The Ptolemy project: a scalable model for delivering health information in Africa

Introduction

How is Africa to build up the medical research it needs? Doctors in African research communities are starved of access to the journals and texts their colleagues in more developed countries regard as fundamental to good practice and research. Isolation, burden of practice, and resource limitations make education and research difficult, but the rapid spread of access to the internet reduces these obstacles and provides an increasingly attractive means to disseminate information and build partnerships in education and research.

The role of electronic health information in building local capacity to find, publish, and implement solutions has been emphasised recently in Science,1 Nature,2 the Lancet,3 4 and the BMJ.5 The Global Forum for Health Research gives priority to interventions designed to build research capacity in developing countries and correct the disparity in health research.6 The Coalition for Global Health Research (Canada) has recently reported how a major effort now can make a substantial difference.7 Access to reliable health information has been described as “the single most cost-effective and achievable strategy for sustainable improvement in health care.”8 We are interested in helping to build research, teaching, and clinical capacity for neglected yet substantial problems such as injury, which kills 5.1 million people annually.9^–11

Origins of the Ptolemy project

The Ptolemy project was conceived in discussion between a surgeon and a librarian. The surgeon (MB) had recently returned from working in Africa and Afghanistan and was aware how his colleagues there were starved for medical literature. The librarian (WH) is electronic resources coordinator at the University of Toronto Library, the largest academic library in Canada and the third largest in North America, and was interested in expanding access to full text health information in and from developing countries.

Two further partners soon joined the discussion. Bioline International, also housed at our university, provides electronic publication for several scientific journals from developing countries, including the East African Journal of Medicine and the Central African Journal of Medicine. The Association of Surgeons of East Africa represents the 400 surgeons who care for a population of 200 million people in eight east African countries. The association already had an informal link with the Office of International Surgery at the University of Toronto, whose mandate is to foster surgical education and research for development.

Starting with the idea that the massive health problems of Africa are most likely to be solved by Africans, who know the right questions to ask in order to get practicable solutions, and believing that access to the medical literature is indispensable for doing the necessary research, we set out to provide our African colleagues with access to it and attempted to measure how they used it. Named after Ptolemy I Sotor (367–283 bc), the general who built the great library in Alexandria that housed the written corpus of the ancient African, Mediterranean, and Middle Eastern worlds, the Ptolemy project links the four institutions (University of Toronto Library, Office of International Surgery, Bioline International, Association of Surgeons of East Africa) in a partnership to build a research community, provide educational resources and clinical information, and investigate whether access to medical literature has a positive effect on surgical research, teaching, and practice in east Africa.

We present a description of the project and an appraisal of what we have learnt.

Ptolemy I Sotor (367–283 BC), who built the great library of Alexandria

Development of the project

The University of Toronto Library agreed to make available 100 proxy server accounts for the project, and, in order to conform to subscription agreements with the various publishers, the participants were appointed as “research affiliates” of the university's Office of International Surgery. All of the library's 20 000 full text journals, 2538 of them medical journals, and hundreds of medical texts and links to free online health resources are available through Ptolemy (see www.utoronto.ca/ois/). The Bioline International collection (http://www.bioline.org.br/) is also available free through Ptolemy, and there are tutorials on searching and critical evaluation of the literature. Online help is always available. The small operating cost of Ptolemy, essentially office and travel expenses and one part time research assistant, is achieved by making use of existing university and electronic publishing infrastructure already in place for other purposes.

To be included in the project, participants had to be doctors practising in a country ranked less than 65th on the human development index,12 they had to have reliable internet access, and that they had to provide informed consent to anonymous monitoring of their internet use while connected to the university's proxy server. Participants were required to adhere to the same library rules regarding respect for copyright and general behaviour as are other members of the university. Preference was given to members of the Association of Surgeons of East Africa because surgical care in Africa has been so badly neglected for so long by the international community.

The Ptolemy project was introduced at the annual meeting of the Association of Surgeons of East Africa in Lusaka, Zambia, in December 2001. A Canadian research assistant with a background in health information science (KL) spent two months visiting Ptolemy participants in six of the eight African countries linked with the association in order to ensure that the proxy server account was functioning correctly on their computers and that the participants were familiar with the basics of using the website and various search engines.

We collected basic demographic information from the participants when they signed up, and we asked them to complete an assessment of their basic information needs. Since the project's inception in December 2001, there have been two surveys (April and August 2002) of Ptolemy participants, who returned positive feedback on the usefulness of the resource. A subgroup of Ptolemy participants is now engaged in a Delphi process to identify the priorities for surgical development in east Africa.

The Ptolemy survey

At the time of the August 2002 survey we had recruited 118 participants since the inception of Ptolemy, and 21 had left the project, primarily because of conflicts between their local area network and the proxy server. Of the remaining 97 Ptolemy participants, 58 were surgeons, 42 were active in research, and 51 taught medical students, interns, and residents. Seventy eight of the participants were in Africa, and 69 were in the eight countries of the Association of Surgeons of East Africa. Seventy two participants were located in their respective capitals, 13 were in provincial capitals, and 25 were in district centres. Of those who reported the location of their internet connection, 62 accessed the internet from home only or from home and work, while only 29 accessed it only from work. Sixty three of the participants paid less than $50 (£30) a month for their internet service and associated telephone charges.

We excluded 30 participants from the August survey: 13 were trying to resolve computer or internet access problems and had yet to use the resource, six had been using Ptolemy for less than a week, four informed us that they were unavailable during the survey period; and seven had registered but had never returned their consent forms. Of the 67 eligible participants, 53 responded within two weeks for an overall response rate of 79%. All but three respondents were men, and 40 were general and orthopaedic surgeons, although obstetricians, district medical officers, medical librarians, and a neuroanatomist also participated. Forty six spent more than an hour on line each week using Ptolemy, and their median monthly cost of internet access (including telephone charges) was $36 (£22).

We asked the participants about the impact and relevance of information derived from Ptolemy to three areas of practice—clinical, teaching, and research. Fifty four found Ptolemy was relevant and had positively affected their practice in each of the three areas, but the positive responses were equally strong for the three areas of work. Perhaps surprisingly, most participants (50) found full text journals to be the most valuable resource, with online texts a distant second. This may be related to how almost twice as many respondents found it easy or very easy to access full text journals (34) compared with online texts (17). The most requested journals were the British Journal of Surgery and the Lancet. Fifty eight respondents rated their overall satisfaction with the Ptolemy project as high or very high. The respondents' comments elicited by an open ended question in the survey paint a good picture of the impact Ptolemy is having in Africa (see box).

Appraisal

Ptolemy was designed to provide access to electronic health information and to analyse whether that service had a positive effect on surgical research, teaching, and practice in east Africa. The interaction between information, knowledge, and behaviour is complex and difficult to measure, but some useful observations can be drawn from our early experience with Ptolemy.