- freely available
Int. J. Environ. Res. Public Health 2015, 12(7), 8103-8124; https://doi.org/10.3390/ijerph120708103
2. The Changing Health Knowledge Economy
2.1. Changes in the Complex Health Knowledge Economy
2.2. Changes in the Use of ICT to Access These Providers
2.3. Changes in the Health Knowledge Economy and Information Seeking
3. Developing an Actor-Centric Approach
- High-level decision-making and policy environment (including government and political private sector actors)
- Supporting Structure of actors that facilitate knowledge flows
- Professional health knowledge agents
- Person-to-person engagement and trusted support.
4. Mapping a Bangladesh Case Study
- Uddin was not at home and he asked his nephew to bring her to Dhaka to ensure that she received treatment.
- They took her to the village doctor, an informal health provider in the village, for treatment and reported to Uddin that her condition was serious and that they would only travel the following morning (see Figure 3a).
- When she arrived in Dhaka (continued in Figure 3b), Uddin consulted with his brother-in-law and
- Decided she should visit Dr. Syed in Jatrabari, Dhaka. He chose Dr. Syed because his brother-in-law worked with the doctor. Uddin’s brother in law said: “Dr. Syed will give what will be best”. Dr. Syed informed Uddin that she needed to go to hospital immediately. They discussed whether a government upazila Health Complex or private hospital would be best and
- Dr. Syed advised against an upazila health complex because of the long wait for an appointment.
- Dr. Syed provided Uddin with the address of a tertiary level government hospital, the Mitford in Dhaka, which offers a free service for the poor, where Uddin’s wife was admitted and had an MRI (Magnetic Resonance Imaging) scan, but where she received no treatment, so
- She went to Salauddin private hospital and
- Then spent a year at PG Government Tertiary Teaching hospital receiving treatment, until they admitted that they could do no more for her, but Uddin continued to seek treatment for his wife.
- While Uddin was in Malaysia, he discussed his wife’s illness with one of his fellow migrants. This migrant told Uddin about “his uncle who is a doctor who lives in Mohakhali” and who worked at the Government specialized cancer hospital. He then talked to his uncle about Uddin’s wife.
- Uddin sent a large sum of money to this doctor as an upfront payment, and this ensured treatment and medicine.
- After being released from this hospital, Uddin’s wife was better able to feed herself and walk around, but then she developed an ulcer on her leg and subsequent complications. She died before she was able to seek further treatment.
5. What is the Role of ICTs in Health Knowledge Systems?
- The lack of skilled healthcare staff: Yonazi et al.  suggest that “eLearning and telemedicine solutions can extend expertise to remote areas and provide otherwise inaccessible care”. This is a key role for the actor centric approach proposed in this paper, and which draws attention to asking who the healthcare workers are, and emphasizes both formal and informal providers. The Bangladesh heath system has community volunteers funded by NGOs, as well as long-standing village doctors. Pharmacists often offer advice. While it is accepted that ICTs could be used to strengthen the skill of healthcare workers, the identification of relevant healthcare workers who require this additional learning is a priority. In addition, as Malone et al. have shown, even in high-income contexts, the quality of access to health care can have a significant impact on online health information seeking with “ease of access” positively influencing information seeking . In contexts such as Bangladesh where access to skilled health care is extremely difficult, the data suggests that online searching is currently not highly valued.
- Health information system inadequacies: “Data collection and surveillance mHealth applications can monitor and track health indicators in real time, providing insight to policymakers on true challenges and providing valuable data enabling health workers to better serve and patients to be more proactive in their own health” . The feedback of data from the field to policy actors has long been recognized as important. But applying an actor centric model forces one to ask: which actors need to supply the data? Will only the formal system provide data, or would it be possible to engage with the informal healthcare workers to provide feedback that might make policy development more evidenced based and potentially more responsive to the needs of the poor? . Village doctors are often, as shown in the above account, a critical entry point into the health system. Experimentation with using mHealth with village doctors in Bangladesh has not, to date, been successful and more work needs to be done for mHealth to offer a useful service to these informal health suppliers.
- Insufficient equipment, medication and other supplies: “Supply Chain Management mHealth applications can decrease stock-out frequency and increase efficacy of and trust in health system” . An actor centric perspective focuses on who is providing drugs and equipment, rather than assuming that these are available only from formal providers. In Bangladesh, the challenge is not just the shortage of drugs and equipment but the attachment of good advice to the provision of drugs and equipment. Data from many emerging economies suggests that fake drugs can be killers, and, in Bangladesh, even a genuine drug taken for an inappropriate illness or in inappropriate dosage is a waste of limited resources and can do more harm than good . In addition, although not explicitly developed in the above account of Uddin’s wife, it is evident that there is substantial scope for patients to receive different and multiple drugs from different providers and to not complete a course of medication.
- Lack of information concerning preventable diseases: “Public health promotion applications can be used to disseminate empowering information in a friendly, personal manner. Engaging without being intrusive” . Our example shows the connectedness of society, and helps visualize the processes of health information seeking through the mapping of information flows. It is not enough to provide information on a Short Message System (SMS) text if no one reads the text. In many resource poor settings, a lack of literacy prevents the reading of a text by a significant portion of the population, and overuse of unsolicited texts has meant that many of those who could read the text no longer bother to. In addition, even though Uddin would have had several possible ways of accessing information through mHealth (phoning a health help line, reading government-sent SMS messages), at no point did he avail himself of these possibilities. An actor centric perspective encourages researchers to explore who talks to who, how they communicate and what kinds of information they are seeking.
- Financial limitations: “Health financing and personal insurance programmes offer increased opportunities for savings, both for patients and healthcare providers” . ICT has opened up financial systems to resource poor communities. Uddin’s story illustrates how less-formalized financial flows compromise an integral part of the health information seeking, and ICTs can facilitate enhanced communication between people, thus aiding individuals in their search for health financing mechanisms, and enable more innovative financial flows between actors.
6. Theory of Planned Behavior
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