International Network for the Availability of Scientific Publications
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Health Information Forum: Working together to improve access to reliable information for healthcare workers in developing and transitional countries

Workshop 2: Meeting information needs for professional education

Report of Proceedings

The workshop was held on Tuesday 8 September 1998 at the British Medical Association, Tavistock Square, London. The meeting was the second of an initial series of six meetings, whose overall objectives are:

to facilitate contact and sharing of skills and experience

to promote analysis

to undertake advocacy

among and across the various sectors of the health information provider community, with the common purpose of improving access to reliable information for healthcare workers in developing and transitional countries.

Chair: Professor Lesley Rees (Director, International Office and Director of Education, Royal College of Physicians).

Guest speakers:

Helga Patrikios (Deputy University Librarian, University of Zimbabwe)
Irene Bertrand (Technical Cooperation Librarian, WHO, Geneva; AHILA-Net Coordinator, Association for Health Information and Libraries in Africa)

Participants:

Dr Geoff Barnard (Institute for Development Studies, University of Sussex)
Dr Peter Bewes (former editor of CME, Uganda)
Ann Burgess (Nutrition Society)
Michael Carmel (South Thames Library and Information Services, Partnerships in Health Information)
Iain Chalmers (Cochrane Collaboration)
Bob Cheshier (University of Ohio)
Andrew Chetley (Healthlink, formerly AHRTAG)
Paul Chinnock (Editor, Africa Health and Medicine Digest)
Dr Michael Eddlestone (Editor, Oxford Handbook of Tropical Medicine)
Elaine Harden (Commonwealth Pharmaceutical Association)
Florence Harding (Commonwealth Secretariat)
John Hudson (British Medical Association)
Manjit Kaur (ECHO international Services)
Resoum Kidane (Sheffield University)
Jane Lethbridge (Healthlink Worldwide, formerly AHRTAG)
Steve McDonald (Cochrane Collaboration)
Dr Pauline Monro (Neurology International Partnership Programme)
Frank Norman (National Institute for Medical Research, Partnerships in Health Information)
Dr Neil Pakenham-Walsh (INASP-Health)
Dr Bill Posnett (Healthlink Worldwide, formerly AHRTAG)
Carol Priestley (Director, INASP)
Victoria Richardson (Healthlink Worldwide, formerly AHRTAG)
Jean G. Shaw (Partnerships in Health Information, formerly SatelLife UK)
Anasuya Sengupta (Oxford University)
Anna Tomlinson (Royal College of Physicians)
Liz Woolley (CAB international)
Virginia Yee (World Bank)

Apologies:

Professor KGMM Alberti (Royal College of Physicians)
Dr Joseph Ana (Nigerian Medical Forum)
Dr Douglas Buchanan (British Council)
Christopher Coyer (Wellcome Trust)
Dr Colin McDougall (tropical dermatologist)
Philippa Saunders (Essential Drugs Project)
Dr Richard Smith (British Medical Journal)

Proceedings

The objective of the meeting was to exchange ideas and experience relating to:

The health sciences library: How can the `health information provider' community work more effectively to support:

1. increased access to essential printed materials?

2. increased access to and appropriateness of Internet services and CD-ROMs?

3. increased support through training, document delivery, partnerships, networking, advocacy?

Helga Patrikios

MEDICAL EDUCATION IN POORER COUNTRIES- SEEKING BEST VALUE IN INFORMATION SUPPORT

May I thank you for inviting me to be here and to speak at this meeting of the Health Information Forum and for your interest in the important matter of information support for medical education - I am very glad and grateful to have this chance to discuss the problems that dominate many hours of my working life- it's not often one gets active encouragement to dwell on the besetting and obsessing difficulties of one's work...

1. ZIMABWE My observations here won't represent particularly the place I work in - in many ways Harare, and its Medical School, are not typical of the sub-Region north of the Limpopo. The Medical School at University of Zimbabwe is seen as a centre of relative excellence in the sub-Region, and its library too. Both the School and the Library have been able to attract donor funding for many projects; and the beneficial effects of those projects are often evident.

2. ADVERSE ECONOMIC TRENDS . But in Zimbabwe we are affected by the same apparently irresistible trend of economic decline affecting most other countries of the sub-Region. That trend has worsened at the same time as two relatively new factors began to show their effects - AIDS, which has taken its highest toll in Central and East Africa; and ESAP, the economic structural adjustment programme imposed on - adopted by? - Zimbabwe and many of the poorer countries.

3. MEDICAL EDUCATION. Economic conditions have inevitably affected medical education - teaching, facilities and resources, including libraries. Lecturers' salaries have lost value along with catastrophic devaluations of local currencies; health services and medical schools have had to contend with the migration of doctors and other health professionals, and with the effects of many of them having to supplement their salaries with private practices, at the expense of their teaching or public service commitments.

4. INADEQUACY OF INFORMATION RESOURCES. Information support for medical education under these circumstances is not good. Levels of information support at most medical schools, and for national health services too, range from gravely to tragically inadequate. The value of budgets declines steadily - some libraries no longer have a budget, except for salaries and stationery.

5. BOOM-FLOP SYNDROME. Most of you will be familiar with the picture I've given - but this generally gloomy scene is often confusingly blurred by what has been called the Boom-Flop syndrome: Boom being a period when library budgets are immensely inflated - for a limited period only - by generous donor grants; and Flop being experienced when budgets revert to negligible monthly payouts, or evaporate altogether in the worsening economic climate. In the Boom phase books and journals are ordered, often in haste and without careful consideration of priorities, to meet a donor deadline. In the more prevalent Flop phases library users grow accustomed to their inability to access current information - there is a downward spiral in information use, expectations of accessing good information are lost, and health professionals learn to do without. The gap in information access between North and South yawns ever wider.

6. LACK OF DEMAND. A widespread and long-term Flop situation thus results in the chronic lack of demand for reliable and current information described in the July Forum meeting by Dr Pauline Munro in the context of the former Soviet Union. She outlined the consequences: "a resistance to change away from outdated and potentially harmful medical practices and poor ability to evaluate new information ... " Here young hospital doctors tell me they learn early on in their careers to do without adequate information in their daily clinical work - which is hard on them and even harder on their patients. As Dr Munro pointed out, a priority must be to seek the support of gatekeepers, the receptive and influential practitioners and educators in the field, with whom health information providers can co-operate in the improvement and development of information services. * These would necessarily include centrally- and nationally-based WHO and local players.

7. NEEDS ASSESSMENTS. In such a situation of information deficiencies it is important to establish what the priorities should be, for medical education, for practitioners. A recent plan to carry out a wide-ranging assessment of information needs of health professionals and students has stalled - and while this caused some dismay, it might be worth asking now whether such an assessment can be really useful or helpful in establishing priorities. A survey would be made among potential information users who have always lacked adequate access to health information. Most students and practitioners have not been fortunate enough to have been exposed, or have ready access, to the new information technologies, or to the wider ranges of levels and of formats of printed material now available in their fields. How do they know what they need – other than the obvious basic essential books and journals - if they don't know what else is now out there for their better-off colleagues in the developed countries? (A survey I made in 1984 certainly confirmed that doctors working at a great distance from a library like ours felt a strong sense of isolation and of being severely disadvantaged. The priorities they gave were to have basic books and journals available at their hospitals. In most countries these basics are not available in the main centres or medical schools, let alone at district hospitals. )

THE PRIORITIES. I have used the results of that 1984 survey, a study of the value of MEDLINE on CD-ROM (which has been available for nine years in our library) and inputs from colleagues in the Library and the Faculty, as well as reports from other medical librarians north and south, to draw up a list of what we feel are the most cost-effective resources we should try to provide and maintain for our users. (Maintainability, or sustainability - long-term viability - are key factors in making these choices; we have to believe that carefully chosen resources and services will attract support in the longer term from the gatekeepers in the Faculty, among donors, and with management. in the larger Library system too, of course. )

As a realistic minimum, every medical school and national or major urban centre should be able to offer the following:-

A. Collections of all basic undergraduate texts, in multiple copies when possible, or as a Reserve or For Reference Only collection. (The selection of titles provided in the defunct ELBS programme would be a sound basis for this collection. Some titles are still available in ELBS, and there is a move to replace some in the embryonic programme which is replacing ELBS, ELST - Educational Low-priced Sponsored Texts).

B. Free or low cost HealthLink (AHRTAG) and TALC publications; Africa Health, a monthly publication, much prized for being free of charge, practical in content, and glossy to boot.

C. Core journal collections - as few as ten or twenty key journals. These can be selected according to rankings based on, for instance, a count of frequency of a journal's references obtained in a MEDLINE search made using a key-word profile of a country's or sub-region's major health issues. (Our Library has used the MEDLINE searches made to produce a national digest, which are processed by a software programme, Papyrus, into a ranked list of journals. The BMJ, the Lancet, Social Science and Medicine, NEJM etc appear high on these lists, not just titles such as Tropical Doctor ).

D. MEDLINE ON CD-ROM; and other databases: POPLINE (free), The Cochrane Library, (CABhealth - at the right price). MEDLINE abstracts, sad to relate, are used as information complete in itself by many students and lecturers. As reprehensible as this use of abstracts may seem, it is preferable to a complete absence of current books and journals - which is often the only alternative.

E. An Inter-Library Loans/Document delivery service. NB The availability of MEDLINE and of a good document delivery service can compensate well for a very poor journal collection.

F. A photocopying service. If the library or centre has enough customers, a commercial service may be able to take the burden from the librarians.

G. A national digest of journal articles on recent research and development, and a newsletter of the Practical Pharmacy type should be provided free of charge to the country's healthworkers, using MEDLINE abstracts (as described in #3); with abstracts of local unpublished reports and studies, if available.

9. INFORMATION TECHNOLOGIES. Are there long-term and widely applicable means of improving support for medical education? I have drawn up a matrix giving outlines of the priorities, and the values, of printed and electronic sources of information which we believe apply in the case of our Faculty, and are relevant in a national medical library too.

The matrix may help explain why I remain convinced that information technology, the Internet in particular, does not provide magical solutions to the problems we are trying to solve. Until every doctor, every student, has his own PC, the value of the Internet and even E-mail, is as limited as the numbers of people having easy access to a computer.

In Africa this is a very tiny elite.

10. CO-OPERATIVE APPROACHES. Efforts to improve the provision of information for medical education and in the health care sector in poorer countries have so far been piecemeal and few and far between. Most countries have not benefited significantly from, for instance, the new technologies; and may have been unable to buy even ELBS or other low cost books. As a matter of urgency, therefore, possibilities should be investigated for a coordinated and coherent effort of all the interested parties, in order to establish mechanisms for common policies and structures in the provision of minimal information resources in the poorest countries. Ideally, donors may be willing and able to form a consortium concerned with establishing long-term support for minimal health information services to these countries.

[email protected]

Helga Patrikios, Deputy University Librarian, Medical Librarian
University of Zimbabwe, P.O. Box M.P. 45, Mount Pleasant
Harare, Zimbabwe Tel 263-4-791631 Fax 795019 Home 339343

Irene Bertrand

Irene Bertrand, Technical Cooperation Librarian at WHO Headquarters, began by agreeing with Helga that the problems in most of Africa were much more severe than those in Zimbabwe. She praised the high standard of Helga's work.

Irene stressed that WHO was itself a health information provider - indeed probably the world's largest - though she was concerned that some of the materials it produced were not well used. She encouraged us all to think beyond publication itself on to issues concerning distribution (particularly to areas outside the capital cities) and use.

Sadly, health information provision was not top priority for any organisation. The situation is indeed deteriorating and it would be a challenge to change this. The importance of health information has not been effectively communicated to those with influence, despite needs assessments and other representations.

One problem with needs assessments is that isolated health workers and training personnel don't know what is available and so cannot specify what they need. In a health training instute in Lesotho, Africa, for example, trainers were asked what books they would like to have access to and they named texts they had used as students 10-20 years earlier - they had not seen anything else since.

The blue trunk scheme aims to provide trunks of appropriate books and journals to form core libraries at suitable locations. It was started in francophone Africa because HI provision is even poorer there than in anglophone Africa. The project will soon be evaluated. WHO is in the early stages of a scheme for anglophone Africa.

Irene said she was concerned about the unreliability and high cost for developing-country users of the Internet at present. She pointed out, for example, that some health ministries have just one telephone line. Emails and email newsgroups probably have more to offer than the worldwide web. Many are not yet used to the culture of email communication.

Librarians continue to have a low profile, and are further undermined by popular misconceptions such as `Who needs libraries - libraries and librarians will soon be made redundant by the Internet!'

Irene felt publishers should be encouraged to make their materials available on websites and to give free passwords to readers in developing countries.

Discussion group 1

How can the `health information provider' community work more effectively to support increased access to essential printed materials?

Key barriers:

• Postage reliability and costs
• Transport infrastructure
• Ensuring information is `essential' – right information to right people, appropriate to target audience and available diagnostic/treatment resources, high-quality, accessible, reliable, current
• Ensuring information is in a format that is appropriate to target audience

Priorities regarding distribution were:

• Need to evaluate methods for distributing information
  discuss with local journal editors and others about distribution methods
• Support marketing and distribution capacity of local publishers.

The group agreed that participants of the Forum and others would benefit from:

• sharing of experiences of distribution methods, evaluation, and mailing lists
• discussing with journal editors within countries to find out their means of marketing, promoting their journals and newsletters, as well as how they distribute them.

In conclusion, the group emphasized that partnership among NGOs to share key pieces of information about the distribution process is essential.

Discussion group 2

How can the `health information provider' community work more effectively to support increased access to and appropriateness of Internet services and CD-ROMs?

Potential benefits

• CD-ROMs are hugely important in the health sciences library as database tools. Once developed, they are cheap to produce, distribute and update as compared with print materials. CD-ROM drives are robust (or at least more robust than their accompanying hard-drive) in different temperatures etc.
• The www bookshop amazon.com was represented as just one example of how the web might improve access.

Problems

• Technical problems continue to be important, particularly in sub-Saharan Africa: some institutions have only a single phone line - and even that is unreliable.
• Economic situation in some countries means that acquisition and maintenance of ICT is difficult if not impossible for many institutions.
• CD-ROMs are expensive to develop, particularly interactive educational CD-ROMs. The latter are rarely if ever commercially viable for developing-country use. The amount of `how-to' CD-ROM information is therefore limited. Many CD-ROMs are not straightforward to use, particularly for those with little experience of ICT. Where necessary, user education must be included, whether through training or clear CD-ROM based instructions.
• Even where available, full Internet access currently meets only a fraction of information needs.
• The content of material on the Web is vast, of very variable quality, difficult to assess, and increasingly complex.
• Material on the Web is rarely available in local languages.
• The WWW has a surprising lack of easily accessible, practical health information that is relevant to healthcare workers in developing countries.
• Products need to be designed to be appropriate to the functional needs of the target audience.

Conclusions

• The internet and CD-ROM will inevitably become more widely available with or without our input, and this is clearly to be welcomed. Our responsibility as health information providers is to maximize their potential benefits and minimize their weaknesses.
• The WWW and CD-ROM are recognized as an important and welcome additional tool rather than as a panacea. Even where internet is widely available, who among us uses it for all or even most of our information needs?
• Currently, nearly all financial and political commitment is being put into the one basket of ICT, diverting attention and resources from print and other media. Participants emphasized the importance of a combined approach embracing both electronic and conventional media.
• Regarding production of educational CD-ROMs, development is expensive but distribution easy and potential benefits high – more support is needed to make such products more available and affordable.
• Participants suggested promotion of flow of information on an electronic/functional hub-spoke model. In poorer countries, information centres such as academic libraries might act as Internet centres/nodes – similar to the national information centres referred to previously - and be responsible for adaptation (eg to local languages) and distribution to rural areas. Later, when peripheral areas are electronically connected, the academic library might also provide an optional `gateway' website for the peripheral areas, guiding them to useful sites (as at the web site for the University of Zambia Medical School). Networking between institutions is also to be encouraged to prevent any one institution having power.

Discussion group 3

How can the `health information provider' community work more effectively to support training, document delivery, partnerships, networking, advocacy?

What would a UK-DC partnership look like?

• exchange visits
• training opportunities
• email discussion lists
• learning about attitudes and new possibilities
• personal/professional development for UK librarians
• share periodical resources

Visits give librarians an impression of what health information resources and services are available and might be beneficial to their own users.

It is useful to get UK/US organizations to recognize benefit of partnerships. There may be a danger of bypassing local infrastructure when giving large grants; while small partnerships might be more cost-effective.

Participants emphasized the need for closer links with librarians in developing countries, e.g through email discussion lists, exchange visits, joint meetings, and WWW links.

Systemic solutions are needed rather than `sticking plasters'. The Forum and others could be advocating a more systematic approach to addressing health information problems, with the involvement of the essential `big players' such as WHO and international organizations. WHO in particular might act as an important advocate. Similarly, increased coordination of policies by development and funding agencies.

Proposals for further action

Participants discussed the low status of health information provision for healthcare workers in developing countries, which as an issue has hitherto been given low priority, even by organizations such as WHO and the World Bank. The situation with both the latter organizations, however, appears to be more highly recognisant of the importance of investing in health informaiton provision.