By:Hendra van Zyl and Nolwazi Mbananga

The South African Medical Research Council (SAMRC) is one of the institutions in South Africa that is conducting and promoting health and medical research. Its vision is to develop a healthy nation through research. It is a known fact that the conduct of research as a process of creating knowledge is not directly linked to changing people’s lives. The change can only occur if the created knowledge is transformed into a number of products, projects and programmes. One of the methods of linking health research to promotion of health is research translation. Research translation takes different approaches some of which are not part of this paper. This paper focuses on research translation which is based on the theory and principles of Consumer Health Informatics (CHI). This approach identifies the information needs of consumers and provides the necessary information via Information and Communication Technology (ICTs). In the process of translating research into applied information and knowledge for the public and decision makers, MRC piloted a model with sub-models. These models have been piloted over time in an endeavour to translate and diffuse health and medical research information and knowledge for use by the public and decision makers.

This paper, presents principles and sub-models that have been used by the MRC in translating research into useable information and knowledge to targeted consumers. The literature review that follows, gives a brief explanation of Consumer Health Informatics. The rest of the paper focuses on one of these sub-models to demonstrate how principles where used in diffusing knowledge supported by an ICT framework and lessons learned.

Consumer Health Informatics (CHI), mentioned earlier in the paper, is the branch of medical informatics that analyses consumers’ needs for information; studies and implements methods of making information accessible to consumers. CHI models integrate consumers’ preference into medical information systems. It stands at the crossroads of other disciplines, such as nursing informatics, public health, health promotion, health education, library science, and communication science, and is perhaps the most challenging and rapidly expanding field in medical informatics; it is paving the way for healthcare in the information age.

According to Dr Peter Drucker, author of The Effective Executive and Management Challenges for the 21st Century: “Knowledge is information that changes something or somebody - either by becoming grounds for actions or by making an individual (or an institution) capable of different or more effective action.

When combining knowledge management and information technology in a medical environment, reference has to be made to another area of medicine that is increasingly making its presence felt in the health arena, namely e-Health. The World Health Organisation (WHO) defines e-Health “as the cost-effective and secure use of information and communication technology in support of health and health related fields, including healthcare services, health surveillance, health literature, health education, knowledge and research.

Eysenbach and Diepgen remarked that the exponential growth of Web sites on the Internet opened up a new source of health information that led to the evolution of the “information age in medicine”. They report that health Web sites are the most visited sites on the Internet.

These statements are further supported through research conducted by Lewis et aliv on Consumer Health Needs that healthcare consumers are actively involved in seeking health information and in using the information they are finding to make decisions about their health. People primarily seek healthcare information on the Internet and thereafter from a variety of sources, which include print and electronic resources, healthcare providers, other consumers, their families and friends including traditional healers. In an eEurope 2002 report: Quality Criteria for Health related Web sitesv, an implementation plan was developed and was accepted by the European Union (EU). The report indicates that Internet users would be actively educated to become acquainted with Codes and Quality labels such as HON. Further education of users should explain that these codes stand for the quality of health content on the Internet. Campaigns were cited as means to achieve this. Of importance in using the Internet is the ability of users to rate Web sites. A plan is needed to assist users in rating Web sites and tools should be made available to consumers, e.g. OMNIvi or MEDCERTAINvii. Both Web site providers and consumers of health information should also be educated about processes and good practices that a Web site should demonstrate. This would involve specific marks to indicate types of information such as DISCERNviii – for treatment choices or QUICKix – for children or HON and NETSCORINGx that would ask consumers to tick off types of information as they find them, e.g. statement of aim, explicit statement of source information.

Overall aim

Against this background, the Web & Media Technologies Division (WMTD) of the SAMRC uses a convergence of ICTs to develop various sub-models for knowledge transfer under the umbrella of consumer health informatics. The purpose of these sub-models is to effectively diffuse knowledge to specific audiences.

Knowledge Diffusion Model

The knowledge diffusion model used by the MRC is divided into four sub models as presented below:

• Peer to peer: This sub-model was developed during the establishment of knowledge centres for HIV prevention programmes at rural South African universities where students are equipped and mobilised to participate and lead the process of HIV awareness building among their peers. This model is currently being compared to a similar model and will be subjected for testing in order to reach a best practice model.

• Experts to students: This is a knowledge transfer sub-model that mobilises South African top scientists to act as ambassadors to elucidate science and provide career guidance to students where ICTs focus on the capturing of tacit knowledge and transfer thereof to the audiences. This model is undergoing further refinement by application to different projects.
• Radio to public: A knowledge transfer sub-model is based on the convergence of prepackaged health content, live panel discussions that are broadcasted via community radio stations to deep rural areas as well as in the form of Web casts from health Web sites.
• Web to public: In this sub-model, knowledge transfer happens from a Web/portal presence to audiences on the World Wide Web. Health content is compiled at the hand of specific principles and then another set of principles is applied for the transforming of the health content into appropriate technologies to ensure effective and reliable knowledge diffusion.

Principles of the Knowledge Diffusion Model

In the provision of information using mass media of any kind the following principles need to be considered and applied for effective communication and use of the information provided. This applies to both content and Web site management.

1. Know targeted audience: It includes the psycho-social understanding of the audience to bridge the gap between understanding and interpretation. This would include the social status, language and cultural background of the audience. Examples that are used in explaining knowledge should fall within a framework of understanding of that audience.

2. Engage typical members of the audience: This is a process to assess assimilation and acceptability of transferred knowledge by specific audiences. Assimilation involves the capacity and ability by the audience for the uptake and processing of knowledge, e.g. ascertaining if knowledge is appropriate for the audience in that it is not too specialized or too simple. Acceptability refers to whether knowledge falls within standards, norms and culture of the audience in order to accept it, the knowledge one wants to transfer might for instance not be acceptable for discussion by your audience.
3. Knowledge level index: Consider the audience’s level of knowledge to prevent redundancy by classifying content in different levels of complexity or by leading visitors via questions to knowledge they do not know. This will ensure that the health literacy of the target audience is respected, allowing them to select the level of knowledge they require.
4. Integrate new knowledge into everyday situations: Show relevance of knowledge to specific audiences so that they can understand how to use and apply knowledge in their environment.
5. Avoid information overload: The audience can become confused and no learning takes place when there is too much knowledge to absorb.
6. Striving for utilization: Knowledge may be relevant and appropriate but it should also be utilized otherwise it is of no value.
7. Address pertinent issues: Knowledge should be relevant and address issues that are real to the audience and that they need assistance with.
8. Never induce fear: Fear is not a successful driver to get the audience to utilize knowledge as people eventually overcome their fear. One then loses the opportunity to influence the audience. Rather use a persuasive approach in knowledge sharing by showing the audience that they will become healthier or feel better when using the knowledge.
9. No model fits all: A model that fits a specific audience will not necessarily be appropriate for another audience. One should investigate the needs of different audiences and adapt the model by using these principles.

After content has been compiled based on the above KD Principles, another set of guidelines have been developed by WMTD according to which content is transformed into technology for the Web to public sub-model.

Web Content Guidelines

1. Push and pull concept: Health knowledge is mostly delivered via the World Wide Web and often combinations of ICTs are used. In the typical push and pull concept, push technologies such as listservs (e-mail discussions lists) and e-Newsletter services are used to push knowledge to “subscribers” which the audiences have joined to be kept up to date with topics of interest. Pull technology examples are discussion forums, news syndication or a section with relevant information on a Web site to which audiences go to browse resources for the acquisition of specific knowledge. Often these technologies are converged to effectively make knowledge available in a holistic way. Depending on the nature of the Web presence, implementing these technologies could play a role to capture tacit knowledge of experts that participate.

2. Package content with cultural understanding: If packaging of content is arranged for different language or cultural groups, the home page should clearly display links to content in other languages. Once commitment has been made about expanding a Web presence into other languages, content should be kept up to date in all the languages.
3. Addressing different audiences: Consider sub-dividing a complete Web presence into different sections for clearly distinguishable audiences so that they know where to find information or use unique symbols to identify content for specific audiences.
4. Accessibility: The Internet has opened up a world of opportunities, also for those with hearing or visual impairmentxi. When converting content into Web format, accessibility for these groups should be kept in mind. This means that graphics should have alternative text describing what it represents; tables and figures provided with headings; video/audio files should have transcripts; the use of colour should not be the only method for navigation or guidance to specific content; and clearly indicate links to pdfs/Word/slideshows files. These are just a few simple additions that should be incorporated to make Web content accessible to health information seekers.
5. Convergence of ICTs: Consider incorporation of other technologies to complement a Web presence. Examples are where knowledge is packaged for a specific audience, yet based on CHI principles, e-Surveys could be conducted to establish if the information needs and preferences of users are met; and what their preferred format for knowledge is. Another option is to complement health content with live or scheduled Web casts of audio documentaries where after focus group discussions of pertinent issues can be continued in discussion forums on the Web site.
6. Engaging audience: Conducting e-Surveys to establish the needs of an audience is acceptable and suitable for this model – especially if there are members that register to the site. Ethical issues should be kept in mind as well and general guidelines for e-Surveys as provided by Eysenbachxii. Some general items are listed below:
   
7. Consent: An introductory page should clearly explain the purpose with contact details for additional enquiries. Insert a logo of where the Web site is hosted (i.e. organisational logo) to show that it is not merely a market research survey. For health related questionnaires, provide radio buttons for the participant to accept voluntary participation or not before acceptance displays a new screen and consider whether the survey should be anonymous or not. Preferably password-protect these e-Surveys.

8. Questions: Preferably number questions for backward tracking if reference is needed or skipping of questions is mandatory.
9. Question types: Radio buttons are more suitable for yes/no answers; drop-down lists are suitable for selection of one option from a list; check boxes are suitable when more than one option could be selected. Text boxes can be for open-ended questions – except no formatting can be done in a text box.
10. Thanking participant: Remember to thank participants before and after the survey.
11. Check that the e-Survey works properly.
12. Pre-contact: A higher participation rate is achieved when potential participants are contacted before the survey. Remember that the best incentive for participation remains the promise of feedback – and giving it.
13. Methodologies for measuring knowledge levels: Once audiences have been identified then content should be classified according to levels of complexity and presented clearly so that the sophisticated visitor does not have to wade through redundant information.
14. Information overload: When there is a lot of knowledge that is to be made available to a target audience, information should be categorised into sub-sections or broken down into shorter pages. This will prevent overwhelming an audience or leaving them to wait for a long page to download and then wade through lists.
15. Navigation to content: An important element of a Web presence is how easy it is for visitors to find the information they are interested in. Clear navigation is important using common Web terminology rather than words or definitions that are not easily understood. Navigating one’s site could further be simplified when sub-sections can be accessed without having to click the browser’s Back button. Achieve this for instance by listing main menu items in a left column and sub-items in a right column.
16. Quality assurance: Measures should be implemented to show users that health content is reliable and accurate. This has also been emphasized in the Principles for Content as developed by AMA Web sitesxiii. It can further be achieved with the implementation of an editorial board of experts on the topic of the Web site with the role to review articles for scientific accuracy before publishing it on the Web site. Credibility could further be achieved with compliance to ethical standards for health content such as provided by the Health On the Net Foundation. When the Web presence has been reviewed for compliance, a seal of approval is carried on the home page to indicate reliability of health content for visitors. By publishing the date when a document was last updated, visitors can determine how up to date content is. Ethical principles as used by the HON codexiv include reliability of content; how private and confidential information is handled; source of health content and Webmaster’s contact details; scientific proof when medical advise or side-effects of drugs are provided; full contact details of owners; funding source; advertising policy and accessibility of content by visually/hearing impaired visitors.
17. Interactivity: Interactive ICTs such as search engines can be implemented, often with the ability to import taxonomies that would enhance a basic search with additional related articles. Links to health search engines can further improve interactivity and reliability of content. If a requirement exists for user interaction, discussion forums, listservs (e-mail discussion lists) or blogs can be considered.
18. Explanations, assistance and terms of reference: When Internet users visit a site or are invited to register as members, they should be informed through privacy policies or terms of reference who the owners of the site is, how private information will be treated, confidentiality and contact details provided. Applications such as online databases or e-Learning applications should be accompanied by explanations or help systems that assist the visitor.
19. Basic components for a health Web presence: Navigation or menu items should be clear and use common Web terminology. Sub-menus or items listing sub-sections should be visible and accessible without the necessity of back clicks. If health content forms the basis of the Web presence, the site should be developed according to the HON Code of Conduct or a similar quality assurance methodology. If more than 10 pages, a Web site should have a search engine or site map. Terms of reference/privacy policy should be visible, preferably on every page. The home page or About section should clearly show who the owners and contributors of the Web site is with contact details. Graphics should be used with discretion so that it will not affect the download time of the home page. If possible, monitor access to documents so that it can be established which pages are less often accessed and attention be given to it. Clearly display multi-language access and funders/partner information.

Results

The models have been piloted over a period of two years. Explanatory results are presented below with one example showing how principles and guidelines have been applied.

The Web to public sub-model has been tested against AfroAIDSinfo, the MRC’s AIDS information portal for southern Africa at www.afroaidsinfo.org and is in its third version of refinement. In the table below, it has been indicated how the discussed principles of the KD framework has been applied.

KD Principles As applied in AfroAIDSinfo

• Know the target audience and their knowledge level index - This principle is applied as in the case of AfroAIDSinfo, an international workshop was conducted where it was decided upon who the AIDS portal would target. The consumer groups included scientists, health professionals, policy makers, educators and the public – those who were interested in information on HIV and AIDS. Content was then developed based on the knowledge level index of each consumer group.

• Engage typical members of target audience - The workshop mentioned above consisted of representatives from all the identified consumer groups. Initial discussions took place to develop a pattern for content development.
• Integrate new knowledge into everyday situations - In this process, the initial pilot group provided guidance which was later enriched and modified during e-Surveys among the AfroAIDSinfo consumer groups. In the public category, a community outreach section was developed where content is based on real life experiences and “offline” activities.
• Address pertinent issues - The AfroAIDSinfo editors and content developer constantly scans the environment, with specific emphasis on southern Africa to ensure that current issues are addressed. This process is taken further during the implementation during e-Surveys to establish consumer needs and preferences.
• Avoid information overload - Categories are based on the consumer groups and sub-categories with content specifically for a consumer group prevents the impression of an information overload.
• Striving for utilization - Constant engagement with the various consumer groups ensures that information is provided according to needs and feedback requested on how it is used.
• Never induce fear - Objectivity is maintained as part of the editorial policy and inducing fear carefully steered from, especially in the education section.

Following the application of the above principles, the Web Content Guidelines were followed.

Web content guidelines - As applied in AfroAIDSinfo

• Push and pull concept and interactivity - A sophisticated search engine allows registered users to find and view articles quickly as content is stored in a content management system. This search engine further allows visitors who regularly view specific information, to automatically be identified in communities of practice allowing them to share information and ideas.

• Packaging of content with cultural understanding - Articles guiding visitors on the basic facts of HIV/AIDS that resides in the Public category has been translated into isiXhosa and Afrikaans (South African indigenous languages) to accommodate for the cultural and language nuances.
• Addressing different audiences - All content in the portal has been categorized according to its five audiences: scientists, health professionals, educators, policy makers and the general public. This has been done based on the original feedback as defined during the applicable KD principle. It guides visitors to information that would address their specific needs. Visitors are invited to register to view the bulk of the content that again is clearly sub-divided according to the five consumer groups. Since the audiences are clearly defined, articles are also written according to their knowledge level index.
• Convergence of ICTs - Registered users get access to a discussion forum and receive monthly e-Newsletters that inform them of new additions to the portal and other news items.
• Engaging with audiences - Regular e-Surveys are conducted to determine whether the needs of users are met and adjustments are made accordingly. Articles in the Science category for instance regularly respond to requests from users, current incidents or publications of major impact. Much emphasis is put in the Education category to address the age group 11-18 with collaborative e-Learning studies and other initiatives to implement HIV prevention strategies.
• Methodologies for measuring knowledge levels - As users are clearly divided in consumer groups, content is written on the level of each audience. New users are requested to indicate in which group they would classify themselves during registration. When logging into the AfroAIDSinfo portal, they land in that category, although they are able to view content in any of the other categories.
• Information overload - Content for each category is further classified into sub-sections and based on the portal’s functionality, the user can browse through lists of articles without having to use Back buttons. Portlets have been used in the Policy section for policy makers in South Africa to lead them from provincial levels to municipality districts from where they can access resources specific to that area for their response to HIV.
• Explanations, policies, TOR - A privacy policy has been instituted where the position of AfroAIDSinfo in terms of the HON principles are explained – funding source; status on medical information; disclosure of content providers and editors; contact details of owners and Webmaster and advertising policy.
  Visitors are invited to register as users and a policy and explanation on how personal information will be handled is included.

• Quality assurance - An editorial board of experts in various fields of HIV/AIDS screens all articles before they appear in the portal and HON accreditation has been achieved and these principles are adhered to.
• Basic components and navigation - The AfroAIDSinfo is developed in portal technology that allows sections of information to be arranged in portlets. This also prevents the illusion of an information overload. A navigation bar with sub-items is displayed at the top of the page and terminology conforms to that used on the World Wide Web. A sophisticated search engine is available for registered users when logged in. A footer displays on every page and contains contact details and site owner information.