Understanding Health Information Needs and Gaps in the Health Care System in Uttar Pradesh, India

Abstract

Health information and the channels that facilitate the flow and exchange of this information to and among health care providers are key elements of a strong health system that offers high-quality services,yet few studies have examined how health care workers define, obtain, and apply information in the course of their daily work. To better understand health information needs and barriers across all of levels of the health care system, the authors conducted a needs assessment in Lucknow, Uttar Pradesh, India. Data collection consisted of 46 key informant interviews and 9 focus group discussions. Results of the needs assessment pointed to the following themes: (a) perceptions or definitions of health information related to daily tasks performed at different levels of the health system; (b) information flow in the public health structure; (c) need for practical information; and (d) criteria for usability of information. This needs assessment found that health information needs vary across the health system in Uttar Pradesh. Information needs are dynamic and encompass programmatic and service delivery information. Providing actionable information across all levels is a key means to strengthen the health system and improve the quality of services. An adequate assessment of health information needs, including opportunities, barriers, and gaps, is a prerequisite to designing effective communication of actionable information.

Health information and the channels that facilitate the flow and exchange of this information to and among health care providers are key elements of a strong health system that offers high-quality services, thus contributing to improved health outcomes (Horton, 2000). Yet, research undertaken to understand the information needs of health professionals is limited (Pakenham-Walsh & Bukachi, 2009; Revere et al., 2007). Few studies have examined how health care workers define or obtain information, and, even more important, how they apply information in the course of their daily work (Kale, 1994). Pakenham-Walsh and Bukachi (2009), in a literature review of information needs of health care workers in developing countries, found that access to information is easier at the central levels of the health system, whereas workers at the subdistrict and grassroots levels have substantial unmet needs for information.

Access to and use of information has recently been reshaped by the telecommunications revolution sweeping across resource-poor nations (Lucas, 2008). New technologies have provided opportunities that were inconceivable just a few years ago. For example, in 1998 Lown, Bukachi, and Xavier (1998) noted, “While the affluent travel at greater speed on the information highway, a majority of the world's population has never made a phone call” (p. 36). Today, India has more than 858 million mobile telephone users, and the number is continuing to grow at a rate of 20 million each month (Telecom Regulatory Authority of India, 2011).

Although India's information technology sector is developing rapidly and expanding access to information, health personnel in India still lack relevant and actionable information. There remains a “need to improve the quality of health-care information in terms of its reliability, relevance and usability” (Godlee, Pakenham-Walsh, Ncayiyana, Cohen, & Packer, 2004, p. 298).

In the face of the health challenges in India, health care providers need relevant and actionable information. In particular, the heavily populated northern states in India, such as Uttar Pradesh, continue to have high levels of maternal and infant mortality (International Institute for Population Sciences & Macro International, 2007). For example, the maternal mortality ratio in Uttar Pradesh is 359 deaths per 100,000 live births, compared with 212 for India as a whole and the Millennium Development Goal of 109 by 2015 (Office of Registrar General, India, 2011). Similarly, the infant mortality rate stands at 73 deaths per 1,000 live births, compared with 57 for India overall and the Millennium Development Goal of 28 by 2015 (Office of Registrar General, India, 2011). Uttar Pradesh has the second highest total fertility rate in India after Bihar, at 3.8, compared with a total fertility rate of 2.6 for India overall (Institute for Population Sciences & Macro International, 2007).

In 2005, India launched the National Rural Health Mission (NRHM) nationwide to improve the health system in rural areas, where 72% of the population resides (Government of India, Ministry of Health & Family Welfare, 2010). As the most populous state in India, with nearly 200 million people in 2011, Uttar Pradesh has a large number of health care workers at the village, block, district, and state levels. In such a large organization, the flow of formal and informal information plays a key role in informed decision making and coordination throughout the health system. However, many grassroots workers have knowledge gaps in the area of reproductive and child health (Constella Futures, 2007).

The larger study on which this article is based examined the needs for actionable information at the state, district, block, and grassroots levels in Lucknow district in Uttar Pradesh. It aimed to map the information requirements of different levels of health personnel in terms of content, quantity, simplicity, and timeliness. It also examined the roles of global and local information—technical and programmatic—at the state, district, and subdistrict levels. In addition, the study aimed to gain a deeper understanding of local patterns of information flow. In this article, we report on definitions of health information: how information flows across the levels of the health system, the information needs at each level of the health system, the information sources, the information-seeking styles, and the perceived usability of information.

Method

Seeking to obtain a full understanding of health information needs and barriers across all of levels of the health care system, the Knowledge for Health (K4Health) project at the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs conducted a needs assessment in Lucknow district, Uttar Pradesh. The research team selected three of the eight community blocks in Lucknow district (Mahilabad, Mohanlalganj, and Sarojini Nagar). In addition, to obtain views on information needs at the national and state levels, the research team also conducted key informant interviews in New Delhi and in Lucknow—the state capital of Uttar Pradesh.

Data Collection

The research team collected data from 46 key informant interviews and nine focus group discussions. Key informants included state-level officials from the NRHM, district and block officials, auxiliary nurse-midwives (ANMs), accredited social health activists (ASHAs), officers from the U.S. Agency for International Development, and staff of nongovernmental organizations and other professional organizations (see Table 1). At the district level, we interviewed the health officer, information officer, and community mobilizer. At each of the three blocks, we interviewed the medical officer, health education officer, and laboratory technician. We also conducted 10 in-depth interviews with representatives of professional networks. (Data on professional networks are not presented in this article.) In addition, we conducted nine focus group discussions, mostly at the grassroots level: five with grassroots workers, including ANMs, anganwadi workers, and ASHAs; two with community members who serve on development committees; one with members of self-help groups; and one with laboratory technicians.

Table 1. Number, location, and types of key informant interviews, by health system level

Health system level	Number	Location	Types
National	6	New Delhi	United States Agency for International Development officials, international nongovernmental organization, and nongovernmental organization staff
State	10	Lucknow	National Rural Health Mission officials
District/block	11	Mahilabad, Mohanlalganj, and Sarojini Nagar blocks	District health officer, district community mobilizer, block health education officer, medical officer, and laboratory technician
Village/subcenter	9	Mahilabad, Mohanlalganj, and Sarojini Nagar blocks	Accredited social health activists, auxiliary nurse-midwives
Network	10	Lucknow	Members of professional networks
Total	46

The research team recruited participants for the in-depth interviews through the Chief Medical Officer of Lucknow district and focus group discussion participants through village-level workers. The team obtained verbal consent from participants after assuring them that all information collected would be kept confidential and that the data set would include no unique identifiers.

Data were collected between September 2009 and November 2009. A two-person team, a facilitator and a note-taker, conducted each key informant interview, while a three-member team consisting of a facilitator, observer and note-taker collected the focus group discussion data. All interviews and focus group discussions were audio-taped with the participants' consent and later transcribed. A senior member of the research team conducted quality assurance of the transcriptions.

Data Analysis

After the research team translated the transcripts into English, the team analyzed them with ATLAS.ti software. A list of 134 codes reflected the main themes and subthemes, including perceptions of information, types of information, information flow, and the need for actionable information. We analyzed the themes and subthemes for each level of the health system. Each theme required at least five participants alluding to the particular issue. Quotes from individuals that other study participants did not support have not been included in the results.

Data analysis occurred in an iterative manner; more in-depth analysis identified five parameters of actionable information. The core theme of actionability emerged in the context of study participants stating in different ways that information should be “used” or “applied.” An adequate level of content saturation was achieved with the data.

Results

Perceptions of Health Information

Health care workers' perceptions of information are directly linked to their primary roles within the health system (see Table 2). The activities that they routinely perform in their daily work drive how they construe information.

Table 2. Definitions of information at different levels of the health system

Health system level	Types of information	What does information mean?	How information is used
National	Evidence-based information Best practices	“Our mantra is to use evidence to inform programs.” “I like executive summaries—not pure data.”	Policy planning
State	Health services and health coverage information, aggregated at district and state levels	“How many gynecologists in the state, district? How many deliveries at the PHC?”	Program planning
District/block	Government guidelines	“We get government circulars, which we read. The government keeps on taking out circulars with new information.”	Program implementation
Village	Referral information Transportation information How to use thermometers Verbal communication	“Generally people in the village sit outside so we explain to them there only. They come to meet us even at one call. Everybody calls me didi (sister) and respects me.” “Information related to how to give a message, how to organize meetings.”	Motivation for behavior change; referrals; how to handle emergencies

At the national level, officials require evidence-based, locally relevant best practices that will help them implement health policies. Context is important: “Global learning is difficult to apply to India … intra-country best practices are more useful” (Key informant interview participant, New Delhi). Best practices and evidence-based information should be relevant to the local Indian scenario because Indian policymakers “are not interested in hearing about best practices from Peru” (Key informant interview participant, New Delhi). At the state level, health care officials need information about health services and health coverage for program planning. For officials at the district level, information consists of program guidelines that are periodically received from national government authorities or developed at the state level and then forwarded to the next lower level. A senior NRHM manager for Uttar Pradesh, described the process of sending information to 71 districts:

We send a hard copy of the guidelines to the district manager chief medical officer and also send the soft copy to the district magistrate … and district community mobilizer … so that it can reach the lower levels. The guidelines that we receive almost always come from the Government of India or NRHM (New Delhi).

The guidelines include instructions and details of program implementation—for example, conducting a village-level event on women's health on the occasion of World Health Day. Each district in Uttar Pradesh is divided into 15 to 19 blocks. At the district and block levels, issues related to program implementation shape perceptions of information. They await guidelines that provide instructions on program implementation. Therefore, prompt arrival of government guidelines at the district and block levels is a major concern. Once government guidelines reach the district level, they are sent to the blocks and community health centers by post. Often the guidelines do not arrive in time at the community health centers for program implementation. In the interim, district officials issue verbal instructions over the phone to block and primary health center staff. A block health education officer of Mahilabad commented, “We do not get letters on time. Recently, a supervisor called to give me information. We could not understand such information [instructions given on the phone].”

How do these guidelines reach the grassroots? A 32-year-old ASHA with an eighth-grade education described the process as follows:

First, the Medical Officer gets the information, then he explains it to his subordinate, then this information is given to the ANM on Tuesday [weekly meeting of ANM], and finally the ANM explains to the ASHA and Anganwadi worker from 11:00 am to 2:00 pm on Wednesday (immunization day at the village level).

Reliance on the spoken word increases as information flows down to the grassroots level. Indeed, the ASHAs interviewed described the process of receiving and sharing information as “talk.”

At the service-provision level, information serves two primary purposes: (a) to help with problem solving at the village level and (b) to craft messages to villagers. One ASHA explained that “information is about how to give a message and how to read a message.” Another described the process of providing information to villagers: “Nobody understands the first time [you provide information]. When people experience [a related situation], then they understand.” Several ASHAs emphasized that how information is delivered is as important as its content; they said that information must be shared with compassion and respect.

Types of Health Information

Findings indicate that information needs vary across the levels of the health system. Information needs may be technical, referring to detailed content on a specific health topic, such as medical eligibility criteria for using specific contraceptives. Health care workers use technical information, found in print materials, such as books, journal articles, manuals, and protocols, to develop their skills and to design policies and programs.

Practical information refers to information necessary for program implementation. The chief example of practical information is instructions conveyed through government guidelines. As noted, program implementation guidelines flow through the health system from the central or national level down to the state, district, and eventually to the subdistrict levels. Program implementation guidelines can refer to an activity, a protocol, a new government scheme, new norms for different health services, a management information system, or how to implement a program such as Pulse Polio. Most health care workers at the subdistrict and village levels equate these program guidelines with information.

Beyond government guidelines, practical information for health care workers at the district level and below includes information to help with problem-solving, answering queries from community members, and mobilizing the community to use health services. Practical information also includes details of nearest secondary and tertiary referral centers, including hours of operation, distance to centers, and related information. It includes where to go for emergency transportation and what to do during a medical emergency. Practical information also entails specific information on government schemes. For example, the Janani Suraksha Yojna program (Safe Motherhood, Janani Suraksha Yojna) provides financial incentives for the ASHA and the woman who has an institutional delivery. The required practical information is where to obtain a Janani Suraksha Yojna form, how to fill it out, and how to obtain the financial incentives.

A 30-year-old ANM from Kaithala village described the challenge:

We will tell women in a group meeting all that is told to us at the [primary health center]. But women keep asking questions based on their own experience [emphasis added]. For example, a woman asked about heavy bleeding after copper T insertion. She has become weak. So I do not have an answer.

Such information needs are dynamic, changing continually with the situations that health care workers face.

Information Flow

As noted, the dominant path of information flow in the health system begins at the national level and, through a series of links, eventually intends to reach service providers (see Figure 1). A 33-year-old health education officer from Mohanlalgunj block describes the chain:

Figure 1 Information flow within the government health system. ANM = auxiliary nurse-midwife; ASHA = accredited social health activist. (Color figure available online.).

My main responsibility is the basic health workers … to send all the information properly to them … [W]e have a fixed date for a meeting on Tuesday. Through this meeting we give the message that comes from the Government of India to the State Government and from the State to the district and the district to me. The information that I get is passed on to [community health center] level.

Just below the district level, written directives give way to oral communication, creating a barrier in the flow of information. Delays are common allowing for a great deal of message distortion, and health personnel rarely use information communication technologies to transmit health information. Obstructing the information chain can have adverse consequences, as this chain is the primary source of information for most subdistrict and village health workers.

The main source of information for workers at the block and village levels is usually the official most immediately above them in the health hierarchy (see Figure 1). For example, a 58-year-old medical officer in charge in Sarojini Nagar block identifies the district health officer (the chief medical officer [CMO]) as his main source of information:

Meetings take place with the CMO [district health officer]. We get the information from state level, which is shared by the CMO at these meetings. They are held at least once a month because we continually take polio rounds. If we need any other information, we get it from our CMO by phone. They give new information and the entire month's work plan. Sometimes they call suddenly.

Information Needs by Health System Level

State Level

State-level study participants expressed two broad unmet needs. First, they require district-level information for program planning and implementation. The director of a large Lucknow-based nongovernmental organization said, “I want information about safe abortion. I want data on how many districts are without a Medical Termination of Pregnancy advocacy committee.” She added, ” … we don't have any data related to gender. Our main source of information should be district-level data.”

Second, state health officials need information related to the development and dissemination of guidelines, which they may receive from central authorities or the state. A senior manager of the State Innovations and Family Planning Services Agency explained:

“At the state level we do not implement. We find information and help districts. If we have a project, we ask the CMO [chief medical officer/district health officer] to implement the project in the district. We supervise, give them guidelines … ”

District and Block Levels

At the district and block levels, information needs are linked primarily to the immense task of managing and supervising the implementation of NRHM programs. A health education officer from Mahilabad block described his work in terms of supervision, monitoring, and problem-solving:

Our work is to supervise and monitor. The grassroots workers who implement the [health] program should be encouraged, and we should solve the problems they encounter in the field … we help the workers. That's our main work.

Several district- and block-level study participants also expressed the need for district- and block-level monitoring information, primarily for monitoring health service coverage.

They also need implementation data at the district and block levels to determine the degree to which program objectives are being met. A concerned study participant from a nongovernmental organization stated:

We need knowledge-practice … data on the kind of users we are addressing … we need to have ongoing district-level data. We have to know the attitude to practice in those areas. We need [data] by gender, by social groups; we require specific information from [a] particular communication activity of [a] campaign. What is more effective? What are consumer concerns? Again, we need the data for [the] frontline worker.

However, a project manager from an international organization in Lucknow was quick to point out that barriers related not only to the lack of data but also to the lack of use of that data. A state-level manager of a maternal health program asked why personnel do not use information to improve service coverage levels, raising the example of an ANM who has spent 25 years at the same subcenter but has not been able to achieve one third of her targets.

Grassroots Level

In rural Uttar Pradesh, ASHAs are the first line of contact with the health system for community members. Consequently, ASHAs primarily require practical information. ASHAs view their role as serving their village:

In case someone in my neighborhood has any problems, my duty is to give them proper advice. If I know what advice to give, I explain it to them. Otherwise, I ask the ANM and then advise them.” (ASHA, 35 years old, eighth-grade education, Behrampur village)

ASHAs must answer queries from the community related to any of the national health programs under NRHM, including those related to family planning, reproductive health, child health, tuberculosis (TB), and leprosy. ASHAs also require information to help them assess the condition of people who are unwell and to suggest appropriate action, including referrals, treatment, and prevention. Their probing abilities are extremely important, as ASHAs have their own knowledge gaps and sometimes require supportive input from others. A 35-year-old ASHA with an eighth-grade education from Mohanlalganj block described her information needs:

I don't have much knowledge about TB. I have given TB medicine to five people. I am confused [about one patient], whether the fever symptoms indicate jaundice or TB. We must know this. We are not aware of many things. I am aware of TT [tetanus toxoid] injections given to pregnant women for care during delivery. But I don't know why IFA [iron and folic acid] tablets sometimes do not suit some women. I don't know.

Because ASHAs care for pregnant women, ASHAs need to know when a delivery is expected to take place as labor progresses, so they can assess if there is enough time to transport the woman to a health facility. They also need to know how to care for newborns. Because ANMs and ASHAs also respond to medical emergencies, they need information on transportation, referral centers, and management of immediate symptoms. A 52-year-old ANM with a 12th-grade education from Sarojini Nagar block declared:

We surely need information. Whatever information we get, it's never enough … sometimes I get a call at night regarding some problem someone is facing; I myself do not know what to do … we should know the symptoms and what to do in this situation. We should also know about emergency treatments.

Information Sources

Although access to the Internet is available at the state level, study participants at the state level use the Internet less frequently and access a more limited range of websites than participants working at the national level. State-level study participants frequently reported getting information from the State Innovations and Family Planning Services Agency Library and NRHM website.

At the district level, an assistant CMO identified the NRHM website as his main source of information. He felt that he had enough information because he had access to the Internet, and he tries to share it:

When we get any information, we download it and give it to our junior staff. Whenever we get the information, we share it with them. But it is not a regular affair.

At the block level, health personnel primarily receive information through posted letters and over the telephone (see Table 3). According to a block-level participant from Mahilabad, health care workers receive two types of letters: one with program implementation instructions and the other with budgetary guidelines for the program activity. He complained:

Table 3. Information sharing at various levels of the health system

Information sharing	State	District/block	Village
With whom?	District authorities Nongovernmental organizations District officials in remote areas	District shares with medical officer in-charge and block health education officers Block shares with auxiliary nurse-midwives and accredited social health activists	Auxiliary nurse-midwife shares with accredited social health activist and village women Accredited social health activist shares with village women, mothers-in-law, other villagers
How?	Meetings Print copies E-mail Letters to remote areas	Meetings Telephone calls	Home visits Meetings Telephone calls
In what form?	Guidelines Circulars Posters Pamphlets (to remote areas)	Guidelines	Guidelines Responses to queries from the community

First we get letters, but we do not get financial guidelines. The financial letters are not given on time. They inform us through phone, but information cannot be remembered.

District meetings are another frequent source of information for block-level health personnel:

We have the meeting at [the] district level on the last Friday of the month. The CMO calls for the meeting at the district level. He outlines the main points in the meeting. If there is a problem, then discussion takes place … ” (female district community mobilizer, 30 years)

Laboratory technicians working at the block level rely on textbooks and colleagues for information. A 48-year-old laboratory technician at the Mohanlalganj Community Health Center explained: “For things that we need some help, we have our group. We have our friends; we take the information from them.”

According to the in-depth interviews and focus group discussions, the ANM is the primary source of information for ASHAs. ASHAs said: “Whenever we need new information, we first go to the ANM,” and “The ANM is the only source of information.” ASHAs also get information from trainings, monthly meetings, and booklets. Meetings, the primary channel for receiving and sharing information, are also ASHAs' preferred source.

Usability of Information

Health care personnel at all levels of the health system require information that addresses their specific needs in their day-to-day work. For example, study participants at the state level have access to information through the Internet, but what they want is specific, evidence-based information that is not too lengthy and that focuses on actionable areas.

Usability, or the need for actionable information, was a core theme that emerged across all levels of study participants. It highlights the need to go beyond issues of access to information. Table 4 presents five parameters of actionable information (language, timeliness, simplification, amount of information, and access to information), with barriers at each level of the health system.

Table 4. Barriers to the five parameters of actionable information, by health system level

	Barriers by Health System Level
Parameters of actionable information	National	State	District/Block	Village
Language	Research data are complex Reports are lengthy	Reading and understanding English is difficult Reports are lengthy	Information in English is not always relevant Reading and understanding English is difficult	High-level Hindi is not easily understood English is not understood
Time and timeliness	Lack of time Information-sharing forums are difficult to organize Conducting searches takes time	Internet is often down Government websites are not updated	Letters are late. Instructions are received verbally Internet access does not exist Computers are inadequate	Information does not reach the village when needed Auxiliary nurse-midwife is the only source of information
Simplification	Key issues in the data are not highlighted	Information is not integrated across departments	There is a language barrier. Posters, pamphlets are not useful	There is a language barrier Simple information linked to health-related queries is lacking Simple information on referrals is lacking
Amount of information	Information is not presented succinctly	Too much information is of no use	Technical information is too lengthy	Practical information in small quantities is lacking
Access to information	Internet is often down	Internet is often down Power often gets cut off	Internet is down Mobile phone networks are weak Power often gets cut off	Internet access does not exist Power often gets cut off Literacy is lacking

The head of a Lucknow-based nongovernmental organization stated that language was a barrier to information use. At the lower levels of the health system, Hindi needs to be simple. Similarly, at the higher levels of the health system, English should be simple. Study participants recommended cutting down the amount of information so that it is easier to understand and quicker to digest. A communication officer from the United Nations Children's Fund declared:

Information for the practitioner has to be quickly digestible. Every person has little time now … research should be presented in a way that is interesting for people to understand. It should not be 100 pages … Packaging of knowledge has to be done in different ways.

Some study participants emphasized that the true challenge is not so much providing access to information as getting people to use it. The general manager for NRHM in Uttar Pradesh identified timeliness and ease of understanding as two major factors to consider in the information-provision process. Several study participants believed that the core issue is providing understandable and actionable information.

The solution, according to study participants, is to tailor information to the needs of personnel at various levels of the health system. Simplification is important, no matter what the level of the health system. At the national and state levels, there is no dearth of information. Rather, evidence-based data must be repackaged into executive summaries, actionable documents, and short but powerful strategic analysis. At the grassroots level, information has to be repackaged into short, simple content that is easy to comprehend and amenable to rapid oral transmission.

Timing and location are also important for the optimal delivery and use of information. Disruptions to the flow of information across the health system result in serious repercussions, especially for newer community workers who have yet to master their responsibilities. A 30-year-old community mobilizer in Lucknow district spent 3 months implementing a school health program in her district according to old guidelines. The new guidelines arrived after she had already completed the program:

The problem is that we had already finished the work according to the old guidelines. When we submitted our work, the higher officials told us to do the work according to new guidelines … by that time we had already finished the work with the old guidelines. They should have informed us on time.

Below the state level, lack of computers and Internet connections pose barriers to information access. Study participants commonly proposed making computers and Internet access more widely available—at the district, block, community health center, subcenter, and village levels—as a solution to the problem of information access.

Discussion

Information Needs across the Health System

Within each level of the health system in Uttar Pradesh, information needs were uniform; however, they varied substantially across levels. For example, policymakers showed a strong desire for information that was evidence-based and that informed best practices. In contrast, at district and subdistrict levels, the focus shifted considerably to information related to program implementation, such as guidelines. At the grassroots level, ASHAs and ANMs working in villages needed a wide range of technical and practical information to help them address a multitude of primary health care needs, including reproductive health.

Technical and practical information needs should be considered in tandem—it is not an either/or proposition. The need for practical information has been identified in other contexts (Haque, Emerson, Dennison, Navsa, & Levitt, 2005; Pakenham-Walsh & Bukachi, 2009). Mechanisms for providing practical information may be developed using information and communications technologies. These could include, for example, a two-way telephone helpline for ASHAs and ANMs; compilations of frequently asked questions accessible through mobile telephones; and Web-based solutions, such as online courses and toolkits for district NRHM offices, most of which have access to broadband services. These findings suggest that designers of health information products, services, and systems need to distinguish between information needed to develop policies and to support public health service delivery. Furthermore, an action focus should drive the design of health information resources for both types of health professionals (Sullivan, Ohkubo, Rinehart, & Storey, 2010).

Information Flow

Findings from this needs assessment indicate an information divide in the vertical flow of information. Information in the form of program implementation guidelines flows well from the national level to the district level, but the flow deteriorates from the district level to the levels below. At the subdistrict and village levels, information flows often are slow. In addition, information is communicated primarily through oral routes, which can lead to misunderstandings or incorrect transmissions.

Monitoring and evaluation data flow up the system, at which point the data are aggregated. However, once the data are aggregated and analyzed, they fail to flow back down the system to levels where the data could be used to guide program design and implementation.

Ensuring an uninterrupted flow of a large amount of information requires addressing barriers from district to subdistrict levels and back up to district levels. For example, mobile technologies that enable loading practical content and films circumvent the issue of Internet connectivity and access at subdistrict levels. Understanding local patterns of information flow and comprehension are crucial to developing information systems and technology applications that meet the specific needs of different health personnel.

Adaptation to Make Information Actionable

Knowledge management research in resource-poor settings has focused more on access to information and less on understanding the factors that enhance the use of information (Global Healthcare Information Network, 2009). Adaptation at the local level is a key to making information actionable for health professionals, as access alone will not translate into action (Godlee, Pakenham-Walsh, Ncayiyana, Cohen, & Packer, 2004).

This study identified five parameters for actionable information—language, timeliness, simplification, quantity, and accessibility. Information use depends on the quality of adaptation, which should take into consideration all five parameters of actionable information. Just as most health communication campaigns are tailored for different audiences, and extensive formative research and pretesting are standard practice (Piotrow, Kincaid, Rimon, & Rinehart, 1997), information for health personnel also needs to be adapted according to the needs of the specific health personnel.

Job aids or tools tailored to the needs of health care workers at specific levels of the health system can be developed. Simplicity is important, no matter what the level of the health system. At the national and state levels, evidence-based data must be synthesized, analyzed, and presented in executive summaries; short, cogent, and strategic analyses; and action briefs, white papers, and policy assessments. At the grassroots level, information has to take the form of short, simple content that is easy to comprehend and amenable to rapid oral transmission. The five parameters can be a useful tool for knowledge management professionals to assess the actionability of information for health care workers, public health practitioners, policymakers, and researchers. These information needs range from grassroots to the higher levels of the health system (Bandyopadhyay, Kumar, Singhi, & Aggarwal, 2003; Bertrand & Certain, 2000).

Conclusion

An adequate assessment of health information needs, including opportunities, barriers, and gaps, is a prerequisite to designing effective and actionable information products. This needs assessment found that health information needs vary across the health system in Uttar Pradesh. Information needs are dynamic and encompass programmatic and service delivery information. Providing actionable information across all levels of the health system is key to strengthening the health system and improving the quality of services.

The exponential growth of information and communications technologies in India, of mobile phones in particular, could have a profound effect on information access and use at the district and subdistrict levels, provided that the applications are designed with the needs and situations of their users in mind. Across all media and whatever the content, policymakers, program planners, and communication/information specialists need to keep in mind the five parameters for actionable information—language, timeliness, simplicity, quantity, and accessibility—to meet the diverse needs at each level of the health system.

Acknowlegment

This needs assessment activity and report could not have been accomplished without the hard work of the authors' outstanding colleagues in India, Heather Sanders, Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (JHU-CCP) and Santosh Singh, O.P. Pandey, and Sridevi from the Sigma Research Agency. The authors also acknowledge the contributions and support of Doug Storey (JHU-CCP), Heer Chokshi (formerly with JHU-CCP, and Meenakshi Dikshit (JHU-CCP). The contributions of those who ably prepared background material for this report are hereby gratefully acknowledged, as are the supportive efforts of the United States Agency for International Development–India Population, Health, and Nutrition Division. The authors thank Vanessa Mitchell (JHU-CCP) and Elsie Mwaniki (JHU-CCP) for their support throughout this study. The authors gratefully acknowledge the editorial assistance of Ward Rinehart (Jura Editorial Services) and Ruwaida Salem (JHU-CCP). K4Health is supported by the Office of Population and Reproductive Health, Bureau for Global Health, U.S. Agency for International Development, Cooperative Agreement No. GPO-A-00-08-00006-00. The views expressed in this document do not necessarily reflect those of the U.S. Agency for International Development or of the U.S. government.

Notes

Note. PHC = primary health center.