"The presence of CME [continuing medical education] materials in a hospital where I worked before coming here used to give me confidence and peace of mind about the management of surgical cases because I was able to perform certain procedures I had never performed before, just by referring to these materials and following the guidelines or instructions. Since I came here, I feel the gap ... I feel professionally 'insecure' without these materials ..." (Doctor) [12
Given the small number of studies and the wide variation among the studies retrieved, their findings should be interpreted with caution. However, the studies do suggest a gross lack of knowledge about the basics on how to diagnose and manage common diseases [7
], including CVDs and diabetes [17
]. This lack of knowledge appears to go right across the health workforce and is sometimes associated with suboptimal, ineffective and dangerous health care practices. The implications are profound.
If this level of knowledge and practice is representative, as it appears to be, it indicates that modern medicine, even at a basic level, has largely failed the majority of the world's population. The human consequences are likely to be massive: death and harm caused directly by health workers; and failure to prevent deaths that are readily avoided by appropriate interventions. The numbers of people affected are likely to represent a daily catastrophe of huge proportions. The impact, however, is diffuse and often invisible, even unrecognized by health workers themselves.
Availability of health information provides confidence in clinical decision-making, improves practical skills and attitude to care [12
] and alleviates professional isolation, yet this resource remains invisible in the complex health care systems. However, where information has been made available through manuals and treatment guidelines, reports show confusion and discrepancies between recommended care and practice [17
], which underscores two points most often ignored – (1) improving the usability of materials (ensuring, for example, that guidelines are clear, easy to use, authoritative, referenced, in the right language, visually attractive and without unnecessary detail); and (2) training of health workers on the use of information. It is therefore emphasized that practical guidelines by experts in the field need to be developed with the active participation of end users, especially primary health care professionals [17
] and there should be a better understanding of local needs. Thus, practical health care information should be user-driven, easy to use and accessible at the point of care.
Information and learning needs
In this digital age, the growing urban-rural divide continues to influence the way health care professionals anywhere in the developing countries learn and gain access to information. For instance, in Africa in health facilities in capitals or medium-sized cities one can expect to have electricity and a telephone line, though both are rarely functioning 24 hours a day. In rural areas, however, such facilities are not always available and Internet connectivity is usually nonexistent [40
]. This disparity in infrastructure limits the ability of health workers to take full advantage of information technologies in meeting their information and learning needs.
Understanding the local disease patterns is a major prerequisite to formulating appropriate strategies towards meeting the information needs of health care providers. In Africa, this pattern is changing rapidly. For instance, a recent review on the role of continuing medical education for health workers in Ghana noted that the country was being ravaged by both newly emerging infectious diseases such as HIV/AIDS and re-emerging infectious diseases such as malaria, TB and cholera. The authors cite local statistics that show that the incidence of noncommunicable diseases also continues to rise sharply, particularly in urban areas [8
]. In the present literature review, over 50% of the publications focused on the major public health areas that cause significant morbidity and mortality in sub-Saharan Africa – (1) MCH; (2) HIV/AIDS, TB and STIs; and (3) CVDs and diabetes mellitus. Interestingly, the ratio of publications in these three broad categories was 3.0 : 1.5 : 1.0, respectively. It is imperative that resource allocation, including the provision of health information, takes into account the "priority diseases" [24
] in any public health setting.
The rise in the prevalence of CVDs and diabetes mellitus in the developing countries presents new challenges to both patients and practitioners, particularly in Africa. There are clear deficiencies in the ability of health care workers to manage these patients [17
]; many patients are underdiagnosed, while others die prematurely of preventable complications [24
]. This is compounded by illiteracy and mistaken sociocultural beliefs among patients that militate against better management, especially for diabetes. In one study, the authors express concern that patients do not possess the necessary knowledge and understanding of the disease to use insulin safely [17
]. One female patient is reported to have said: "There is no way that I can go on insulin because my husband will divorce me if I go on insulin".
Several studies illustrated the important role of health workers as health educators: one study [41
] found that "The source of health educational interventions was more important than their frequency. Receiving health information through a physician or nurse was found to be a protective factor for diabetic complications as compared to mass media and health news." The quality of health education is clearly dependent on the knowledge of the health worker. A cross-sectional study of the quality of care provided to diabetic children in public children's hospitals in Egypt [42
] showed "marked deficiencies in the provision of information to children with diabetes and their parents".
Health education is necessary for people to be aware of treatment possibilities. A study in rural Gambia showed that only 16% of people with active epilepsy were aware that it was possible to prevent attacks with medical treatment. The same study demonstrated how health education also needs to take into account social and cultural barriers and beliefs about health and illness: "the cause, persistence and treatment of epilepsy were accepted as ultimately under God's will and power" [7
A number of studies suggested an association between availability of health care information (or lack of it) and knowledge or quality of health care:
• "We have shown that appropriate investigations are strongly associated with access to literature based scientific evidence (access to medical library, use of local journals and local and western textbooks)" [15
• Quote from an East African surgeon [13
]: "Laparoscopic surgery is fast developing and textbooks are not able to keep up with it. Before doing a complex laparoscopic surgery I read all the material on the subject available in the journals through this account and then make my plan. Frequently you will find descriptions and tips which are not in books."
• Quote from an East African surgeon [13
]: "Four weeks ago I had to do penile reconstruction (after amputation for carcinoma). I searched abstracts and text to find about recent methods of reconstruction that is not involving microvascular surgery. I found several articles that helped me to make up my mind what to do."
• An article on the Blue Trunk Library (a WHO initiative that provides mini-libraries of books for district health care) noted "a discernible improvement in health care delivery services" [40
] following the provision of the mini-libraries, but further details were not given.
This snapshot highlights the breadth and depth of the existing knowledge gaps among health practitioners that must be addressed in order to make health services safe for patients. These knowledge gaps contribute to the great fear among the general population of health services, and particularly hospitals, which are seen as places that will lead to your death rather than your cure. As one community health worker reported: "The father refused the mom to take the child to hospital because if he's injected and he has the charms he'll die". [10
] This fear can extend to health workers themselves: in one of the papers reviewed, a community health worker declared: "I am in the faith which does not take children to hospital." [10
Methodologies for assessing information needs
"Information needs" is a complex, heterogeneous concept that encompasses several different perspectives, including:
• information needs or "wants" as perceived by health care providers
• information needs inferred by assessment of knowledge
• information needs inferred by assessment of health care practice.
Information needs or "wants" may include (1) recognition by health care providers of their own knowledge deficits and (2) identification by health workers of what they consider would be useful to improve their practice. Basing information provision on perceived needs is important, not least because it is more likely that information provided in response to expressed needs ("pulled" information) is more likely to be put into practice than information that is "pushed".
However, expressed needs are not the same as actual needs. Previous studies indicate a poor correlation between perceived knowledge deficiencies as reported by health care providers and actual knowledge deficits. And it is well known (although not described in the studies of this review) that the value of questionnaires of the type that ask "What books do you need?" is often limited by the respondents' knowledge of what is available: many have answered with titles of books they once used as students 30 years previously that are no longer in print.
Also, information needs of health workers are not fixed. Every individual health worker has unique information needs. Furthermore, a health worker's perceived and actual needs change with time, place and clinical caseload. Needs vary also according to availability of diagnostic, treatment and referral facilities. And they may also be influenced by social and cultural factors.
Similarly, methods for assessing information needs vary. In this review, the studies focused mainly on nurses, doctors and health assistants in rural or urban settings. In general, the studies we reviewed looked at needs in three dimensions: needs perceived by health workers, knowledge deficits and/or observation of health care practice.
Five studies were based on literature review [4
]. Studies using structured questionnaires were applied in a significant number of the studies [14
]. These were followed by a mixture of qualitative and quantitative methods that used structured and semistructured interviews, observations and focus group discussions [7
]. One study used qualitative methods alone [12
], while others were descriptive prospective and case control studies [31
It is well recognized that availability of relevant, reliable information is a prerequisite for effective care, but is only one of a complex range of factors that determine effective care. Many of the studies in this review looked at the closely related area of training needs. One study [43
] claims to provide a practical method to evaluate health care services for diabetes and other chronic disease management in resource-poor settings.
A comprehensive discussion on the merits of various methodologies, especially in the assessment of information needs, is not possible on the basis of these studies. However, some important observations are made:
1. Assessment of information needs requires a mix of quantitative and qualitative research. Quantitative methods were particularly useful to identify deficits in knowledge and practice, and it is noteworthy that multivariate analysis is often required to try to unpick the many confounding factors. Qualitative methods are particularly important in assessing information needs, and are particularly useful for assessing needs as perceived by health care providers. Studies using qualitative methods tend to take longer [12
] and require expert knowledge in the analysis and interpretation of the results.
2. It is highly appropriate to assess local information needs within the broader context of local epidemiology and health care services. The RAPIA (Rapid Assessment Protocol for Insulin Access) approach [43
] promises to be a practical approach that can be readily adapted to evaluate health care services for chronic disease management in resource-poor settings.
3. Explicit knowledge from research studies is unlikely to lead us to a "complete understanding" of information needs. Our understanding of changing needs can be strengthened by "continuous information needs assessment" – for example, by capturing tacit knowledge through email communities among specific health groups [37
4. Assessments of information needs are prone to bias, as indicated in the discussion sections of some of the papers reviewed [21
• In questionnaires and interviews, health workers may give information that in reality they do not practise.
• Health workers may prepare themselves for the interview or questionnaire, giving information in line with official guidelines, not reflecting their true practices.
• There may be self-selection bias if non-participating doctors are different from the participants, e.g. those with less knowledge or who do not follow guidelines may be more likely to refuse interviews or ignore the questionnaire. Respondents to questionnaires may not be typical of the wider group that is being studied. The authors of the study of East African surgeons [13
], for example, recognized that "participants are a self-selected group that includes opinion leaders, teachers, and researchers of the region. Thus it is possible that their valuation of Western literature is higher than that of other surgeons practicing in Africa".
• Another problem is that respondents may say what they think the researcher wants to hear, or they may tailor their response to benefit in some way: "It is not surprising that Ptolemy participants find Ptolemy the most useful gateway to the literature" [13
• "Whenever observation methods are applied, the question arises of whether the presence of the observer may cause a Hawthorne effect, in the sense that the health care worker may have followed the treatment guidelines and the essential drug policy more rigorously than usual" [30
5. Assessments of knowledge and practice produced two kinds of results: specific (e.g. "only 33 (66%) knew the most important symptoms of TB [and] only four doctors prescribed the correct regimen") and non-specific (e.g. 90% had "poor knowledge of the disease"). The specific results are easier to interpret and it would be easier to monitor changes in the future with specific knowledge gaps.
Limitations of the review
This review used a single combination of search terms; other combinations and other search terms would inevitably yield a large number of additional papers, some of which would contain information relevant to the review. The authors of this review are aware of other relevant publications that were not identified by this search and which are therefore not included in this review.
The review is restricted to articles published in the last 10 years. It is possible that earlier articles may shed further light.
The reviewers were able to gain access to most, but not all, of the articles identified.
The selection of the 149 potentially relevant papers, from among the 1762 papers retrieved by the Medline search, was made on the basis of title and abstract alone; it is likely that some of the 1613 unselected articles may have contained valuable information.
Of the 149 articles retrieved, 35 were selected for detailed study. The remainder may have contained useful information. Furthermore, almost all of the 149 articles retrieved contain a list of references. These references were not explored, but are highly likely to yield further useful information for the review.
The original brief for this review included search of other databases such as WebSPIR, Biblioline, CABDirect, Web of Science and LISTA. However, due to resource constraints, it was agreed to restrict the review to Medline. This is an important limitation, as Medline indexes only a small proportion of the formal medical literature, and, in particular, excludes the vast majority of scholarly literature published in African journals. Also, Medline does not include the vast body of informal literature that might contain useful information (e.g. PhD and MSc theses, evaluation reports, proceedings of meetings and the content of email discussion lists).