Attitudes of health professionals to the development of information systems and the use of information

Leadbeter Health Information Specialist

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Deana

Introduction

My background and why I started this research project (arose from a perceived need) Aims of the research and how these have changed slightly during the research project (action research approach) Approach and Methodology and how this may be of interest more generally Progress so far Results so far How useful is this both the methods and the results?
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My background

Statistician / Health Information Specialist Worked in UK as:

Statistician in Pharmaceutical Research, Regional Statistician S E Thames Director of Information Services SEIPH In Uganda, Palestine, Tajikistan, Uzbekistan, Georgia, Romania, Bangladesh, Bosnia, Kosovo, Croatia, Russia, Poland (and teaching international courses to staff from many more)

International Health Information Specialist.

My background (continued)

Chair Health Statistics User Group

=> national level meetings and discussions on information systems developments in the UK UK Professional Awards in IM&T (for info specialists) Dip in Leadership & Management Info Module (for UK clinicians) at Salomons International MBA Health Population and Nutrition Info Module at Keele => experience of individuals in use of information and development of systems

Teaching / Training / Professional Development

Main aim of all my work

Helping to improve health services by:

Improved availability and use of information Development of information systems, both manual and computerised (or enhancement of existing systems) Improved understanding of how information can be used, and how to use it appropriately Willingness to use the information
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Which is achieved by:

So people issues are as important as technical issues

Context of my work

Project work in many different parts of the health care system, in many different countries (which also can sometimes prompt a fresh look at your own country) Health systems in all countries depend on information to support the development of policy and implementation of changes in practice, and not just to support operational activities. In general, there may be different health care systems in different countries but basic principles are the same so information problems and solutions will be similar although not identical

What prompted this research project?

Experience is that implementation of health information systems are often not as successful as anticipated and dont deliver the expected benefits

particularly when applying approaches or solutions developed elsewhere to a different context Applies to all countries (UK is no exception)

Differences in how well or badly information systems developments work prompts questions:

What makes info systems developments work (or not work)? How can we be more successful in what we are trying to do (all very expensive so waste of money if it is ineffective)

Are reasons the same? Can lessons be learnt?

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What prompted this research project (continued)?

Despite the electronic age, collecting data, running the systems and using the information relies on the involvement of health staff at many different levels Any development of the systems should take these staff, and their views, into account

What prompted this research project (continued)?

Although a lot of interest in this area, there has been only a limited amount of research (in UK or internationally) on attitudes to health information (not just IT) The research done has not tended to result in practical advice or tools that can be used on the ground to increase chances of successful information system developments

What can be done to improve the situation and how can research help?
Hofstede states, One of the reasons why so many solutions do not work or cannot be implemented is because differences in thinking among the partners have been ignored. Understanding such factors is at least as essential as understanding technical factors. This accords with my own practical experience and applies between groups within an organisation, between organisations or groups within a country as well as between countries
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Cultural Dimensions according to Hofstede (are others but this is most widely used and quoted)
Classifications (and indices) are: Power distance (PDI = Power Distance Index) Uncertainty avoidance (UAI = Uncertainty Avoidance Index) Collectivism / individualism (IDV = Individualism Index) Masculinity / femininity (MAS = Masculinity Index) Long term orientation (LTO = Long Term Orientation Index) Intuitively these seem to be factors that may affect how staff interact with information
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Cultural Dimensions according to Hofstede (some links to health care)

Example of some correlations found in other studies are: PDI = Power Distance Index, positively correlated with preferring cure over care IDV = Individualism Index, positively correlated with satisfaction with health care system

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Cultural Dimensions according to Hofstede (suggested links to IT acceptance from other research by Zakour)

PDI = Power Distance Index. If high may not accept IT because it threatens the hierarchy (may also apply to information) UAI = Uncertainty Avoidance Index, If high may use IT less because doesnt allow social presence (but may use information more??) IDV = Individualism Index. If IDV high i.e. low level of collectivism, then more difficult to get common agreement needed for IT implementation (also applies to information - for example, for agreement on common data definitions)
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Are other classifications e.g Lewis where each group gathers information in a different way

Linear-actives

who plan, schedule, organise, pursue action chains rely mainly on data

Multi-actives

lively, loquacious, many things at a time, prioritise according to relative thrill/importance each appointment brings rely on face to face encounters and dialogues

Reactives

prioritise courtesy and respect, listen quietly and calmly, react carefully - gather information by a combination of both methods
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Is understanding of cultural differences needed for successful deployment of IT?

One view (Myers and Tan) An understanding of cultural differences is important, but suggest that the concept of "national culture" that has tended to dominate the IS research literature is too simplistic Information systems researchers should go beyond models of national culture. We propose that IS researchers should adopt a more dynamic view of culture - one that sees culture as contested, temporal and emergent

=> Need to take a dynamic, flexible approach to investigation. Dont get too fixed on specific cultural dimensions
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Cross cultural studies - Strengths and weaknesses

Are many criticisms Over simplistic Study design (wording and questions) can be very ethno centric (usually W Europe / America), which may determine results. Researchers themselves warn that they are looking at groups, and cannot be used to predict individual behaviour But Results are widely used in business and management If you have experience of different cultures, and then look at results can be surprisingly insightful see for example Lewis (Cross cultural communication)
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Research Topic and Aim

Original Topic of Research (as registered)

The effect of cultural differences in organisational and professional relationships within the health sector on how information is accessed and used to influence policy development and practice

Current Aims

To obtain information on attitudes of health staff to information systems, To investigate whether these attitudes vary between different countries To provide approaches and tools that will assist collaborators in different countries improve their understanding of attitudes, so that they can adjust information system development and implementation plans accordingly

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Approach to Methodology

One view is that this is all too difficult, and that attitudes cannot be quantified in a way that provides any meaningful information

So is quite challenging!

So

looked at research in similar areas to identify approaches that could be used, and modified for this purpose In practice, it is possible that the development of these approaches may be more useful as an output from the study, than any results from the data analysis
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Challenge 1: Cultural differences in attitudes to health information systems are too difficult to quantify Response: Cross cultural research widely used in other areas, so should be possible to apply to this area Obtained permission to use Hofstede questions as Part 1 of questionnaire:

Can then use Hofstede formula to calculate the indices to see if any correlation with responses to other questions These questions include comments on working relationships, so provide a relevant general introduction to questionnaire
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Challenge 2: Questions developed within one culture will be ethnocentric and influence the results (particularly for soft issues like attitudes)
Note: this comment can also apply to developing questionnaire within one organisation or group that will be used more widely Response: Draw on international literature to identify statements made about information systems developments Develop method, based on work by Triandis, which is designed to produce questions that are not organisation / country /culture specific. Use Triandis method with different groups (UK staff, and also international groups, and also by e-mail discussion)

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Challenge 2 (continued): Triandis Method

Work in a group using a brainstorming type of approach Draw up 3 columns (antecedents, concepts, consequents) In middle column, ask for list of all the general concepts, elements, intangible things that can apply to an information system e.g. things like feasibility, feedback systems etc, not hard items like computers. Then, for 1st column antecedents, ask each person to specify 3 things that need to be in place for the concept / thing to occur Then, for last column consequents, ask each person to specify 3 things that are a consequence of the concept / thing being in place. Then share and discuss
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Challenge 2 (continued): Comments on the Triandis Method

Did not work well trying to use this in a Delphi style approach through e-mail discussion. Did not want to influence the thinking by making suggestions, but then made it too vague. However, although approach is difficult to describe at first, it works well in a group session once people see how it is going Although originally developed this approach to help with questionnaire design, have found this to be a good technique to get groups to think outside their preconceived ideas so now use it often in workshop sessions

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Challenge 3: Hypotheses that study is designed to test may be ethnocentric (or organisation centric)
Response: Although original design is influenced by previous cross cultural research and questionnaire collects Hofstede data, the main focus is on responses to information system questions within country and how these vary between countries so not restricted by cultural dimensions Questions are defined by issues of concern raised in literature and by colleagues not by hypotheses
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Challenge 4: Collecting information on views thro scoring system does not give meaningful results
Response: Include some questions that address similar issue in a different way to check internal consistency Use approach suggested by Handy (adapted from questionnaire by Harrison) where series of statements are listed and participants are asked to rank these

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Response to Challenge 4 (continued): Using ranking approach instead of scoring

Part 2 of Questionnaire includes statements on issues relating to health information grouped as:

Knowing what data to collect Developing information systems Data collection Making the information available Using the information

For statements with which they agreed: Ranked 1 as most important, 2 as next most important etc Ranked 0 if did not agree

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Response to Challenge 4 (continued): Comments on use of ranking approach in practice

Some participants found the ranking hard, because it meant they actually had to think about the statements, rather than just quickly ticking the boxes (which was the point of the design!) But participants said they found the thinking process helpful so completing the questionnaire was a useful development exercise in itself After completing with their own views then, if desired, can share and discuss which prompts useful discussion

Comment that easier to raise issue of concern if on the questionnaire than putting forward as their own view

Also, approach in Handy includes looking at ranking two ways:

own view their perception of organisations view

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Challenge 5: Staff will not bother to fill in this type of questionnaire, or may give to junior to fill in for them so get poor response Response: Include as part of meeting or workshop that is being held anyway, or use the questionnaire as a the basis for a workshop

Needs to be at start of meeting (takes about an hour) Small numbers but good completion so similar amount of data as from a larger, self completion sample Provides some immediate benefit if meeting is designed with opportunity for immediate feedback and discussion

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Challenge 6: Funders of health information work tend to be interested in systems development only and wont fund studies on soft issues like this.
Response (as before): Include as part of meeting or workshop that is being held anyway, possibly for professional development because use of questionnaire highlights some general management issues as well as information ones Include questions that are relevant to an information requirements analysis (Part3 based on questions tested elsewhere for this purpose) Develop workshop programme in which the questionnaire can be used (1 or 2 day programme)

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Challenge 6 (continued) : Use of questionnaire as part of workshop.

Day 1: Attitude Survey Listing of information needs Impact Analysis
Technique to identify actions that will result from producing the information (who does what, when, where etc?)

Issues affecting development & running of information systems

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Challenge 6 (continued) : Use of questionnaire as part of workshop.

Day 2: Qualities of Data and Information (Triandis approach) Feedback on initial results of attitude survey (Part2 ranking of statements) Discussion of Issues arising from Results Actions / Way Forward individually or as a group

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Attitude Questionnaire - Summary

Part 1 of the questionnaire: general introductory questions on attitudes to work and life (Hofstede) intended to be used when comparing the results with responses from other groups Part 2 of the questionnaire: issues that need to be considered when developing and using information systems. This section of the questionnaire was divided into five parts considering factors that need to be taken into account:

When deciding what data to collect in an information system When developing information systems When collecting data in relation to health care services and to the health of the population When making health care information available When trying to ensure that the information is well used
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Attitude Questionnaire - Summary (continued)

Part 3 of the questionnaire listed some of the main types of information relating to health and health care and asked the respondents which of these types of information:

they thought should, ideally, be available to them to help them in their job, what was currently available whether they were satisfied with the quality..

The final question in part 3 asked the respondents about what information had most influence in helping them improve the way they worked
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Progress So Far.

Questionnaire has been used in 3 countries:

Georgia, Tajikistan, Uganda (with my personal input to set up intially then run subsequently by local colleagues)

If this is to be useful then needs to be possible for people to use the materials themselves. In discussion with colleagues in:

Brazil, Chile, Palestine, Syria (and possible Sri Lanka)

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Other Issues - Translation.

Where local language is not English then questionnaire needs to be translated Also needs to be back translated and checked against original to make sure that sense hasnt changed This highlights some issues in relation to concepts that can be misunderstood, or lost in translation, and so need careful explanation so annotated version of questionnaire has been produced (many of issues highlighted are also relevant in English speaking countries) In Syria have translated the questionnaire prior to agreeing to use it, because it can be used to improve communications
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Other Issues Links to Other Work - Tajikistan

A brief comparison of the information from the research questionnaire with the results from the WHO standard questionnaire on information systems has been carried out. The results have also been compared with a field assessment of Health Management Information Systems. Comparisons so far indicate that: The results from the research questionnaire are consistent with those from the surveys, but that the research questionnaire provides complementary, and more detailed, information on attitudes. The research questionnaire can be administered quite easily and cheaply compared to the other surveys
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Other Issues Links to Other Work - Uganda

Analysis of staff attitudes was carried out in 2005, and was reported in the strategy for HR Information Systems, and taken account of in development plans Staff views are also being taken into account on an ongoing basis during the testing phase of systems being develop. Before end of project (March 07), information on staff views, from attitude survey and pilot, will be reviewed - to identify lessons learnt that can assist in rollout of the systems, or in any other similar developments. Results will be presented during study tour in Scotland in March 07 to get feedback on relevance for UK Will also be compared to (less successful) developments in Georgia
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Other Issues Links to Other Work Experience of international consultants

As well as collecting data from health professionals within the individual countries, members of the international project teams were asked to complete Part 2 (the ranking of statements), not with their own view but from their experience of information systems developments in other projects in which they has worked.

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Final Question does using the attitude questionnaire and other techniques help?
The Process: Using the questionnaire, and other techniques, helps:

Involve users in development, Improve communications and facilitate discussions on prioritisation of factors to be addressed in information systems development

This improved communications and understanding may, in itself, help to improve the chance of successful implementation The Results: Should help system developers identify issues of concern so that they can address these
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Final Question does using the attitude questionnaire and other techniques help (continued)?
What about comparisons between countries and link to cultural dimensions? Some differences found in rankings found from countries so far so is not just a standard response (small example on flipchart) May be difficult to assess fully without getting results from more countries So far the Hofstede dimensions havent produced useful results need to investigate further Most useful results are probably the process and the tools
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