Epidemiological characteristics of crashes and pattern of motorcycle injuries presenting to hospitals in Kisumu City, Kenya: a cross-sectional study.

Introduction: motorcycle injuries comprise considerable morbidity, disability and mortality of road traffic casualties. The study aimed to assess the pattern and characteristics of motorcycle crash injuries that sought care at the Emergency Departments in Tier III hospitals in Kisumu City during a six-month period from May to November 2019. Methods: this was a cross-sectional study of all motorcycle injury patients presenting to three tier III public and private hospitals in Kisumu City. Using a structured questionnaire, data were collected on human and injury characteristics. Multiple logistic regression model was used to determine the predictors of fatality. Statistical significance was set at p<0.05. Results: a total of 1073 of motorcycle crash injury patients sought and obtained care at the hospitals. The majority (73.6%) were males. Seventy-three cases resulted in death (case-fatality rate of 6.80%. The age range was 2-84 years, with a mean of 29.6 years (± SD 12.19). Majority, (43.3%) were aged 21-30 years. Most of the crashes occurred during the daytime (79.1%). Of all motorcycle riders and pillion passengers 30.6% wore helmets at the time of the crash. Head injuries (43.6%) were the most common. Injury seventy scores (ISS) ranged from 1 to 51. Glasgow comma scale <3, un-helmeted patients and major trauma (ISS > 16), significantly influenced mortality (P< 0.001). Conclusion: these findings confirmed and strengthened the documented substantial morbidity, mortality that motorcycle crashes place on individuals and society, contribute to the body of literature on motorcycle injuries and potentially assist in policy decisions on motorcycle transport safety.

"You'll Be Chased Away": Sources, Experiences, and Effects of Violence and Stigma among Gay and Bisexual Men in Kenya.

Gay and bisexual men in Kenya face extreme socio-political stigma which manifests in widespread violence and discrimination across socio-ecological levels. We conducted individual in-depth interviews with 60 gay and bisexual men in western and central Kenya. Interview transcripts were thematically analyzed using an inductive, phenomenological approach to qualitatively examine experiences of stigma and violence at the interpersonal and institutional levels. A total of seven primary themes and four sub-themes emerged from the data. At the interpersonal level, participants described stigma and violence from family, friends, and romantic/sexual partners with sub-themes for gay-baiting violence, blackmail, intimate partner violence, and commitment phobia. At the institutional level, participants described stigma and violence from religious, employment, educational, and healthcare institutions. This stigma and violence severely impacted the lives of participants including their mental health, physical health, sexual health, socioeconomic status, and ability to access health-promoting services. These data identify sources of stigma and describe how this stigma manifests in the everyday lives of gay and bisexual men in Kenya. Study findings and quotes from participants highlight the severity of violence, stigma, and discrimination faced by this community and emphasize the need for decriminalization of same-sex sexualities as well as interventions to support health and wellbeing.

The Burden of Motorcycle Crash Injuries on the Public Health System in Kisumu City, Kenya.

BACKGROUND: In Kenya, the increased use of motorcycles for transport has led to increased morbidity, mortality, and disability. These injuries exert a burden on the public health system, yet little information exists on health care resource usage by motorcycle crash injury patients. We aimed to estimate the burden of motorcycle crash injuries on the health system in Kisumu City. METHODS: We conducted a 6-month prospective study of all motorcycle crash injury patients who presented to 3 Tier III public and private hospitals in Kisumu City between May and November 2019. We collected data on demographics, emergency department (ED) visits, admissions, anatomic injury site, services used, and injury severity. We reviewed hospital records to obtain denominator data on all the conditions presenting to the EDs. RESULTS: A total of 1,073 motorcycle crash injury cases accounted for 2.0%, 12.0%, and 13.6% of total emergency visits, total injuries, and total admissions to the hospitals, respectively. Men were overrepresented (P<.001). The mean age was 29.6 years (±standard deviation [SD] 12.19; range=2-84). The average injury severity score was 12.83. Surgical interventions were required by 89.3% of patients admitted. Of the 123 patients admitted to the intensive care unit, 42.3% were due to motorcycle accident injuries. CONCLUSION: Motorcycle injuries impose a major burden on the Kisumu City public health system. Increased promotion and reinforcement of appropriate interventions and legislation can help prevent accidents and mitigate their consequences. Focusing on motorcycle injury prevention will reduce accident-related morbidity, hospitalization, severity, and fatalities and the impact on the public health system.

"When you talk it out you will feel like the burden has somehow gone down, you will feel light": Social Support Received by Gay, Bisexual, and Other Men Who Have Sex with Men in Western Kenya.

Gay and bisexual men and other men who have sex with men (GBMSM) experience many sexual orientation-related stressors that negatively influence physical and mental health, making it imperative to understand their experiences of resilience-promoting resources such as social support. We utilized qualitative and participatory methodologies to examine sources of social support and types of social support received by GBMSM in Western Kenya through in-depth interviews with 60 GBMSM, including both peer educators and community members. GBMSM received emotional, informational, and instrumental support from six different relationship types: friends and peer groups, family of origin, sexual and romantic partners, healthcare providers, peer educators, and other people including work colleagues and police officers. A key finding from this study is the centrality of sexuality-specific support across all sources and types of support. Implications for clinics and LGBTQ organizations, policy, and future research are discussed.

"God Didn't Make a Mistake in Creating Me": Intrapersonal Resilience Processes among Gay and Bisexual Male Youth in Kenya.

Gay and bisexual male youth in Kenya experience human rights violations, including pervasive stigma and discrimination, and these oppressive forces are associated with elevated rates of mental health concerns. Despite these challenges, many gay and bisexual male youth in Kenya are thriving during this critical developmental period. This study explored intrapersonal processes that gay and bisexual male youth in Kisumu, Kenya, highlight as important to developing, and demonstrating resilience in the face of adversity. We conducted qualitative in-depth interviews (IDIs) with 40 gay and bisexual male youth, ages 20-30 (mean = 26.4), and an additional 20 IDIs with gay and bisexual men, ages 22-45 (mean = 26.6), who were working as peer educators (total n = 60), all in Kisumu, Kenya. A total of nine primary themes emerged which describe various intrapersonal resilience processes enacted by gay and bisexual male youth, including sexual identity acceptance, self-confidence, self-love, religious/spiritual affirmation, adaptive coping, successful navigation, legal rights awareness, economic stability, and advocacy satisfaction. These data demonstrate the range of positive personal processes that promote mental health and wellbeing among gay and bisexual male youth in Kenya. We discuss implications of these findings for community-based interventions, and call for a research paradigm shift away from deficits and toward resilience.

Awareness and Acceptability of pre-exposure prophylaxis (PrEP) among gay, bisexual and other men who have sex with men (GBMSM) in Kenya.

Kenyan gay, bisexual, and other men who have sex with men (GBMSM) are significantly affected by HIV. Pre-exposure prophylaxis (PrEP) is an effective biomedical approach to HIV prevention. We conducted a cross-sectional survey of 459 HIV-negative Kenyan GBMSM to assess individual and interpersonal correlates of PrEP awareness/acceptability using univariate and hierarchical logistic regression modeling. We found that 64.3% of participants had heard of PrEP and 44.9% were willing to use PrEP. In hierarchical logistic regression models for PrEP awareness, condom use with regular partners, higher condom use self-efficacy, higher perceived ability to use PrEP, history of STI, and membership in LGBT organization were significantly associated with being aware of PrEP (χ2 = 69.6, p < .001). In hierarchical logistic regression models for PrEP acceptability, higher self-esteem, higher condom use self-efficacy, depression/anxiety, higher perceived ability to use PrEP, willingness to engage in PrEP follow-up visits, coercion at sexual debut, and family exclusion were significantly associated with being acceptable to PrEP (χ2 = 231.8, p < .001). Individual and interpersonal factors were significantly associated with PrEP awareness and acceptability. Our findings underscore the need to promote awareness and understanding of PrEP as an effective HIV prevention tool in combination with other safer-sex methods that are appropriate given an individual's personal circumstances.

Gender Role Strain and the Precarious Manhood of Sexual Minority Kenyan Men.

Examining the impact of precarious manhood on the mental health of sexual minority men living in Kenya, we hypothesized that (a) men who have sex with men exclusively (MSME) and men who have sex with men and women (MSMW) would display differential patterns of conformity to norms of masculinity; (b) these differences would result in distinct patterns of association between masculine conformity and symptoms of psychological distress for MSME and MSMW; and (c) conformity to norms of masculinity would be bidirectionally associated with symptoms of depression and anxiety. Using data collected from 391 young men who participated in a community-based, cross-sectional study of HIV-related risk and resilience among young sexual minority men in western Kenya, we ran a multivariate analysis of variance (MANOVA) to assess differences in conformity to masculine norms and four hierarchical linear regression models to examine the associations between conformity to masculine norms and symptoms of anxiety and depression for MSME and MSMW. MANOVA results revealed no significant differences between MSME and MSMW in overall conformity to masculinity, although MSMW were significantly more likely to conform to the masculine norm of power over women. Regression results revealed that conformity to norms of masculinity was bidirectionally associated with psychological distress and that these patterns of association were distinct for MSME and MSMW. The discussion explores possible explanations for revealed differences between MSME and MSMW using existing research. Clinical implications, limitations, and opportunities for future research are also discussed.

Prevalence and predictors of injuries in Kenya: findings from the national STEPs survey.

BACKGROUND: Injuries are becoming an increasingly important public health challenge globally, and are responsible for 9% of deaths. Beyond their impact on health and well-being, fatal and non-fatal injuries also affect social and economic development for individuals concerned. Kenya has limited data on the magnitude and factors associated with injuries. This study sought to determine the magnitude and risk factors for injuries in Kenya and to identify where the largest burden lies. METHODS: A national population-based household survey was conducted from April-June 2015 among adults age 18-69 years. A three-stage cluster sample design was used to select clusters, households and eligible individuals based on WHO guidelines. We estimated the prevalence of injuries, identified factors associated with injuries and the use of protective devices/practices among road users. Multivariate logistic regression was used to identify potential factors associated with injuries. RESULTS: A total of 4484 adults were included in the study. Approximately 15% had injuries from the past 12 months, 60.3% were males. Four percent of the respondents had been injured in a road traffic crash, 10.9% had experienced unintentional injuries other than road traffic injuries while 3.7% had been injured in violent incidents. Among drivers and passengers 12.5% reported always using a seatbelt and 8.1% of the drivers reported driving while drunk. The leading causes of injuries other than road traffic crashes were falls (47.6%) and cuts (34.0%). Males (p = 0.001), age 18-29 (p < 0.05) and smokers (p = 0.001) were significantly more likely to be injured in a road traffic crash. A higher social economic status (p = 0.001) was protective against other unintentional injuries while students had higher odds for such types of injuries. Heavy episodic drinking (p = 0.001) and smoking (p < 0.05) were associated with increased likelihood of occurrence of a violent injury. CONCLUSIONS: Our study found that male, heavy episodic drinkers, current smokers and students were associated with various injury types. Our study findings highlight the need to scale up interventions for injury prevention for specific injury mechanisms and target groups. There is need for sustained road safety mass media campaigns and strengthened enforcement on helmet wearing, seatbelt use and drink driving.

Resilience among gay/bisexual young men in Western Kenya: psychosocial and sexual health outcomes.

OBJECTIVE: To explore associations between intrapersonal and interpersonal factors and both sexual and psychosocial resilient outcomes among young gay, bisexual, and other men who have sex with men (GBMSM) in Western Kenya. DESIGN: Cross-sectional observational study. METHODS: Five hundred and eleven GBMSM ages 18-29 were recruited from nine communities in Western Kenya using community-based mobilization strategies. Participants completed an audio computer-assisted self-interview survey in English or Duhluo. We estimated four three-step hierarchical linear regression models to examine associations between predictors (intrapersonal and interpersonal factors) and four resilient outcomes (psychological well-being, self-esteem, condom use, HIV testing). RESULTS: Psychosocial well-being model (modeled conversely as depression/anxiety) was significant (F(13,424) = 106.41, P < 0.001, R = 0.765) with loneliness, lesbian/gay/bisexual (LGB) difficult process, LGB identity superiority, and reactions to trauma as predictors. Self-esteem model was significant (F(12,425) = 6.40, P < 0.001, R = 0.153) with known HIV-seropositivity, perceived social support, internalized homonegativity, and LGB difficult process as predictors. Condom use model was significant (F(13,379) = 4.30, P < 0.001, R = 0.128) with perceived social support, self-esteem, and reactions to trauma as predictors. HIV testing model was significant (F(12,377) = 4.75, P < 0.001, R = 0.131) with loneliness, LGB identity uncertainty, LGB difficult process, and LGB identity superiority as predictors. CONCLUSION: This study demonstrates the variety of ways in which intrapersonal and interpersonal factors are associated with HIV-related resilient outcomes for young GBMSM in Western Kenya. HIV prevention programs for this population should be developed in collaboration with GBMSM and include intervention components that promote resilience.

Sensitivity of fever for diagnosis of clinical malaria in a Kenyan area of unstable, low malaria transmission.

BACKGROUND: Malaria in highland areas of Kenya affects children and adults. Local clinicians include symptoms other than fever when screening for malaria because they believe that fever alone does not capture all cases of malaria. METHODS: Individuals who presented to dispensaries in a highland Kenya site of low, unstable malaria transmission from 2007-2011 with 1 or more of 11 symptoms were tested by microscopy for malaria. Clinical malaria was defined as asexual Plasmodium falciparum infection on peripheral blood smear in an individual with any screening symptom. Asymptomatic P. falciparum infection was assessed in a cohort at ten time points to determine the extent to which symptomatic episodes with parasitaemia might be attributable to baseline (asymptomatic) parasitaemia in the community. RESULTS: 3,420 individuals were screened for malaria, 634 < 5 years of age and 2,786 ≥ 5 years of age. For the diagnosis of clinical malaria, the symptom of fever had a sensitivity and specificity of 88.9% and15.4% in children <5 years, and 55.8% and 54.4% in children ≥5 years, respectively. Adding the symptom of headache increased sensitivity to 94. 4% in children <5 years and 96.8% in individuals ≥5 years, but decreased specificity to 9.9% and 11.6%, respectively, and increased the number of individuals who would be tested by 6% and 92%, respectively. No combination of symptoms improved upon the presence fever or headache for detection of clinical malaria. In the cohort of asymptomatic individuals, P. falciparum parasitaemia was infrequent (0.1%). CONCLUSION: In areas of low, unstable malaria transmission, fever is a sensitive indicator of clinical malaria in children <5 years, but not in older children and adults. Adding headache to fever as screening symptom increases sensitivity of detection in individuals ≥5 years old at the cost of decreased specificity. Screening for symptoms in addition to fever may be required to accurately capture all cases of clinical malaria in individuals ≥5 years old in areas of low malaria transmission.

Pattern of pedestrian injuries in the city of Nairobi: implications for urban safety planning.

Pedestrians are overrepresented in road traffic injuries and deaths in Nairobi, the capital city of Kenya, yet little research has been done to provide better understanding of the characteristics of pedestrian injuries. This paper presents the data obtained from road traffic injury admissions to Kenyatta National Hospital (KNH) over a 3-month period starting from 1 June to 31 August 2011. A total of 176 persons involved road traffic injuries in Nairobi were admitted to KNH during this period. Pedestrians comprised the highest (59.1 %) proportion of road traffic injury admissions, followed by motor vehicle passengers (24.4 %) and motor cyclists (9.7 %). Bicyclists and drivers accounted for 5.1 and 1.7 %, respectively. Cars (39.4 %) were the leading category of motorized four-wheeler vehicles that were involved in collisions with pedestrians, followed by matatus (35.5 %). Seventy percent of pedestrians were hit while crossing the road, 10.8 % while standing by the road, and 8.1 % while walking along the road. The highest proportion of pedestrian crashes occurred on Saturdays (25.5 %) and Sundays (16.7 %). Most of the pedestrian injuries (67.7 %) affected the limbs. The paper argues that safety of pedestrians should be a priority in road safety efforts in the city of Nairobi. Urban road safety planners should adopt existing cost-effective interventions to improve the safety of pedestrians such as area-wide traffic calming to limit the speeds of motor vehicles to 30 km/h, providing sidewalks for pedestrians, traffic calming in residential neighborhoods, people-and-not-car-oriented urban road designs, traffic education, and enforcement of traffic regulations.

The use of non-standard motorcycle helmets in low- and middle-income countries: a multicentre study.

BACKGROUND: The use of non-standard motorcycle helmets has the potential to undermine multinational efforts aimed at reducing the burden of road traffic injuries associated with motorcycle crashes. However, little is known about the prevalence or factors associated with their use. METHODS: Collaborating institutions in nine low- and middle-income countries undertook cross-sectional surveys, markets surveys, and reviewed legislation and enforcement practices around non-standard helmets. FINDINGS: 5563 helmet-wearing motorcyclists were observed; 54% of the helmets did not appear to have a marker/sticker indicating that the helmet met required standards and interviewers judged that 49% of the helmets were likely to be non-standard helmets. 5088 (91%) of the motorcyclists agreed to be interviewed; those who had spent less than US$10 on their helmet were found to be at the greatest risk of wearing a non-standard helmet. Data were collected across 126 different retail outlets; across all countries, regardless of outlet type, standard helmets were generally 2-3 times more expensive than non-standard helmets. While seven of the nine countries had legislation prohibiting the use of non-standard helmets, only four had legislation prohibiting their manufacture or sale and only three had legislation prohibiting their import. Enforcement of any legislation appeared to be minimal. INTERPRETATION: Our findings suggest that the widespread use of non-standard helmets in low- and middle-income countries may limit the potential gains of helmet use programmes. Strategies aimed at reducing the costs of standard helmets, combined with both legislation and enforcement, will be required to maximise the effects of existing campaigns.

Low reliability of home-based diagnosis of malaria in a rural community in western Kenya.

INTRODUCTION: Home-based management of malaria is promoted as a major strategy for improving prompt delivery of effective malaria treatment in Africa. This study aimed to determine the proportion of children who tested positive for malaria with routine light microscopy among those whose mothers had made a home-based diagnosis in a rural community in Western Kenya. METHODOLOGY: This cross-sectional study was conducted at Bokoli location, Bungoma East District in November and December 2007. Mothers of children five years of age or under with malaria diagnosed by their mothers were interviewed (n = 96). Duplicate blood smears were collected, stained by field stain A (Methylene blue, Azure) and B (Eosin), and examined for malaria parasites using light microscopy. RESULTS: Only 30/96 (31.2%) specimens were positive for Plasmodium falciparum. Elevated temperature (70/96; 72.9%) in their children was the most commonly cited criterion for diagnosis of malaria by the mothers. In 57 of the 96 cases, information was given by the mothers regarding treatment during the current malaria episode; of these, 10 (17.5%) had received treatment for malaria, but six (60%) of these were parasite negative. This means that only 4/21 (19.0%) with positive smear microscopy received treatment. The most common anti-malaria drugs used were Fansidar (37.8%) and Metakelfin (29.7%). CONCLUSION: The difficulty of diagnosing malaria accurately at home increases the urgent need for improved diagnostic tools that can be used at the community level in poor populations. Intervention measures are needed to increase the treatment rate to reduce reservoirs and malaria parasite transmission.

Low Reliability of Home-Based Diagnosis of Malaria in a Rural Community in Western Kenya

Introduction: Home-based management of malaria is promoted as a major strategy for improving prompt delivery of effective malaria treatment in Africa. This study aimed to determine the proportion of children who tested positive for malaria with routine light microscopy among those whose mothers had made a home-based diagnosis in a rural community in Western Kenya. Methodology: This cross-sectional study was conducted at Bokoli location; Bungoma East District in November and December 2007. Mothers of children five years of age or under with malaria diagnosed by their mothers were interviewed (n = 96). Duplicate blood smears were collected; stained by field stain A (Methylene blue; Azure) and B (Eosin); and examined for malaria parasites using light microscopy. Results: Only 30/96 (31.2) specimens were positive for Plasmodium falciparum. Elevated temperature (70/96; 72.9) in their children was the most commonly cited criterion for diagnosis of malaria by the mothers. In 57 of the 96 cases; information was given by the mothers regarding treatment during the current malaria episode; of these; 10 (17.5) had received treatment for malaria; but six (60) of these were parasite negative. This means that only 4/21 (19.0) with positive smear microscopy received treatment. The most common anti-malaria drugs used were Fansidar (37.8) and Metakelfin (29.7).Conclusion: The difficulty of diagnosing malaria accurately at home increases the urgent need for improved diagnostic tools that can be used at the community level in poor populations. Intervention measures are needed to increase the treatment rate to reduce reservoirs and malaria parasite transmission

Supporting formal education to improve quality of health care provided by mothers of children with malaria in rural western Kenya.

BACKGROUND: Home management of malaria (HMM) has been shown to be an effective strategy for reducing childhood mortality from malaria. The direct and especially indirect costs of seeking health care from formal facilities may be substantial, providing a major barrier for many households. Further evaluations of HMM and community-based utilization of available options will help to optimize treatment strategies and maximize health benefits. The purpose of this study was to determine the effect of education, occupation, and family income on the choice of health care options for malaria. METHODOLOGY: This was a cross-sectional, community-based study conducted between November 2007 and December 2007, using quantitative data collection methods. Mothers of children aged younger than five years were interviewed using a questionnaire to elicit responses on the mothers' level of education, occupation, income and malaria health care options. RESULTS: A total of 240 mothers of children aged younger than 5 years were interviewed between November and December, 2007. There was a direct relationship between formal education and occupation. The mean monthly family income was highest among those employed (KSh. 14,421) followed by businesswomen (KSh. 3,106) and farmers (KSh. 1,827) respectively (p<0.01). Those employed were more likely to take their ill children to a health facility (p = 0.05) or choose an antimalarial drug for home treatment. CONCLUSION: Supporting formal education may scale up the income of family health care providers and improve the quality of HMM among children living in rural communities.

Distribution of orofacial clefts and frequent occurrence of an unusual cleft variant in the Rift Valley of Kenya.

OBJECTIVE: To investigate the pattern and distribution of nonsyndromic orofacial clefts among patients in the Rift Valley region of northwestern Kenya. METHODS: Subjects were categorized anatomically for occurrence of an atypical cleft lip variant (ACL), typical cleft lip (CL), cleft lip and palate (CLP), or cleft palate (CP), and family history of orofacial clefts. Tribal ethnicity data were obtained from both cleft and noncleft clinic attendees. RESULTS: There were 194 patients with CL (52.7%), 153 with CLP (41.6%), and 21 with CP (5.7%). CL constitutes a greater fraction of orofacial clefts in the Rift Valley region than reported elsewhere in Africa, principally due to frequent occurrence of ACL (52.5% of all CL). Among noncleft clinic attendees there was a lower fraction of Bantu and larger fraction of Nilotic-Paranilotic tribal ethnicity than in Kenya overall. In contrast, among patients with orofacial clefts there was significant underrepresentation of Bantu and overrepresentation of Nilotic-Paranilotic tribes, particularly Kalenjin. Patients of Kalenjin origin had a much higher rate of positive family history of orofacial clefts than Bantu patients. CONCLUSIONS: There is an unusual anatomic distribution of orofacial clefts in the Kenya Rift Valley, with frequent occurrence of an atypical CL variant. Our findings indicate that Bantu tribes have lower risk of orofacial clefts than Nilotic-Paranilotic tribes, possibly due to inherited genetic differences, perhaps accounting for the relatively low prevalence of orofacial clefts through much of Africa.

Innovative approaches to application of information technology in disease surveillance and prevention in Western Kenya.

We describe an electronic injury surveillance system that provides data for improving patient care and monitoring injury incidence and distribution patterns. Patients with injuries visiting a rural Kenyan primary care center were enrolled consecutively over 14 months. Injury information was added onto an existing medical record database that captures data for each patient visit. A new injury data encounter form and entry screen were created that included geographical coordinates of the injury site. These coordinates were obtained using a handheld global positioning system (GPS) device, and data were downloaded to the database and linked to each patient. We created digital maps of injury spatial distribution using geography information systems (GIS) software and correlated injury type and location with patients' clinical data. A computerized medical record system, complemented by GIS technology and an injury-specific component, presents a valuable tool for injury surveillance, epidemiology, prevention and control for communities served by a specific health facility.

Evaluation criteria for the district health management information systems: lessons from the Ministry of Health, Kenya.

BACKGROUND: The District Health Management Information Systems (DHMISs) were established by the Ministry of Health (MoH) in Kenya more than two decades ago. Since then, no comprehensive evaluation has been undertaken. This can partly be attributed to lack of defined criteria for evaluating them. OBJECTIVE: To propose evaluation criteria for assessing the design, implementation and impact of DHMIS in the management of the District Health System (DHS) in Kenya. METHODS: A descriptive cross-sectional study conducted in three DHSs in Kenya: Bungoma, Murang'a and Uasin Gishu districts. Data was collected through focus group discussions, key informant interviews, and documents' review. The respondents, purposely selected from the Ministry of Health headquarters and the three DHS districts, included designers, managers and end-users of the systems. RESULTS: A set of evaluation criteria for DHMISs was identified for each of the three phases of implementation: pre-implementation evaluation criteria (categorised as policy and objectives, technical feasibility, financial viability, political viability and administrative operability) to be applied at the design stage; concurrent implementation evaluation criteria to be applied during implementation of the new system; and post-implementation evaluation criteria (classified as internal - quality of information; external - resources and managerial support; ultimate - systems impact) to be applied after implementation of the system for at least three years. CONCLUSIONS: In designing a DHMIS model there is need to have built-in these three sets of evaluation criteria which should be used in a phased manner. Pre-implementation evaluation criteria should be used to evaluate the system's viability before more resources are committed to it; concurrent (operational) - implementation evaluation criteria should be used to monitor the process; and post-implementation evaluation criteria should be applied to assess the system's effectiveness.