Background
Ready access to reliable and up-to-date research can help doctors make informed decisions about best practice, and improve patient care and outcomes. Healthcare professionals in training in Sub-Saharan Africa could also benefit from better electronic access to reliable, up-to-date medical knowledge and literature. A major constraint, however, is the high commercial on-line subscription costs for many journals.
The World Health Organization enables free access to full text articles in low-income countries via the HINARI programme (Health InterNetwork Access to Research Initiative), which provides free or very low-cost online access to 3,300 major journals in biomedical and related social sciences to local, non-profit institutions in developing countries. There are presently 2,000 institutions in 106 countries registered for HINARI. During 2005, users at these institutions downloaded more than 3,500,000 articles. There are 113 countries eligible for HINARI. In some cases journals charge a reduced price to developing countries, and there are also open-access journals.
The DFID-funded Effective Health Care Research Consortium has a remit to produce Cochrane Reviews in malaria, tuberculosis, diarrhoea and tropical diseases; the other core activity of the Consortium is promoting use of this evidence in health policy and practice in low- and middle-income countries. Ready access to the Cochrane Library and other subscription journals is a prerequisite for health practitioners and policymakers making evidence-informed decisions. We wanted to find out levels of awareness and use of online medical information among future medical leaders in African countries.
To do this we conducted a survey in October 2006 to describe internet access patterns and awareness of initiatives that enable free access among postgraduate doctors working in national medical institutions in four countries in Africa, and used semi-structured interviews to explore what factors influence use.
Main findings
We found high and regular use of the internet among postgraduate doctors in four selected national medical institutions in Africa, and internet cafés are the most important internet access point for two of the four institutions studied.
Among these doctors, awareness of free access initiatives is variable; it is highest for PubMed and lowest for BioMedCentral.
HINARI helps access in some research-led institutions, but there are problems with organising distribution of passwords in others, and some users report difficulties making HINARI work.
In discussions with policymakers, we drew out the following policy implications relevant to three different sorts of policy specialist or manager:
Senior staff in medical training institutions
HINARI is important and ensures free access to subscription journals in low-income countries.
HINARI is critically dependent on the political and managerial commitment of deans and senior managers in postgraduate institutions. They need to ensure access is organised, advertised, and managed.
Small, carefully managed investments in connectivity will increase access to a large amount of up-to-date medical literature.
There is a demand from postgraduate doctors for specific training in accessing up-to-date online articles and formal orientation to available online resources. Deans and senior managers need to ensure effective training for post-graduate and undergraduate students is provided.
Senior managers need to review the role of librarians in this new environment, as medical staff and students shift to online resources as their main source of up-to-date information. Job descriptions need revising, staff may need to be retrained and re-skilled, and the role of information technology within institutions adjusted.
National policymakers
Increasing evidence-informed decision-making in the health sector requires access to up-to-date medical knowledge. Ministries of education and health could seek tax discounts on computer equipment for medical institutions and health professionals to enable access to online medical knowledge.
Evidence-informed practice requires clinicians trained in understanding and using current best evidence. Ministries of health could seek to revise national curricula to both include critical appraisal of current research and training in information resource use, and make accessing up-to-date online articles a strict requirement.
Institutional research capacity may be strengthened by securing better links to the international research community through effective access to online journals.
Internet cafés may be useful commercially run centres where medical staff can access essential health information.
International stakeholders
Many doctors in national medical institutions in Africa remain unaware of HINARI and are not regular users; this raises concern over the visibility and promotion of the programme.
Most doctors are aware of PubMed (Medline) but report problems accessing free full-text articles and this may be because they are not logged into HINARI; WHO may consider advertising the €˜search through PubMed€™ function more widely, particularly on the PubMed website.
Commonly reported technical problems accessing materials for free suggests HINARI may wish to review the ease of use of its interface. HINARI welcome feedback and are already making steps to improve access.
What kinds of challenges have you encountered in developing communications strategies?
What kind of capacity-building would have made the process more effective?
What would you do differently the next time around?
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