Global Healthcare Knowledge System
Understanding information needs
Undertaking health research
Publishing health research
Making health research available
Producing systematic reviews
Developing clinical guidelines
Producing end-user materials
Making end-user materials available
Facilitating use of information
Evaluating the impact of information
Acknowledgement: The knowledge cycle above is adapted from The Lancet 2004 ‘Can we achieve health information for all by 2015?’.
1. Understand information needs.
When considering information needs, it is important to distinguish between perceived needs and actual needs. A primary health worker, for example, may perceive that they need better information on the management of childhood illness, whereas an assessment of actual needs may demonstrate that the health worker actually has a sound knowledge of management of childhood illness, but has important knowledge deficits in relation to infant feeding and prevention of illness.
2. Undertake health research in low-income countries that addresses the disease priorities of the majority poor, as advocated as the 10/90 gap by the Global Forum for Health Research (now merged with Council on Health Research for Development).
3. Publish health research that is relevant to or carried out within low-income countries.
4. Make health research available. Most original research is published in subscription-based journals held by commercial publishers. Medical libraries in low-income countries cannot afford the subscription fees of journals. Arguably the greatest driver for more widespread availability of health research is the Open Access movement, where journals make their content free to everyone. Increasingly, governments and research funding agencies are insisting that health research papers are made openly and publicly available in this way.
5. Produce systematic reviews. A systematic review is a rigorously conducted literature review focused on a single question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine. The Cochrane Collaboration has been a spectacularly successful example of global collaboration for the production of systematic reviews. Most of the source original research is from high-income countries and most systematic reviewers are based in high-income countries. Nevertheless, as a global collaboration, Cochrane has considerable output that is highly practical in low-resource settings and provides good coverage of many of the priority health issues of low-income countries, thanks for example to the work of its Infectious Diseases group, and also the Virtual Reproductive Health Library, a collaboration between Cochrane and WHO, involving production of practical e-resources for health professionals in LICs based on systematic reviews. The Collaboration also gave rise to a Cochrane Developing Countries Network. For reasons that are unclear this has not taken off.
Systematic reviews have and will dramatically help us to implement the knowledge we already have. Their importance needs to be more widely understood by health professionals, by publishers, by the media, and by policymakers.
Systematic reviews have the potential to break down hierarchies between different cadres of health worker. And to reduce idiosyncrasy between different doctors working in the same hospital. Too often, as we have seen in the India paper, there is an unquestioning acceptance by lower cadres to take instructions. What is needed is for lower cadres to develop an understanding of evidence and systematic reviews. The same is indeed true of journalists and citizens – an understanding, at least, that an obscure single study of laboratory mice fed different diets found a slightly increased risk of tumors in those fed exclusively chocolate, should not be reported as “Chocolate causes cancer.”
6. Produce clinical guidelines. Clinical guidelines are formal statements designed to help practitioners and patients decide on appropriate healthcare for specific clinical conditions and/or circumstances. http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/WhatareClinGuide.pdf
The process for guideline development among international organizations has increasingly shifted away from overreliance on expert opinion, and towards a multi-source approach, with systematic reviews taking a central role. The current dominant model is the production of a generic, international guideline that is then available for adaptation by national ministries of health.
7. Produce reference and educational materials. This category includes all information of ANY kind that is written primarily for the healthcare provider (using the term in its broadest sense, from mothers to midwives, nurses and doctors – and also information for promotion of health and prevention of illness, i.e., health education). Ideally this requires a synthesis of generic knowledge, such as systematic reviews and generic guidelines, with relevant local epidemiological and sociocultural knowledge, including a deep understanding of the end-user groups for which the materials are being prepared. To do this well is a highly skilled endeavor requiring well-resourced teams of health information professionals working with educators and representatives of the end-user group. In reality, such expertise and such resources are rarely available, resulting all too often in low reliability and/or low relevance.
8. Make reference and educational materials available. This refers to all processes that make available content that already exists. It includes information delivery mechanisms such as print, TV, radio, internet, mobile phone technology. Of course, the greatest challenge is that the increasing availability of ICTs means that many end-users are moving from a position of information poverty to information avalanche. Using another metaphor, it has been said it is like trying to drink from a fire hose. The problem for the end-user is increasingly to be able to find, appraise and thereby identify information that is both reliable and relevant to their specific, contextual needs at that particular moment, from among the tens of thousands of unreliable and/or irrelevant items of information (including myth, misinformation, and commercially biased information) that are competing for their attention. Librarians play an essential tole in finding and appraising information for end users.
9. Promote use of information. Making information available that is relevant and reliable in every way for the end user is the surest way that the information is used. By contrast, chronic lack of relevant, reliable information and learning opportunities in low-income countries has contributed to frustration and mistrust with regard to the substandard materials that are available, and reliance on transferring information (and misinformation) by word of mouth. There is therefore a challenge to promote a culture of information; encouraging healthcare providers to access and apply information; facilitating use of information; and learning/training in information skills.
Efforts to improve access to relevant, reliable health information should be accompanied by steps to help individuals to find relevant and reliable information, to interpret it, and to apply it in practice. Such capacities include measures to direct users to the information they need, as well as support with basic literacy and information skills.
10. Evaluate the impact of healthcare information.
