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HEALTH INFORMATION FORUM: Working together to improve access to reliable information for healthcare workers in developing and transitional countries

REPORT: The role of CD-ROMs for health care in developing countries

Wellcome Trust, London, Tuesday 25 November 2003

The meeting was preceded by an international CD-ROM exhibition

Chair: Rajendra Kale, Editorials Editor, British Medical Journal

Objective: To share experience on the production and application of CD-ROMs for healthcare in developing countries, and to discuss ways forward to maximize their impact.

Format: Four short presentations and four 'peer-assist sessions' (small group discussion where a person describes a challenge in his/her work, and colleagues work together to identify solutions):

1. MMA Healthserve: Presentation plus Peer-Assist

2. TDR: Presentation plus Peer-Assist

3. Wellcome Trust: Presentation plus Peer-Assist

4. e-TALC: Presentation only

5. Source International: Peer-Assist only

1: MMA Healthserve: 'Developing Health CD-ROM' Steven Fouch, UK 

Background

MMA Healthserve and the Christian Medical Fellowship run a two-week clinical update course for health professionals (usually from the UK) who are working with Christian mission and development agencies and national NGOs in developing nations.

The emphasis of the course is on essential clinical skills in resource poor situations.  The course usually has 20-30 participants each year, and has evolved over time to meet the needs of course participants. Training is provided by skilled medical and nursing practitioners with extensive experience of providing health care in the developing world setting.

One of the course contributors suggested that the training and information available on the course should in some way be captured and made available for other health professionals who are unable to attend the course.

First Steps

All the course notes were converted into html in order to create a web based set of lecture notes and Power Point slides.  However, initial structure and coding made it hard to use the CD on most machines, so we opted to go for as simple a system as possible. Our IT Coordinator totally re-structured the CD, simplified its navigation, and slimmed down the size of the fields, including necessary freeware for viewing PDFs, Power Point Slides and Word documents.

Additional content in the form of WHO texts on malaria, E-Medicine papers, and papers from the on-line versions of the Journal of Community Eye health were also added with permission.

The resultant pilot was then sent out to around a hundred people, including course participants and lecturers, and other contacts in hospitals and health projects in developing countries, complete with a detailed questionnaire on how useful the content was, how easy it was to use, etc.

Feedback from that questionnaire and updated content form this year's course, plus further information resources were then added, and a final version of the CD will be completed by the New Year of 2004.

Next Steps

The CD aims to be a useful aide memoir for course participants, and a training tool that can be used individually and with colleagues.  MMA will also be sending it to others who have requested copies, and will distribute it free of charge to all who request it.  Again, we aim to include a feedback form that will enable us to continually improve the content.

One area we wish to evaluate is how the CD is used as training resource - who uses it, do they do so alone or in tea training setting, is it used didactically by a lecturer, or is it used interactively by a group?  Depending on how it is used, we shall refine its presentational design and options, and will look at including training modules on using CDs as educational tools in future refresher course (and also as notes on the CD itself).

We have started with what we know. Next we want to learn how such a tool can be used and developed as a resource for professional training.

PEER ASSIST: MMA Healthserve

• How can MMA identify training needs for the core audience?
• What content does MMA need to address these needs?
• How can MMA distribute their CD-ROMs more effectively?

Training needs

The core audience for MMA is general healthcare workers in developing countries, typically doctors, nurses, midwifes in a secondary care setting.

Training needs may be met by analysis of national educational criteria and working in association with medical training curricula for individual regions. If curricula used by national education institutions are identified, it would be easier to identify those topics that need updating or reviewing. Curricula may also provide guidance on the type and level of information required on CD-ROM.

However, people in remote rural hospitals may not get to the level of training described in national curricula. Curricula do not account for the training needs of health care professionals in every setting. A general updated clinical information resource is required that can be shared at all training levels.

Local application of CD-ROM resources is a key problem. Ideas to address this issue include:

Ø      contact trainees in the field and take their recommendations on what information to update and develop further in their own professional context

Ø      maintain contacts to better understand weaknesses and strengths of CD-ROM material in context

Ø      develop a practitioner network who may assist how material is used

The following questions need to be asked of the core audience:

Ø      how are CD-ROMs being used? i.e. one-to-one teaching/teaching groups/individual use?

Ø      who is going to translate material to make it useful for local training?

Ø      where does training come in the priorities of the target audience e.g. resource allocation, staffing etc?

Content needs

How can the value of the information be maximised? Ideas to address this issue include:

Ø      incorporate a content management system where chunks of information can be easily organised and updated

Ø      content management system could be used in partnership with NGOs, and may be particularly useful for CD-ROM translations

Ø      publish a print version to support CD-ROM material

Ø      publish handbooks on how to use CD-ROM to allow users to maximise their time on the CD-ROMs and fully utilise available information

Ø      provide an open content system which allows local groups to adapt information for their own needs

Effective distribution

Perhaps it would be advantageous to develop local networks where people may copy CD-ROMs legitimately onto the hard drive of their PCs, then distribute the original disc within their community.

Further information: Steve Fouch   [email protected] ;  www.healthserve.org 

2. TDR: 'CDs - the right medium?' Andy Crump, TDR, Switzerland (Special Programme for Research and Training in Tropical Diseases, Geneva)

See Powerpoint presentation

Andy Crump outlined some broader issues in use and access of ICTs and CD-ROMs, with reference to the World Summit on the Information Society, including a quote from 'Fundamental Lines of Action, NGO-UNESCO Liaison Committee for WSIS': "The UN should act to create a universal and regional clearinghouses to share and expand already existing knowledge resources (databases of local expertise, research, websites, CD-ROM, brochures, etc)"

Information is now doubling every 4 to 5 years. Information available in 1997 is less than 1% of what will be available in 2050. According to 1999 figures, information in books and newspapers is increasing at 2 per cent per year, as compared with 100 per cent for disk drives and servers.

There are now more than 195 million CD-ROM drives worldwide, making this one of the most widely available technologies.

TDR produces a range of CD-ROM products:

·        Website (multipurpose)

·        Image Library (resource)

·        Video (resource, advocacy)

·        Databases (+co-productions)

·        Training

·        Multi- or dualmedia packs

·        Meetings + internal admin.

Andy ended with a question for further discussion: How can TDR best evaluate the impact of our CDs?

PEER-ASSIST: TDR

What is the measure of success with regard to CD production and use? And how can it be measured?

Firstly, most individuals indicated that they did not have close contact with distributors or users and did not have any effective mechanisms for monitoring and evaluating impact of their CDs. There were no clear answers to the questions raised.

• One option would be to take a small group survey and extrapolate (i.e. has use of the CD actually changed behaviour of users?). This may work with a small, highly-targeted audience for the CD, but not for a CD intended for a diverse audience(s).

• One measure of impact could be the number of languages that the original CD is translated into.

• Use of a newsletter with the CD or other follow documentation could encourage feedback on the use and impact of the CD - although this would incur extra costs.

• With regard to e-learning, clinical audits could be carried out to try and establish where training has indeed had any positive impact on morbidity or mortality.

• With respect to e-learning, course participants could be requested to provide feedback.

• An alumni of individuals supported by the agency producing the CD could be called into play to try and provide feedback as to the impact of CDs as observed by them.

• CDs could be distributed with a request for users to register their use of the CD (perhaps with incentives being given to encourage registration (e.g. likely free delivery of future updates, etc).

During plenary discussion, it was also suggested that groups could link up with other organisations (such as LEAP, HIFnet, INASP, etc) in order to obtain and document examples of impact.

Further information: Andy Crump [email protected] ;  www.who.int/tdr 

3: Wellcome Trust: ‘Topics in International Health’, Tim Beanland, Wellcome Trust, UK

See Powerpoint presentation

Topics in International Health is a CD-ROM series of 12 titles, aimed at  postgraduate students and teachers, and healthcare professionals in training. It has a focus on developing countries. Titles are organised by disease and distributed in partnership. More than 17,000 discs have been distributed in more than 70 countries.

PEER ASSIST: WELLCOME TRUST

How do we (Wellcome Trust) best develop and maintain a relationship with the users of our CDs, to learn about how they are using them, what their needs and expectations are, how they would like to see them changed?

Topics in International Health seems to lie between two extreme models:

(a) the TALL-type model, in which materials are specifically developed for a course - and so the relationship with end-users comes built-in;

(b) the e-TALC approach, in which the shear number of users makes it very hard to build up a meaningful relationship with all of them.

The consensus for building up a relationship with TIH end-users seems to be a middle ground in which we use the 'trainers' as the conduit: building up relationships with teachers using the CDs in courses or with groups of students, as these teachers would seem to be best placed to advise or comment on their suitability etc. (This of course ignores use by individuals in isolation.)

The relationship should be built into every stage of product development thru to evaluation - if users feel that they are involved in the direction and shape of the series, then this might be sufficient motivation for their continued support.

Further information: Tim Beanland [email protected] ;  http://www.wellcome.ac.uk/en/1/biosertmrtih.html 

4: 'e-TALC', David Chandler, e-TALC, UK

See Powerpoint presentation

David Chandler discussed the background, lessons learned, and future directions of the e-TALC CD-ROMs, produced by Teaching-Aids at Low Cost. He outlined some of the reasons that TALC has chosen to produce healthcare CD-ROMs:

* large capacity to store information

* cheap to produce

* light weight to mail

* easy to use

* easy to use as reference

* easy to store

* not reliant on Internet connection

Four editions of e-TALC CD-ROMs have been produced since 2002, with a total of 34,500 CD-ROMs, sent to 91 countries worldwide. Future plans include 'special focus' CD ROMs, eg Tropical medicine, Eye health, Paediatrics, Surgery, HIV/AIDS.

Further information: David Chandler [email protected] ;   www.e-talc.org 

5. Source International: PEER-ASSIST SESSION: Source International is interested to explore the possibility of developing a catalogue of CD-ROMs for healthcare in developing countries - how might we go about this and what can you do to help?

Peer-assistee: Victoria Richardson, Healthlink Worldwide/Source International

Summary of discussion: In order to establish such a resource it is essential to decide who the resource is for, which products will be included, eg. based on agreed criteria such as availability, affordability, usability etc., and what form the resource will take. For example, a web-based product would be easily searchable and allow publishers to take responsibility for adding their product to the database, but may not be accessible for many users in developing countries, where a CD-ROM or print resource might be better. How would the database be organized? by topic? quality? Compiling the database would be a mammoth task, and we should explore ways of working with people who are already making progress in this area, eg. the Nutrition Society, CABI Public Health database. Linking up with partners and other organizations would help spread the work. We would also need to think about publicising the resource - TALC and Healthlink Worldwide distribution lists are potential avenues for this. Perhaps the most important thing is to be realistic - if we aim too high, then nothing is likely to get done.

Further information: Victoria Richardson [email protected]  www.asksource.info 

Acknowledgements: Thanks to the Wellcome Trust, which provided free facilities facilities for this meeting, and to the BMJ Publishing Group and Exchange (a DFID-funded networking and learning programme on health communications for development), which provides financial support for HIF. Special thanks to Ruth Brassington (Wellcome Trust) for help with organization, and to Sarah Palmer (Wellcome Trust) and Tim Stentiford (Wellcome Trust), who helped compile this report.  

HIF meetings are organized by INASP-Health: www.inasp.info/health  with assistance from volunteers on the HIF organizing group.