S et al [28], 2019	Amhara	East Gojjam zone	IBCSS	Health extension workers	Purposive sampling	Self-administered	302	100	53.3
Abajebel S et al [25], 2011	Oromia	Jimma Zone	FBCSS	Health facility and unit heads	Purposive sampling	Observation and interview	362	100	32.9
Andualem M et al [9], 2013	Amhara	Bahir dar Town	IBCSS	Health workers	Purposive sampling	Self-administered and observation	350	96.9	97.1
Shagak S et al [30], 2014	SNNPR	Gamo Gofa Zone	IBCSS	Health extension workers	Cluster sampling technique	Self-administered	457	92.1	58.2
Teklegiorgis K et al [24], 2014	Dire Dawa	Dire Dawa	FBCSS	Health facility and unit heads	Purposive sampling	Self-administered	239	100	52.7
Emiru K et al [31], 2018	Oromia	East Wollega zone	IBCSS	Health facility and unit heads	Purposive sampling	Face to face interview	306	100	54.2

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Meta-analysis

Risk of bias assessment for the included studies. The quality of each original studies was critically assessed using the Newcastle-Ottawa scale tool adapted for cross-sectional studies. From the total included studies, the quality assessment summary showed about four-fifth (n = 8, 80%) of the studies had high quality, and the reaming one-fifth (n = 2, 20%) of studies had medium quality (Table 2).

Table 2. Quality assessment of primary studies included in the meta-analysis of utilization of routine health information and associated factors among health workers in Ethiopia, 2020.

Studies ID	Selection (Maximum of five star)	Comparability (Maximum two star)	Outcome assessment (Maximum of three stars)	Overall quality
Asemahagn MA	********	*	*******	High
Shiferaw AM et al	********	**	**	High
Dagnew E et al	*****	**	**	High
Wude H et al	********	**	*******	High
Yitayew S et al	*******	*	**	Medium
Abajebel S et al	*******	*	*******	High
Andualem M et al	********	*	**	High
Shagak S et al	********	*	**	High
Teklegiorgis K et al	*******	*	**	Medium
Emiru K et al	********	**	*******	High

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Utilization of routine health information among health workers in Ethiopia

Overall, the pooled estimate of routine health information utilization among health workers in Ethiopia was 57.42% (95% CI: 41.48, 73.36). High heterogeneity across the included studies was exhibited (I² = 99.4%; p < 0.001) in estimating the pooled utilization of routine health information among health workers. Hence, to estimate the pooled prevalence of routine health information utilization among health workers, random effects model was used during meta-analysis (Fig 2).

Subgroup analysis

Subgroup analysis was carried out based on the regions where the primary studies were conducted. Accordingly, the highest routine health information utilization was observed in Amhara region with a prevalence of 62.67%(95% CI: 39.36, 85.97), and the lowest routine health information utilization was observed in Oromia region with a prevalence of 43.51%(95% CI: 22.57, 64.46) (Fig 3).

Publication bias

Visual inspection of the asymmetry in funnel plots, and Egger regression tests were employed to assess the existence of publication bias. Accordingly, the result of both funnel plots and the Egger’s tests revealed the absence of publication bias in the included studies. The result of Egger’s test was not statistically significant (p = 0.182), which declared absence of publication bias. Additionally, visual inspection of the funnel plots showed a symmetric distribution of studies (Fig 4).

Factors associated with utilization of routine health information

In this study, some of the factors associated with utilization of routine health information were pooled quantitatively and some were not due to inconsistent classification (grouping) of the independent variables with respect to the outcome (utilization of routine health information).

Six studies indicated that supportive supervision has a significant association with utilization of routine health information. The odds of routine health information utilization were 2.25 times (AOR = 2.25; 95% CI: 1.80, 2.82) higher among health care workers who received supportive supervision on routine health information when compared with those who have not received supervision. In this meta-analysis, included studies were characterized with no existence of heterogeneity (I² = 0.0%, P = 0.939). Thus, a fixed effect model analysis was used (Fig 5).

Five studies showed that regular feedback has a significant association with utilization of routine health information. Health workers who got regular feedback were 2.86 times (AOR = 2.86; 95% CI: 1.60, 5.12) more likely to use routine health information than those who did not get feedback. A random effect model was used in this meta-analysis as the included studies were characterized by existence of heterogeneity (I² = 84.3%, P <0.001) (Fig 6).

Three studies also showed that availability of standard guideline has an association with utilization of routine health information. The odds of utilization of routine health information were about 2.53 times (AOR = 2.53; 95% CI: 1.80, 3.58) higher among health workers who have standard guideline than their counterpart. A fixed effect model was used in this meta-analysis as the included studies were characterized by absence of heterogeneity (I² = 0.0%, P = 0.463) (Fig 7).

Furthermore, four studies indicated that data management knowledge has an association with utilization of routine health information. Accordingly, increased odds of good health information use were observed among health care workers who had good data management knowledge than their counterpart (AOR = 3.04; 95% CI: 1.75, 5.29). A random effect model was used in this meta-analysis as the included studies were characterized by existence of heterogeneity (I² = 76.1%, P = 0.006) (Fig 8).

Four studies indicated that training on health information has an association with utilization of routine health information. The odds of utilization of routine health information were about 3.45 times (AOR = 3.45; 95% CI: 1.96, 6.07) higher among trained health workers when compared with their counterparts. A random effect model was used in this meta-analysis as the included studies were characterized by existence of low heterogeneity (I² = 69.1%, P = 0.021) (Fig 9).

Discussion

Use of routine health information can potentially circumvent several of the structural and systemic barriers faced by health workers in delivering health care. Evidence suggests that use of routine health information for healthcare delivery is feasible for health workers irrespective of their education or prior training [32]. Thus, this systematic review and meta-analysis was conducted to estimate the pooled prevalence of routine health information utilization and associated factors among health workers in Ethiopia. Accordingly, more than two-fifth of health workers did not use their routine health information. This finding implies that the need for close monitoring and evaluation of the strategies that promoted the utilization of data generated from health care systems. Furthermore, this finding infers the need to make plans once identify performance gaps. Evidence revealed that strengthening health information system focusing on organizational structures, technical, and behavioral is one important components for improving the quality and use of data for decision making [33,34].

In this review, the pooled estimate of routine health information utilization among health workers in Ethiopia was 57.42% (95% CI: 41.48, 73.36). Even though there is no meta-analysis on this research question, the utilization of routine health information reported in the present study is consistent with other studies conducted in Uganda (59%) [35], Tanzania (58%) [36] and South Africa, (65%) [37]. However, the finding in this meta-analysis is higher than a study carried out in Cote D’Ivoire which reported the utilization of routine health information as 38% [11]. This variation might be due to differences in health information system structures and health care workers’ attitude towards routine health information utilization [38].

This meta-analysis revealed that health workers who received supportive supervision were more likely to use routine health information as compared with those who have not received supervision. This finding was supported by other studies conducted in Tanzania [36] and rural of South Africa [37]. This could be due to the fact that supportive supervision has an important role in identifying organizational, technical and behavioural gaps, and improving health workers’ performance.

This study also indicated that health workers who got regular feedback were 2.86 times more likely to use routine health information than those who did not get feedback. This finding implies the need to give due attention for all levels of health facilities in terms of regular feedback by the government [39]. Literatures also documented that regular feedback given to health workers is important to improve the utilization of routine information in health care systems [39,40].

Availability of standard guideline was another determinants of routine health information utilization. Accordingly, the odds of utilization of routine health information were about 2.53 times higher among health workers who have standard guideline than their counterpart. This finding is supported by other studies. This could be due to the fact that the presence of data sources (standard indicators, guidelines) can help health workers to utilize routine health information for evidence based decision making [41].

This study also identified that data management knowledge has an association with utilization of routine health information. Health workers who had good data management knowledge were more likely to use routine health information as compared with their counterpart. This finding is supported by other previous studies [23,42,43]. This could be due to the fact that health workers with adequate knowledge on how to process and manage health information can develop skills in their daily activities, so that they can use routine health information easily. Furthermore, health workers who have good data management knowledge can transform data into meaningful information for utilizing routine health information. An evidence from India revealed that utilization of health information depends on data analysis skills and organizational factors [44].

Furthermore, training on health information was another determinants of routine health information utilization. The odds of utilization of routine health information were about 3.45 times higher among trained health workers when compared with their counterparts. This finding is supported by other studies [23,42]. This could be due to the fact that health workers who trained on health information can have the potential to collect, compile, analyze, and utilize health information generated in the routine day-to-day activities. Moreover, workshop presentations are one of the outputs of data processing skills which will then increase health workers’ data management knowledge and utilization of routine health information.

Limitations of the study

Though this study is the first systematic review and meta-analysis about routine health information utilization among health workers in Ethiopia, it was not without limitations. In this meta-analysis, articles published only in the English language and have available full-text versions were included. The pooled odds ratio for all variables associated with routine health information utilization among health workers were not examined because the included studies classified the variables in different ways. All of the included articles were facility based cross-sectional studies which may reduce the generalizability of the finding. Furthermore, this study represented only studies reported from four regions which may affect the pooled prevalence of routine health information utilization.

Conclusion

This systematic review and meta-analysis found that more than two-fifth of health workers did not use their routine health information. Supportive supervision, regular feedback, availability of standard guideline, data management knowledge and training on health information were identified factors associated with utilization of routine health information among health workers in Ethiopia. This study suggests the need to conduct regular supportive supervision, provision of training and capacity building, mentoring on competence of routine health information tasks, and strengthening regular feedback at all health facilities with collaborative effort of policy-makers, programmers, and implementers as well as other concerned stakeholders. In addition, improving the accessibility and availability of standard set of indicators (guidelines)is important to scale-up information use.

Supporting information

S1 Checklist. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.

(DOC)

Click here for additional data file.^{(65.5KB, doc)}

Acknowledgments

The authors would like to thank the authors of the included primary studies, which used as source of information to conduct this systematic review and meta-analysis.

Abbreviations

AOR: Adjusted odd ratio
CI: Confidence intervals
PRISMA: Preferred Reporting Items for Systematic review and Meta-analysis
SNNPR: South Nation and Nationality Peoples Regional

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0254230.r001

Decision Letter 0

Frank T Spradley

11 Apr 2021

PONE-D-21-01653

Routine health information utilization and associated factors among health care workers in Ethiopia: a systematic review and meta-analysis

PLOS ONE

Dear Dr. Mekonnen,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Academic Editor

PLOS ONE

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Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1.The authors said that "Health information is the processed and generated data that an individual, group or institutions use to support their decisions in the health care system." It's still confused me about the precise definition of Routine health information utilization. Do participants only need to read patients' medical records? Or do some statistical analysis and report their conclusion?

2.How to make a quantitative assessment of the utilization of routine health information? The authors said that "computed by dividing the number of health workers who had a good level of routine health information utilization by the total number of health workers in the study (sample size) multiplied by 100." So what is the standard of "good level of routine health information utilization"? Notably, whether the standards in 10 studies included in this meta-analysis papers are consistent?

3.I noticed all identified factors associated with Routine health information utilization were personal factors. I understand that healthcare workers use this routine health information during clinical work. However, the same person in a different objective environment has a different ability to use routine health information. For instance, if I worked in a hospital with poor informatization, I might have to write medical records by hand and had poor health information utilization. In 10 studies included in this meta-analysis, differences in hospitals will be a big bias factor.

4.It is emphasized that this is the first report in Ethiopia, but what is special about routine health information utilization of healthcare workers in Ethiopia? Are there some different factors compared with other countries?

5.The authors said that "In this meta-analysis, articles published only in the English language." Why only English publication if you emphasize the first report in Ethiopia?

Reviewer #2: This paper addresses the estimated impact of factors designed to facilitate use of routine health data on the utilization of the data in Ethiopia. This paper addresses the impact of factors designed to facilitate use of routine health data in Ethiopia and indeed in all developing countries. It does this through a meta-analysis of available and relevant data. This is an important issue. Improving the utilization of routine health data for decision-making at every level of the health systems is key to developing efficient health systems, and is especially important in countries where the funding for the system is limited.

The study uses appropriate methods to search for information, to extract the data, to assess bias and to select and measure the outcomes. It is described clearly and with detail in the Methods section. I am unfamiliar with the Funnel and Forest plots so cannot comment on these.

There is an extensive review of literature on the District Health System in other African countries which provides the context for the aims and results of the present investigation.

The outcomes noted that training, supervision and support for health workers, and regular feedback is associated with improved utilization of health data. The existence of guidelines and data management training also has a positive impact. The limitations are clearly stated. The recommendations arising out of these findings should encourage health systems managers in developing countries to further implement the measures in order to make better use of their information systems.

There are many grammatical errors in the paper and it will be advisable for the authors should arrange to have these corrected.

**********

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Reviewer #1: Yes: Zhenghao Wu

Reviewer #2: No

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PLoS One. 2021 Jul 7;16(7):e0254230. doi: 10.1371/journal.pone.0254230.r002

Author response to Decision Letter 0

12 May 2021

Author’s Point-by-point response letter to reviewer

Title: Routine health information utilization and associated factors among health care workers in Ethiopia: a systematic review and meta-analysis

Authors: Birye Dessalegn Mekonnen and Senafekesh Biruk Gebeyehu

Corresponding author: Birye Dessalegn Mekonnen

Email: birye22@gmail.com

ORCID: 0000-0003-3879-1330

Teda Health Science College, Ethiopia

May, 2021

Dear, Editors of PLOS ONE

This is a point-by-point response letter that accompanies the responses for the editor and reviewers’ comments concerning the manuscript entitled ‘Routine health information utilization and associated factors among health care workers in Ethiopia: a systematic review and meta-analysis’. It is known that the manuscript has been reviewed by reviewers and sent back to authors to carry out the corrections to meet the reviewers’ concern, and resubmission.

As authors of this manuscript, the comments and concerns raised by the reviewers’ were highly insightful and enabled us to improve the quality & scientific plausibility of the manuscript. To do so, we have tried to address all the editor’s and reviewers’ concerns point by point and described below in table as per your guide. Therefore, we are pleased to resubmit the revised version of the manuscript for further process and facilitation of its publication on PLOS ONE.

Author’s Point-by-point response

Reviewers’ Comments and authors’ responses

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Authors’ response: First of all, thank you very much for constructive feedback. We correct and ensure that our manuscript meets PLOS ONE's style requirements, including those for file naming.

2. We note that you have stated that you did not include date limits on your search for articles. Yet, your search results included studies from 2011-2020. Please amend your Methods section and results to more clearly define the date range that was searched, and if applicable, explain why no studies earlier than 2011 were included.

Authors’ response: First of all, thank you very much for constructive feedback. We tried to make it clear and correct in the document. All publications reported up to November 18, 2020 were considered. However, there were no studies reported earlier than 2011. Therefore, all the included studies were published and reported from 2011-2020.

3. We note that this manuscript is a systematic review or meta-analysis; our author guidelines therefore require that you use PRISMA guidance to help improve reporting quality of this type of study. Please upload copies of the completed PRISMA checklist as Supporting Information with a file name “PRISMA checklist”.

Authors’ response: First of all, thank you very much for constructive feedback. We upload copies of the completed PRISMA checklist as Supporting Information with a file name “S1 Table” as per PLOS ONE's guidelines.

4. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Authors’ response: First of all, thank you very much for constructive feedback. We will do that as per your requirement.

5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Authors’ response: First of all, thank you very much for constructive feedback. We include captions for our Supporting Information files at the end of your manuscript.

Reviewer #1:

1. The authors said that "Health information is the processed and generated data that an individual, group or institutions use to support their decisions in the health care system." It's still confused me about the precise definition of Routine health information utilization. Do participants only need to read patients' medical records? Or do some statistical analysis and report their conclusion?

Authors’ response: Dear reviewer, first of all thank you very much for your interest for reviewing our paper, and constructive feedback. We tried to make more precise. The definition of ‘Health information’ and ‘Routine health information utilization’ is quite different. Yes, ‘Health information is the processed and generated data that an individual, group or institutions use to support their decisions in the health care system’. But, the operational definition for Routine health information utilization is included in the revised manuscript from the method section at the sub-topic of ‘outcome measure’.

Authors’ response: Dear reviewer, again thank you very much for your concern and constructive feedback. In the primary studies, utilization of routine health information was assessed using a standardized assessment tool which adapted from the Performance of Routine Information System Management (PRISM) framework tool. In this systematic review and meta-analysis, the quantitative assessment of the utilization of routine health information was computed from the reported good level of routine health information utilization in the primary studies against the total number of health workers included in the study.

Authors’ response: Dear reviewer, again thank you very much for your concern and constructive feedback. Of course, the same person in a different objective environment may have a different ability to use routine health information. This differences in hospitals may be a bias factor. This systematic review and meta-analysis computed the pooled estimate of determinants which were reported in the primary studies. However, because of primary studies have not investigated facility level factors, almost all identified factors associated with Routine health information utilization were personal factors.

Authors’ response: Dear reviewer, again thank you very much for your concern and constructive feedback. Sorry, we are not clear for the question you raised ‘what is special about routine health information utilization of healthcare workers in Ethiopia?’ In this study, identified factors associated with utilization of routine health information were also supported with other studies conducted in some other countries. However, some different factors have identified in this study compared with other countries.

5.The authors said that "In this meta-analysis, articles published only in the English language." Why only English publication if you emphasize the first report in Ethiopia?

Authors’ response: Dear reviewer, again thank you very much for your concern and constructive feedback. To the authors knowledge, this study is the first systematic review and meta-analysis about routine health information utilization among health workers in Ethiopia. Again, we don’t understand your concern that you relate ‘only English publication’ and ‘being the first report in Ethiopia’. In the study setting (Ethiopia), the possibility of studies conducted and reported in the English language is very less likely. Moreover, if it isn’t more necessary to state it as limitation of study we can remove it.

Reviewer #2:

This paper addresses the estimated impact of factors designed to facilitate use of routine health data on the utilization of the data in Ethiopia. This paper addresses the impact of factors designed to facilitate use of routine health data in Ethiopia and indeed in all developing countries. It does this through a meta-analysis of available and relevant data. This is an important issue. Improving the utilization of routine health data for decision-making at every level of the health systems is key to developing efficient health systems, and is especially important in countries where the funding for the system is limited.

Authors’ response: Dear reviewer, first of all thank you very much for your interest for reviewing our paper, and constructive feedback. We appreciate your insight regarding our paper.

Authors’ response: Dear reviewer, again thank you very much for your concern and insight.

There is an extensive review of literature on the District Health System in other African countries which provides the context for the aims and results of the present investigation.

Authors’ response: Dear reviewer, again thank you very much for your concern and insight.

Authors’ response: Dear reviewer, again thank you very much for your concern and constructive feedback. We really appreciate the way you see and understand the full manuscript.

There are many grammatical errors in the paper and it will be advisable for the authors should arrange to have these corrected.

Author’s response: Dear reviewer, again thank you very much for your constructive feedback and concern. We accept and tried to modify it in the manuscript. We made grammatical corrections as per your concern.

I look forward to hear from you at your earliest convenience.

Birye Dessalegn Mekonnen (MPH in Reproductive and Child Health)

Corresponding author

PLoS One. doi: 10.1371/journal.pone.0254230.r003

Decision Letter 1

Frank T Spradley

8 Jun 2021

PONE-D-21-01653R1

Routine health information utilization and associated factors among health care workers in Ethiopia: a systematic review and meta-analysis

PLOS ONE

Dear Dr. Mekonnen,

The reviewer still has some comments that must be addressed. Notably, the authors must contact a copyeditor to proof the English grammar and syntax prior to resubmitting this manuscript.

Please submit your revised manuscript by Jul 23 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'

We look forward to receiving your revised manuscript.

Kind regards,

Frank T. Spradley

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: No

**********

6. Review Comments to the Author

Reviewer #2: The article still contains many minor grammatical errors. For example, In the first sentence of the Introduction the authors state "Health information is the processed and generated data that an individual, group or institutionS use . . " mixing singular and plural amongst the nouns and verbs. While the meaning is clear the format is incorrect. Other examples: "A proper[ly] functioning health information system" and " "data usually sat in [on] the shelves. These minor errors do not affect the meaning of the article, but because PLOS does not copy-edit articles it is important the the authors attend to this aspect of presentation.

In my view the authors have responded adequately to the other comments from the reviewers. The findings from this meta-analysis of 10 studies in Ethiopia show that very simple measures such as good training of health workers, supportive supervision and regular feedback can improve the uptake of routine health data substantially. The problem of poor uptake of information is a common one in developing countries and the authors point to similar findings in several African countries. The article is timely, not only for African health systems, but globally. The COVID-19 pandemic has made us all aware that health systems across the world are interdependent, and should all function efficiently in order to contain communicable diseases which may spread from country to country. I would therefore urge the authors to attend to the copy-editing problem so as not to delay publication.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

PLoS One. 2021 Jul 7;16(7):e0254230. doi: 10.1371/journal.pone.0254230.r004

Author response to Decision Letter 1

16 Jun 2021

Author’s Point-by-point response letter to reviewer

Title: Routine health information utilization and associated factors among health care workers in Ethiopia: a systematic review and meta-analysis

Authors: Birye Dessalegn Mekonnen and Senafekesh Biruk Gebeyehu

Corresponding author: Birye Dessalegn Mekonnen

Email: birye22@gmail.com

ORCID: 0000-0003-3879-1330

Teda Health Science College, Ethiopia

June, 2021

Dear, Editors of PLOS ONE

Author’s Point-by-point response

Reviewers’ Comments and authors’ responses

Editor’s concern 1:

The reviewer still has some comments that must be addressed. Notably, the authors must contact a copyeditor to proof the English grammar and syntax prior to resubmitting this manuscript.

Author’s response: Dear Editor, first of all thank you very much for your constructive feedback and concern. We have carefully review and made some amendments to the grammatical structure of the manuscript. We have also invited English language expertise to review this manuscript, and they made some corrections. Thus, we made grammatical corrections as per your concern.

Additional Editor Comments (if provided):

Author’s response: Dear Editor, again thank you very much for your concern. We have checked our reference list to ensure that it is complete and correct. We haven’t cited papers that have been retracted. Thus, we didn’t make any change in the reference list.

Reviewer #2:

The article still contains many minor grammatical errors. For example, In the first sentence of the Introduction the authors state "Health information is the processed and generated data that an individual, group or institutionS use . . " mixing singular and plural amongst the nouns and verbs. While the meaning is clear the format is incorrect. Other examples: "A proper[ly] functioning health information system" and " "data usually sat in [on] the shelves. These minor errors do not affect the meaning of the article, but because PLOS does not copy-edit articles it is important the the authors attend to this aspect of presentation.

Authors’ response: Dear reviewer, thank you very much for your interest for reviewing our paper, and constructive feedback. We accept your concern and tried to made some modification in the manuscript. We have carefully review and made some amendments to the grammatical structure of the manuscript as per your concern.

Authors’ response: Dear reviewer, again thank you very much for your interest for reviewing our paper, and constructive feedback.

I look forward to hear from you at your earliest convenience.

Birye Dessalegn Mekonnen (MPH in Reproductive and Child Health)

Corresponding author

PLoS One. doi: 10.1371/journal.pone.0254230.r005

Decision Letter 2

Frank T Spradley

23 Jun 2021

Routine health information utilization and associated factors among health care workers in Ethiopia: a systematic review and meta-analysis

PONE-D-21-01653R2

Dear Dr. Mekonnen,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Frank T. Spradley

Academic Editor

PLOS ONE

PLoS One. doi: 10.1371/journal.pone.0254230.r006

Acceptance letter

Frank T Spradley

25 Jun 2021

PONE-D-21-01653R2

Routine health information utilization and associated factors among health care workers in Ethiopia: a systematic review and meta-analysis

Dear Dr. Mekonnen:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Frank T. Spradley

Academic Editor

PLOS ONE

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Routine health information utilization and associated factors among health care workers in Ethiopia: A systematic review and meta-analysis

Birye Dessalegn Mekonnen

Senafekesh Biruk Gebeyehu

Roles

Abstract

Background

Methods

Results

Conclusion

Background

Methods

Eligibility criteria

Search strategy and information sources

Data extraction

Risk of bias (quality) assessment

Outcome measurement

Data synthesis and analysis

Result

Search results

Fig 1. Flow chart of study selection for systematic review and meta-analysis of utilization of routine health information and associated factors among health workers in Ethiopia, 2020.

Characteristics of the included studies

Table 1. Descriptive summary of primary studies included in the meta-analysis of utilization of routine health information and associated factors among health workers in Ethiopia, 2020.

Meta-analysis

Table 2. Quality assessment of primary studies included in the meta-analysis of utilization of routine health information and associated factors among health workers in Ethiopia, 2020.

Utilization of routine health information among health workers in Ethiopia

Fig 2. Forest plot of the pooled utilization of routine health information among health workers in Ethiopia, 2020.

Subgroup analysis

Fig 3. Subgroup analysis (by region) of studies included in meta-analysis on utilization of routine health information among health workers in Ethiopia, 2020.

Publication bias

Fig 4. Graphic representation of publication bias using funnel plots of all included studies, 2020.

Factors associated with utilization of routine health information

Fig 5. Forest plot showing the pooled odds ratio of the association between supportive supervision and utilization of routine health information health workers in Ethiopia, 2020.

Fig 6. Forest plot showing the pooled odds ratio of the association between regular feedback and utilization of routine health information health workers in Ethiopia, 2020.

Fig 7. Forest plot showing the pooled odds ratio of the association between availability of standard guideline and utilization of routine health information health workers in Ethiopia, 2020.

Fig 8. Forest plot showing the pooled odds ratio of the association between data management knowledge and utilization of routine health information health workers in Ethiopia, 2020.

Fig 9. Forest plot showing the pooled odds ratio of the association between training on health information and utilization of routine health information health workers in Ethiopia, 2020.

Discussion

Limitations of the study

Conclusion

Supporting information

Acknowledgments

Abbreviations

Data Availability

Funding Statement

References

Decision Letter 0

Frank T Spradley

Roles

Author response to Decision Letter 0

Decision Letter 1

Frank T Spradley

Roles

Author response to Decision Letter 1

Decision Letter 2

Frank T Spradley

Roles

Acceptance letter

Frank T Spradley

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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