Study area and design
Tanzania is divided into 25 administrative regions that are subdivided into 113 districts that are further subdivided into divisions, wards and villages. Administratively, the ministry of health is the main coordinating body for health information in the country, the regional level is responsible for coordinating activities in the districts and the districts are responsible for coordinating services delivery activities at the health facility levels. The 12 HMIS booklets in Tanzania include the guidelines, summary (from the other books), village profile, inventory (ledger for equipment, drugs and supplies), outpatient services, antenatal services, postnatal services, family planning services, communicable diseases, HMIS report book, dental services and delivery services. These booklets consist of forms and registers, where the registers are pre-set frameworks for data processing.
In an attempt to map the gaps and factors for change in the country's HMIS a cross-sectional descriptive study was conducted between January and February 2008 in Kilombero, one of the most rural districts in Tanzania. Kilombero district is in the southeastern part of the country about 230 km from Morogoro, the headquarters of the region and 420 km from Dar es Salaam, the largest business city in the Tanzania. The district has a total area of 14,018 km 2, a population of 321,611 people  and 44 health facilities. Among these health facilities are 2 hospitals both owned by non-governmental institutions, 4 health centres (all owned by the government) and 38 dispensaries of which only 15 are owned by the government. The health facilities were as far as 180 km from the district headquarters and are expected to provide all primary health care services, refer complicated cases and complete the relevant booklets.
Sampling and size
A stratified random sampling technique was used to obtain one hospital, one health centre and 9 dispensaries. Of these facilities, 5 were governmental and 6 non-governmental. A total of 11 health facilities were involved in the analysis, fulfilling WHO recommendation to cover at least 25-30% of the health facilities in the area when assessing quality of care [13, 14]. The study team aimed to interview at least 5 health care providers including those in-charge of the health facility available on the day of study visit. However, the team managed to interview 43 care providers because many of the facilities had less than five health care providers. At the hospital a list of care providers was obtained from the administration and the following departments were included: outpatient, reproductive and child health (RCH) clinic and labour ward where at least 2 health workers were interviewed from each department.
Data collection, processing and analysis
Data collection was carried out by the author and 4 research assistants. A semi-structured questionnaire was used to interview health care providers and facility administrators to assess their level of knowledge, attitudes and practices concerning HMIS and factors for change (Additional file 1). After the interview the research team requested to see the 2007 HMIS booklets (number 6, 7 & 12) in order to review the completeness of records. The parameters recorded in booklet 6 (antenatal services register) included: 1) booking visit: date, registration number, name, age, gravidity, gestation age, height, danger signs; 2) re-attendance visits: presence of anaemia, oedema, proteinuria, lie of the foetus, vaginal bleeding, syphilis test, date of TT vaccine for the index pregnancy, last childbirth (year, live or died) and referral information. The parameters for book 7 (underfive services register) were: date, registration number, date of birth, weight, date for BCG, DPT, polio, measles vaccinations and vitamin A, mother's information (name and TT vaccination status); and those for book 12 (delivery services register) were: date, registration number, name of the mother, age, gravidity, parity, date of admission, date of delivery, mode of delivery, birth before arrival (BBA), complication of labour, status at birth (live birth or stillbirth), condition of the mother at discharge and name of the health provider. The parameters which were mostly not recorded were documented. In the cases of frequent incomplete records, the research team inquired about reasons for the incompleteness. The research team also interviewed the district HMIS coordinator for the factors that affected health information system. The data were entered in the Statistical Package for Social Science (SPSS) version 10 and analyzed by generating frequencies. Exact binomial confidence intervals at 95% were used to compare the proportions of clinicians and nurses with regards to the training, knowledge, attitude and utilization of HMIS data in their health facilities. The permission to carry out this study was obtained from district medical authority and verbal consent was obtained from the interviewees.