Research

Eysenbach, G. and Wyatt, J. Using the Internet for surveys and health research. Journal of Medical Internet Research 4(2):e13 (2002). Available at: www.jmir.org/2002/2/e13/index.htm.
This tutorial reviews the use of the Internet in the research process. Although it is written for a developed-country audience, many of these observations apply to developing-country research. The research process includes identifying research issues, using databases for literature searches, using the Internet for surveys and clinical trials, pre-publishing, and publishing research results. Reviews of electronic discussion groups may help to identify health beliefs, common topics, motives, information, and emotional needs of patients, and point to areas where research is needed. A synopsis of important techniques and tips for implementing web-based surveys is given, and ethical issues involved in online research are discussed. Internet addresses for finding methods and protocols are provided. The Internet is also being used to assist in the identification of ongoing clinical trials. Finally, the Internet is used for two distinct types of electronic publication: publication of protocols or work-in-progress and publication of peer-reviewed reports in online journals.

Hewett, P.C. et al. The feasibility of computer-assisted survey interviewing in Africa: experience from two rural districts in Kenya. Policy Research Division Working Paper No. 168. New York: Population Council (2003). Available at: www.popcouncil.org/pdfs/wp/168.pdf.
As part of ongoing research on adolescent sexual behavior, audio-CASI technology was employed to obtain information about sensitive issues, including sexual initiation, risky sexual behavior, coerced sex, and drug and alcohol use. This paper explores the technical aspects of the research and evaluates the feasibility and experience of implementing a computer-assisted, household-level survey in a developing-country setting. It also includes a literature review. The audio-CASI software was programmed using Microsoft Visual Basic version 6.0 and Access 2000. The startup software and hardware cost was about US$2,000 per interviewer at the initiation of the project in February 2000. At the time of the fieldwork, alternative technologies, such as handheld computers, did not offer audio playback and had limited hard-drive capacity. In both settings, the computer remained closed and in its carrying case during the interview. The respondent used a set of audio headphones to listen to the questions and the response options. The adolescent answered the questions by using an external miniature keypad that included numbers and two color-coded keys, a red key for replaying the question and a blue key to enter a response. The respondents could select one of three languages for the interview: English, Kiswahili, or the local language. No significant problems were found with the computer hardware or software, and no computers were stolen during the fieldwork. The authors suggest that where segments of the community have doubts about project activities, the use of computers can exacerbate the suspicions of parents and adolescents. This effect seemed to influence the data-collection process, although its effect on data quality is harder to assess.

Rhodes, S.D. et al. Collecting behavioral data using the World Wide Web: considerations for researchers. Journal of Epidemiological and Community Health 57(1):6873 (January 2003). Abstract available at: http://jech.bmjjournals.com/cgi/content/abstract/57/1/68.
The authors identify and describe the advantages, challenges, and ethical considerations of web-based behavioral data collection. Their findings are based on their own experience and a literature review: the advantages of using the World Wide Web to collect behavioral data include rapid access to numerous potential respondents and previously hidden populations, respondent openness and full participation, opportunities for student research, and reduced research costs. Challenges identified include issues related to sampling, competition for the attention of respondents, and potential limitations resulting from the much-cited "digital divide," literacy, and disability. Ethical considerations include anonymity and privacy, providing and substantiating informed consent, and potential risks of malfeasance. The World Wide Web may be useful to survey some previously hidden population subgroups. Many of the criticisms of online data collection are common to other survey research methodologies.

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Networking and Advocacy

infoDev. Increasing Electronic Connectivity between Strategic Allies in the HIV/AIDS field in South East Asia. Washington, DC : World Bank (August 2001). Available at: www.infodev.org/projects/health/075unaids/075final.pdf.)
UNAIDS. infoDev: Facilitating Communications in Response to HIV/AIDS in South-East Asia. Best Practice Case Study. Geneva: UNAIDS (2001). Available at: www.unaids.org/publications/documents/care/general/JC494-infodev-E.pdf.
The infoDev program at the World Bank and UNAIDS jointly facilitated email connectivity between key institutions in seven South East Asian countries to disseminate HIV/AIDs information. Forty organizations in each country were strengthened through either private-sector support services or through employing an information officer who provided technical support and training. Other activities included negotiation with national authorities, provision of modems, and evaluation of the impact of increased connectivity. The Best Practice Case Study describes how networking developed in each country. The development of information-sharing has been on an intra-country basis rather that inter-country as was expected.

Among the lessons learned about technology introduction:

Kanyengo, C. Information and Communication Technologies (ICT) and Networking in Support of Health Services in Rural Zambia. Lusaka, Zambia: University of Zambia Medical Library. Available at: www.infodev.org/icsf/mwala/Healthnet.cbu.conference.doc.
The University of Zambia Medical Library provides users with several Internet applications: Health-L, Medguide website, Sister Library programs, and Communication for Better Health. The author describes the benefits and challenges associated with two of these programs. HealthNet is a program that has evolved from an intra-organizational electronic discussion list to a discussion list for rural health care workers and health professionals in developing countries supported by SATELLIFE technology. It was conceived as a means to combat the isolation of rural health care workers and is used to disseminate literature, improve supply ordering (as users can verify supplies through email), monitor epidemiological data, make referrals, and organize conferences and workshops. Health-L, an electronic discussion group, began as a discussion group on health issues in Zambia. It has evolved primarily in an information channel with a few active members supplementing the information the moderator posts. The author concludes that until every health care worker has access to a telephone and personal computer, there will be a need for health information resource centers to repackage information and disseminate it in printed form.

Pacific Institute for Womens Health (PIWH). Women Connect! The Power of Communication to Improve Womens Lives. Los Angeles: PIWH (2002). Available at: www.piwh.org/pdfs/wc2002.pdf.
The Women Connect! Initiative was carried out by the Pacific Institute for Women's Health in Los Angeles and the Annenberg Center for Communication at the University of California. The project was intended to bring about greater empowerment of women through the effective use of communication strategies in media and technology and through collaboration, communications training, and information-sharing. An additional aim was to help womens organizations strengthen their ability to achieve their own objectives, especially in the areas of womens health and well-being. Thirty womens NGOs were assisted in the use of traditional media (posters and brochures), mass media (newspapers, radio, magazines, and television), and computer-based technologies (email and the Internet). This evaluation report briefly describes the needs assessment to identify participants, the training program in media and computer-based technologies, the small grants program, technical assistance, distribution and repackaging of health materials, and efforts to ensure ongoing financial support.

The report recommends:

See the Program Example from Uganda, Zambia, and Zimbabwe for more details about this program.

Vyas, A. Connecting voices and expanding horizons. Development 45(4):5560 (December 1, 2002).
The author has described the genesis, developments, doubts, dilemmas, and challenges of moderating BOL, an electronic discussion list on gender issues in South Asia. She points out that email is one of the technologies most commonly and effectively used by women. It is considered a more horizontal than hierarchical communication format. She describes the contents, subscribers profiles, methodology, and technical issues relating to BOL. She observes that the culture of being an active information user is yet to develop; most users of the listserv are passive receivers. She suggests that e-discussion lists have immense potential for resource-sharing, networking, and advocacy activities, which needs to be fully explored and utilized by the womens groups and researchers in the South Asian region. Specifically, she suggests that technologically savvy womens groups create more awareness of the networking potentional of new technology; that more training be offered to womens groups to effectively use the technologies; that more organizations make more effort to document best practices; and that donors fund efforts to initiate, support, and sustain ICTs for womens information, networking, and empowerment.

World Bank and Development Gateway. ICT: A Powerful Tool to Combat Trafficking of Women. Presentations from the Gender and the Digital Divide Seminar Series #27, Washington, DC (March 20, 2003). Available at: www.worldbank.org/gender/digitaldivide/digitaldivide27.htm.
This web page hosts presentations from a panel discussion on the actual and potential applications of ICT for advocacy to end the global trafficking of women. About 700,000 people, mostly women and children, are subjected to trafficking yearly. The Internet has been used since as early as 1995 to build an alliance, discuss strategies, and share experiences in efforts to end trafficking. In other applications, ICT is used to gather data on trafficking, to inform the public, rescue trafficked women, and rehabilitate those who returned through job training.

For the at-risk women we work with, the Internet is both a positive and negative technology. On the one hand, it is revolutionizing the job search processwomen who are looking for employment are turning to the Internet as a tool in their job search. On the other hand, the Internet is also a source of illegitimate job offers abroad and mail-order bride schemes.

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Training

JHPIEGO. Increasing access to reproductive health information in low-resource settings: evaluation of a technology-assisted learning center in La Paz, Bolivia [fact sheet based on JHPIEGO Technical Report JHP-16]. (February 2002). Available at: www.jhpiego.jhu.edu/pubs/tr/tr219sum.htm.
In 1999, JHPIEGO established a technology-assisted learning center (TALC) at the Health Sciences Library of the Universidad Mayor de San Andrs (USMA) in La Paz, Bolivia. JHPIEGO trained library staff and faculty to conduct Internet searches and to use basic software applications. Library staff members were also trained in maintenance of the network and hardware. During the first year, there were more than 5,300 faculty and student TALC user sessions recorded, and a successful cost-recovery system garnered US$3,600. The evaluation showed that the TALC succeeded in increasing professional and academic access to up-to-date reproductive health information, opening up the online world for UMSA faculty and students, and promoting South-to-South collaboration in a variety of ways. Access to the TALC helped university officials realize that computer skills, access to the Internet, and the ability to read English were essential tools for their students and faculty. In the first year of the TALC's operation (and because of the TALC) UMSA staff and faculty initiated three projects exploiting technology and focusing on South-to-South collaboration for Bolivia: establishing a regional library network, putting Bolivian medical journals online, and developing distance-education strategies. For further details about JHPIEGO TALCs, see www.jhpiego.jhu.edu/pubs/infoshts/talc.pdf or www.jhpiego.jhu.edu/global/talc.htm.

JHPIEGO. Implementing a new training approach: pilot test of ModCal in Zimbabwe [fact sheet based on JHPIEGO Technical Report FCA-28]. (April 1997). Available at: www.jhpiego.org/pubs/TR/tr728sum.htm.
By using computer technology to maximize training efficiency, trainers can redirect their time, which is scarce, to areas that depend on intensive trainer-learner interaction. ModCal uses the computer to enable participants to absorb new knowledge at their own pace so that more trainer time is available for skills practice.

Long, P.J. and Kiplinger, N.E. Making It Happen: Using Distance Learning to Improve Reproductive Health Provider Performance. Chapel Hill, North Carolina: INTRAH (1999, second printing 2002). Available at: www.intrah.org/rtlpubs.html.
This is a practical and thorough how-to guide for developing distance-learning programs in low-resource settings. Distance learning refers to training where trainers and learners are not together in the classroom and the training content is in a prepared instructional package. The benefits of distance learning are increased access, increased flexibility, assured quality learning, empowered learners, and cost-effectiveness. A range of technologies is used in distance learning, including solar-powered tape players and tapes, online instruction, telephones, and videos. The authors describe the advantages, limitations, and requirements for each technology. They recommend planned interventions to reduce isolation or confusion when the trainer and the learner cannot see each other. Two trainings are reviewed, and findings and lessons learned are reported.

Among the lessons learned:

Two program evaluations with lessons learned are included.

Management Sciences for Health (MSH). The Best of Both WorldsBlended Learning Programs in International Health [presentations]. Technical Seminar series, Washington, DC (March 18, 2003). Available at: www.msh.org/news_room/seminars/18mar03.html.)
This seminar on blended learning is based on the premise that websites, on-line discussions, and other virtual communication methods are not substitutes for face-to-face technical assistance. When electronic tools are carefully integrated with face-to-face learning, they can enhance development opportunities for health care professionals. Panelists present their experiences in combining face-to face and distance delivery methodologies to best suit the needs of health professionals in the field.

Ntiro, S. and Mrema, J. Information and Communication Technologies and Continuing Medical Education in East and Southern Africa. Report on an ICT conference, Moshi, Tanzania (April 810, 2003). Available at: www.cordaid.nl/uk/News/Inzet-ICT-in-Afrika--intro.doc_cvt.htm.)
This conference was organized by the Centre for Educational Development in Health in Arusha (CEDHA), Cordaid, and the International Institute for Communication and Development (IICD) to explore how ICTs can be used to develop and deliver continuing medical education (CME) of rural health care workers in Kenya, Malawi, Tanzania, Uganda, and Zambia. Attendees identified the many benefits of using ICTs as opposed to more traditional methods. The benefits included: information delivery unconstrained by distance and time, access to mega databases, access to free full-text journals and books, downloaded materials that are free from damage, regularly updated material, learning tailored to need, less disruption of service due to less long-distance travel, and context-based learning. The challenges in using ICTs were also discussed in order to define realistic programs. The country groups identified next steps for broadening participation and convening specific project and program formulations. In addition, the participants called for improved networking around the issues raised at the conference.

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Reaching Youth

EnCompass LLC. Evaluation Report of WBIHDs ICT for Education AIDSWEB Project. Submitted to World Bank Institute. EnCompass LLC (November 23, 2002). Available at: www.worldbank.org/worldlinks/aidsweb/online-project.html.)
AIDSWEB is a school-based project that was begun 1998 by the World Bank Institute's ICT for Education program to explore the use of ICT for use in HIV/AIDS educational and peer-outreach activities. Project activities included an email-based collaborative project, teacher exchange visits, adaptation of HIV/AIDS educational material for ICT platforms, HIV/AIDS and ICT workshops (for schools, policy makers, and NGOs), and material development. AIDSWEB currently serves approximately 500 youth in 70 schools in 8 African countries. The evaluation results show that AIDSWEB students were almost twice as likely to correctly identify all four methods of HIV/AIDS prevention and transmission. These results were consistent across countries, except for Uganda (a country that, according to evaluators, has well-established programs in HIV/AIDS education and youth development). The program also increased computer access: Students who were not in the program were almost six times more likely to have less than one hour of computer access in the previous month. In the intervention group, 51 percent reported having more than four hours of computer access in the previous month compared to 23 percent in the control group. In the previous month, 35 percent of control respondents reported no computer access; 6 percent in the intervention group reported no access. Most of the students (85%) accessed the Internet and AIDSWEB information alongside others (in student groups, with their teacher, or in AIDS clubs), while only 15 percent accessed it alone. Sixty-three percent in the control group and 85 percent of the intervention group responded that they helped their communities by sharing information about HIV/AIDS with family, friends, or health workers; volunteering with local organizations or health clinics/hospitals; or developing a social action plan. AIDSWEB students were similar to students outside the program in their choices of social action, but AIDSWEB students were more than twice as likely to develop social action plans.

International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR). Rock and male roles: using technology and music to teach young men about gender roles and sexual and reproductive health. Forum 15(1):45 (January 2001). Available at: www.ippfwhr.org/publications/serial_article_e.asp?SerialIssuesID=17&ArticleID=39.
The "Rock and Male Roles" CD-ROM was developed by APROFA, the Chilean affiliate of IPPF/WHR. It uses seven mini-programs as a tool for young men to look critically at gender and how it influences their sexual and reproductive health. The CD-ROM, with photos, reference documents, self-tests, and MTV-style music videos, is an interactive and engaging way for young people to explore their own attitudes and behaviors about these issues. This format encourages the user to take initiative in seeking information and in deciding what he wants to learn. It is a perfect tool for youth, said APROFA psychologist Dr. Patricia Hamel, because it does not impose a sequence or an order. The issues are laid out on the page, and its up to the users to follow their own interests, at their own rhythm. APROFA tested "Rock and Male Roles" with a group of 400 young men aged 15 to 19 at four high schools in Santiago. Each student filled out a survey before and after using the CD-ROM in order to help APROFA assess the impact of the CD on his knowledge and attitudes. The great majority of those who used the CD said they found it useful.

See the global Program Example from Staying Alive for more details.

International Plannned Parenthood Federation/Western Hemisphere Region (IPPF/WHR). Youth and Technology: IPPF/WHR Experiences to Promote Sexual and Reproductive Health. New York: IPPF/WHR (2001). Can be ordered from International Planned Parenthood, 120 Wall Street, 9th Floor, New York, NY 10005-3902 USA.
This report documents IPPF/WHRs first generation projects targeting youth using computer technologies to enhance sexual and reproductive health. Key issues and lessons learned were collected and synthesized from projects using cyber centers, websites, interactive multimedia CD-ROM programs, email counseling services, and a computer chip-activated baby doll. The advantages of using these technologies include the ability for youth to remain anonymous while accessing information, the lure of game-based learning, and the ability to reach a subset of the population. Most technology-based resources are new and exciting, and the novelty makes them attractive. Youth responded favorably to all these uses of technology. In the programs where pre-and post-testing were done, positive changes related to sexual and reproductive health and to gender roles were seen.

To strengthen programming for youth using technology the authors recommend:

Project descriptions from Chile, El Salvador, Guatemala, and Peru in IPPF's report give more details on activities, target audiences, and user statistics.

Moch, L. and Stevens, C. Reaching adolescents through hotlines and radio call-in programs. In FOCUS (December 1999). Available at: http://pf.convio.com/pf/pubs/focus/IN%20FOCUS/PDF/dec99.pdf.
The authors interviewed staff at number of hotline and radio call-in programs for this report by the FOCUS on Young Adults program on the benefits and challenges of using phones to discuss young adults reproductive health concerns. They conclude, Despite the challenges, hotlines and radio call-in programs can be an effective way to reach large numbers of youth at relatively low cost. They provide youth with convenient, confidential, interactive and compassionate access to information, counseling and referrals, and they can help parents and community members understand the unique sexual and reproductive health needs of young people.

Palmer, A. Reaching Youth; John Hopkins University /Center Communication Programs 1995–2000, Working Paper 6. Baltimore, Maryland: Johns Hopkins University, Bloomberg School of Public Health, Population Communication Services (JHU/PCS) (2002). Available at: www.unicef.org/aids/aids_jhu_reaching_youth.pdf or www.jhuccp.org/pubs/wp/6/.
JHU/PCS, the Population Council in Peru, and the Peruvian Institute for Responsible Parenthood (INPPARES, an International Planned Parenthood Federation affiliate) joined together in 1997 to evaluate the capability of interactive multimedia CD-ROM technology to deliver family planning, reproductive health, sex, and sexuality information to adolescents and young adults in Peru. They designed, produced, and beta-tested Isabel: Your Electronic Counselor. Isabel is an interactive CD-ROM intended to increase levels of knowledge about sex, sexuality, unplanned pregnancy, contraception, and gender to influence the eventual adoption of a family planning method and avoid risky health behaviors. It used existing materials produced by the Ministry of Health and Advocacy in Population Programs (APROPO). In the evaluation, nearly 60 percent of users found it easier to interact with Isabel than a traditional counselor. Others felt a counselor could provide more information in a more confidential setting.

Siecus. United Kingdom BBC's Sexwise provides critical sexual health information worldwide. Making the Connection 2(1): 6–7 (2002). Available at: www.siecus.org/inter/connection/Connection2_1.pdf.
The British Broadcasting Corporation (BBC) and International Planned Parenthood Federation (IPPF) are working together to speak to people in their own languages about sexual health and reproductive rights through a program called Sexwise. Sexwise consists of a website, book, and radio programs that have been translated into 22 languages by the BBC in collaboration with IPPF and national family planning associations. The program, which has spanned the globe in three phases, aims to provide listeners, readers, and online users with accurate information about sexual health issues, along with useful contacts about sexual and reproductive rights. See the global Program Example from Sexwise for more details.

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Improving Health Systems

Pan American Health Organization (PAHO). Setting Up Healthcare Services and Information Systems. PAHO Occasional Publication, No 120. (2001). Book and CD-ROM available for purchase from PAHO at: http://publications.paho.org/english/moreinfo.cfm?Product_ID=524.
These practical guidelines suggest activities for health care and health systems professionals as they plan and develop information systems. The publication covers requirements analysis; technical specification of computer-based applications; preparation of requests for proposals (RFPs) for information systems, technology, and services; evaluation and selection of providers; and contracting aspects when acquiring information systems and technology for health care services. Guidelines available in English and Spanish.

For more information, see the Program Example from Peru about a project that connected rural primary health care personnel, and the Program Example from Uganda about a project that enabled traditional birth attendants to speak directly to the next referral level of the health system.

Rotich, J.K. et al. Installing and implementing a computer-based patient record system in sub-Saharan Africa: the Mosoriot Medical Record System. Journal of American Medical Informatics Association 10(4):295303 (July–August 2003).
The authors implemented an electronic medical record system in a rural Kenyan health center. Visit data were recorded on one paper encounter form, which eliminated duplicate entry in multiple clinic logbooks. A Microsoft Access database was used and was supported by redundant power systems. The system began in February 2001, and 10,000 visit records were entered for 6,190 patients in six months. The authors present a summary of the clinics visited, diagnoses made, drugs prescribed, and tests performed. After the system was implemented, patient clinic visits were 22 percent shorter. They spent 58 percent less time with providers (p < 0.001) and 38 percent less time waiting (p = 0.06). Clinic personnel spent 50 percent less time interacting with patients, about 65 percent less time interacting with each other, and more time in personal activities.