Chapter 1

INTRODUCTION

Background of the Study

The health status and conditions of the mothers and their children become a

center of attention of scholars and policy-makers across the globe. Various literatures

reported that these two are taken as important parameters of a country or a regions

mechanism to improve its human development and quality of life indices. Although

the reviews have furthered knowledge by identifying factors thought to influence

implementation processes and their outcomes, the underlying mechanisms at work

have not been well characterized or explained. More so, as the call towards faster

and more reliable reporting mechanisms are obliged to expedite results, e-health

programs and systems are required.

Globally, the central role of mother and child health has been recognized as a

crucial part of the Medium-Term Development Goals (United Nations Childrens

Fund, 2010). Accordingly, children of parents with at least a basic education are more

likely to survive after the age of five because educated parents, particularly mothers,

have been reportedly shown to make better use of available health services and

provide greater quality care to their children. In the context of Europe, it has been

discovered that methodologies used in developing the said project lessen the time in

decision-making. Information and communication technology (ICT) in health

recognizes the impact in the quality, access and efficacy of healthcare (Jan, 2010). In
some first world countries like Europe and US are embracing innovative ICTs to

enable better cures and better means for early detection of diseases.

In the Philippines, two main challenges of todays health system are access to

health care services, and access to real time information for decision making. At

present, 70% of the population living in rural areas are still struggling with no or

limited access to quality inpatient and outpatient care services. Recent health

demographics studies showed that the segmented distribution of the health facilities

and healthcare providers contribute largely to this alarming situation as exemplified

by the fact that only 13% of healthcare providers and 40% of tertiary hospitals are

situated in non-urban areas; let alone that on the average, the time it takes to travel

to a local health facility usually takes around 39 minutes. Together with the national

development plans, government-wide ICT plans, assessments of ICT programs and

health information systems, and priorities of the health sector, the DOH has updated

its e-health framework to support Universal Health Care. It sets the health program

goals, strategies, performance indicators and targets for the health sector to achieve

Universal Health Care by 2016, or transport the health sector to its desired outcomes

or results.

It is estimated that for every maternal death there is at least 20 to 30 other

women who suffer from serious complications, some of which are life-long. Maternal

health conditions are the leading causes of burden of disease among women. Due to

these reasons, monitoring and evaluation system in health programs play a crucial

role in addressing the issue of maternal, newborn and child health and nutrition for

the Philippines to achieve Millennium Development Goals 4 (Reduce child mortality)

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and 5 (Improve maternal health) (Marcelo et al., 2011). Specifically, the Cardinal

Santos Medical Center (CSMC) in San Juan City encounters a more complicated but

challenging experience about using the technology of internet in terms of health. The

implementation of the e-health in the hospital is by means of WiFi connectivity. Thus,

the perception of most establishments offering free WiFi connectivity to its patrons is

considered the use of technology as its step to the exploration and satisfaction on the

need of the clinical equipment. Through this, the use of technology was able to break

the barrier in terms of healthcare offerings, such as improvement in patients safety,

delivering better services and increase employees productivity. The experience of the

CSMC may lead to the continuing study of the performance of technology in the field

of health sector (Tuazon, 2011).

In Davao del Sur, particularly in Digos City, the need to effectively and easily

monitor the maternal, neonatal and child health and nutritional status in an electronic

platform that would serve to integrate, analyze, and display geographic and spatial

information of the mothers and children to further determine which are considered in

the critical level in terms of health and nutrition for easier monitoring and intervention.

As cited by Sobejana (2014), an e-health system would be equally imperative in

allowing the formulation of appropriate decision-making concerning maternal and

child health and nutritional monitoring such that it will provide collated statistics of

which area is critical or not in a given time. However, the study was not able to

address the concerns of each of the barangay in the City of Digos as to its

preparedness to implement any electronic means of health system that would monitor

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the status of the maternal and child health and nutrition such that it is somewhat new

as to its implementation (Apao, Noran&Villamor, 2013).

In light of the foregoing problems, it is noteworthy to assess the preparedness

of the barangay health centers in Digos City with regards to a proposed

implementation to have an electronic health care system for maternal and child

health and nutrition. The study will gauge into the gap between the needs of the

barangays with regards to maternal and child health and nutrition and benchmark

with its current state of preparedness. This gap between the needs of barangays with

regards to maternal and child nutrition and its current state of preparedness to

implement an e-health system pose significant problems that need to be addressed

to achieve the Millennium Development Goals. Thus, this study is proposed.

Review of Related Literature

This section includes the review of related literature, theoretical basis, and

conceptual framework, which pertains to the preparedness of health centers relative

to having an electronic health system for monitoring maternal and child nutrition.

Maternal Health and Nutrition

The growing interest in the quality of maternal health services over the last

decade has emanated from a concern with the high levels of maternal mortality and

morbidity in developing countries. Health professionals and organizations working in

4
the developing world are now actively seeking more effective ways to prevent

maternal deaths and improve womens health care.

While most births in industrialized countries happen in a hospital setting, the

percentage is the highest in the United States. According to Blocks (2012)

introduction to her book Pushed The Painful Truth about Childbirth and Modern

Maternity Care, 99% of women give birth in a hospital. Comparatively, 20 to 30

percent of all births in the Netherlands are homebirths with almost no medical

intervention (Block, 2012). He describes how, while hospitalization is the norm for

laboring women.

Recently, it was reported that the health of a pregnant woman is influenced by

a multitude of factors, some of which are within her control, and many of which are

not. Positive health practices are those behaviors a woman engages in while

pregnant to optimize maternal and fetal health. These health promoting practices can

have positive effects by decreasing risk factors for poor outcomes including low birth

weight, prematurity, congenital abnormalities, or the development of gestational

diabetes (US Department of Health and Human Services, 2010). Certain modifiable

maternal behaviors and experiences during pregnancy are associated with adverse

health outcomes for the mother and her infant (e. g. smoking, substance abuse, poor

nutritional intake), however; what influences a woman to maintain favorable health

practices during pregnancy is not fully understood.

Likewise, the World Health Organization (2011) published a fact sheet, quoting

that maternal mortality is a prevalent problem particularly in developing countries.

This has given rise to the United Nations agency for health, World Health

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Organization setting a millennium development goal on achieving maternal health by

2015.The two targets for assessing this Millennium Development Goal (MDG) 5 are

reducing the maternal mortality ratio (MMR) by three quarters between 1990 and

2015 levels and achieving universal access to reproductive health by 2015.

The high number of maternal deaths in some areas of the world reflects

inequities in access to health services, and highlights the gap between rich and poor.

There are also large disparities within countries, between people with high and low

income and between people living in rural and urban areas (Salomon et al., 2013).

A woman's physical and emotional health is associated with both health

practices during pregnancy as well as infant outcomes. The associations between

gestational diabetes, obesity, and preeclampsia as contributing factors to adverse

pregnancy and birth outcomes have been well established in the literature (Inamura,

et al., 2012; Diaz, et al., 2015). Furthermore, the recent Healthy People 2010 mid-

course report (US Department of Health and Human Services, 2010) indicates that

racial disparities in these areas are increasing, yet the reasons remain largely

unexplained. The consequences of poor emotional health during pregnancy include

poor maternal-fetal attachment yet the mechanism of how poor maternal emotional

health contributes to both maternal-fetal attachment as well as health practices

during pregnancy in ethnic minorities has been largely overlooked.

Likewise, recent studies indicate that psychological stress plays a possible

role in adverse birth outcomes. While credible biological pathways linking stress and

preterm birth exist, the role that poor emotional health plays in preterm birth has not

been fully elucidated. Thus, it is imperative to assess a woman's emotional health

6
when trying to illuminate its role in maternal-fetal health, health practices during

pregnancy, and ultimately, neonatal outcomes (Harville, et al., 2010).

Wilkinson (2011) mentioned that women living in poverty-stricken areas are

more likely to be obese and engage in unhealthy behaviors such as cigarette

smoking and drug use, are less likely to engage in or even have access to legitimate

prenatal care, and are at a significantly higher risk for adverse outcomes for both the

mother and child. A study conducted in Kenya observed that common maternal

health problems in poverty-stricken areas include hemorrhaging, anemia,

hypertension, malaria, placenta retention, premature labor, prolonged/complicated

labor, and pre-eclampsia.

In contrast, Rogan and Olvea quoted by Sobejana (2014) noted that the

dangers of childbearing can be greatly reduced if a woman is healthy and well

nourished before becoming pregnant, if she has a health checkup by a trained health

worker during her pregnancy, and if a skilled birth attendant assists the birth. The

woman should also be checked during the 12 hours after delivery until six weeks

after giving birth.

Rogan and Olvea cited by Diaz and colleagues (2015) furthered that the

maternity care aims to ensure that every expectant and nursing mother maintain

good health, learns the art of child care, has normal delivery and bears healthy

children. Maternal health care begins from the time of conception of the child,

therefore, the pre and postnatal care of the expectant mother is included in the health

care system. The prenatal care ensures that the health of expectant mothers more

especially their nutritional status is safe guarded and avoidable complications of

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pregnancy are prevented or treated. The natal care also includes the care for

expectant mothers during childbirth, preferably by a trained health worker or a doctor.

The postnatal care covers maternal health care services after delivery.

Sobejana (2014), in his dissertation, mentioned that maternal deaths are

caused by factors attributable to pregnancy, childbirth and poor quality of health

services. Newborn deaths are related to the same issues and occur mostly during the

first week of life. Child health depends heavily on availability of and access to

immunizations, quality management of childhood illnesses and proper nutrition.

Improving access to quality health services for the mother, newborn and child

requires evidence-based and goal-oriented health and social policies and

interventions that are informed by best practices.

Maternal care practices vary in healthcare settings. Certain intrapartum care

practices that have been proven without benefit are still being routinely done. Among

these are the use of enemas, shaving the perineum, withholding food and drink

during labor, routine insertion of intravenous fluids and routine episiotomy. Also,

practices which have been proven to be beneficial such as the use of the WHO

partograph to monitor labor, allowing position of choice during labor, allowing a

companion of choice during labor, and the use of oxytocin in the active management

of the third stage of labor are under-implemented by health professionals in the

majority of government and privately owned health facilities (Thomas, et al., 2012;

Navales, et al., 2015).

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Child Health and Nutrition

Newborn health and survival depend on the care given to the newborn,

although newborn care is a very essential element in reducing child mortality, it often

receives less than optimum attention. There have been agreements to affirm the

worlds commitment to improving newborn health. Current global evaluations confirm

that commitment to improving newborn health makes meaningful socio-economic

contributions (Patil & Metgud, 2013). Various reasons can be attributed to why the

health of the newborn has been neglected despite the huge mortality rates and why

most neonatal deaths are unseen and undocumented.

The World Health Organization (WHO) stressed the need to focus more

on the most vulnerable children: the newborns. Many conditions resulting in newborn

deaths can either be prevented or treated using low-cost interventions. There is the

need for a combined approach to the mother and her baby during pregnancy, to have

someone with knowledge and the skills with her during child birth and effective care

for both mother and baby after birth (WHO as cited by Sobejana, 2014).

Diaz and colleagues (2015) cited Tinker and Ransom (2011)who

mentioned that, though newborn health is closely related to that of their mothers,

newborns have a unique need that must be addressed in the context of maternal and

child health services. They further argued that millions of newborn deaths could be

avoided if more resources were invested in proven low-cost interventions designed to

address newborn needs.

Alhusen and colleagues (2011) revealed that low birth weight is a major

public health problem in the United States contributing substantially both to infant

9
mortality and adverse childhood outcomes. Unfortunately, many of the known risk

factors associated with low birth weight, such as socioeconomic status, ethnicity,

genetic makeup, and obstetric history are not within a woman's immediate control.

According to UNICEF (2013), the last decade has seen a large increase in

death among young children due to HIV/AIDS contracted from their parents,

especially in countries where poverty is high and education levels are low (Toure and

colleagues, 2013). Although several preventative measures do exist, cost and

infrastructure are two central problems that international organizations and health

agencies find when trying to implement solutions to the problem of mother-to-child

HIV transmission in developing countries. Having HIV/AIDS while pregnant can also

cause heightened health risks for the mother. A large concern for HIV-positive

pregnant women is the risk of contracting tuberculosis (TB) and/or malaria, in

developing countries.

Yamey (2011) verbalized that in the context of mother and child nutrition,

gestational weight gain should typically fall between 11-20 pounds in order to improve

outcomes for both mother and child. For mothers who just delivered their newborn,

increased rates of hypertension, diabetes, respiratory complications, and infections

are prevalent in cases of maternal obesity and can have detrimental effects on

pregnancy outcomes (Luomaranta, 2014).Obesity is an extremely strong risk factor

for gestational diabetes. Research has found that obese mothers who lose weight (at

least 10 pounds) in-between pregnancies reduce the risk of gestational diabetes

during their next pregnancy, whereas mothers who gain weight actually increase their

risk.

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 However, Usta and Balk (2012) argued that there are many actions a

woman can take to reduce her chances of adverse infant outcomes. Health care

practices, such as cigarette smoking, use of other drugs, and nutrition, play an

important role in determining fetal growth.

This study examined the influence of maternal physical and emotional health

on neonatal outcomes.

Electronic Maternal, Neonatal and Child Health and Nutrition (MNCHN)

Maternal, newborn and child outcomes are interdependent; maternal morbidity

and mortality impacts neonatal and under-five survival, growth and development.

Thus service demand and provision for mothers, newborns and children are closely

interlinked. Integration of MNCH services demands reorganization and reorientation

of components of the health systems to ensure delivery of a set of essential

interventions for women, newborns and children. A focus on the continuum of care

replaces competing calls for mother or child, with a focus on high coverage of

effective interventions and integrated MNCH service packages as well as other key

programs such as Safe Motherhood (SM), Family Planning (FP), Prevention of

Mother to Child Transmission (PMTCT) of HIV, Malaria, Expanded Program of

Immunization (EPI), Integrated Management of Childhood Illnesses (IMCI),

Adolescent Health and Nutrition. Sustained investment and systematic phased scale

up of essential MNCH interventions integrated in the continuum of care are required

(Lawn & Kerber, 2013).

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 There is strong evidence of the effects and potential of information systems in

maternal and child nutrition interventions. According to several reports from several

countries, there are rapid and significant improvements in health services indicators

and health outcomes that can be achieved. Considerable experience has been

gained in implementing (parts of) the package of interventions for maternal, neonatal

and child health and nutrition. Implementation has involved unique combinations and

sequencing of health system actions policies and advocacy, planning, involving

communities, enrolling other sectors, programming including piloting, training and

support, strengthening supplies, simplifying information systems, and monitoring and

documenting progress.

The WHO Global Observatory for e-Health (2013) cited that the use among

health-care workers and patients themselves is gaining momentum. At the same

time, governments are steadily moving towards ICT-based integrated health

information systems, and adopting e-Health policies. Since 2012, at least seven more

countries have adopted an e-Health strategy. The National e-Health Strategy Toolkit,

developed and published jointly by WHO and the ITU, has quickly become an

invaluable guide for all countries. The ability of people in general, together with

health-care professionals and policy-makers, to make better-informed decisions has

been transformed by ICT-enabled solutions. These trends are set to continue in the

coming years and to have profound effects on people at all levels.

The study of Navales and colleagues (2015) quoted the use of an information

system in the Ministry of Health and Family Welfare in Bangladesh, which have been

maintaining hierarchical reporting system called Management Information System

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(MIS). Prior to that, a statistics compilation unit called 'Service Statistics Cell (SSC)'

was founded in early 1975. During the Third Five Year Plan period the concept of

SSC was abandoned and its resources were placed under the new project titled

Strengthening of MIS unit' with a goal for establishing a regular system of data

collection and analysis of performance statistics received from all over the country.

Accordingly, MIS began to collect the service statistics on contraceptive service

delivery, particularly distribution of oral pills, condoms and a number of sterilizations

performed and IUD inserted, and produce monthly report from the year 1980 Up to

1989, different initiatives were taken to establish a regular system of data collection

and reporting through Directorate of Family Planning (DFP) and Directorate General

of Health Services (DGHS). Since then two separate streams of information systems

has been running by the two directorates.

Zimbiri, Kapito and Jesman(2014) reported that there was limited use of

treatment protocols by health care workersagainst high number of patients that need

care. Likewise, they mentioned that among other issues and concerns were non-

systematic continuity of care (loss of patient records, multiple use of health

passports), inadequate patient information for health care workers to make informed

decisions about patient's health status, lack of systematic and ease of documentation

of reported births at health facilities, and poor health care access and services.

The International Communications Union (2010) reported that through mobile

health (m-Health), or the use of wireless information and communication devices like

mobile phones and smartphones, and mobilephone networks for health, not only can

frontline health workers carry tools loaded with protocols, but captured data can also

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flow through a health system in real-time and deliver critical information to support

womens and providers needs in a timely and efficient manner. Additionally,

combining mobile technologies with existing health system resources offers

opportunities in stimulating demand for available services and expanding access to

effective and already existing programs through growing mobile phone networks,

both of which can lead to higher levels of efficiency in service delivery, supervision,

and management practices.

Alam (2012) reported that a workable information system is one of the

essential programmatic needs for the Health, Nutrition and Population (HNP) sector

programs in Bangladesh. At present, Ministry of Health and Family Welfare is

maintaining hierarchical reporting system called Management Information System

(MIS) for assessing, evaluating and monitoring its health, nutrition and population

sector programs. In response to the needs for evidence-based decision making and

enabling the system to deliver timely reliable information to the planners, managers

and professionals, government has taken significant initiatives for improvement of

information systems at all levels of the sector.

However, Alam (2012) warned that the bifurcated structure in the Ministry of

Health and Family Welfare (MOHFW), adequate and timely monitoring of sector

performance is not yet a reality and the culture of using information for decision-

making has not yet taken roots. Duplication of services, delay in placing manpower,

equipment, among others, still reduces the possibility to make facilities fully

functional. Insufficient coordination between various sub-sectors in health, population

and nutrition resulted in duplication, wastage and missed opportunities both at the

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top as well as at the operational level. Though MOHFW has been in the process of

developing a routine data system, it has been severely criticized for its narrow

coverage, faulty output, and underutilization of data.

Issues in Using e-Health System for Maternal and Child Health and Nutrition

Non-existence of an appropriate system (or availability) and consequences are

the factors that led the researcher to this topic. Many things are needed for

consideration, and as an information technology practitioner, there is a need to

identify these factors.

In the Philippines, promotion, information and constant monitoring, as reported

by the Department of Health (DOH, 2011) in the Philippines are crucial factors to be

considered in effectively monitoring health and nutritional status of women and their

children. One tasking challenge is the monitoring of the adequacy and

appropriateness of drugs, supplies including family planning commodities,

micronutrient, vaccines and the like is critical in the provision of services.

In addition, the DOH-MNCHN Manual of Operations (2011) similarly noted that

for MNCHN, to be fully-received and implemented, needs for setting-up and

maintenance of a logistics management and information system that would forecast

requirement of all LGUs in the locality; facilitate procurement from reliable suppliers;

15
distribute drugs, commodities and supplies to all LGUs following standards in cold

chain maintenance, and the like; maintain an inventory management to monitor

availability of drugs, commodities and supplies; and develop a logistics management

information system that would guide LGUs in planning for next cycle of procurement.

The DOH has been providing and can provide drugs, commodities and other supplies

to the LGUs. It is therefore important to coordinate with DOH on the availability of

stocks and provide feedback on the distribution of goods to clients to allow DOH to

plan its support to LGUs (DOHMNCHN Strategy Manual of Operations, 2011).

San Vicente (2013) reported that in the context of the Province of Samar, even

with sound plans and budgets, evidence is only one factor influencing investments in

health. Political considerations at a local level and issues related to decentralization,

influence prioritization and implementation of plans. In addition to the strengthening of

capacity at local level, a parallel process at a higher level of government to relieve

fund channeling and coordination issues is critical for any evidence-based planning

approach to have a significant impact on health service delivery

Soto et al. (2014) likewise found that community-based strategies have been

considered for rural populations served predominantly by public providers, but this

analysis suggests that the scaling-up of maternal, newborn, and child health services

requires health system interventions focused on 'getting the basics right'. These

include upgrading or building facilities, training and redistribution of staff, better

supervision, and strengthening the procurement of essential commodities. Some of

16
these strategies involve substantial early capital expenditure in remote and sparsely

populated districts.

Theoretical Framework

This study primarily anchors on the Activity Theory of Morf and Weber (2000).

Activity theory is a conceptual framework based on the idea that activity is primary,

that doing precedes thinking; that goals, images, cognitive models, intentions, and

abstract notions like definition and determinant grow out of people doing things.

Activity Theory uses the whole work activity as the unit of analysis, where the activity

is broken into the analytical components of subject, tool and object. The subject is the

person being studied, the object is the intended activity, and the tool is the mediating

device by which the action is executed (Hasan, 1998).

In addition, the MNCH strategy is based on a theory of change of Graham,

McCaw-Binns and Munjanja (2013), which charts a pathway towards impact on

maternal and neonatal survival. Both supply and demand are critical, as is a policy

environment which supports program effectiveness. The theory includes initiatives

which work across the continuum from discovery and development of tools and

technologies to the implementation of delivery strategies that lead to high, equitable,

and cost-effective coverage of key interventions.

In addition to the Activity Theory, the Web-to-Public Knowledge Transfer Model

(WPKTM), is an e-health technique to guide the development of health websites (Van

Zyl&Dartnall, 2010).It addresses the need to identify an audience, establish what

17
information would be relevant and required, classification of health information

according to health literacy levels, and highlighting relevance of new knowledge while

avoiding information overload and encouraging utilization. The model is indeed

suitable such that preparedness towards the implementation of the system is first

initiated with planning and assessment of needs of the respondents.

Contextualizing the theories in the current study, this shows that preparedness

of health centers in Digos City is a set of activities, where the respondent midwives,

barangay health workers, nurses and health volunteers are the persons being

studied, the monitoring of maternal and child nutrition is the intended activity, and

thee-health system is the mediating device by which the action is executed.

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Conceptual Framework

Input Process Output

Preparedness Level
of Health Centers in
Implementing e-
Health System

Logistic Support
System Capabilities Survey Needs
Training Data Analysis Assessment
Work Needs Met Key Informant Program
IT Capability of Interviews (KII)
Personnel

Figure 1.Research Paradigm

Figure 1 show the input, process and output variables of the study. The input

variable is the level of preparedness of the respondents on the e-health program in

monitoring maternal, neonatal and child nutrition, while the process involves survey,

19
data analysis and field interviews and focus-group discussions. A needs assessment

program will thus be the output of this work.

Statement of the Problem

The study sought the level of preparedness of Digos City health centers for an

e-health system in monitoring maternal and child nutrition.

Specifically, this study seeks to provide answers to the following questions:

1. What is the level of preparedness of the respondents for an e-health system

in addressing maternal and child nutrition in terms of:

1.1 Logistic Support

1.2 System Capabilities

1.3 Training

1.4 Work Needs Met

1.5 IT Capability of Personnel

2. What are the challenges and opportunities perceived by the midwives that

can be contributory in the implementation of an e-health system in maternal and child

health and nutrition monitoring?

3. What needs assessment program can be developed?

Definition of Terms

Operational definitions for the terms used are presented below for clarity and

better understanding of the readers.

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 Community Health Workers. This refers to personnel in-charge stationed in

the barangay health centers, who are also tasked in monitoring maternal, neonatal

and child health and nutrition.

E-health System. This refers to the transfer of health resources and health

care by electronic means. It encompasses the delivery of health information, for

health professionals and health consumers, through the Internet and

telecommunications, using the power of IT and e-commerce to improve public health

services, e.g. through the education and training of health workers, and the use of

best electronic practices in health systems management.

IT Capability of Personnel. This refers to the competency and capability of

the personnel in using the system as well as its specifications. It also includes their

technical know-how in using the software and hardware components of the e-health

system, as contextualized in this study.

Logistic Support. This refers to the amount of personnel and material support

in using the e-health system in monitoring maternal and child nutrition to address its

difficulty and the need for continuous training.

System Capabilities. This refers to the ability for the e-health system in

monitoring maternal and child nutrition to increase productivity, reliability, meeting

work need and ease of usage.

Training. This refers to the assurance of teaching and imparting knowledge on

the use of the e-health system in monitoring maternal and child nutrition.

Work Needs Met. This refers to the quality, time and cost of accomplishing

the work done using the e-health system in monitoring maternal and child nutrition.

21
Significance of the Study

The outcome of this research will benefit the following sectors:

Department of Health. The study is essential for the said office since the

results could be a strong and additional basis in the improvement and funding of the

implementation of e-health system(s), by which purpose is to effectively and

efficiently monitor maternal and child health and nutrition status per barangay.

Digos City Health Office. The study will benefit the City Health Office since it

will aid in the monitoring and evaluation of the need to implement an e-health system

to monitor the nutritional conditions of both mothers and children. The study will

support in the decision-making of the City Health Office as well as the Chairperson of

the Committee on Health and Nutrition in order to mitigate problems on malnutrition

among the mothers and their children in the barangays under Digos City.

Mothers. This study will provide them insights on the importance of evaluating

the preparedness of having an e-health system in monitoring maternal and child

nutrition. When a proper e-health systems were implemented. Access to the services

of the health centers will not be difficult or a burden for them.

Community Health Workers. The system will provide community health

workers the ease in doing their work relative to the maternal and child nutrition

monitoring. The study can give way for the local government to appropriate funding in

establishing an e-health system that can improve the services of the community

health workers (doctors, nurses, midwives, barangay health workers) to its

constituents.

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 Future Researchers. This study will become one of the bases of future

researchers in terms of expanding the knowledge and study on the e-health systems

that are useful in monitoring maternal and child nutrition.

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Chapter 2

METHODOLOGY

In this chapter, the researcher presented the research design, setting,

participants, instruments, data-gathering procedure, statistical tools that were

employed, and the scope and limitations of the study.

Research Design

This study used the mixed method design, which means that both quantitative

and qualitative research designs were used to address the problems of the study.

Mixed research method involves collecting, analyzing, and mixing both quantitative

and qualitative research and methods in a single study to understand a research

problem (Creswell, 2012). It is also said that mixed method research provides a

better understanding of your research problem than either quantitative or qualitative

research design can do alone.

In this study, quantitative research design was applied in the manner of survey

to obtain data that seeks to describe the variables as to the level of preparedness of

the health centers in Digos City for an e-health system in monitoring maternal and

child nutrition. Qualitative research design was also applied in the sense that the

researcher relies on the views of participants by asking broad, general questions

regarding the insights and perceptions on the implementation of an e-health system

in the barangay health centers, describing and analyzing the gathered responses for

24
themes, and conducting the inquiry in a subjective, biased manner which brackets

out the personal viewpoints of the researcher. The use of in-depth interviews would

also draw out confirmation if the statistical findings concur with what the respondents

answers are during the conduct of discussions.

Setting

This study was conducted in all barangay health centers in Digos City, the

capital city of the Province of Davao del Sur. This included both the rural and urban

barangay health centers. There are 24 barangays that are under the political

jurisdiction of the City.

Participants

The respondents of the study were community health workers, which include

community health nurses, rural midwives and barangay health workers (BHWs). As

much as the research merits it, purposive sampling was utilized, such that only the

rural community health worker (midwife) from each barangay in the City were

surveyed and asked to participate in the researchs in-depth interviews.

Measures

The study made use of an adopted instrument in the form of 5-point scaled

questionnaire. It is composed of two parts. The first part (Part I) asks questions on

the demographic profile of the respondents. The second part (Part II) will ask

questions on the level of preparedness of health centers of having an e-health

system in monitoring maternal and child nutrition in Digos City in terms of logistic

25
support, system capabilities, training, work needs met, and IT capability of personnel

as perceived by the respondents. The questionnaire was lifted from the dissertation

of Sobejana (2014), which is also an ISO 9251-8 certified questionnaire intended to

measure IT-related systems.

In order to ensure that the items included in the questionnaire are suitable for

the context of the study, validity and reliability tests were conducted. Validity test

required at least three (3) experts who checked the questionnaire for suitability of the

items as well as clarity of each item. Meanwhile, reliability test was conducted by

conducting pilot testing involving 10 community health workers of the health centers

in the Municipality of Sta. Cruz, which was not included in the final respondent count.

Alpha coefficients were computed to ensure reliability of each and the overall scales

of the questionnaire.

Procedure

Prior to gathering of data, a request letter signed by the research adviser

addressed to the Dean of the College of Medical Entrepreneurship of Davao Doctors

College was first sent to secure approval in the conduct of the study. Secondly, upon

approval, the researcher asked permission in writing from the City Health Officer of

Digos City in the conduct of research as well as distribution of survey instruments to

the respondents. The survey tool was beforehand translated to vernacular so as to

convey and obtain the desired information needed from the respondents. Assistance

was obtained and was subject to validation.

26
 Thirdly, the researcher proceeded in the distribution of the questionnaires to

the respondents. This took a week before the researcher retrieved each of the

questionnaires. For the purpose of eliciting views and opinions that yielded qualitative

responses which would corroborate or triangulate the findings, an in-depth face-to-

face interview was conducted using a set of guide questions to those midwives who

agreed to participate on the second phase of data-gathering. Informed consents were

signed by the midwives to ensure that their interest is protected and that the gathered

data would be treated for academic purposes only.

Fourthly, after all the answered questionnaires were gathered, responses were

then collated, analyzed using statistical tools and interpreted. Data was then treated

with appropriate statistical tools. Upon arriving with the statistical findings, theories

and similar studies made in the review of literature will be used to support or negate

the findings. Lastly, significant findings from the analysis were then summarized with

which conclusions and recommendations were drawn.

Statistical Tools

The following statistical techniques were used in analyzing the data gathered:

Mean and Weighted Mean. This was used to describe the level of

preparedness of the barangay health centers for an e-health system as evaluated by

the respondents in monitoring maternal and child nutrition in Digos City in terms of

logistic support, system capabilities, training, work needs met, IT capability of

personnel.

27
 Thematic Analysis. This was used to treat the qualitative responses of the

informants of the challenges and problems encountered as a means of triangulating

the descriptive findings. Themes were presented in a narrative manner and are used

to triangulate or confirm the statistical results of each of the areas of preparedness.

Ethical Considerations

In the conduct of the study, all of the rural midwives are requested to

participate in the study after a letter of permission was granted by the City Health

Office. However, arrangements were done with the rural midwives as to their

availability for survey and interview so as not to hamper their normal functions in the

Health Centers.

In the conduct of the in-depth interview, those midwives who agreed to

participate were only considered. The rights to refuse in the study was consented by

the researches as stated in the Informed Consent Form, since most of the rural

midwives have seminars attended or were busy attending check-ups at the conduct

of the follow-up interview.

Scope and Limitations of the Study

This study was limited to the community health workers, which included

nurses, rural midwives and barangay health workers (BHWs) in Digos City as

respondents of the study. Data gathering started on the last week of April 2015.

The study largely relied on mixed method of research. This means that study

dwelt on getting the level but is not restrictive because the emotions, feelings,

28
insights, motives, intents, views and opinions of the subject are also taken into

account in corroboration with their self-assessments on the preparedness of their

health centers.

29
 Chapter 3

RESULTS AND DISCUSSION

This chapter deals with the presentation and interpretation of the data

gathered about the level of preparedness of health centers in Digos City for an e-

health program. The analysis is presented according to the order of the problems

previously enumerated. The presentation commences on the discussion on the five

areas assessed for preparedness, which includes training, logistic support, work

needs met, system capabilities and IT capability of personnel. The results are also

supported and confirmed by narratives from the rural midwives gleaned from the

thematic analysis. Lastly, the study also presents the intervention from the needs

analysis conducted.

Preparedness of Health Centers in Digos City

for an e-Health Program

The following discussions focused in the results of the statistical analysis

which presented the assessed preparedness of the health centers in Digos City for

an e-health program. Such implementation entails determining how prepared are the

health centers as assessed by their rural community midwives in terms of logistic

support, system capabilities, training, work needs met and IT capability of personnel.

Each of the areas is discussed distinctly.

30
Table 1. Overall Mean of the Level of Preparedness of Health Centers Measured
in Terms of Indicators
Item Overall Descriptive
Mean Level
1. Level of Preparedness in Terms of
3.73 High
Logistic Support
2. Level of Preparedness in Terms of
3.69 High
System Capabilities
3. Level of Preparedness in Terms of
3.60 High
Training
4. Level of Preparedness in Terms of Work
3.73 High
Needs Met
5. Level of Preparedness in Terms of IT
3.44 High
Capability of Personnel

By and large, the table above reflects the levels of preparedness of health

centers for an e-health system. Among the levels, the indicator pertaining to logistic

support and training have the highest overall mean. Both these indicators have 3.73

overall mean while the indicator pertaining to IT capability of personnel had the

lowest overall mean of 3.44. The implications of these overall means are further

explained specifically below.

Logistic Support. Presented above is the level of preparedness of health

center for an e-health system in addressing maternal and child nutrition in terms of

firstly, logistic support. Computations revealed an overall mean score of 3.73 or high

rating indicating that the said respondents were highly prepared in terms of logistic

support. The score was derived from the mean scores arrived from the different

specific items guided from the responses given by the rural midwives.

Data revealed that four items had manifested a high level of indication that

health centers in Digos City are highly prepared in terms of logistic support. These

31
were obtained from the given responses provided by the rural midwives. These

included the easy access on the technical support personnel any time if difficulties

arises in using the new system with a mean rating of 3.96, the timely manner of

response from the technical support personnel if technical difficulties take place in

learning the new system with a mean score of 3.87 and likewise to the necessity for

the City Health Office in providing additional information resources related to e-

health. On the other side, two specific items revealed moderate scores indicated that

health centers are moderately prepared. These covered the adequacy of the

materials and resources in the health center in implementing the e-health system

provided by a mean rating of 3.22 and the sufficiency of the funds to be allocated for

implementing e-health system with an average score of 2.87.

The findings were found to be inimical to what was envisioned by the World

Health Organizations Millennium Development Goals 2 and 5. According to

International Federation of Red Cross and Red Crescent Societies (2012),

interventions and strategies for improving MNCH and survival are closely related and

must be provided through a continuum of care approach. When linked together and

included as integrated programs, these interventions can lower costs, promote

greater efficiencies and reduce duplication of resources. With such worries by the

midwives, Digos City health centers are still a long way to go for implementation.

System Capabilities. Also presented in the table above the level of

preparedness of health centers in Digos City in terms of system capabilities.

Computations divulged an overall mean score of 3.69 or high percentage which

shows that the health centers were highly prepared. The said overall mean score was

32
instigated from the particular items provided with the responses given by the rural

midwives.

Data denoted that all of the responses by the rural midwives provided into the

given items revealed a high score. These encompassed that the e-health system

should allow a rural midwife in meeting imposed work commitments with 3.74 as the

mean score, that the e-health system should increase one`s capacity to carry out

one`s work provided with a mean score of 3.74, that the e-health system should be

compatible having a the same mean rating of 3.74, that e-health system`s software

will be reliable indicating a mean score of 3.61 and a the same mean score on the

item that the e-health system should be powerful enough for one`s work needs.

The above findings are coherent with the elucidations of the study ofAlam

(2012), who averred that while the electronic means of monitoring may be promising,

it may be facing some serious threats to its implementation structure. Such problems

include the concern of addressing adequate and timely monitoring of sector

performance, which is not yet a reality and the culture of using information for

decision-making has not yet taken roots. Alam also added that duplication of

services, delay in placing manpower, equipment, among others, still reduces the

possibility to make facilities fully functional. Insufficient coordination between various

sub-sectors in health, population and nutrition resulted in duplication, wastage and

missed opportunities both at the top as well as at the operational level. Though

MOHFW has been in the process of developing a routine data system, it has been

severely criticized for its narrow coverage, faulty output, and underutilization of data.

33
 Training. Results revealed that as a whole, the barangay health centers in

Digos City are found to be highly prepared in implementing an e-health program, as

seen in the overall mean of 3.60, which is described as High. With these results, it is

reflected that the level of preparedness for training personnel to adapt an e-health

system is positive and high. The above data does not directly reflect the adequacy of

training provided for the employment of an e-health system but what can be gleaned

from the tool is the positive attitude of the personnel towards the prospective training

that might be needed or required of them to successfully implement the e-health

system.

The high level of score was obtained from the three specific items guided from

the responses given by the respondents. These items included a 3.83 mean score for

an indication to rural midwives willingness to be trained if an e-health system was

introduced and which required regular training, the dedication to give time for formal

training in using an e-health system which has an indication of 3.83 mean score and

a 3.74 mean score for the dedication to give time for ongoing training in using the e-

health system. Furthermore, rural midwives showed a moderate level of

preparedness which was obtained from the two specific items provided from the

responses by rural midwives. These encompassed tapping the persons who are

capable in training the staff with the use of e-health systems with a mean score of

3.35 and looking for the resources to equip one`s self in using e-health system with a

mean score of 3.26.

With these having been obtained,

34
 Work Needs Met. The table above also reflects the level of preparedness of

health centers in Digos City in terms of work needs met. Computations revealed an

overall mean score of 3.73 or high rating indicating that the health centers were

highly prepared. The overall mean score was originated from the particular items

provided with the responses given by the rural midwives.

The indication that the health centers in Digos City were highly prepared in

terms of work needs met was derived from the items guided with the responses from

the rural midwives where four specific items disclosed a high level. These comprised

of the following items; that the e-health system should enhance the quality of one`s

work and that the e-health system should economize costly procedures with both

mean rating of 3.83, that the e-health system should save one`s time with an mean

score of 3.78 and that e-health system should allow one`s self to accomplish more

work in the same time frame with a mean rating of 3.74. On the other hand, a

moderate level was obtained on one specific item with a mean score of 3.48. This

was the item denoting that the e-health system is foolproof and does not require

costly maintenance.

The above findings were found to be consistent with the study of Sobejana

(2014), who elucidated that there is strong evidence of the effects and potential of

information systems in maternal and child nutrition interventions. Rapid and

significant improvements in health services indicators and health outcomes can be

achieved but in the long terms. He added that implementation of change, especially

when the processed is new, receives resistance at first. Considerable experience has

been gained in implementing (parts of) the package of interventions for maternal,

35
neonatal and child health and nutrition. In furtherance, he noted that health centers in

the context of Sta. Cruz need further orientation. Implementation involves unique

combinations and sequencing of health system actions policies and advocacy,

planning, involving communities, enrolling other sectors, programming including

piloting, training and support, strengthening supplies, simplifying information systems,

and monitoring and documenting progress (Soto, et al., 2014).

IT Capability Personnel. Lastly, the level of preparedness of health centers in

Digos City in terms of IT capability personnel is also shown. The overall computations

revealed a general mean score of 3.44 or high percentage which shows that the

health centers were highly prepared. The said overall mean score was covered from

the particular items provided with the responses given by the rural midwives. High

descriptive level was obtained from the three specific responses provided in the

specific items given by the respondents which are the rural midwives. These covered

looking for ways to implement a new system related to health into the health center

after hearing about it with a mean percentage of 3.65, being not hesitant to try out

new information technology with a mean score of 3.57 and liking to experiment with

new information technology and systems having a mean of 3.43. On the other hand,

the data reveals a moderate level which was depicted from the two specific items.

These were being the first to try out new technology among colleagues with a mean

score of 3.30 and the capability in using computers and computer-related systems

containing a mean score of 3.26.

36
 The above findings are consistent with the elucidations of the study ofSoto et

al. (2014), who found out that community-based strategies have been considered for

rural populations served predominantly by public providers, but this analysis suggests

that the scaling-up of maternal, newborn, and child health services requires health

system interventions focused on 'getting the basics right'. These include upgrading or

building facilities, training and redistribution of staff, better supervision, and

strengthening the procurement of essential commodities. Some of these strategies

involve substantial early capital expenditure in remote and sparsely populated

districts. In the same stratum, the WHO Global Observatory for e-Health (2013) cited

that the use among health-care workers and patients themselves is gaining

momentum. At the same time, governments are steadily moving towards ICT-based

integrated health information systems, and adopting e-Health policies. Since 2012, at

least seven more countries have adopted an e-Health strategy. The National e-Health

Strategy Toolkit, developed and published jointly by WHO and the ITU, has quickly

become an invaluable guide for all countries. The ability of people in general,

together with health-care professionals and policy-makers, to make better-informed

decisions has been transformed by ICT-enabled solutions. These trends are set to

continue in the coming years and to have profound effects on people at all levels.

Challenges and Opportunities Encountered

in the Implementation of an e-Health Program
as Perceived by Rural Midwives

37
 Furthermore, in order to enrich the discussions pertinent to the problem of

identifying the challenges and opportunities encountered by midwives in the

implementation of an e-health program in monitoring maternal and child health

nutrition in Digos City. Results were gathered via follow-up interviews conducted

among participating midwives, which were then treated thematically with the intention

of confirming the results of the previous statistical analyses. Triangulation of the

results was done by presenting the qualitative responses of the midwives from the

conducted face-to-face in-depth interviews (IDI). This is to ensure that the descriptive

findings are consistent with the pronouncements of the informants. Qualitative

responses of the in-depth interview participants ( n=5) were elicited with their

observations in the preparedness of the health centers.

Training

Based on the in-depth interviews, it was found out that the rural midwives both

view the training aspect as promising and adequate. As to the statement of Mabel

(IDI # 2, full name withheld), rural midwives benefit adequate trainings from the

Department of Health and the Local Government of the City as well in health

programs like e-health. She thus made the following pronouncements:

Well, in my 23 years in service isip usa ka midwife diri sa

Digos, Makita jud nako nga ang lokal nga panggamhanan,
dako jud kayo ug value sa kahimsog sa panglawas sa iyang
mga lumulupyo. Ang City Health [Office] nagasiguro nga
updated jud pirmi pati kaming mga midwife sa training, mao
nga regular jud mi mag-attend ug trainings nga sponsored sa
City or sa DOH. Mas maayo man gud nga maka-train para
kabalo jud ta unsaon ang pag-manage sa operations sa
health center. (##Archive 217)

38
 In addition, same with Mabels pronouncements, another respondent (Berna,

IDI #4) also remarked that training should be regular to keep them abreast with the

new trend in health monitoring. Berna further mentioned that it is not only her that

should be trained, but also the entire workforce of the health center (the BHWs):

Ahmm, sa akoang kabahin, dili siguro midwife lang ang

dapat ma-train sa mga programa sa gobyerno sama aning e-
health noh? Dapat pud ang tanang BHWs and the BNS,
ahmm, kinahanglan sab na ma-train sa e-health kay dili sa
tanang panahon, naa ming mga midwife sa health center.
Kinahanglan na sila pud mismong mga BHWs, trained pud
kay lain pud kung isa ra ang kabalo unya daghang i-
accommodate na mga inahan na magpacheck-up, diba?
(##Archive 408)

Yet, contrasting was the point of Alejandra (IDI #5), who verbalized that their

health center encounters difficulty in being trained for health programs. Because of

the bulk of reports to be presented and submitted to the City Health Office as well as

the Regional Health Office, implementing e-health seemed to be untimely. She

mentioned:

Sa tinuod lang, dili regular ang trainings unya kung naa man,
limitado lang sa mga midwife ang pag-apil. Dako kaayong
problema ang budget kay daghan gud mi mga BHW gud,
magdepende na sa gidaghanun sa purok o gidak-on sa
barangay. Maayo unta to na makaapil jud mi kay ang e-
health program nindut jud siya, perokung i-implement diha-
diha dayon, untimely jud siya kay daghan pa man mi ug
reports gud na humanunon. Sa pagmonitor jud sa kahimsog
sa mama ug sa bata, mano-mano nga survey ra jud amoang
sistema. (##Archive 524)

39
 The above findings are consistent with the pronouncements of Bhattacharya,

Shahrawat and Joon (2012), citing that one of the corestrategies for achieving the

goal of ensuring that there is a reduction of maternal and child deaths due to

malnutrition is to strengthen capacities for data collection, assessment and review

towards evidence based planning, monitoring and supervision. This can be done by

affording trainings for optimum functioning. Likewise, Verma and Prinja (2011) noted

that the staff involved in data collection and management must be aware of meaning

of different indicators in the new formats so that correct data can be generated for its

effective use. Towards this, efforts taken to maintain quality need to be assessed

regularly so that observed deficiencies may be timely addressed.

Support

More so, it was found out that the rural midwives see that there is a degree of

support afforded to them by the national and local government units in the agenda of

implementing an e-health program for monitoring maternal and child health and

nutrition. Based on the pronouncements of Alejandra (IDI # 5), health centers have

been given sufficient budget to cover its activities for rural intervention, by which

funds were from the Department of Health and the Local Government of the City.

However, she further noted that because of proliferation of problems that need

immediate focus, upgrading the health centers initiatives for implementing e-health to

monitor maternal and child health becomes a pending entry in the list. She thus

made the following pronouncements:

40
 Daghan kaayo ug priorities ang gobyerno sa pagkakaron, so
murag kadudahan nga maimplement ang e-health especially
diri sa Digos. Dili pud realistic kung magfocus dayon ta sa its
implementation sa maternal and child health monitoring kay
taas pa na ug proseso, especially, daghan pa ug ikonsidera
nga factors like budget ug manpower. Might be na supportive
and DOH (Regional Office) u gang City Health, yes, pero
gastos jud na ang e-health. Kinahanglan jud nga ang
commitment sa gobyerno ani is tinud-anay. (##Archive 511)

Likewise, Celia(IDI #1)expressed her worries about adopting an electronic

means of monitoring maternal and child nutrition to be just a burden in the part of the

rural midwife and the barangay health workers, too. She further stressed that while it

is important that the government will look into the readiness of the staff, it should

have afforded full support by providing adequate guide resources on how the system

will ease their work. She thus stated:

Kung ang intention sa e-health system is mapadali ang

trabaho, kinahanglan equipped ug kumpleto ang guide ug
mga reference materials unya kinahanglanmasabtan siya
namong mga midwife.Kinahanglan pud na ang gobyerno
maghimo pud ug guide na masabtan sa amoang sitwasyon
diri sa Digos, dili dapat general or broad ra ang guide.
Siyempre, part na gud sa guide ang data storagekay mahimo
maning basehan DOH sa pag-monitor sa health and nutrition
status sa mga inahan diri sa Digos. (##Archive 125)

Implementation

Also, Amparo (IDI #3) expressed that the system can also be difficult to

implement knowing that there is a big question on the e-healths capacity to

eliminate paperwork. She mentioned:

Ang nakapait man gud sa atyoang sistema sa gobyerno,

puros lang by the paper, for the sake lang na nay ma-
document. Mao naman gud na ang naandan. Siguro, dili jud

41
 100% na garantiya na ang e-health system makagaan sa
amoang trabahuon kay mao man gihapon, gina-require man
mi sa DOH sa pag-submit ug reports ug documents nga
written and printed. Dili man gihapon purely electronic.So,
gastos ra gihapon siya. (##Archive 318)

In addition, based on the in-depth interviews, it was found out that the rural

midwives are at a divide whether to appreciate the proposed implementation of an e-

health program in monitoring maternal and child nutrition in Digos City. These

pronouncements focused more on the concern that e-health is just one of the

governments experiments and may be doomed to an epic failure. Such was evident

in the pronouncements of Berna, citing that at her experience being a rural midwife in

her station, she has witnessed a lot of changes happening in the health system that

were not pushed due to inconvenience. She remarked:

Mao ra gihapon ning patabo-a sa gobyerno, usually dili jud

successful. Sa pagpahamtang pa lang ug technology sa
atoang operations, mamroblema naka kung competent ba
ang mga staff na mohandle kay ang paghire ug mga tao,
politically-motivated pud. Naay uban nga dili jud kabalo
magcomputer.Ang pagtrain pa jud ana nila, dakong
problema. So all in all, ang pag-implement sa e-health
program, dili jud siya madalag is aka gabii lang. (##Archive
472)

The same remark was also averred by Amparo, who expressed that in her

more than 30 years in service, e-health would be a challenge in their part. She

commented thus:

Dili mi andam jud sa pag-implement sa e-health program.

Kinahanglan mi ug dugang na mga staff. Kanang staff nga
kabalo jud sa trabaho nga ipa-implement. Kay kung hawud
amoang ga staff, mas paspas ang trabaho ug mas dali sa
amoang part na mamonitor ang tanang mga inahan nga

42
 buntis o adunay mga anak na bag-ong gihimugso. Para
mahitabo ni, kinahanglan jud mi ug dugang tao, ma-train
permente ug ma-update sa mga kabaghuan sa e-health.
(##Archive 365)

On the other way around, there are positive notions elicited from the

informants. In the case of Mabel, she made mention of the promising outcomes of e-

health for monitoring maternal and child nutrition. She has this notion that it would be

of tremendous help to them and, since they are situated in one of the barangays near

the City center, would not be a problem if implemented. She mentioned:

Kung ma-implement man gani ning e-health, mas mopaspas

jud amoang trabaho. Dili na mi maglisud ug pagpangita sa
information sa inahan o sa bata kay naka-encode naman
tanan ilang personal data sa database. Makagenerate na
sab mi sa report kung kinahanglan.Sa akoang panlantaw,
kung ing-ani kapaspas ang sistema, andam mi modawat sa
pag-implement sa e-health para mahapsay ang dagan sa
health center. (##Archive 284)

The in-depth interviews also were presented, finding out that the rural

midwives primary concern is how to ease-of-use of the system and interact with it.

Since e-health system requires computer applications, the midwives found

themselves a little hesitant but somehow hopeful that the system will be user-friendly.

Such was evident in the opined thoughts of Celia, stating her hopes that the system

will not be the same as with others that can be infiltrated by external system threats

(viruses) and that the system interface is understandable and state-of-the-art. She

thus opined:

Parehas ba na sa Facebook nga ma-hack? (laughs).Aw, sa

tinuod lang, nindut man ang e-health program kay
technology na gud na siya. Pero kinahanglan safe ug

43
 secured ang data nga naka-encode ana. Basin magsugod na
sab sa uno ang mga surveyors. Kinahanglan usab na ang
mogamit ani, trained ug kinahanglan iupgrade pud sila
permente. Dapat safe ug dili dali ma-virusan ang system.
(##Archive 109)

Similarly, Alejandra expressed excitement on the implementation of e-health

but hesitates if their health center is capable to implement it. She commented thus:

Dili ikalimud na nay mga barangay sa Digos na taas ug

malnutrisyon sa part samga inahan ug sa mga bata.
Kinahanglan ni iimplementar kay mao na jud ni ang legacy
nga ikabilin sa atoang gobyerno kung ma-implement ni siya.
(##Archive 572)

Capability

Lastly, the in-depth interviews revealed that the rural midwives primary

concern is their capability to be competent in computers and computer applications.

Since e-health system requires computer applications, the midwives found

themselves a little hesitant because they have accustomed with manual processes.

Although computers are present in their work, Berna made mention that she

delegated the computer works to a much younger health worker. She thus stated:

Ang e-health kinahanglan ug training.Pero dili tanan tao nga

gi-train mga antigo ug bata. Naay uban nga naa na sab sa
ilang kahamtung nga pangidaron Maglisud naka ug delegate
sa ilaha ug trabaho, kini pa kaha na technology man kaha
ang e-health? Dako ni nga challenge sa pagtrain kay nay
uban mga BHW, moatras na sa kadaghang encodunon na
data ilabi na nga dili sila suweto sa computer. (##Archive
448)

Such pronouncements of Berna were coherent with the findings of the descriptive

analysis, which was interpreted as moderate. This means that the midwife Similarly,
44
Alejandra expressed excitement on the implementation of e-health but hesitates if

their health center is capable to implement it. She commented thus:

Nanghinaut ko nga ang City Health [Office], maimplement

jud ni sa tanang health centers. Makita man gud nimo na
taas ang incidence sa malnutrition sa mga buntis ug mga
inahan especially sa mga rural areas. Excite dmi mogamit sa
system kay makatabang man jud ni siya para momenos ang
gidaghanon sa amoang trabaho. Mobilib ko sa gobyerno
kung tinuod na maimplementar ni. (##Archive 572)

45
 Chapter 4

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

Presented in this chapter are the summary of the findings, conclusions and the

recommendations necessary to address the problems of the study.

Summary

This needs assessment study was conducted to determine the level of

preparedness of health centers in Digos City in implementing an e-health system in

monitoring maternal and child health nutrition. This intention was backed with the

second ad fifth Millennium Development Goals of the World Health Organization of

reducing mortality among women and their children and ensuring their health. A

mixed method research was utilized, employing descriptive design to ascertain the

level of preparedness of the health centers in terms of training, logistic support, work

needs met, system capability and IT capability of personnel, while qualitative method

was used to triangulate the findings by gleaning the narratives and insights of the

informants. There are 22 rural midwives who participated in the survey and five from

them agreed to be the informants for the in-depth interviews that followed. In the

analysis of the findings, descriptive statistics via weighted mean and thematic content

analysis were utilized to give depth and profundity of the descriptive results.

Based on the analysis, the following are the findings of the study:
46
 1. Health centers in Digos City were found to be prepared in implementing an e-

health system in monitoring maternal and child health and nutrition. The mean

scores revealed interpretations of high in the areas of training, logistic support,

work needs met, system capability and IT capability of personnel. Overall,

Digos City health centers exhibited preparedness in implementing the system.

2. Qualitative analysis revealed that the descriptive findings were corroborated

and confirmed by the narratives of the participating midwives. Themes that

emerged include training, support, fore seen difficulty of implementation, ease-

of-use, and personnel competence.

Conclusion

Based on the findings, the following conclusions were drawn:

1. The health centers in Digos City are found to be highly prepared in terms of

implementing an e-health system in monitoring maternal and child health and

nutrition.

2. Issues on training, support, foreseen difficulty in implementation, ease-of-use

and personnel competence are the primary constraints that might be

encountered on its implementation, but the analyses further revealed that

adequate staffing, proximity in the City Health Office and regular training would

be the opportunities favorable for the implementation.

Recommendations

Based on the findings of the study, the following conclusions are drawn:

47
 1.For the Department of Health and the City Health Office in particular, they

may consider the findings of the study as a strong and additional basis in the

improvement and funding of the implementation of e-health system(s), by which

purpose is to effectively and efficiently monitor maternal and child health and nutrition

status per barangay. Likewise, they may base their decisions on the studys results.

2. For the community health workers, they may glean the findings as a way of

signifying the need to improve some areas of evaluation relative to e-health

implementation. The results of the study can be utilized as a means of giving each of

the health centers an opportunity to improve its areas prior to implementation.

3. For the future researchers, they are encouraged to conduct related and

long-term studies to expand the knowledge and study on the e-health systems that

are useful in monitoring maternal and child nutrition.

48
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51
 Republic of the Philippines
Province of Davao del Sur
CITY HEALTH OFFICE
Magsaysay St., Digos City

NEEDS ASSESSMENT PLAN FOR E-HEALTH IMPLEMENTATION

SY 2014-2015

Objective Program(s) Description Person(s) Responsible Time Frame Budget

To involve all community 1. Three-day seminar on e- City Health Officer June 2016 Php 50,000 OR as
health workers in the health used in monitoring DOH Representatives appropriated by the
pre-implementation of maternal and child nutrition City Health Medical City Health Office
the e-health program of with the following topics: Officers
the Department of IT System in health Community Health Nurses
Health Monitoring Rural Midwives
Maternal and Child Barangay Health Workers
Nutrition Risks (BHWs)
Primer on e-Health
System
Challenges and To be appropriated
Opportunities of e- by the CHO as
Health July to August approved by the City
City Health Officer 2016 Local Government
2. Conducting of performance Rural Midwives
reassessment on BHW
competencies

To identify the gap 1. Conduct of Monthly and City Health Officer June to To be appropriated
between future Quarterly Meeting and DOH Representatives December by the CHO as
performance and Performance City Health Medical 2016 approved by the City
importance of e-health Assessments Officers Local Government
among barangays Community Health Nurses
Rural Midwives

0
 Barangay Health Workers
(BHWs)

To expand the health 1. Regular monitoring and Rural Midwives Whole year Based on the
services afforded among announcements for Barangay Health Workers approved budget
mothers and their maternal and child (BHWs) from the City Health
children nutrition check Mothers and their Infants as well as barangay
counterpart

Prepared by:

Carlos Teogenes J. Maniago, RN, RM

Nurse III

1
 Appendix A

Letter to the City Health Office

0
 Appendix B

Survey Questionnaire

SURVEY ON THE PREPAREDNESS OF HEALTH CENTERS TO IMPLEMENT

e-HEALTH PROGRAMS IN MONITORING MATERNAL ANDCHILD
NUTRITION IN DIGOS CITY

Being a worker of a health center in the City, the researcher believes that you are in
the best position to give feedback to the extent of preparedness of your health center
for an e-health program. Your perception on the score is very important to the
success of the system. Please read and evaluate each item according to the rating
scale below. Mark your answer per item by checking the appropriate box of your
choice. Kindly do not leave any item unanswered.

PART 1: Profile of the Respondent

Respondent Classification (Please Check)

Midwife BHW Community Health Doctor/Nurse

PART 2: Determine how prepared is your health center in implementing an e-health

program in monitoring maternal and child health and nutrition based on the following
parameters.Please indicate your perception in terms of training, logistic support, work
need met, system capabilities, IT capability of personnel. Please put a check () mark
in the appropriate cell that represents your perception based on the following scale:

Point Rating 5 4 3 2 1
Description Very High High Average Low Very Low

Note: If you have any comment/suggestion on how the system could still improve,
please write them in the space provided for.
Training 5 4 3 2 1
1. The e-health system was properly introduced and
required regular training and retraining were provided.
2. I was given a formal training on e-health system.
3. On-going trainings and updates are periodically given.
4. I am equipped in using e-health systems.
5. There are adequate personnel that maybe tapped to
provide subsequent training to other personnel.
Logistic Support 5 4 3 2 1
1. There are adequate technical support personnel that
should be easy to reach at any time in case of
difficulties that may be encountered.

1
 2. The technical support personnel responds in a timely
manner.
3. The materials and resources in the health center are
adequate in implementing e-health system.
4. There is a need for the City Health Office to provide
additional information resources related to e-health.
5. Funds are sufficient and allocated for implementing e-
health,
Work Need Met 5 4 3 2 1
1. The e-health system should allow me to accomplish
more work in the same time frame.
2. The e-health system should enhance the quality of my
work.
3. The e-health system should save me time
4. The e-health system should economize costly
procedures.
5. The e-health system is foolproof and does not require
costly maintenance.
System Capabilities 5 4 3 2 1
1. Work commitments are easily reached with the
employment of an e-health system.
2. The e-health system increases my capacity to carry
out my work.
3. The e-health system is compatible to my work needs.
4. There is a reliable e-health systems software.
5. There is an e-health system software powerful enough
for my work needs.
IT Capability of Personnel
1. If I heard about a new system related to health, I would
look for ways to implement it in the health center.
2. Among my colleagues, I am usually the first to try out
new technology.
3. I like to experiment with new information technology
and systems
4. I am not hesitant to try out new information technology.
5. I am capable in using computers and computer-related
systems.

Suggestions:
__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

2
 Appendix C

Validation Sheets

3
 Appendix D
Item Result of Each Indicator

Table 2. Level of Preparedness of Health Centers in Terms of Logistic Support

Descriptive
Item SD Mean
Level
1. There are adequate technical support personnel
that should be easy to reach at any time in case .752 3.74 High
of difficulties that may be encountered.
2. The technical support personnel responds in a
.717 3.83 High
timely manner.
3. The materials and resources in the health
center are adequate in implementing e-health .736 3.78 High
system.
4. There is a need for the City Health Office to
provide additional information resources related .778 3.83 High
to e-health.
5. Funds are sufficient and allocated for
.947 3.48 Moderate
implementing e-health,

Overall .694 3.73 High

Table 3. Level of Preparedness of Health Centers in Terms of System

Capabilities
Descriptive
Item SD Mean
Level
1. Work commitments are easily reached with the
.689 3.74 High
employment of an e-health system.
2. The e-health system increases my capacity to
.689 3.74 High
carry out my work.
3. The e-health system is compatible to my work
.752 3.74 High
needs.
4. There is a reliable e-health systems software. .783 3.61 High
5. There is an e-health system software powerful
.839 3.61 High
enough for my work needs.

Overall .687 3.69 High

4
Table 4.Level of Preparedness of Health Centers in Terms of Training
Descriptive
Item SD Mean
Level
1. The e-health system was properly introduced
and required regular training and retraining .717 3.83 High
were provided.
2. I was given a formal training on e-health
.778 3.83 High
system.
3. On-going trainings and updates are periodically
.689 3.74 High
given.
4. I am equipped in using e-health systems. .964 3.26 Moderate
5. There are adequate personnel that maybe
tapped to provide subsequent training to other .935 3.35 Moderate
personnel.

Overall .655 3.60 High

Table 4.Level of Preparedness of Health Centers in Terms of Work Needs Met

Descriptive
Item SD Mean
Level
1. The e-health system should allow me to
.752 3.74 High
accomplish more work in the same time frame.
2. The e-health system should enhance the quality
.717 3.83 High
of my work.
3. The e-health system should save me time .736 3.78 High
4. The e-health system should economize costly
.778 3.83 High
procedures.
5. The e-health system is foolproof and does not
.947 3.48 Moderate
require costly maintenance.

Overall .694 3.73 High

Table 5.Preparedness of Health Centers in Terms of IT Capability of Personnel

Descriptive
Item SD Mean
Level
1. If I heard about a new system related to health, I
would look for ways to implement it in the health .689 3.65 High
center.
2. Among my colleagues, I am usually the first to .689 3.30 Moderate

5
 try out new technology.
3. I like to experiment with new information
.752 3.43 High
technology and systems
4. I am not hesitant to try out new information
.783 3.57 High
technology.
5. I am capable in using computers and computer-
.839 3.26 Moderate
related systems.

Overall .687 3.44 High

Appendix E

6
 Reliability Test Results

Reliability

Scale: Training Scale

Case Processing Summary

N %

Cases Valid 10 100.0

Excludeda 0 .0

Total 10 100.0

a. Listwise deletion based on all variables in the

procedure.

Reliability Statistics

Cronbach's Alpha N of Items

.775 5

Item Statistics

Mean Std. Deviation N

Train1 3.7000 .67495 10

Train2 3.6000 .69921 10

Train3 3.4000 .51640 10

Train4 2.8000 .91894 10

Train5 3.0000 .81650 10

7
 Item-Total Statistics

Scale Mean if Scale Variance if Corrected Item- Cronbach's Alpha

Item Deleted Item Deleted Total Correlation if Item Deleted

Train1 12.8000 5.733 .303 .806

Train2 12.9000 4.767 .626 .709

Train3 13.1000 5.211 .716 .705

Train4 13.7000 4.011 .628 .709

Train5 13.5000 4.500 .577 .724

Scale Statistics

Mean Variance Std. Deviation N of Items

16.5000 7.167 2.67706 5

Scale: Logistic Support Scale

Case Processing Summary

N %

Cases Valid 10 100.0

Excludeda 0 .0

Total 10 100.0

a. Listwise deletion based on all variables in the

procedure.

Reliability Statistics

Cronbach's Alpha N of Items

.756 5

8
 Item Statistics

Mean Std. Deviation N

Logis1 3.8000 .78881 10

Logis2 3.7000 .67495 10

Logis3 3.1000 1.19722 10

Logis4 3.7000 .67495 10

Logis5 2.7000 .94868 10

Item-Total Statistics

Scale Mean if Scale Variance if Corrected Item- Cronbach's Alpha

Item Deleted Item Deleted Total Correlation if Item Deleted

Logis1 13.2000 6.178 .759 .633

Logis2 13.3000 6.678 .758 .652

Logis3 13.9000 4.767 .684 .653

Logis4 13.3000 8.678 .162 .809

Logis5 14.3000 6.900 .397 .760

Scale Statistics

Mean Variance Std. Deviation N of Items

17.0000 9.778 3.12694 5

9
Reliability

Scale: Work Needs Met Scale

Case Processing Summary

N %

Cases Valid 10 100.0

Excludeda 0 .0

Total 10 100.0

a. Listwise deletion based on all variables in the

procedure.

Reliability Statistics

Cronbach's Alpha N of Items

.762 5

Item Statistics

Mean Std. Deviation N

Work1 3.6000 .51640 10

Work2 3.6000 .51640 10

Work3 3.7000 .67495 10

Work4 3.7000 .67495 10

Work5 3.1000 .99443 10

10
 Item-Total Statistics

Scale Mean if Scale Variance if Corrected Item- Cronbach's Alpha

Item Deleted Item Deleted Total Correlation if Item Deleted

Work1 14.1000 4.322 .766 .665

Work2 14.1000 4.544 .646 .698

Work3 14.0000 3.778 .762 .635

Work4 14.0000 3.778 .762 .635

Work5 14.6000 4.711 .124 .925

Scale Statistics

Mean Variance Std. Deviation N of Items

17.7000 6.233 2.49666 5

Reliability

Scale: System Capabilities Scale

Case Processing Summary

N %

Cases Valid 10 100.0

Excludeda 0 .0

Total 10 100.0

a. Listwise deletion based on all variables in the

procedure.

11
 Reliability Statistics

Cronbach's Alpha N of Items

.841 5

Item Statistics

Mean Std. Deviation N

System1 3.6000 .51640 10

System2 3.5000 .52705 10

System3 3.4000 .69921 10

System4 3.2000 .63246 10

System5 3.4000 .69921 10

Item-Total Statistics

Scale Mean if Scale Variance if Corrected Item- Cronbach's Alpha

Item Deleted Item Deleted Total Correlation if Item Deleted

System1 13.5000 5.167 .189 .906

System2 13.6000 4.044 .734 .791

System3 13.7000 3.567 .690 .798

System4 13.9000 3.433 .872 .742

System5 13.7000 3.344 .799 .762

Scale Statistics

Mean Variance Std. Deviation N of Items

17.1000 5.878 2.42441 5

Reliability

Scale: IT Capability Scale

12
 Case Processing Summary

N %

Cases Valid 10 100.0

Excludeda 0 .0

Total 10 100.0

a. Listwise deletion based on all variables in the

procedure.

Reliability Statistics

Cronbach's Alpha N of Items

.515 5

Item Statistics

Mean Std. Deviation N

IT1 3.4000 .51640 10

IT2 2.9000 1.19722 10

IT3 3.3000 .48305 10

IT4 3.5000 .52705 10

IT5 2.7000 .94868 10

13
 Item-Total Statistics

Scale Mean if Scale Variance if Corrected Item- Cronbach's Alpha

Item Deleted Item Deleted Total Correlation if Item Deleted

IT1 12.4000 3.378 .866 .211

IT2 12.9000 3.433 .095 .682

IT3 12.5000 4.500 .271 .481

IT4 12.3000 3.789 .596 .336

IT5 13.1000 3.878 .137 .573

Scale Statistics

Mean Variance Std. Deviation N of Items

15.8000 5.289 2.29976 5

Reliability

Scale: All Scales

Case Processing Summary

N %

Cases Valid 10 100.0

Excludeda 0 .0

Total 10 100.0

a. Listwise deletion based on all variables in the

procedure.

14
 Reliability Statistics

Cronbach's Alpha N of Items

.877 25

15
 Item Statistics

Mean Std. Deviation N

Train1 3.7000 .67495 10

Train2 3.6000 .69921 10

Train3 3.4000 .51640 10

Train4 2.8000 .91894 10

Train5 3.0000 .81650 10

Logis1 3.8000 .78881 10

Logis2 3.7000 .67495 10

Logis3 3.1000 1.19722 10

Logis4 3.7000 .67495 10

Logis5 2.7000 .94868 10

Work1 3.6000 .51640 10

Work2 3.6000 .51640 10

Work3 3.7000 .67495 10

Work4 3.7000 .67495 10

Work5 3.1000 .99443 10

System1 3.6000 .51640 10

System2 3.5000 .52705 10

System3 3.4000 .69921 10

System4 3.2000 .63246 10

System5 3.4000 .69921 10

IT1 3.4000 .51640 10

IT2 2.9000 1.19722 10

IT3 3.3000 .48305 10

IT4 3.5000 .52705 10

IT5 2.7000 .94868 10

Item-Total Statistics

Scale Mean if Scale Variance if Corrected Item- Cronbach's Alpha

Item Deleted Item Deleted Total Correlation if Item Deleted

Train1 80.4000 81.822 .531 .870

Train2 80.5000 80.500 .620 .868

Train3 80.7000 81.789 .719 .868

16
 Item Statistics

Mean Std. Deviation N

Train1 3.7000 .67495 10

Train2 3.6000 .69921 10

Train3 3.4000 .51640 10

Train4 2.8000 .91894 10

Train5 3.0000 .81650 10

Logis1 3.8000 .78881 10

Logis2 3.7000 .67495 10

Logis3 3.1000 1.19722 10

Logis4 3.7000 .67495 10

Logis5 2.7000 .94868 10

Work1 3.6000 .51640 10

Work2 3.6000 .51640 10

Work3 3.7000 .67495 10

Work4 3.7000 .67495 10

Work5 3.1000 .99443 10

System1 3.6000 .51640 10

System2 3.5000 .52705 10

System3 3.4000 .69921 10

System4 3.2000 .63246 10

System5 3.4000 .69921 10

IT1 3.4000 .51640 10

IT2 2.9000 1.19722 10

IT3 3.3000 .48305 10

IT4 3.5000 .52705 10

IT5 2.7000 .94868 10

Item-Total Statistics

Scale Mean if Scale Variance if Corrected Item- Cronbach's Alpha

Item Deleted Item Deleted Total Correlation if Item Deleted

Train1 80.4000 81.822 .531 .870

Train2 80.5000 80.500 .620 .868

Train3 80.7000 81.789 .719 .868

17
 Item Statistics

Mean Std. Deviation N

Train1 3.7000 .67495 10

Train2 3.6000 .69921 10

Train3 3.4000 .51640 10

Train4 2.8000 .91894 10

Train5 3.0000 .81650 10

Logis1 3.8000 .78881 10

Logis2 3.7000 .67495 10

Logis3 3.1000 1.19722 10

Logis4 3.7000 .67495 10

Logis5 2.7000 .94868 10

Work1 3.6000 .51640 10

Work2 3.6000 .51640 10

Work3 3.7000 .67495 10

Work4 3.7000 .67495 10

Work5 3.1000 .99443 10

System1 3.6000 .51640 10

System2 3.5000 .52705 10

System3 3.4000 .69921 10

System4 3.2000 .63246 10

System5 3.4000 .69921 10

IT1 3.4000 .51640 10

IT2 2.9000 1.19722 10

IT3 3.3000 .48305 10

IT4 3.5000 .52705 10

IT5 2.7000 .94868 10

Item-Total Statistics

Scale Mean if Scale Variance if Corrected Item- Cronbach's Alpha

Item Deleted Item Deleted Total Correlation if Item Deleted

Train1 80.4000 81.822 .531 .870

Train2 80.5000 80.500 .620 .868

Train3 80.7000 81.789 .719 .868

18
19
 Appendix F

Informed Consent

20
 Appendix G

Guide Questions

I am CARLOS TEOGENES J. MANIAGO, a registered midwife and nurse and

currently working at the Davao del Sur Provincial Hospital. I am currently working for
my thesis entitled Preparedness of Digos City Health Centers for e-Health Programs
in Monitoring Maternal and Child Nutrition in partial fulfillment of the requirements
for the degree, Master of Arts in Nursing major in Clinical Management. Inasmuch
that you are one of the chosen key informants for the topic because of your
experience, competence and designation, I believe that you will be one of those
people who envisions for a better health for our mothers and their children. It is the
intention of this discussion to elicit your valued ideas to address the questions posed
by my research study.

If you have no questions, we may now begin.

1. In your work as a rural/community health worker, how can you assess the
system of monitoring maternal and child health?

2. Do you find difficulty in monitoring maternal (or child) deaths in your area?
How do you monitor them the quickest way?

3. How is the system been working so far? Is it efficient (inefficient)? In what

way?

4. What facilities/gadgets/things are necessary to speed up your monitoring?

5. How are you in terms of technology?

6. If in case the system will be electronic, will it speed up your work? In what
way? Will it be beneficial in your part?

7. To what extent does the City Government and the DOH support your barangay
health center? Are your requests usually granted?

8. In your viewpoint, is your barangay health center prepared to implement

an electronic health system to address the need of a speedy monitoring
and reporting for maternal and child health and nutrition?

9. In case e-health will be implemented, what sort of things do you expect

for the government and the locality to do to comply with the
implementation?

21