Provision of health information for all
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d4151 (Published 30 June 2011) Cite this as: BMJ 2011;342:d4151
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
In the federal polity of India, where Health is a state subject, many
state governments have established Information, Education, and
Communication Bureau within their respective public health systems.
Rajasthan was one such state where an IEC Bureau was established in early
nineties. The mandate of IEC Bureau has been to generate awareness on
health including population issues. They tried to exploit the media in
informing and communicating with people which includes placing educative
material in newspapers, on various channels as TV spot and radio ad,
organizing puppet show, skits, nukkad-natak, posters, wall writings,and
distributing pamphlets, and hand bills. Inter-personal communication was
stressed by hooking in opinion leaders at the peripheral democratic bodies
which in India is known as Panchayats.
But with a literacy rate of northern Indian states between 50 to 70
percent (with female literacy still lower), the IEC efforts could not
elicit as much as the investments made therein!
Over these two decades, information technology has revolutionized. Even
in the remote villages of a largely desert state like Rajasthan, signals
of cellular phones have reached! We have reached a point of reinventing
inter-personal communication through which an illiterate (or neo-literates
whose number is fastly increasing) can be empowered. Mechanics need to be
evolved albeit 2015 is too close to create such a culture.
There is certainly need to draw inputs from HIFA 2015 which as a forum is
providing worldwide experience through its net.
Competing interests: No competing interests
Peoples-uni (http://peoples-uni.org) strongly supports the proposed
action to improve access to health information for all. As providers of
low-cost online education for Public Health capacity building for health
professionals in low income settings, we would make the point that in
order to turn information into action, an educational component is
required. Peoples-uni stands ready to help support the goal expressed by
Smith and Koehlmoos, as I am sure will other educational initiatives and
organisations.
Competing interests: No competing interests
BMJ 2011; 342:d4151 doi: 10.1136/bmj.d4151 (Published 30 June 2011)
Dear Editor
Health information must address all promotive, preventive and
treatment of diseases. The description of HIFA 2015 in this article has
left a strong impression on me. First, such an initiative recognizes the
importance of health information for all both at the household level and
among health providers. It is encouraging that HIFA 2015 has prioritised
middle and low income countries which suffer the most in terms of lack of
access to health information. WHO 2006 recognizes that Africa alone bears
25% of the global disease burden but only 2-3% of African doctors and
nurses are well informed on sources to health information and having
access to electronic information
It is indeed commendable that the editor stresses the challenges in
developing countries. I would however mention that as much as the
information is available, language remains an important obstacle to
accessing health information, which is experienced both in developed and
developing countries. In ever-increasingly globalized societies, there are
migrations; meaning that different languages are brought together and
health information is not easily translated into individuals' first
languages; moreover, in the process of translation, context of the
information may be changed. For developing countries language is a
critical issue because it is almost impossible to communicate at the rural
levels where indigenous languages are plenty and English illiteracy levels
are very high. In addition, much as there is improved electronic access to
information, this avenue isn't applicable for most developing countries
where computer and internet resources are limited and even if available,
there is very limited knowledge to access.
Competing interests: No competing interests
Dear Editor
We welcome Smith and Koehlmoos's call for a major funding agency to
support HIFA2015 (Healthcare Information For All by 2015;
www.hifa2015.org). [1] In 2006, when HIFA2015 was launched, Dr Tikki Pang
of the World Health Organization said "HIFA2015 is an ambitious goal, but
it can be achieved if all stakeholders work together". [2] The full range
of stakeholders - from the World Health Organization in Geneva to
grassroots organisations in Uganda - are indeed now working together. What
is needed now is for a single major funding agency to commit to the
HIFA2015 goal - to commit to a world where the availability and use of
basic healthcare knowledge are no longer a major contributing factor to
avoidable death and suffering.
Smith and Koehlmoos focus on the modest financial needs of HIFA2015
itself. HIFA2015 needs funding to expand from its current staffing level
of one person. We shall then be able to build on what we have achieved
(bringing together over 5000 providers and users of health information
globally, nationally and across different languages), and develop the
second and third components of our strategy: a specialised knowledge base
of information needs and how to meet them, and an advocacy programme to
raise awareness of the importance of healthcare information and the need
for increased political and financial commitment to support the diverse
efforts of health information services and projects worldwide.
In 1993 the late James Grant, former Executive Director of UNICEF,
said: "The single biggest piece of unfinished business of the 20th century
is to extend the basic benefits of modern science and medicine... The most
urgent task before us is to get medical and health knowledge to those most
in need of that knowledge. Of the approximately 50 million people who were
dying each year in the late 1980s, fully two thirds could have been saved
through the application of that knowledge." [3] Since then, as Smith and
Koehlmoos point out, there has been 'little progress in meeting the
information needs of frontline healthcare providers and ordinary
citizens'. A recent literature review by us, with a focus on Africa,
confirmed 'a gross lack of knowledge about the basics of how to diagnose
and manage common diseases, going right across the health workforce and
often associated with suboptimal, ineffective and dangerous health care
practices'. [4] This is not due to the health workers themselves. It is
due to lack of financial and political commitment to address their
information and learning needs. The unfinished business of the 20th
century has carried forward to the 21st, largely unaddressed. 'It is
unlikely that this ambitious goal [HIFA2015] will be achieved', say Smith
& Koehlmoos. If it is not achieved, it will be, again, because of lack
of financial and political commitment.
Similar calls have been made repeatedly since 1993, including that in
2006 by the international health leaders Pang, Gray and Evans: "The Gates
Foundation identified fourteen challenges but a fifteenth challenge stares
us plainly in the face: The 15th challenge is to ensure that everyone in
the world can have access to clean, clear, knowledge - a basic human
right, and a public health need as important as access to clean, clear,
water, and much more easily achievable." The authors emphasise that access
to healthcare knowledge is 'critical for achieving the Millennium
Development Goals'. [5]
We call on funding agencies and governments to commit to the goal of
healthcare information for all by 2015.
Neil Pakenham-Walsh (Global Healthcare Information Network &
Coordinator, HIFA2015) and Frederick Bukachi (Senior Lecturer, University
of Nairobi Medical School, Kenya)
On behalf of the HIFA2015 Steering Group [6]
1. Smith R & Koehlmoos T P. Provision of health information for
all. BMJ 2011;342:doi:10.1136/bmj.d4151 (Editorial, Published online 30
June 2011)
http://www.bmj.com/content/342/bmj.d4151.full?sid=5748dbb0-459d-4f56-81cc-
91568fac317e
2. http://www.hifa2015.org/resources/letter-of-support/
3. Grant J. Opening Session, World Summit on Medical Education,
Edinburgh 1993. Medical Education 1994; 28 (supplement 1): 11.
4. Pakenham-Walsh N & Bukachi F. Information needs of health care
workers in developing countries: a literature review with a focus on
Africa. Human Resources for Health 2009, 7:30doi:10.1186/1478-4491-7-30
http://www.human-resources-health.com/content/7/1/30
5. Tikki Pang (WHO), Muir Gray (NHS, UK), and Tim Evans (WHO): A 15th
grand challenge for global public health. The Lancet 2006; 367:284-286.
http://www.thelancet.com/journals/lancet/article/PIIS0140673606680501/fu...
Competing interests: No competing interests
I am a social pediatrician in Turkey. In Turkey, we are trying to
develop General Practitioner System throughout the country. But we have a lot
of problems especially related to pediatric care.
1. Our generel practioners dont have enough training.
2. In rural areas there is no acess to knowledge and health care.
So what is happening in Turkey now? We can't achieve success in
increasing breastfeeding rates because our general pediatricians don't know how
to train mothers about expressing breastmilk in difficuilt situations.
Formula companies are faster and rich. They can easily access mothers.
I know that even some pediatricians recommend to stop breastfeeding when
the infant has hyperbilirubinemia.
I think health information is very important for my country especially for
general practitioners. I am very impressed with HIFA 2015 group that they
have a lot of professionals for discussing primary health care problems (I've been in that group for 4 months). I hope this organisation can find a
strong fund from some private organisations.
Competing interests: No competing interests
Dear Editor,
This editorial and added comments confirm the view taken by such
organisations as EIFL and the Electronic Publishing Trust for Development
(EPT) 'that knowledge starvation has an adverse effect on mortality and
ill health in resource-poor settings'. It is true that it is difficult to
put figures on the impact on health of lack of access to knowledge, but
new assessment tools are under development and will perhaps provide the
figures that would prove the point. While we wait for these developments,
HIFA2015 has made an enormous contribution towards raising awareness about
the need for information in parallel with the need for medical treatment.
Such initiatives are at the forefront of the drive towards open access to
all publicly funded research - the starting block for the development of
effective treatments at the front line.
The following articles consider this issue and may be of interest:
"Excluding the poor from accessing biomedical literature: A rights
violation that impedes global health",
http://www.hhrjournal.org/index.php/hhr/article/view/20/88;
"The chain of communication in health science: from researcher to health
worker through open access", Open Medicine 2009; 3(3):111-119,
http://www.openmedicine.ca/article/view/298/245
Leslie Chan, Barbara Kirsop, Subbiah Arunachalam,
Trustees of the EPT
Competing interests: All three authors have published articles relating to the importance of knowledge for development and worked to promote open access to publicly funded information.
CHILD 2015 is a partner member of HIFA 2015 and brings together child
health professionals from all over the world in an exchange of information
on paediatrics and child health.
The forum has really impressed me by bringing together grass roots workers
from a number of different health disciplines, and promoting contacts with
academic and UN agency workers from major centres. The former have not
previously had access to authoritative sources whilst the latter had
little contact with rural health realities. This cross fertilisation is
one of the huge benefits of HIFA and all its groups and I back up the
views of the authors in saying that it is a very worthy beneficiary of new
funding.
Tony Waterston
Competing interests: No competing interests
Language is a key issue in access for information. Speakers of a
dominant language like English - including most of the highly educated
professionals in developing countries - can too easily overlook the fact
that the people who most need healthcare information are not likely to
have a good understanding of English (nor of French, Spanish, or
Portuguese).
Language is a significant obstacle to comprehension, whether we're
talking about training community healthcare workers with varying levels of
educational achievement, or simply delivering information to the end
consumers - frequently people in rural communities.
Ironically, people with scant knowledge of English tend to be those
who need access to information the most. If we take just Africa alone,
with 25% of the world's disease burden and only 2-3% of its doctors and
nurses, well informed healthcare workers are critical. However, if neither
the people themselves, nor the village healthcare workers meant to help
them, have strong English skills, the information they have access to will
be understood imperfectly, or not at all. And the whole information access
chain breaks down.
Competing interests: No competing interests
Access to the high quality information is the basis of practicing
evidence-based medicine (EBM) yet issues around fair and equitable access
to information are still present. Without the actual information (i.e.,
journal articles, books, etc, in either electronic or print format) how
can EBM be practiced or how can evidence be used to inform decision-making? Why is there such a lack of understanding or support for the
provision of access to information? Why do libraries and those
championing access to information need to prove that using knowledge is
beneficial? To conduct a study that "quantifies" the use of information
is quite difficult. A Cochrane Review that tried to do so found of
improvements in knowledge but not changes in professional behavior. It
did find that knowledge of the Cochrane Reproductive Health Library was
better among health care professionals that had training.1
In a rich country like Canada, librarians have been struggling for
more than a decade to fund a national network of libraries for health to
provide equitable access to information for health care providers. They
have only recently been able to create the framework for a Canadian
Virtual Health Library/Biblioth?que virtuelle canadienne de la sant?
(http://cvhl-bvcs.ca) with funding from the Canadian Institutes of Health
Research. Muir Gray stated in 2006 that it seemed paradoxical; it has
always seemed paradoxical that Canada, a country that introduction of
evidence-based medicine to the advances in knowledge translation and
implementation does not have a national library.2 Still there is no
national license to The Cochrane Library in Canada.
After working in Kazakhstan, it is clear that there is little access
to health information. As well, the issue of language (the main languages
are Russian and Kazakh) mean that access to English material is only part
of the problem and requires additional monies because of the need for
permissions to use and translate information. As of January 1, 2011,
Kazakhstan does not quality for Band 1 (free access) or Band 2 (low-cost
access). Fortunately, after raising this issue, The Cochrane
Collaboration's Evidence Aid project graciously agreed to provide access
to The Cochrane Library in Kazakhstan for 2011, despite the fact that
Kazakhstan has "graduated" from HINARI. This is an example of a small
win.
The issues around championing access to information are critical. We
all need to help HIFA2015 become a reality and allow everyone access to an
informed healthcare provider.
References
1. McGowan JL, Grad R, Pluye P, Hannes K, Deane K, Labrecque M, Welch
V, Tugwell P. Electronic retrieval of health information by healthcare
providers to improve practice and patient care. Cochrane Database of
Systematic Reviews 2009, Issue 3. Art. No.: CD004749. DOI:
10.1002/14651858.CD004749.pub2.
2. Gray JAM. Canadian clinicians and patients need clean, clear knowledge
[editorial]. CMAJ 2006;175(2):129.
Competing interests: No competing interests
Health Information is Important but not Simple
Equalising health information among developing countries is a complex
problem. Information as it has been identifed by HIFA2015 is essential to
improve the quality of health systems in the developing world. Information
is a powerful tool and is often taken for granted. However, information
has many diffferent meanings and needs to be considered in relation to its
many contexts. Firstly, information is a key medical resource that
contains the accurate procedural information needed to displace
traditional practices in local 'knowledges'. Secondly, it needs reliable
infrastructures to be in place to ensure effective dissemination. Thirdly,
content has to be addressed: infomation needs will differ from user to
user. Therefore, it has to be made specific to local needs. Information
itself simply cannot be enough, these factors are interlinked and need to
be in place before information can be used effectively. Therefore, health
information should be considered not only within a medical context but
also take into account social factors.
This is best represented through a sociological health model such as
Marc Lalonde's (1974) 'Health Field Concept'. Within this concept Lalonde
highlights four categories to which, he argues, any health problem can be
traced back. These categories include Human Biology, Environment,
Lifestyle and Health Care Organisation. The categories that are of
particular interest are Lifestyle, Environment and Health Care
Organisation. For example, the Internet is a useful tool in distributing
health information. But for this to be successful within the environment
there need to be phone lines to support an Internet connection. However,
even with access to the Internet the issue of content is problematic.
Information overload can be just as harmful as lack of information. Health
care providers need to be able to identify reliable information among the
huge amount of data available. So we can see that equalising health
information distribution among developing countries is far from a simple
solution. There are many challenging obstacles to overcome, but I believe
that using Lalonde's Health Field Concept as a framework will help
identify the areas within any given society that need to be adapted or
implemented to provide the knowledge so many health care providers need to
make informed decisions.
Lalonde, M. (1974) A New Perspective on the Health of Canadians: A
Working Document. Minister of Supply and Services, [online] Available at:
http://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/1974-lalonde/index-
eng.php [Accessed: 7th August 2011].
Competing interests: No competing interests