The Tennessee Health Department Bureau of Health Services divides the state into thirteen statistical regions, six urban and seven rural. The six urban regions or counties are Davidson (Nashville), Shelby (Memphis), Hamilton (Chattanooga), Knox (Knoxville), Madison (Jackson), and Sullivan (Johnson City). Tennessee has a county-level health officer in each of the ninety-five counties in addition to a local county director and a board of health. These health regions are shown in . Respondents were asked to select from twenty-five categories to describe their specific job functions, as shown in (N = 553). The total number of six physician respondents listed in is misleading, because physicians are represented in other categories such as epidemiologists, communicable disease investigators, dentists, and regional health directors. Nurses are represented in categories for nurse practitioner, nursing director, educators, and health education or health promotion worker. (N = 560) shows the distribution between urban and rural regions of survey respondents and the level or jurisdiction where they worked. Fifty-four percent were from urban regions and 46% from rural regions. The majority of respondents worked at the city or county level. In urban regions, 65.5% work on the city or local or county level, while 55.3% of the rural sample worked on the city or local or county level. The slight difference in urban versus rural percentages varies between and , because the response rate for job category (N = 553) is lower than the response rate for jurisdiction level (N = 560).
Table 1 Distribution of public health officials by job function (N = 553)
Table 2 Urban versus rural health professionals: level of jurisdiction (N = 560)
The education distribution shown in reveals 22% had either master's or doctorate degrees, while 38% had bachelor's degrees (N = 571). Seventy-seven percent of respondents were female and 23% male (N = 541). Twelve percent of respondents were African-American, while 86% listed themselves as white; very small percentages of respondents classed themselves as American Indian, Hispanic, Asian, or other (N = 565). Ninety-seven percent of respondents used English language exclusively, while 3% used other languages such as Spanish, Sign, Thai, and Arabic in the workplace (N = 540).
Educational distribution of respondents (N = 571)
Respondents were fairly evenly distributed in the number of years they have been employed in public health; a high number of respondents, almost 30%, indicated they had greater than twenty years of experience in the field. Twelve percent indicated they had sixteen to twenty years of experience, 19% had eleven to fifteen years, 14.71% had six to ten years, 20.49% had one to five years, and 3% had less than one year of experience (N = 571). outlines respondents' years of experience.
Public health workers: years of experience
Computer and Internet access.
We asked users to indicate all methods of computer access: machine at desk at work, shared machine at work, or machine at home. All local health departments in Tennessee had at least one Internet-capable office computer in 1999. However, no state email system was available for all health department employees at the time of the survey. The survey results showed that the number of individuals sharing computers was much higher than we expected. We defined a high frequency of sharing desktop computers as one-third of respondents in any job category. Frequencies in do not add up to 100% because respondents could have checked all three methods if they had a computer on their desks but had to share it with others, in addition to having computer access at home. shows respondents by job category who had access to the Internet at work or at home and the percent who had no access. Data shown in are derived from only 394 respondents who answered a series of questions about both computer and Internet access.
Table 3 Computer and Internet access by job function
Though a total of 553 respondents categorized their job function in , not all of these professionals answered the computer-related questions. The two animal control workers whose jobs were primarily in the field and who responded to this question had no access to a computer or the Internet either at work or home. Thus, a value of 100 in the “No Access” column of is interpreted as no person in that job category had Internet access at any location. Seventy-five percent of nursing director respondents had desktop computer access compared to 50% of nurse practitioners. The nursing directors also showed a higher percentage of Internet access at work (81.3%), compared to nurse practitioners, of whom only 60% had Internet access at work. Only in the job categories of epidemiologists and environmental engineers did 100% of respondents indicate having a desktop computer and Internet access at work.
However, unlike the desktop computer–access questions, the Internet access data do not show if the individuals' Internet access was on their desktop or from a shared computer in the same office. The key partners who reviewed the survey questions advised us that Internet access was not widespread throughout the regional offices and local health departments; therefore, we did not structure the survey to ascertain the number of individuals sharing Internet access in an office. Although two job categories had 100% of respondents with desktop computers and Internet access, we cannot conclude the Internet access was from the respondents' desktop computer.
Physicians, counselors, and computer support staff respondents had 100% access to desktop computers but did not all have Internet access from these machines. Several other job groups who had limited Internet access at work indicated having access at home: health officers, 100%; dieticians, 81.8%; health safety inspectors, 66.7%; dental or oral services workers, 90%; educators, 74.1%; and communicable disease investigators, 68.8%. Many respondents had multiple methods of computer access. It is important to note that though many had access through a shared computer at work, this computer could be the primary desktop of another worker, rather than an open-access machine found in a library. Access to the Internet at work did not necessarily mean exclusive use of the computer. Those who had desktop computers—such as nurses, 66.7%; nurse practitioners, 50%; and nursing directors, 75%—also indicated a high percentage of computer sharing. Another job category revealing a high frequency of computer sharing was social worker; while 80% had desktop access, 40% had to share and 25% had no access to the Internet at work or home. Values and frequencies shown in reveal the small sample size in these job categories; however, the trend toward limited computer and Internet access is clear across most job groups. Of the twenty-five job categories in , fifteen, or almost two-thirds, showed a sharing frequency above 33%. The survey did not determine the number of individuals sharing a single computer. It is important to remember that in 1999 Internet service in many small communities in Tennessee did not exist, so the absence of home access was not necessarily by choice.
Many of these professionals were involved with direct patient care daily, so the survey queried respondents about hours of work-related computer use per week (other than patient system/data entry). The median number of hours of weekly computer use by epidemiologists was 40 hours; nursing directors, 5 hours; nurse practitioners, 2 hours; nurses, 5 hours; community assessment workers, 20 hours; environmental engineers, 15 hours; health educators, 10 hours; physicians, 5.5 hours; counselors, 20 hours; and communicable disease investigators, 5 hours. Though many workers shared computers, these data showed that, for most job categories, tasks requiring a computer were not their primary work activities.
Computer proficiency and email access.
The survey also asked respondents to rate their computer expertise as beginner, intermediate, or advanced. indicates the urban versus rural respondents' self-ranking of their expertise (N = 384). Self-reported “intermediate users” in both urban and rural regions were similar, ninety and 127, respectively, but sixty-seven of the rural respondents rated themselves as beginners, while only sixty-two of the urban respondents rated themselves beginners. In marked contrast, only five of rural respondents considered themselves advanced users, while thirty-three of urban respondents self-reported as advanced users.
Self-ranking of computer expertise (N = 384)
Sixty-four percent of the urban and 43% of the rural respondents had email access at work, and more than 50% of both urban and rural respondents had email at home (N = 289). Of those who did not have email in 1999, 94% of urban and 92% of rural respondents indicated they did want to use email (N = 143).
Twenty percent of respondents indicated they wrote grants; 0.05% noted that grant writing “could be” a job duty. The needs assessment also asked participants what grant-related training they desired. Of the 221 respondents who answered this question, 95% (N = 210) indicated they needed basic instruction in locating grant sources and the mechanics of writing a proposal. Other respondents noted they wanted instruction in administering a grant after its award, and a few listed specific kinds of grants they were seeking—health department construction funding, funding for housing facilities for alcoholics or substance abusers, and funding for health maintenance and education programs. One respondent desired instruction in writing outcome-based goals and objectives and in designing evaluation strategies.
Information-seeking behaviors and resources used.
We modified the public health information categories described by Rambo [32
] to ask respondents to indicate how often they used various categories of information. This paper presents a subset of the voluminous frequency data for each of these resources. Frequency data from selected questions give us insight into the information-seeking habits of the respondents. We asked respondents whether they used any of the following methods to locate information (respondents could select as many methods as applied): looking for information themselves, asking an assistant to locate information, asking a colleague to locate information, or asking a librarian to locate information. Not surprisingly, 95% of respondents (N = 542) indicated they looked for information themselves. Just 24% asked assistants to locate information, and, as is often seen in the biomedical community, overall 65% of respondents noted they asked colleagues for information.
The survey briefly defined each resource category and left room for respondents to add categories if they desired. The most frequently consulted categories of information included directory information (telephone numbers/addresses, schedules for official meetings, events, etc.), used daily by 51% of respondents, and internal communications (telephone calls, memos, etc.), used daily by 62% of respondents (N = 553). Many respondents, 24%, also used internal documents such as unpublished reports, manuals, and policies daily, and 24% of respondents indicated they used information about their computers daily.
Health professional subgroup usage of electronic resources.
Pooled responses from fourteen job functions encompassing individuals in clinical medicine, nursing, epidemiology, and public health services management were targeted for a subgroup analysis to focus on their information-seeking habits as opposed to the broader diverse population. Jobs selected for this analysis were: communicable disease investigator, community development assessment, counselor, dental or oral services worked, dietician, educator, health education or promotion worker, nurse, nurse practitioner, nursing director, physician, program director, regional director, and social worker. Data in show this subgroup analysis of responses from the major health profession categories, revealing usage and frequency of major resources critical to the public health mission. The survey form divided frequency into five categories: never, seldom, monthly, weekly, and daily, but the subgroup analysis collapsed frequency into three groupings, “Never or Seldom,” “Monthly,” and “Weekly or Daily.” Results revealed that the top five electronic resources used weekly or daily were: email, 44.8%; Internet search, 35.8%; internal databases, 29.3%; mailing lists and email discussion lists, 16.4%; and Tennessee Department of Health Website 15.9%. The CDC was ranked sixth, with 6.5% using the site daily or weekly. The five sites most frequently identified as never or seldom used are: (1) Environmental Protection Agency (EPA) Website, 85.8%; (2) Census Bureau, 85.3%; (3) Food and Drug Administration (FDA) Website, 82.3%; (4) Agency for Health Care Policy and Research (AHCPR), 81.9%; and (5) National Center for Health Statistics (NCHS), 81%. CDC Wonder was never or seldom used by 80.6% and Health Information Tennessee (HIT) by 74.6%. also reports frequency of missing values or no response for the resource, because, in some cases, these numbers are large.
Table 4 Frequency of use of electronic resources by subgroup of major health professions (N = 232)
Nonelectronic resources: urban versus rural.
The survey asked respondents to indicate how frequently they consulted various nonelectronic resources for information. shows the summary results subdivided by urban or rural respondents. Colleagues were among the most frequently used resources for information, with 60% of urban respondents and 65% of rural respondents consulting colleagues daily, shown in question 1 of . Personal or departmental books were highly used resources as well, with 52.8% of urban respondents consulting books daily or weekly and 62.7% rural consulting personal collections either daily or weekly (, question 2). Dependence upon mass media (including newspapers, radio, and television), shown in , question 3, was not surprising, because public health services work is frequently “complaint-driven” and reported in mass media. The distribution between urban and rural areas did not vary substantially.
Table 5 Frequency of use of non-electronic resources (N = 571)
Libraries and electronic resources use: urban versus rural distribution.
reports frequency categories: never, seldom, monthly, weekly, or daily and the urban versus rural distribution of all respondents (N = 571) for nine resources recognized as important for public health officials. Question 1 in documents the low use of libraries. More than 58% (58.4%) of urban and 70.9% of rural respondents never or seldom use libraries to find information. Currently, academic medical library collections are located in Memphis, Nashville, Knoxville, and Johnson City. Public health officials in the counties surrounding Nashville can purchase an access card for the EBL. The Davidson County Metropolitan Health Department is the only health department in the state with its own library collection and full-time professional librarian.
Table 6 Frequency data for libraries and electronic resources: urban versus rural distribution (N = 571)
shows the responses from questions asking if the respondents either use or need the electronic resource or a specific type of health information. We wanted to determine if respondents use the appropriate electronic resource to meet an identified information need. , question 2, reveals that only about 9% of urban and 4% of rural respondents use the CDC Website either daily or weekly for information. Approximately 71% of urban public health officials never or seldom use the CDC Website, while 78% of rural respondents do not use this site. Still, the subgroup analysis of 232 health professionals reported in showed 6.5% used the CDC site weekly or daily.
Health statistics data and Health Information Tennessee.
In 1997, the Tennessee Health Department and University of Tennessee Knoxville, Community Health Research Group (UTK CHRG) [33
], launched a new Website, Health Information Tennessee (HIT), containing health status reports from all thirteen regional health councils and ninety-five counties. A component of the HIT system, Statistical Profile of Tennessee (SPOT), has been designed so users may enter a query to retrieve vital statistics, staff numbers, facilities, and other health surveys by county accompanied by maps, plots, charts, or tables. Question 4 in shows that only 14.7% of urban and 13.7% of rural users use
the HIT site at least monthly, but question 5 shows that 50.2% of urban and 47.1% of rural respondents needed or used
county-level data at least monthly. Clearly, the respondents recognize the need for health statistics data to support outcomes-based community planning; however, users apparently either do not recognize a relevant specific primary source or encounter obstacles in its use. Obviously, those who do indeed use county-level health data did not access the HIT site. The HIT resource has been specifically created to fulfill the need for county data. In fact, the HIT/SPOT Website has been available since early 1997 with death and survey data sets, followed by birth data. The HIT component MapMaker, online since 1999, allows users to construct thematic maps showing data distributions on county-level maps. Question 6 in indicates that state health statistics data are used or needed at least monthly by 42.3% of urban and 43.1% of rural respondents. Tennessee summary data are available on the HIT site, but respondents are unable to correlate their expressed need with the most relevant resource.
Published medical literature.
Question 8 in regarding the published literature shows only 18.7% of urban and 19% of rural respondents needing or using medical information either daily or weekly (N = 571). Monthly use by 20% of urban and 17% of rural respondents is low considering the broad scope of the question (N = 571).
Question 9 in (N = 571) shows the frequency of daily or weekly use for MEDLINE. Only 4.3% of urban and less than 3% of rural region respondents reported daily or weekly use. Over 60% of urban and rural respondents never use or need MEDLINE.
The survey also included open-ended questions, including one asking which tools or resources would enable respondents to work better. Respondents often indicated multiple items (N = 285). One hundred twenty-two (43%) noted they would be best served by computer or Internet access, a finding which echoes recommendations from the AMIA 2001 Spring Congress that “computers and information technology are part of public health practice, [and] computers should be on all desks” [34
]. Sixty-eight respondents (23.8%) indicated they needed training in basic computer use or concepts, and thirty-four (11.9%) desired access to specific software or training in specific software. Twenty-five respondents (8%) to the question noted they needed general Internet training, and lesser percentages indicated a need for more time, assistance, books or journals, data sources, or technical support.