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Health Information Forum: Working together to improve access to reliable information for healthcare workers in developing and transitional countriesWorkshop 3: The role of local resources and local publishingThe Workshop was held on Tuesday 10 November 1998 at the British Medical Association, Tavistock Square, London. The meeting was the third 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 Harrison Spencer (Dean, London School of Hygiene and Tropical Medicine) Guest speakers: Dr Erik Nordberg (Medical Director, African Medical Research Foundation, Nairobi, Kenya) Isabel Carter (Editor, Footsteps, Tear Fund) Participants Dr Joseph Ana (Nigerian Medical Forum) Announcements Neil Pakenham-Walsh drew the attention of the meeting to a study by the Institute for Development Studies (Sussex) on health information and communications, commissioned by the Department for International Development. All those with an interest in health information in developing and transitional countries are encouraged to attend the DFID/IDS consultative meeting, which will be held in early-mid January (date and venue to be confirmed). Jean Shaw said a few words about the African Index Medicus (AIM) database, which is a collaborative project collecting information published in Africa that has usually not been recorded in any other database. Much of it comprises what could be considered `grey' literature. Jean made the case for this kind of information, quoting from e-mails she had received from Margaret Mathai (WHO, African Regional Office, Zimbabwe) and Elizabeth Mbatia (Librarian, AMREF, Nairobi). AIM allows the experience of individual workers to be shared. The objective was to exchange ideas and experience relating to: Access to health information: The role of local resources and local publishing 1 What are the advantages and disadvantages, strengths and weaknesses, of local publications? Which target audiences are they best placed to serve? 2 What are the advantages and disadvantages, strengths and weaknesses, of generic publications? Which target audiences are they best placed to serve? 3 How might NGOs and publishers, North and South, work together more effectively to improve access to reliable, appropriate information for healthcare workers in resource-poor countries? Speaker 1: Dr Erik Nordberg: Medical Director, African Medical and Research Foundation The gap between need and demand In Dr Nordberg's experience, there is a large gap between need and demand for health information. Health information needs are increasing rapidly, especially for middle-level staff. The number of health facilities and the number of staff have increased. The tasks that have to be performed are becoming more complex and staff need to be familiar with epidemiological and demographic changes. As medical knowledge increases there is obviously more information to be disseminated. By contrast, the demand for information is relatively low in Dr Nordberg's experience. Many African health workers do not make use of health learning materials, even where they are present. There is not much pressure on healthcare workers to keep up to date and Dr Nordberg suggested that perhaps incentives are needed. Dr Nordberg suggested that there is inadequate donor support for knowledge dissemination. Furthermore, there is little knowledge in Africa of what resources are actually available. The result is a lack of health learning materials for those who need it, and a slow uptake of new techniques, methods and policies. Provision Present materials need to be revised/updated and new methods found to disseminate them. In particular, materials need to be affordable: resources are scarce in developing countries, particularly in the health sector, and ability to purchase is declining. Books and journals are generally unaffordable. Possibilities to improve the situation include: action by training institutions to encourage the use and production of information; newspapers, radio, telephone etc.; publishers could be approached to allow free photocopying of selected materials; finding support from donors for local publishing of health learning materials. There have been important developments in new technology for information transfer but these are only relevant to senior staff and to librarians. It will be a long time before peripheral health workers can be reached in this way. Nevertheless, Dr Nordberg said the new technology gave people like him access to health information which could then be disseminated in appropriate form, and with modifications if needed, to other health workers. AMREF's activities in health information provision AMREF's work is mainly in the countries of East Africa and in South Africa, although it has supplied consultants further afield. The range of activities in which AMREF is involved is quite remarkable, including community-based projects, health education, reproductive health, emergency evacuations, and research and training in laboratory medicine. AMREF is involved in health library development, and in the development, production and distribution of health learning materials. It has been active in such work for over 25 years but both production and distribution are proving increasingly problematic because of costs and because of the difficulties of reaching peripheral workers. AMREF has published 52 books but many are in need of revision and/or updating.There are book distribution units in Nairobi, Kampala and Dar es Salaam. These units distribute AMREF's own publications plus a limited range from other publishers. There is also a printing unit on Dar es Salaam, although most printing is done by commercial printers. Development of health learning materials will continue to be a major priority for AMREF, with the needs of middle-level staff particularly in mind. Quality and affordability are both seen as important. AMREF seeks to collaborate with other organizations with similar goals. Dr Nordberg urged those of us involved in this area in the UK to work towards improving access to information for workers at middle level and in the field. Observations from the floor following Dr Nordberg's presentation included that health workers needed training to make proper use of books. There was also interest in the idea of organizations like AMREF collecting health information electronically and then `reshaping' it before distributing it in print to district level. Isabel Carter: Editor of Footsteps Isabel has submitted the text of her talk, which reads as follows. For the past 10 years I have edited the newsletter Footsteps. This is funded by Tearfund and is available, free of charge in English, French, Spanish and Portuguese with a world-wide distribution of over 33,000. It is written in simple language for those who may be reading in a second language, and aims to be very practical in content. We assume that many of those reading have little or no access to resources or funding. It covers a wide variety of subjects appropriate to community interests, of which health is only one. Over the years it has become apparent that articles in Footsteps are being adapted, translated and shared in a variety of ways. Background to research A research programme was initiated in 1995 to investigate the access of third world farmer groups to agricultural information. The research was funded by DFID and combined PhD study at Leeds University. It comprised three techniques to gain a balanced picture of who is producing what in terms of printed information on agriculture and whether the materials both reach and meet the needs of farmers for information. Two of these sections also directly relate to the availability of health rescues.
Postal survey findings Surveys were sent to groups and organisations who had indicated their involvement in sharing information, together with a random sample of Footsteps readers. 196 responses from 49 countries were received. In total 60% of these were producing printed information of some nature. However 47% of the control sample were also producing materials. Just over half lacked adequate office facilities indicating that survey respondents ranged from large well equipped organisations to small groups lacking funding: 58% were large NGOs and Government organisations 31% were Grassroots Development organisations 11% were Rural People's Associations. Postal survey respondents rated books and newspapers as their most important source of information, four times more important than other sources mentioned such as NGOs and resource people. Over half the respondents received 3 or more newsletters but few (5%) commented that they received too many to read. Only a quarter of respondents were reasonably satisfied with their ability to discover necessary information on a given subject. The remainder listed various restrictions, a lack of funding to buy books, a lack of contacts and irrelevant information. The most well used methods of sharing information were small group teaching, drama and role plays, teaching notes and posters or charts. Language preferences showed a strong bias towards reading in both national and local languages, preferences rarely reflected in available materials. Of the printed materials produced by respondents, teaching notes, newsletters and booklets were the most important. Two thirds of respondents either owned or had access to a typewriter or computer, but many had problems in obtaining supplies, particularly of paper and ink or spare parts. Informal survey of organisations in Ghana and Uganda sharing information Over a third of the 95 organisations visited, produced some kind of printed information: newsletters, reports and teaching notes in particular. These were usually in the national language and produced by urban based organisations. Most were aimed at staff in similar organisations and inaccessible to farmers. The language level used made their content very difficult for readers without sixth form or university education to understand. Resourcing was not the key limiting factor, rather motivation and policy. Just 13% were producing materials aimed at grassroots level, often in local languages. Production of these was often by highly motivated individuals with a clear vision of what is needed, working with local Grassroots Development Organisations (GDOs) and often based in smaller towns. Production of these was severely restricted by lack of resources. What is reaching the farmers? Participatory research techniques examined the present sources of agricultural information for farmers and their preferences in receiving information. In Uganda their own experience and observations (26%) were rated most important as a source of new ideas, followed by friends (11%), trainers (10%) (usually informal group leaders) elders (9%), NGOs (9%) and the church (8%). Sources outside the immediate community provided just a third of new ideas and as well as NGOs, radio (7%) books (6%) and extension agents (4%) were mentioned. Members stressed their desire to have more access to these sources. Radio broadcasts in local languages tended to be transmitted at difficult times and extension agents were rarely seen. In Ghana farmers rated extension agents (15%), radio (13%) and NGOs (12%) as much more apparent and useful. This is in part due to the huge funding inputs from the World Bank into the extension services. Nearly a third of groups included printed information in their top five most trusted sources despite the fact so few had access to them. Over a third of groups had no access at all to printed information on agriculture and just 6% had good access with over two thirds of members owning at least one item of information. When groups with no literate members were asked if printed information was seen as important, they stressed their desire to obtain materials: “The school teacher or our children can read them to us”. What are the consequences? Research with the self formed farmer groups revealed a number of stages of development with reference to their access to outside information. When access is good, printed information provides one of five key factors which may result in the empowerment of groups. A highly significant relationship exists between the groups' access to printed information and the likelihood of the group providing informal training both within and outside their group. 63% of groups with medium or improved access to books carried out regular training within their group, compared with 9% of groups without access. Policy implications · Rural grassroots farmers and thus presumably health workers, are indeed able to access printed information even through the barriers of language and low literacy levels. · Printed information cannot replace the enormous benefit of a sensitive and caring trainer. However where these are available, it can provide useful back-up material. When such people are not available (the majority of situations) it is a means of distributing useful information to health workers over a wide geographical area which can remain useful over many years. · Print is a well trusted source of information · Printed information is scarce and much valued, with the consequence it is a relatively permanent method of sharing information · Good resources are produced by key individuals not by policy. Discussion of Isabel's presentation focused mainly on how keen farmers seemed to be to read, which seemed to contrast with the impressions of Dr Nordberg and others as regards health workers. Discussion group 1: What are the advantages and disadvantages, strengths and weaknesses of local publications? Which target audiences are they best placed to serve? The group identified three possible meanings of `local' health information materials: produced outside the area but targeted to specific areas where they are to be used, produced in the area by those who live there, and produced by those who live there and in a local language. The group assumed `local' to mean `locally published/produced' (ie the second and third groups) and focused specifically on such publications. The target audience was seen as a key issue, with peripheral workers the most important. The need for local language publishing was considered to vary; in Uganda most health workers have reasonable English but this is less so in Tanzania and in Ethiopia very few have adequate English. In many situations the best option may be publishing in simple English, which is much cheaper than local language publishing. All health information (HI) publishing has problems with cost and the small size of the market, but this is particularly so for publications in local language. Print is trusted more than radio but good editing, design and printing are important and may not be available locally. Quality and appropriateness are both important in HI and both depend on the sources from which the information is collected. Local collection of information is desirable. Local collection and publishing also encourages useful networking. Discussion group 2: What are the advantages and disadvantages, strengths and weaknesses of generic publications? Which target audiences are they best placed to serve? The term `generic' was new to members of the group. It was decided that there were `worldwide generics' (for example the BMJ and WHO publications) and generics intended for resource-poor countries (Africa Health, HealthLink publications, Practical Pharmacy etc.) Only the end-users of such publications could really assess how useful they were and there was inadequate information on what end-users thought. It was also hard to generalise about generic publications because strengths and weaknesses varied so much between types of publication and individual publications. Nevertheless the following points were agreed on. Strengths Generics are more trusted, more up-to-date and make readers feel part of a worldwide community of healthcare providers. Production standards are generally higher and it is easier to keep generic books in print. Weaknesses Generic publications often contain information that is inappropriate and this leads to frustration. They tend to be more expensive. The level of language used is often too high. Information published in an international publication requires adapting to local situations but even information published in the same country may require some modification. It should also be noted that just because a publication has been brought out by a local team or individual it is not necessarily appropriate to local needs. Before any HI is put to effective use it seems to need the presence of a particular individual or other local catalyst to make things happen. Discussion group 3: How might NGOs and publishers, North and South,worktogether more effectively to improve access to reliable, appropriate information for healthcare workers in resource-poor countries? Encouraging reading and making learning part of the culture of health workers are important goals and there should be collaboration towards achieving them. How could people be motivated to use HI? Suggestions included demonstrating how it could be done, and making it an obligatory requirement for continuing medical education or for free insurance policies (!) Peripheral workers in particular might be harder to motivate. Publishers should strive to make their publications appropriate and in particular note the need for brevity. NGOs could collaborate with publishers in, for example, making it possible to include good colour illustration. NGOs could also become `mediators of the electronic world' and take on the task of receiving HI through that medium in order to disseminate by conventional means to peripheral workers. The fragmentary nature of the developing world meant that there were many unconnected projects but collaborating was still desirable where possible. Final discussion HS said the printed word was not enough; HI must also be used appropriately. JA said group working encouraged reading. Peter Bewes stressed the need for good quality editing and production and wondered how people in the South could be trained in this. Neil Pakenham-Walsh said INASP and others were involved in organizing workshops for journal editors and publishers, and described the Hans Zell `Handbook of Good Practice in Journal Publishing' as being a useful complementary tool for such workshops. JS said the European Association of Science Editors could perhaps help, via the African Association of Science Editors. Liz Woolley said it was the needs of isolated health workers that needed particular consideration. Neil Pakenham-Walsh spoke of other problems. There was little available on the Internet as yet that was useful to isolated health workers in the developing world. For local publishers, electronic access to full-text, good quality basic information is limited, even from the major health agencies. Whether printed or electronic, reproduction and adaptation of generic materials for local use are often hampered by copyright restrictions – it is still necessary, for example, to obtain permission to reprint materials from WHO. Chris Zielinski said there were good reasons for WHO maintaining its permission procedures. He also said there should be a better flow of HI from South to North and from South to South. Paul Chinnock said that when publications from the North included material written by health workers in the South it boosted the level of interest for readers and created a feeling of ownership. Professor Spencer said the experience of emerging nations in recent years reflected much of what had been said here about the developing world. Health Information Forum: Workshop 4, January 19th 1999 The fourth workshop will be at the BMA on 19th January, at 4pm to 6pm. The theme of the meeting will be `Where is the political and financial commitment to health information provision'. Participation is free of charge. Limited places are available - please contact Neil Pakenham-Walsh (email ) to reserve a place. |
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