MEDLINE Services to the Developing Countries* BY ROLF WEITZEL, Head
WHO MEDLINE Centre World Health Organization Geneva, Switzerland ABSTRACT Supplying MEDLINE services to a widely dispersed user population in the developing countries creates numerous problems not encountered by other MEDLINE centres. The inability to interact with the user complicates system promotion and makes search formulation sometimes a gamble. Nevertheless, an evaluation survey has shown high user satisfaction. Of great concern is the still inadequate solution of document delivery. Near-term objectives are the broadening of geographic coverage and the integration of search processing with supporting hard copy supply.
STATISTICS In its first 18 months of operation the WHO MEDLINE Centre processed a total of 4,079 searches. Of these, 2,653 or 65% were for requesters in 70 WHO Member States, the majority being developing countries. Although the centre has a primary service obligation toward the Third World countries in Africa, Asia, and Oceania, services are also supplied to a number of other countries, with the exception of those that have concluded a bilateral service agreement with another MEDLARS centre. The remaining 1,426 searches, representing 35% of the total, were for WHO staff or WHO collaborating scientists and institutions. The percentage of searches for non-WHO users is steadily increasing and by September 1975 amounted to roughly 75%.
THE WHO MEDLARS Centre started operating in February 1972. Both retrospective and current awareness searches were processed against the MEDLARS tapes on the IBM 360/55 of the International Computing Centre, the supporting retrieval program having been PROMOTION supplied by the Biomedical Documentation The first task after the centre began on-line Centre, Stockholm. In April 1974 the centre search operations in April 1974 was to promote converted to on-line operations. the system to its user community. Simple promotional material was prepared in the form COMMUNICATIONS of one-page leaflets and great care was taken to Access to the MEDLINE data base at the avoid the use of technical jargon from the National Library of Medicine is through the computer and information science field. The Tymshare network. The centre's DI-AN 9030 first target group addressed were university terminal (30 cps impact printer) is linked by staff. The informational material was sent to dial-up telephone lines to a multiplexer located the chancellors of all universities, the deans of at Lausanne, Switzerland, and from there medical faculties and the medical librarians in through a dedicated line to the Paris Tymshare Asia, Africa, and Oceania. Latin American node. Routine access times are between 8 A.M. countries were omitted as they are served by the and 2 P.M. local time, except on Tuesdays when regional medical library at Sao Paulo, Brazil. the system only becomes accessible for EuroQuantitatively the first promotion campaign pean users at 5 P.M. and the SUNY data base at has reached its immediate objective. It was 2 P.M. obvious that only a minor percentage of the * Revised version of a paper presented at the 1975 promotional effort would result in recruiting acMEDLARS Conference, April 28-30, 1975, York, tive MEDLINE users. There can be no doubt United Kingdom. that by far the most effective method of promot32
Bull. Med. Libr. Assoc. 64(1) Jan. 1976
MEDLINE SERVICES TO THE DEVELOPING COUNTRIES ing an information retrieval system is by demonstration, possibly backed up by audiovisual aids. Remote promotion, by letter and leaflet, would meet with a low response anywhere. Among the technologically unsophisticated user population for whom the program was intended, the message was frequently not understood and the benefits that could be derived from the services offered were not recognized. This had been expected. In fact, a higher response rate would have faced the centre's staff with a quantity of requests which it would, during this early phase, have been unable to handle. There is less reason to be satisfied with the results of the semantic effort made. It proved that the care taken in phrasing the promotional texts had nevertheless been insufficient. From the reactions received at the centre it became evident that numerous misunderstandings existed regarding the nature, scope, and coverage of the system. Frequently MEDLINE was understood to be a data bank storing factual inf'ormation such as statistical data or it was seen purely as a photocopy supply service. These misunderstandings have been carefully analyzed and taken into consideration for the preparation of a revised set of promotional material. There is some doubt whether it will be sufficient to rely on just one textual version, in English and French, or whether a more diversified approach would guarantee better results. More specif'ically: Is it reasonable to expect the same text and the same presentation to be equally effective in Sierra Leone and Indonesia? Or would an optimal promotional campaign require different sets of material adapted to certain regional cultural characteristics? These are complex questions to which no ready answer exists but which seem worthwhile investigating and for which an international organization offers an excellent basis for study. A highly effective method of system promotion is the training of intermediaries such as librarians and documentalists. It was noticed that MEDLINE was particularly well accepted in some institutions whose librarians had been exposed to the system in the U.S.A. or Europe or who had attended special training courses like the one given in Geneva in the autumn of' 1972. A detailed plan for an intensive training program for such intermediaries has been develBull. Med. Libr. Assoc. 64(1) Jan. 1976
oped. Negotiations have been engaged with a donor agency and we hope to start implementing this training plan in the not too distant future. A second promotional campaign got under way early in 1975. In its first phase a follow-up promotion was directed to the health authorities in thirty-five developing countries from which so far no MEDLINE requests had been received. In the second phase a broad spectrum approach was chosen to assure that the message was received by as wide an audience as possible. In particular announcements of the MEDLINE services were sent for publication to twenty-five medical journals published in developing countries. In addition, promotional material was sent to a number of associations in the medical and allied health fields and to selected research institutions. The impact of this campaign became noticeable in summer 1975. SEARCH ACTIVITIES The topics of the retrospective demand searches received at the WHO MEDLINE Centre cover the entire spectrum of' the medical and health related sciences. This means that the users' interests differ not significantly from those of other centres. A subject breakdown of a random sample of 100 searches conf'irms this (Table 1). The only feature which is peculiar to the WHO MEDLINE Centre is the high proportion of searches in the public health field. On the other hand, nursing, which is a prominent subject in the developing countries, is still rather poorly represented because the promotional effort has not yet been directed specifically to this user group. Language is a serious problem. Roughly 85%7. of the requests received are in English, 15%7 in French. There can be no doubt that frequently the precision with which the requirements are TABLE 1 SEARCH SUBJECT CATEGORIES
Medical and drug research Clinical medicine Public health Psychiatry and mental health Medical education
Nursing
34.8 7
30.3% 27.11'
4.5,;% 2.0
.
1.3%
33
ROLF WEITZEL
stated suffers from an inadequate command of the language used. Added to the language problem is the frustrating fact that it is not possible to contact the user. It is estimated that for more than 50% of the search requests it would really be desirable to discuss the requirements with the requester, to obtain more details, to check the meaning of terms or to clarify imprecise statements. This means that often the search formulation has to be based on the search analyst's subjective interpretation of the request. This inability to interact with the user is the most critical problem faced by the centre. Many request forms are not completed by the requester himself but by an institutional librarian. This proved to be another source of search request deterioration. Most of these librarians have inadequate professional training and their English is usually even more elementary than that of their patrons. It is suspected that they are responsible for a number of puzzling or incomprehensible requests. Here, too, an intensive training program could significantly improve the quality of the requests submitted to the centre. Yet another problem is communication. The average search turn-around time, from the day the request is mailed to the day the printout is received by the requester is twenty days. This is still a fairly long delay in the context of an on-line system. The remarkable fact is that this impression is not shared by the centre's users who seem to have a different notion of time. In fact, the most frequent comment made refers to the surprising speed of the service. More worrying is the fact that the centre gets claims for searches which were never received or, more frequently, claims for printouts which were dispatched but which never reached the requester. In one extreme case the same search printout has just been sent for the third time to a frustrated user in a Southeast Asian country. However, this is a problem over which the centre has no control and to which there is no better remedy than to repeat the search. An analysis of the geographical distribution pattern of the search request origin reveals a number of particularly active countries. In Africa they are Egypt, Tunisia, and Morocco north, Zaire, Uganda, and particularly Nigeria south of the Sahara, but there is also the remarkable fact that twelve searches were proc34
essed for three users in Lesotho, a country for which statistics give a total of forty-two physicians. In Asia there are Israel, India, Iraq, Iran, Indonesia, Turkey, and Thailand which show the densest clustering of requests. It is cbvious that the services of the centre cannot be limited to MEDLINE searches. Many of the users served have no alternative sources of information. Whenever possible we try to avoid giving a negative reply. In addition to MEDLINE other data bases such as ERIC, Chemical Abstracts, and COMPENDEX have been used on an experimental basis to test their value as complementary resources. In many cases where the computer data bases cannot supply the required information, conventional literature searching is undertaken. EVALUATION During a period of six months every search printout released was accompanied by an evaluation form. The evaluation aimed at establishing two values: the usefulness of the citations retrieved and the overall value of the searches (Tables 2 and 3). It must be stressed that the values in Table 2 do not represent a citation relevancy rating but give an indication how useful MEDLINE-generated bibliographies are to a user group with severely limited access to library facilities. It becomes obvious from the remarks made on the forms returned that often perfectly relevant citations were considered "not useful" if the periodicals in question were TABLE 2 CITATION VALUE RATING.
Citations Useful Partly useful Not useful
Number
Per Cent
5485 1696 2848
54.7 17.0 28.3
TABLE 3 SEARCH VALUE RATING
Searches Great value Good value Little value No value
Number
Per Cent
128 114 34 11
44.6 39.7 11.9 3.8
Bull. Med. Libr. Assoc. 64(1) Jan. 1976
MEDLINE SERVICES TO THE DEVELOPING COUNTRIES
not available to the requester or were written in a language he did not read. This citation assessment, therefore, does not accurately reflect the search quality.
USER EDUCATION Since the initial promotion had not always succeeded in getting across to the potential users an exact idea of what MEDLINE is, a follow-up is necessary in the form of a continuing process of user education, both at an individual and a collective level. The objective of the follow-up is to supply to the users information that would give them a realistic appreciation of the system's capabilities and to keep them updated about new developments. Individual user education is systematically supplied in response to search requests. Practically every search printout released is accompanied by some explanatory remarks. Where considered useful, these are frequently developed into a detailed description of the search formulation to give the user insight into certain system constraints. The medium for collective user education is Health Literature Topics, a newsletter issued since the beginning of 1975. This newsletter has carried activity reports of the centre, a glossary explaining certain technical terms essential for an understanding of the system such as data base, terminal, or on-line/off-line, an article giving detailed advice on how to complete a search request form, and so on. Again an attempt has been made to use a simple language with a minimum of technical terms. Health Literature Topics has a large mailing list which comprises all regular institutional users of the WHO MEDLINE Centre. DOCUMENT DELIVERY
The operational experience of the WHO MEDLINE Centre has shown the feasibility of a medical literature information service for the developing countries. However, it is obvious that the centre's responsibility cannot end with the dispatch of the search printout. Once his need for secondary information is satisfied, the requester faces his next, and much more formidable problem-document delivery. Everybody knows that the library facilities in the developing countries are inadequate but the degree of Bull. Med. Libr. Assoc. 64(1) Jan. 1976
this inadequacy is usually grossly underestimated. Numerous field visits have shown that in many areas library facilities are not just inadequate, they are nonexistent. In countries where a rudimentary library infrastructure exists, the effective use of the resources is hampered by a variety of factors, such as broken and incomplete sets of journals, restrictive loan policies, untrained staff, and absence of copying equipment. There is usually no cooperation between libraries in the same country, or even in the same city. Procurement from abroad of photocopies, when they have to be paid for, is difficult because of the lack of foreign currency. Assistance in the form of free photocopy supply is given by a number of institutions such as the National Library of Medicine, the British Council, and some others. As concerns the World Health Organization, an effort is made to satisfy the immediate need of the MEDLINE user by offering to supply a small amount of photocopied articles per search. A more liberal offer of assistance is at present prevented by the severely limited copying resources. There is little hope to solve this serious problem unless it is tackled on a vast scale. There is an urgent need for a global health literature program having as its main objectives: to upgrade the library infrastructure in general; to establish library cooperation; to provide training facilities for local librarians and documentalists; and to improve the supply of biomedical literature, for instance, by encouraging the publication in microform of reference aids and certain standard journals. This in brief is the content of the WHO global HELP (Health Literature Programme) of which the MEDLINE service constitutes one part. OUTLOOK As regards the near future, it is the main objective of the centre to enlarge its geographical coverage even more and to introduce MEDLINE to countries which have not yet been served. A particular effort will be made to intensify the service for that group of countries in Africa and Asia which are usually referred to as the "least developed of the developing countries." It is hoped that this action can be accompanied by a parallel effort to assure at the same time the supporting document delivery.
35
WHO MEDLINE Centre World Health Organization Geneva, Switzerland ABSTRACT Supplying MEDLINE services to a widely dispersed user population in the developing countries creates numerous problems not encountered by other MEDLINE centres. The inability to interact with the user complicates system promotion and makes search formulation sometimes a gamble. Nevertheless, an evaluation survey has shown high user satisfaction. Of great concern is the still inadequate solution of document delivery. Near-term objectives are the broadening of geographic coverage and the integration of search processing with supporting hard copy supply.
STATISTICS In its first 18 months of operation the WHO MEDLINE Centre processed a total of 4,079 searches. Of these, 2,653 or 65% were for requesters in 70 WHO Member States, the majority being developing countries. Although the centre has a primary service obligation toward the Third World countries in Africa, Asia, and Oceania, services are also supplied to a number of other countries, with the exception of those that have concluded a bilateral service agreement with another MEDLARS centre. The remaining 1,426 searches, representing 35% of the total, were for WHO staff or WHO collaborating scientists and institutions. The percentage of searches for non-WHO users is steadily increasing and by September 1975 amounted to roughly 75%.
THE WHO MEDLARS Centre started operating in February 1972. Both retrospective and current awareness searches were processed against the MEDLARS tapes on the IBM 360/55 of the International Computing Centre, the supporting retrieval program having been PROMOTION supplied by the Biomedical Documentation The first task after the centre began on-line Centre, Stockholm. In April 1974 the centre search operations in April 1974 was to promote converted to on-line operations. the system to its user community. Simple promotional material was prepared in the form COMMUNICATIONS of one-page leaflets and great care was taken to Access to the MEDLINE data base at the avoid the use of technical jargon from the National Library of Medicine is through the computer and information science field. The Tymshare network. The centre's DI-AN 9030 first target group addressed were university terminal (30 cps impact printer) is linked by staff. The informational material was sent to dial-up telephone lines to a multiplexer located the chancellors of all universities, the deans of at Lausanne, Switzerland, and from there medical faculties and the medical librarians in through a dedicated line to the Paris Tymshare Asia, Africa, and Oceania. Latin American node. Routine access times are between 8 A.M. countries were omitted as they are served by the and 2 P.M. local time, except on Tuesdays when regional medical library at Sao Paulo, Brazil. the system only becomes accessible for EuroQuantitatively the first promotion campaign pean users at 5 P.M. and the SUNY data base at has reached its immediate objective. It was 2 P.M. obvious that only a minor percentage of the * Revised version of a paper presented at the 1975 promotional effort would result in recruiting acMEDLARS Conference, April 28-30, 1975, York, tive MEDLINE users. There can be no doubt United Kingdom. that by far the most effective method of promot32
Bull. Med. Libr. Assoc. 64(1) Jan. 1976
MEDLINE SERVICES TO THE DEVELOPING COUNTRIES ing an information retrieval system is by demonstration, possibly backed up by audiovisual aids. Remote promotion, by letter and leaflet, would meet with a low response anywhere. Among the technologically unsophisticated user population for whom the program was intended, the message was frequently not understood and the benefits that could be derived from the services offered were not recognized. This had been expected. In fact, a higher response rate would have faced the centre's staff with a quantity of requests which it would, during this early phase, have been unable to handle. There is less reason to be satisfied with the results of the semantic effort made. It proved that the care taken in phrasing the promotional texts had nevertheless been insufficient. From the reactions received at the centre it became evident that numerous misunderstandings existed regarding the nature, scope, and coverage of the system. Frequently MEDLINE was understood to be a data bank storing factual inf'ormation such as statistical data or it was seen purely as a photocopy supply service. These misunderstandings have been carefully analyzed and taken into consideration for the preparation of a revised set of promotional material. There is some doubt whether it will be sufficient to rely on just one textual version, in English and French, or whether a more diversified approach would guarantee better results. More specif'ically: Is it reasonable to expect the same text and the same presentation to be equally effective in Sierra Leone and Indonesia? Or would an optimal promotional campaign require different sets of material adapted to certain regional cultural characteristics? These are complex questions to which no ready answer exists but which seem worthwhile investigating and for which an international organization offers an excellent basis for study. A highly effective method of system promotion is the training of intermediaries such as librarians and documentalists. It was noticed that MEDLINE was particularly well accepted in some institutions whose librarians had been exposed to the system in the U.S.A. or Europe or who had attended special training courses like the one given in Geneva in the autumn of' 1972. A detailed plan for an intensive training program for such intermediaries has been develBull. Med. Libr. Assoc. 64(1) Jan. 1976
oped. Negotiations have been engaged with a donor agency and we hope to start implementing this training plan in the not too distant future. A second promotional campaign got under way early in 1975. In its first phase a follow-up promotion was directed to the health authorities in thirty-five developing countries from which so far no MEDLINE requests had been received. In the second phase a broad spectrum approach was chosen to assure that the message was received by as wide an audience as possible. In particular announcements of the MEDLINE services were sent for publication to twenty-five medical journals published in developing countries. In addition, promotional material was sent to a number of associations in the medical and allied health fields and to selected research institutions. The impact of this campaign became noticeable in summer 1975. SEARCH ACTIVITIES The topics of the retrospective demand searches received at the WHO MEDLINE Centre cover the entire spectrum of' the medical and health related sciences. This means that the users' interests differ not significantly from those of other centres. A subject breakdown of a random sample of 100 searches conf'irms this (Table 1). The only feature which is peculiar to the WHO MEDLINE Centre is the high proportion of searches in the public health field. On the other hand, nursing, which is a prominent subject in the developing countries, is still rather poorly represented because the promotional effort has not yet been directed specifically to this user group. Language is a serious problem. Roughly 85%7. of the requests received are in English, 15%7 in French. There can be no doubt that frequently the precision with which the requirements are TABLE 1 SEARCH SUBJECT CATEGORIES
Medical and drug research Clinical medicine Public health Psychiatry and mental health Medical education
Nursing
34.8 7
30.3% 27.11'
4.5,;% 2.0
.
1.3%
33
ROLF WEITZEL
stated suffers from an inadequate command of the language used. Added to the language problem is the frustrating fact that it is not possible to contact the user. It is estimated that for more than 50% of the search requests it would really be desirable to discuss the requirements with the requester, to obtain more details, to check the meaning of terms or to clarify imprecise statements. This means that often the search formulation has to be based on the search analyst's subjective interpretation of the request. This inability to interact with the user is the most critical problem faced by the centre. Many request forms are not completed by the requester himself but by an institutional librarian. This proved to be another source of search request deterioration. Most of these librarians have inadequate professional training and their English is usually even more elementary than that of their patrons. It is suspected that they are responsible for a number of puzzling or incomprehensible requests. Here, too, an intensive training program could significantly improve the quality of the requests submitted to the centre. Yet another problem is communication. The average search turn-around time, from the day the request is mailed to the day the printout is received by the requester is twenty days. This is still a fairly long delay in the context of an on-line system. The remarkable fact is that this impression is not shared by the centre's users who seem to have a different notion of time. In fact, the most frequent comment made refers to the surprising speed of the service. More worrying is the fact that the centre gets claims for searches which were never received or, more frequently, claims for printouts which were dispatched but which never reached the requester. In one extreme case the same search printout has just been sent for the third time to a frustrated user in a Southeast Asian country. However, this is a problem over which the centre has no control and to which there is no better remedy than to repeat the search. An analysis of the geographical distribution pattern of the search request origin reveals a number of particularly active countries. In Africa they are Egypt, Tunisia, and Morocco north, Zaire, Uganda, and particularly Nigeria south of the Sahara, but there is also the remarkable fact that twelve searches were proc34
essed for three users in Lesotho, a country for which statistics give a total of forty-two physicians. In Asia there are Israel, India, Iraq, Iran, Indonesia, Turkey, and Thailand which show the densest clustering of requests. It is cbvious that the services of the centre cannot be limited to MEDLINE searches. Many of the users served have no alternative sources of information. Whenever possible we try to avoid giving a negative reply. In addition to MEDLINE other data bases such as ERIC, Chemical Abstracts, and COMPENDEX have been used on an experimental basis to test their value as complementary resources. In many cases where the computer data bases cannot supply the required information, conventional literature searching is undertaken. EVALUATION During a period of six months every search printout released was accompanied by an evaluation form. The evaluation aimed at establishing two values: the usefulness of the citations retrieved and the overall value of the searches (Tables 2 and 3). It must be stressed that the values in Table 2 do not represent a citation relevancy rating but give an indication how useful MEDLINE-generated bibliographies are to a user group with severely limited access to library facilities. It becomes obvious from the remarks made on the forms returned that often perfectly relevant citations were considered "not useful" if the periodicals in question were TABLE 2 CITATION VALUE RATING.
Citations Useful Partly useful Not useful
Number
Per Cent
5485 1696 2848
54.7 17.0 28.3
TABLE 3 SEARCH VALUE RATING
Searches Great value Good value Little value No value
Number
Per Cent
128 114 34 11
44.6 39.7 11.9 3.8
Bull. Med. Libr. Assoc. 64(1) Jan. 1976
MEDLINE SERVICES TO THE DEVELOPING COUNTRIES
not available to the requester or were written in a language he did not read. This citation assessment, therefore, does not accurately reflect the search quality.
USER EDUCATION Since the initial promotion had not always succeeded in getting across to the potential users an exact idea of what MEDLINE is, a follow-up is necessary in the form of a continuing process of user education, both at an individual and a collective level. The objective of the follow-up is to supply to the users information that would give them a realistic appreciation of the system's capabilities and to keep them updated about new developments. Individual user education is systematically supplied in response to search requests. Practically every search printout released is accompanied by some explanatory remarks. Where considered useful, these are frequently developed into a detailed description of the search formulation to give the user insight into certain system constraints. The medium for collective user education is Health Literature Topics, a newsletter issued since the beginning of 1975. This newsletter has carried activity reports of the centre, a glossary explaining certain technical terms essential for an understanding of the system such as data base, terminal, or on-line/off-line, an article giving detailed advice on how to complete a search request form, and so on. Again an attempt has been made to use a simple language with a minimum of technical terms. Health Literature Topics has a large mailing list which comprises all regular institutional users of the WHO MEDLINE Centre. DOCUMENT DELIVERY
The operational experience of the WHO MEDLINE Centre has shown the feasibility of a medical literature information service for the developing countries. However, it is obvious that the centre's responsibility cannot end with the dispatch of the search printout. Once his need for secondary information is satisfied, the requester faces his next, and much more formidable problem-document delivery. Everybody knows that the library facilities in the developing countries are inadequate but the degree of Bull. Med. Libr. Assoc. 64(1) Jan. 1976
this inadequacy is usually grossly underestimated. Numerous field visits have shown that in many areas library facilities are not just inadequate, they are nonexistent. In countries where a rudimentary library infrastructure exists, the effective use of the resources is hampered by a variety of factors, such as broken and incomplete sets of journals, restrictive loan policies, untrained staff, and absence of copying equipment. There is usually no cooperation between libraries in the same country, or even in the same city. Procurement from abroad of photocopies, when they have to be paid for, is difficult because of the lack of foreign currency. Assistance in the form of free photocopy supply is given by a number of institutions such as the National Library of Medicine, the British Council, and some others. As concerns the World Health Organization, an effort is made to satisfy the immediate need of the MEDLINE user by offering to supply a small amount of photocopied articles per search. A more liberal offer of assistance is at present prevented by the severely limited copying resources. There is little hope to solve this serious problem unless it is tackled on a vast scale. There is an urgent need for a global health literature program having as its main objectives: to upgrade the library infrastructure in general; to establish library cooperation; to provide training facilities for local librarians and documentalists; and to improve the supply of biomedical literature, for instance, by encouraging the publication in microform of reference aids and certain standard journals. This in brief is the content of the WHO global HELP (Health Literature Programme) of which the MEDLINE service constitutes one part. OUTLOOK As regards the near future, it is the main objective of the centre to enlarge its geographical coverage even more and to introduce MEDLINE to countries which have not yet been served. A particular effort will be made to intensify the service for that group of countries in Africa and Asia which are usually referred to as the "least developed of the developing countries." It is hoped that this action can be accompanied by a parallel effort to assure at the same time the supporting document delivery.
35
