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Planning and Evaluating Health Information Outreach among Minority Communities: Model Development Based on Alaska Native/American Indians in the Pacific Northwest

Project Advisory Panel Meeting

June 12, 1998, University of Washington

Key Points of Discussion

Panelists: Judith Bendersky, John Bowes, George Baldwin, Laura Cailloux, Jo Dorsch, Bill Dutton, Sherri Fuller (Panel Chair), Mark Haselkorn, Walt Hollow, Peter House, Carol Jenkins, Steve Kerr, Joanne Marshall, Everett Rogers, Ted Mala, Kim Witte

Project Staff: Catherine Burroughs, Nancy Press, Roy Sahali, Elliot Siegel, Karen Wallingford, Fred Wood

(Not present: Neil Rambo, Fran Lewis, Carrie Paton)

At the second project advisory panel meeting, panelists discussed a working draft of the planning and evaluation resource developed by RML staff. In addition, panelists reviewed a draft evaluation plan for two pilot interventions of the Tribal Connections project. John Bowes, consultant to the Northwest Portland Area Indian Health Board presented a preliminary outline for evaluation of the Circle of Health project.

At the meeting, several ideas for further refinement and iterations of the draft resource were suggested. Given limitations of time, staff, and resources on the project, priorities have been established for follow through on these ideas. The first priority is to revise the current draft to become a practical and user-friendly field manual in print format (by September 1998). Future iterations to be scheduled may include a web resource, continuing education course, informational brochure (promoting the various resources), and a compilation of the consultant papers for publication.

The following summary provides key points from the discussion as they relate to further development of the various iterations of the planning and evaluation resource.

The content of the resource is logical and valid, but its usability is currently limited. For greater access and benefit, there should be several versions.
- Field manual - One version should be in print (for easy access and use) and the content a superset of the current detailed complexity. It will be something like an applied manual, or field manual, that is targeted to outreach planners, such as librarians, health educators, or others involved in information dissemination. Features, such as examples or stories, will help motivate interest and appeal. Also, the revision should be restructured for easy use by providing a typology of needs, settings, or audiences that are mapped to methods, theories, or principles. This concept could be conveyed through graphic representation or case scenarios. Overall, the field manual will provide descriptions, context and/or examples of appropriate theory in a user-friendly presentation, with referral to additional materials (e.g. consultant papers) for more in-depth discussion.
- Web resource - Another version should be a web resource that leverages new media techniques to offer multiple access points to the content that will include both applied and practical text, as well as links to the academically-based discussion and consultant white papers. As with the print version, there could be a typology of needs, settings, or audiences that are mapped to methods, theories, or principles. The web design would offer a way for a user to tailor the information output according to their particular needs (i.e. "I need to show numbers" or "I need to better understand my targeted audience" or "What is the theory behind this?"). Developing such a web resource is acknowledged to be complex and to be done well will require significant effort.
- Continuing education course - Content included in the print or web versions could usefully be presented in a full-day course, with the field manual being the course text. Such a course may be provided through MLA or as part of an RML resource to network librarians (or both).
- Curriculum textbook - Depending on other outcomes, a textbook version for use in library education curriculum might be considered, published by a university press rather than NLM.
  In addition to the above, other products envisioned include: 1) a promotional piece listing the availability of the field manual, web site, CE course, etcs; 2) a panel forum at MLA in Chicago '99 about the whole project, its findings and outcomes; and 3) a published compilation of the consultant white papers, perhaps in a symposium issue of the Bulletin of the Medical Library Association.
The resource needs a stronger sense of mission or purpose.
It is currently weak in conveying why health information outreach is worth doing in the first place. There is a working assumption that needs to be stated up front as introductory context- that access to relevant and needed health information will help improve the delivery of healthcare, the prevention of disease, and the promotion of health. This is the ultimate purpose of outreach, although the guide will not be a tutorial on why outreach is important. What outreach actually is can be defined very broadly - a targeted service to address the unmet need of potential clientele. This broad definition includes a wide range of settings and audiences, with the cross-cutting assumption that information access will improve health. For example, for outreach to Alaska Native/American Indian groups, the assumption is that access to Indian health data will help improve the health of Indians. This should be the working assumption (and not a hypothesis) -and the resource will help outreach designers to assess what information is needed, to use best practices in outreach to facilitate access, and to be able to tell whether and how these efforts to improve information access are making a difference for targeted individuals, organizations, or communities.
The resource should encourage needs assessment techniques that are creative and effective in identifying unmet needs.
Library services are being reinvented to become more user-based and to facilitate information access at the point of local need. This customized approach requires working closely with the targeted audience to identify unmet needs. What is currently happening?- how is information being used?, what are the unmet needs?, what political or cultural aspects need to be considered? Whether working with minority groups or rural and isolated populations, there are environmental or cultural characteristics that shape the types and ways of using information most critical to improving health.
The resource needs more emphasis on building and assessing change at a community level.
The planning and evaluation resource currently emphasizes motivational strategies for individual level of behavior change in adopting and using technology to access information. However, it needs to be flexible, robust, and broad enough to take into account outcomes such as the development of a community of users. Building community capacity development into the outreach objectives can be an effective way to maximize diffusion of innovation. Depending on the context of the outreach setting, assessing community-based outcomes may be appropriate. For example, for the Alaska Native/American Indian community, access to Internet technologies provides the potential to have control over the development and use of Indian health data within and among tribal communities. The success of the Tribal Connections outreach project could be measured, in part, by the extent to which it generates a community of users who promote Indian health data and its use in Indian communities.
George Baldwin has studied online communities and has some suggestions for ways to measure them as indicators of a successful online project. He says that the critical mass for a sustainable online community must include at least 10-15 people.
The phrase "community" has specific meaning in the field of community capacity development. Its definition is that the characteristics of a community include people who share place (location) and common values and beliefs, and who make decisions together and talk among themselves.
Alaska Native/American Indians have rich communities by this definition and outreach to these communities may serve as a model for community capacity development projects. Other models could include the AIDS community and how it has used and developed information resources to create its own identity and voice and impact the health status of its community members.
Librarians have also used community capacity development strategies, but may not have acknowledged the impact that these activities have made. The resource guide should help add to our knowledge base by formalizing the importance of community capacity development and include principles for why it is important, how to do it, and how to assess its impact.
The resource needs clarification about what audience it addresses
The resource will be targeted to outreach planners who can benefit from it in varying degrees - whether from practical and user-friendly applied guidelines (field manual) to full description of theory (web resource and curriculum text). Potential users of the resource (in its various versions) will need a clear picture of how it can be useful to their situation. We shouldn't assume that people are motivated to use the resource. Especially for the field manual and web resource, organizing the content for user friendly presentation by mapping users, targeted audience, settings, or evaluation objectives with methods and techniques may be helpful (could use graphic representation to show this). Other motivational techniques to help influence its use could be the use of example scenarios, stories of success, stories of failures, etc., that are sprinkled throughout the resource. For example, bring pieces of the Spokane story into the main text.
The intended user of the resource design outreach interventions targeted to health providers as well as consumers.
Audience groups of outreach can range from health providers to consumers of health information for personal use. In minority communities, both health providers and consumers may need health information not typically included in the content of Western-based medical resources. For example, the Alaska Native/American Indian community includes traditional Indian beliefs about health and disease. The planning and evaluation resource needs to emphasize the importance of knowing the beliefs, taboos, values, and environmental characteristics of the targeted audience so to better assess the type of information that is most critical and helpful. As an orientation to this concept, the planning and evaluation resource should give examples of various cultural beliefs that impact the types and ways of using health information that is considered acceptable and valid. For example, in the Alaska Native/American Indian community, open discussion of AIDS is taboo.
To encourage use of health information, the outreach designer can choose from several theories about motivating behavior change. The Stages of Change model shows how change is processed and motivated at an individual level first, and then maintained through motivation and reinforcement at a community level.
The resource should be pilot tested by intended users.
Current plans to pilot test the field manual include the two pilot interventions of the Tribal Connections project. Thus far, a preliminary draft of the pilot intervention evaluation plan has been drafted and will be revised with feedback from panelists. That process has already helped identify the level of practical application that will be needed in the field manual for effective understanding. When the field manual has been drafted as a user-friendly document, it will be pilot tested by a library that is conducting an outreach project to tribal college librarians in Montana. The outreach librarian will be asked to use the guide in developing and conducting an evaluation of the proposed outreach project. In addition, Carol Jenkins has proposed that pilot testing of the resource might be feasible within one or more projects at the University of North Carolina, Chapel Hill.
Given that outreach embraces many settings and audiences with differing environmental or cultural factors, the resource should encourage creative designs of outcome assessments that are helpful in problem solving unmet information needs at the local level.
In the field of education, this approach encourages the idea of "teacher as researcher" where the evaluation results empower local problem solving. The field manual should reflect a broader definition and understanding of outreach and the full range of its impacts. The evaluation process helps the local outreach planner better understand (i.e. research) how health information is most critically needed and most usefully promoted. Thus, in a community such as Alaska Native/American Indians, just tracking user increases of Western-based knowledge resources will ignore other outcomes more important to this community, such as development, control, and/or identification with data relevant to Indian health. Likewise, for local decisions about maintaining library resources in a rural hospital, tracking the increase in document requests may not be as useful an outcome as tracking the ways this information has changed or influenced patient care decisions. Hospital administrators are not as interested in numbers of documents ordered, as they would be in quality measures about health delivery (e.g. reduced in-patient stays).
Practical, user-friendly versions of the resource (the field manual and web resource) need to convey how and what kinds of evaluation can be done in settings with limited resources and staff. The resource needs to motivate librarians to see that evaluation will be beneficial to their projects and will help build evidence based approaches for the library profession.
The planning and evaluation resource should avoid being perceived as a directive from NLM about what is expected in an evaluation. It will be a waste of money and time to simply go through the motions of evaluation if the results are not used for local decision making or for knowledge contributions to the field. The local outreach designer, working with key contacts in the targeted audience, is the best judge of how and what the evaluation should address. However, the resource should include sample survey instruments or standardized questions that could be used in the locally designed evaluation and then reported back to NLM.
Best practices will be reflected in the printed field manual, and also on the Web version, where new best practice examples can be added (or linked) as appropriate.
Different groups have varying politics about information access relevant to the success of outreach activities. To the extent to which these are known, they should be reflected in the resource and future evidence-based outreach projects will add to this knowledge. One example is the natural tension between tribes and librarians about access vs. control of Indian health data. The answer to this could be outreach to facilitate development and access to resources via Intranet technologies. Also, evaluation research in tribal communities should respect local tribal government policy, which outreach planners need to determine before forging ahead. Another example could be the policies of restricted Internet access in an organization due to management concerns that employees don't "waste time."
The resource should encourage outreach designers to think more broadly in identifying what health information is most critically needed and will make a difference to their targeted audience. While librarians have created a role as gatekeepers of information, their quality filters need to go beyond the traditional model of what is health care knowledge. Other forms of information may be legitimate health information, depending on the needs and context of the user base. For example, for Alaska Native health aides, it could be communication access with other aides, or operational and logistics information, such as weather information in remote areas for land or air ambulance rescue. In a rural clinic, some of the most important health information access could mean electronic transmission of laboratory test results.

The planning and evaluation resource provides a tool to help the outreach designer assess what is really needed; use best practices and theory-based strategies to address those needs; find out what works and what doesn't; and determine whether and how outreach made a difference.

Evaluation Project, Index of Contents