Overcoming Inertia: Increasing Public Health Departments’ Access to Evidence-Based Information and Promoting Usage to Inform Practice

Abstract

In 2010, the New England Region–National Network of Libraries of Medicine at University of Massachusetts Medical School received funding to improve information access for public health departments in 6 New England states and Colorado. Public health departments were provided with desktop digital access to licensed e-resources available through special pricing. In January through mid-April 2012, we evaluated the effectiveness of providing access to and training for using e-resources to public health department staff to motivate usage in practice. We found that additional strategies are needed to accomplish this.

Access to scientific evidence is vital to evidence-based public health and evidence-based decision-making, yet access is underutilized, limited, or both.^1,2 Many public health departments (PHDs) have no access to evidence-based resources beyond those provided by the National Library of Medicine or its funding.^3,4 Factors influencing evidence-based practice include information access, training, skills, leadership vision, and organizational change.^5–9 By 2009, tools giving access to evidence-based information to policymakers existed but all were underutilized, as was training or technical assistance to enhance uptake.² By 2012 many PHDs experienced massive reductions in staff or resources resulting in variable awareness of the value of using evidence to inform decision-making.⁸

Barriers to information access include competing responsibilities, lack of full-text access, credibility of information retrieved, and infrequent training on information searching.¹ Better methods of indexing, searching, and filtering information through single portal access, archiving information, and early notification of relevant information can improve access and movement toward evidence-based practice.¹⁰

Beginning in 2010, University of Massachusetts Medical School Library received National Network of Libraries of Medicine funding for its Public Health Information Access (PHIA) project, which provides (1) direct electronic access to full-text scientific literature to a convenience sample of state PHDs in 6 New England states and Colorado, (2) training, and (3) a pilot for a sustainable business model to expand access nationwide.

Resources selected (see the Box on page e2) for a digital library were based on national initiatives,^11,12 suggestions from PHD grant partners, and metrics on resource use from publishers. The PHIA project adds journals as it identifies articles frequently requested through subsidized delivery service (Loansome Doc; National Library of Medicine, Bethesda, MD). The 7 PHDs customized the digital library template on their intranet or used shared file capability with links to e-resources. Hospital and academic medical libraries in each state provide resources not available through the digital library.

Example of Resources Provided to Public Health Departments by the Public Health Information Access Project

Single-title e-journals available through the digital library page included

• American Journal of Tropical Medicine and Hygiene

• Health Affairs

• Journal of Agricultural Health and Safety

• Journal of Food Protection

• Journal of Medical Entomology

• Journal of Public Health Policy

• Journal of Studies on Alcohol and Drugs

• Journal of Wildlife Research

• New England Journal of Medicine

• Pediatrics

• Public Health Reports

Publisher packages included access to an additional 97 e-journals:

• Annual Reviews (n = 8)

• American Society for Microbiology (n = 12)

• Centers for Disease Control and Prevention (n = 3)

• Mary Ann Liebert (n = 11)

• Oxford University Press (n = 25)

• Sage (n = 8)

• Springer (n = 24)

• University of Chicago Press (n = 6)

A limited number of copies of EndNote, subsidized by Thomson Reuters, were distributed to public health departments to encourage saving information for use and reuse.

Seven hours of hands-on training included practice locating, appraising, and saving information with their own digital library pages. About 18 public health professionals per site attended.

Note. Resources included specialized databases (notably PubMed), other licensed databases, e-books, journals, and notable reports provided through Internet Protocol address authentication and enterprise licensing for all public health departments. Databases included an e-book collection through STAT!Ref, CABI’s Global Health, and The Cochrane Library. Resources are reviewed and updated depending on usage and cost of use.

METHODS

The PHIA project evaluation aimed to (1) assess usefulness and usage of resources provided and (2) identify effective dissemination strategies PHDs used to motivate utilization and compare them with factors identified in the literature.

From January through mid-April 2012, the evaluator collected qualitative data regarding digital library usage in the 7 states. Evaluation interview questions addressed digital library use and usefulness, impact on practice, and effectiveness of training on using digital library resources.

The evaluator interviewed lead contacts at 7 PHDs and their library partners and collected information from digital library users in PHDs via focus groups, interviews, and surveys. In all, we collected data from 50 participants across the 7 PHDs. The evaluator transcribed and subjected to a thematic analysis^13–15 all data from focus groups, surveys, and telephone interviews.

RESULTS

Evaluation findings related to the 2 broad categories of (1) usefulness and usage and (2) dissemination challenges, strategies, and effectiveness.

Usefulness and Usage

Interviewees noted using digital library resources to

• Search for

  1. Peer-reviewed articles to inform program planning or grant-writing,

  2. Evidence-based programs or contact information for other states doing similar work,

  3. Cross-discipline evidence,

  4. Articles related to Behavioral Risk Factor Surveillance System and other health survey data,

  5. Science and lab-related topics, and

  6. Gray literature;

• Stay current on latest research and epidemiology methods;

• Review e-books and guidelines for care and treatment; and

• Subscribe to e-alerts from STAT!Ref (Teton Data Systems, Jackson, WY) or PHIA-funded journals.

The PHIA project tracked PHIA-funded direct-access journal usage electronically (Table 1).

TABLE 1—

Sample Digital Library Usage Statistics From January 2011 Through March 2012 Across 7 Public Health Departments

Publisher (No. Titles)	Jan 2011	Feb 2011	Mar 2011	Apr 2011	May 2011	Jun 2011	Jul 2011	Aug 2011	Sep 2011	Oct 2011	Nov 2011	Dec 2011	Jan 2012	Feb 2012	Mar 2012	Total
Public Health Reports (1)	0	0	0	0	0	0	0	0	4	5	14	0	2	29	37	91
Annual Reviews (10)	0	0	0	0	15	10	52	33	43	150	68	41	49	22	32	515
New England Journal of Medicine (1)	791	655	1172	863	421	762	1002	1177	1354	1120	1031	846	1218	1384	1585	15 381
Oxford University Press (15)	86	224	499	470	492	413	547	728	571	497	579	557	547	716	656	7582
Springer (21)	0	0	27	84	159	160	63	76	145	128	220	219	149	165	179	1774
University of Chicago Press (5)	0	0	9	3	57	60	26	19	45	18	23	32	28	24	30	374
Monthly totals	877	879	1707	1420	1144	1405	1690	2033	2162	1918	1935	1695	1993	2340	2519	25 717

Lead contacts at PHDs said PHIA “restores access to our science base,” allows full understanding or critique of evidence, makes access equitable to all staff (beyond those with academic affiliations), fosters workforce development, and encourages publishing in refereed journals. The PHD workforce users said it shortens time to acquire evidence-based resources (making travel to medical libraries or identification of staff with academic affiliations unnecessary), adds credibility to their work and promotes evidence-based practice. All PHDs gave positive feedback on article delivery. Users said full-text articles, PubMed, and article delivery service were the most useful digital library components.

The PHIA training covered all resources accessible via the digital library page and their application to practice and trained about 18 trainees per PHD. After training, most felt comfortable with PubMed searches and Loansome Doc requests. Connecticut proactively offered 1.5-hour demonstrations of resources to 80 additional people. Colorado offered Prevention Services Division (PSD) staff additional training on searching and rating evidence and integrating it into evidence-based strategic planning.^16–19

Dissemination Challenges, Strategies, and Effectiveness

Every PHD mentioned being short-staffed and overworked, limiting the number attending trainings and doing searches. Most advocated restoring a culture of evidence-based practice, by identifying appropriate, committed PHD staff with the authority to champion evidence-based practice and usage of digital library resources. Most PHDs relied on staff trained by PHIA to disseminate knowledge about the digital library throughout their organization. However, some described this strategy as ineffective.

Colorado applied Brownson’s approach to evidence-based public health practice,^16,17 training about 60 PSD staff to conduct literature reviews by using the digital library to inform future strategy.^18,19 A PSD informant observed:

We in PSD would never have attempted the large obesity prevention literature review in 2.5 months without the ease of access to full text articles and systematic reviews and without the timely document delivery. Having the [digital library] really made our commitment to [evidence-based public health] possible.

DISCUSSION

The PHIA program addressed many barriers^1,8 by providing onsite training; time-saving, full-text access to credible resources; early notification of relevant information through PubMed myNCBI; quick turnaround on article delivery service via library partners; and affordable EndNote licenses (Thomson Reuters, New York, NY) to archive and reuse information. Some states provided additional training.

In some PHDs, staff acknowledged being so unaccustomed to having these resources that a culture change intervention, beyond training and access, was needed to overcome inertia and promote usage of digital library resources to inform evidence-based practice. Literature^5–7,9,10 and Colorado’s experience suggest that this intervention should include strong leadership promoting evidence-based practice, collaboration, and organizational change. Of the 7 PHDs, Colorado came closest to addressing all factors promoting use of evidence-based resources:

• They engaged PSD staff in using the digital library to conduct a large literature review collaboratively across areas of expertise.

• They used the review to inform collaborative strategic planning with external partners.

• Their division directors consistently supported the use of scientific literature, regardless of its convenience.

The PHIA project began as a small demonstration pilot to provide limited resources licensed for access to only potential users or about 10% to 15% of the PHD staff. Publishers included in the digital library agreed to change their licensing and pricing model to accommodate PHIA. Publishers of a few key public health journals have not yet agreed to such changes, so access to these is through the subsidized article delivery service. Therefore, essential to the success of estimating costs of this model is the National Network of Libraries of Medicine network of resource libraries and their literature collections that make the delivery service and access to these key public health journals possible.

According to our evaluation findings, giving access to evidence-based resources and providing training were useful and necessary first steps. Yet more could be done. Strong leadership and collaboration to promote literature review help reinforce a culture of evidence-based practice.

The PHIA project is adding digital library access to 4 more states, and adding digital library resources on the basis of gaps identified by this evaluation and surveys done in each state. Evaluation is needed in added states to explore findings further. The University of Massachusetts Library and the National Library of Medicine are seeking additional national funding sources to extend this effort nationwide.