Journal of Biomedical Informatics 40 (2007) 410–421

www.elsevier.com/locate/yjbin

Understanding the information needs of public health practitioners:

A literature review to inform design of an interactive digital
knowledge management system
Debra Revere a,b,d,*, Anne M. Turner a,d,f, Ann Madhavan b,c, Neil Rambo a,b
,
Paul F. Bugni a,b, AnnMarie Kimball a,d,e, Sherrilynne S. Fuller a,b,f
a
Center for Public Health Informatics, University of Washington, Box 357155, Seattle, WA 98195-7155, USA
b
Health Sciences Libraries, University of Washington, Seattle, WA, USA
c
Public Health—Seattle and King County, Seattle, WA, USA
d
Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, WA, USA
e
Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle, WA, USA
f
Division of Biomedical and Health Informatics, School of Medicine, University of Washington, Seattle, WA, USA

Received 29 March 2006

Available online 11 January 2007

Abstract

The need for rapid access to information to support critical decisions in public health cannot be disputed; however, development of
such systems requires an understanding of the actual information needs of public health professionals. This paper reports the results of a
literature review focused on the information needs of public health professionals. The authors reviewed the public health literature to
answer the following questions: (1) What are the information needs of public health professionals? (2) In what ways are those needs being
met? (3) What are the barriers to meeting those needs? (4) What is the role of the Internet in meeting information needs? The review was
undertaken in order to develop system requirements to inform the design and development of an interactive digital knowledge manage-
ment system. The goal of the system is to support the collection, management, and retrieval of public health documents, data, learning
objects, and tools.
Method: The search method extended beyond traditional information resources, such as bibliographic databases, tables of contents
(TOC), and bibliographies, to include information resources public health practitioners routinely use or have need to use—for example,
grey literature, government reports, Internet-based publications, and meeting abstracts.
Results: Although few formal studies of information needs and information-seeking behaviors of public health professionals have
been reported, the literature consistently indicated a critical need for comprehensive, coordinated, and accessible information to meet
the needs of the public health workforce. Major barriers to information access include time, resource reliability, trustworthiness/credi-
bility of information, and ‘‘information overload’’.
Conclusions: Utilizing a novel search method that included the diversity of information resources public health practitioners use, has
produced a richer and more useful picture of the information needs of the public health workforce than other literature reviews. There is a
critical need for public health digital knowledge management systems designed to reflect the diversity of public health activities, to enable
human communications, and to provide multiple access points to critical information resources. Public health librarians and other infor-
mation specialists can serve a significant role in helping public health professionals meet their information needs through the development
of evidence-based decision support systems, human-mediated expert searching and training in the use information retrieval systems.
Ó 2007 Elsevier Inc. All rights reserved.

Keywords: Grey literature; Information needs; Information resources; Information systems; Knowledge management; Literature review; Public health

*
Corresponding author. Fax: +1 206 543 3389.
E-mail address: [email protected] (D. Revere).

1532-0464/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.jbi.2006.12.008
 D. Revere et al. / Journal of Biomedical Informatics 40 (2007) 410–421 411

Data, properly shared as information, are the currency searching for the relevant recent report or statistical infor-
of public health. mation that would help them develop an effective response.
–Sosin & Thacker, 2002 In this setting timeliness is a key concern, decisions cannot
be delayed, and practitioners must be as well informed as
possible.
1. Introduction Complicating the situation is the fact that public health
includes many disciplines; its workforce is diverse; and
In October, 2005, the University of Washington was public health job functions are variable and often overlap-
awarded one of the first Centers for Disease Control and ping. This diversity of backgrounds and roles presents a
Prevention (CDC) grants to establish a Center of Excel- challenge to those studying public health information
lence in Public Health Informatics (CEPHI). CEPHI’s mis- needs, ways to improve access and reduce barriers to need-
sion is to improve the public’s health through discovery, ed information and public health information sources of
innovation, and research related to health information most importance for meeting information needs.
and information technology. A key CEPHI research area A clear understanding of the unique information needs
is design and development of an interactive digital knowl- of public health professionals is vital to the design process
edge management system to support the collection, man- for a digital knowledge management system. This review
agement, and retrieval of public health documents, data, sought to synthesize findings from a comprehensive review
learning objects, and tools. A long-term goal of the project of the literature into a coherent statement of current under-
is the implementation of a successful knowledge manage- standing regarding information needs of public health
ment system that is tailored to the public health practitio- professionals.
ners information needs, work processes, and environment
and which improves access to and use of digital informa- 2.2. Definitions and scope
tion resources in support of evidence-based public health
practice. Ultimately the vision is a system which will create The library and information science literature is rich in
an environment in which public health professionals can studies of information needs, information seeking behav-
pose questions and receive answers rather than simply a list ior, and human-computer interaction. This literature indi-
of possible places to look for answers to those questions. cates that: (1) users experience gaps in knowledge that
Achieving this goal requires a comprehensive understand- interfere with their ability to articulate what they know
ing of the information needs of public health practitioners. and do not know; (2) information seeking is situational,
This paper—a literature review of research examining contextual, and unique to the information seeker; and (3)
the information needs of public health professionals— knowledge of users’ tasks can help point to systems
represents a first step towards establishing a framework designed to support those tasks [1,2].
for developing system requirements that will inform the However, the concept of a public health ‘‘information
design and development process. need’’ can be problematic to define, given its reliance on con-
text, problem, and the organization in which the information
2. Background need occurs. We used Forsetlund and Bjørndal’s (2001) def-
inition of information as ‘‘any stimulus that reduces uncer-
2.1. Rationale tainty in a decision-making process’’ and an information
need as both the recognition of what information can reduce
The need for rapid access to information to support crit- this uncertainty as well as unrecognized or potential infor-
ical decisions in public health cannot be disputed. Relevant mation needs [3]. We also used the Institute of Medicine’s
resources to support public health decision making span a definition of a public health professional: ‘‘a person educat-
multiplicity of publication formats (e.g., print and electron- ed in public health or a related discipline who is employed to
ic) produced at local, state, national, and international lev- improve health through a population focus’’ [4].
els—including, disease incidence data (county/state/ The authors reviewed the public health literature to
national), vaccination guidelines, industrial effluent data, answer the following questions:
laws and regulations, legislative issues updates, metadata
on data sets, outcome measurement resources, synthesized 1. What are the information needs of public health
knowledge bases of information and guidelines, among professionals?
others. However, a limited amount of this critical informa- 2. In what ways are those needs being met?
tion is published through standard channels and conse- 3. What are the barriers to meeting those needs?
quently finding a resource, let alone locating the answer 4. What is the role of the Internet in meeting information
to a question within a resource, is extraordinarily difficult needs?
for busy public health professionals.
In the event of a disease outbreak or other public health Our multidisciplinary review team consisted of profes-
emergency, public health professionals are often reduced to sionals representing the fields of library and information
scrambling through piles of paper reports in their offices, science; biomedical, health and public health informatics;
412 D. Revere et al. / Journal of Biomedical Informatics 40 (2007) 410–421

epidemiology; and public health practice. The team repre- 4. Results

sented considerable experience of both research and prac-
tice in public health, informatics, and health care A total of 31 publications were included in the literature
information systems. review and are shown in Table 3 at the end of the paper.
Information was abstracted from each article and
3. Methods synthesized descriptively. Due to the heterogeneity of the
data and methods it was not possible to perform a meta-
3.1. Search strategy analysis. It is important to note that several non-USA
studies that appear to be conducted on non-public health
The findings that public health literature is poorly workforce segments met the inclusion criteria. This is a
indexed in bibliographic databases and dispersed across a reflection of the diversity of health services organizations
wide variety of journals and other sources across many dis- outside of the USA that include those whose prime respon-
ciplines [5,6] required special attention in developing a sibility is the provision of core public health activities. For
comprehensive search strategy. The goal was to capture a example, in the UK, ‘‘community nurse prescribers’’
comprehensive picture of public health information needs perform the same role functions as public health nurses
across the diverse literature of public health. in the USA.
Table 1 lists resources searched by category: (1) biblio- Literature in this review includes many disciplines: the
graphic databases, searched for peer-reviewed articles, ‘‘general’’ public health workforce (13 papers); communi-
reviews, and meeting abstracts; (2) tables of contents of cable disease specialists and epidemiologists (7); public
four public health journal titles, selected by Journal Cita- health clinicians (5); health officers (3); public health nurses
tion ReportsÓ ranking, were hand-searched; (3) Internet (3); health policy makers (3); environmental health special-
searching for books, meeting abstracts, and government ists (2); veterinarians (2); and occupational health and safe-
reports; and (4) compilations of public health reference ty workers (1). Also included are 4 studies by libraries that
materials. Search strategies were tailored according to provide public health information services. All but 6 publi-
database or resource used. cations were from the USA. Included are reviews (15
A list of search terms used is in Table 2. In database papers); studies using qualitative methodologies (13); pilot
searches, terms were combined in multiple ways using studies (2); and one comparative study. Qualitative meth-
Boolean operators (AND, OR, NOT). Truncation and ods included studies utilizing questionnaires and surveys
wild carding were used when available. Publications were (8 papers); focus groups (7); interviews (4); and observa-
limited to English. Terms were modified to reflect the orga- tions (3).
nization of the database used. A summary of public health information needs can be
The initial cross-resource search yielded 427 publica- found in Table 4.
tions which were downloaded into a bibliographic software Content was sorted into four categories reflecting the
tool; the total was reduced to 281 after elimination of focus of the review questions:
duplicates.
1. Identification of public health information needs;
3.2. Inclusion/exclusion criteria 2. How information needs are being met;
3. Access vs. barriers to meeting information needs; and
To maintain the focus on public health information 4. Use of the Internet as a vehicle for systems that provide
needs, the following exclusion criteria were employed. Arti- resources that meet public health practitioner informa-
cles were excluded if they: (1) focused solely on public tion needs.
health workforce training and/or workforce development;
(2) described information systems and/or technologies 4.1. Identification of public health information needs
applied to public health settings; (3) described public health
infrastructure; (4) only evaluated public health technology/ 4.1.1. Synthesized and collated information
digital literacy skills; or (5) focused on public health compe- The need for timely, easy to digest, and up-to-date infor-
tencies. Articles that solely focused on public health infor- mation that is filtered, summarized, and synthesized from
mation needs and/or information needs assessment but authoritative content sources was reported in nine studies
also included one or more of the exclusion criteria were [7–15]. Content sources cited included external databases,
included. research reports and research findings, meta-analyses and
The selection procedure is depicted in Fig. 1. The first systematic reviews. The need was specifically for synopses
eligibility review applied the exclusion criteria to titles of information that had been proactively read, filtered,
and abstracts (when available) of the citation list, resulting reviewed, and made easily accessible [7,12,15–18]. Five
in 78 publications. Next, full-text documents—as well as studies also cited the need for collated information from
examination of article references and key authors for addi- agencies or institutions, both public and private (e.g., state
tional publications—were reviewed and exclusion criteria health department, CDC, local emergency room diagnoses)
applied. [8,9,11–13].
 D. Revere et al. / Journal of Biomedical Informatics 40 (2007) 410–421 413

Table 1
Resources searched
Bibliographic databases Coverage
BiosisPreviewsÒ International life sciences journals and meetings
CINAHLÒ Nursing and allied health literature
Current contentsÒ Research journals, books, reviews and meeting abstracts in the sciences
and social sciences
LISA (Library and Information Science Abstracts) Library and information science
Library Literature and Information Science (12/1984 to 01/2006) Library and information science
National Library of Medicine’s MEDLINEÒ (01/1966 to 02/2006) database Biomedical literature
through the PubMedÒ interfacea
PAIS International Social and public policy
Web of ScienceÒ Science and social science journals and cited references
Journal tables of contents
American Journal of Public Health Journals selected on the basis of ranking by Journal Citation ReportsÓ
Annual Review of Public Health
Journal of Public Health Management & Practice
Public Health Reports
Internet-based publications
CDC websiteb Centers for disease control and prevention
Librarian’s Internet Indexc Websites selected, described and organized by librarians
New York Academy of Medicine’s Grey Literature (NYAM GreyLit) Grey literature
libraryd
Scout Reporte Part of NSF’s National Science Digital Library Project, provides guides to
online resources
www.google.com search engine General searches
GPO Accessf Government reports
NLM Gatewayg Biomedical books and meeting abstracts
Compilations
Annotated bibliography for syndromic surveillanceh (CDC) Evidence-based Practice for Public Health Projecti (Lamar Soutter Library
Public Health Information Needs and Information-Seeking Behavior at the University of Massachusetts)
Bibliographyj (MN Dept of Health Library)
Current Bibliographies in Medicinek (NLM) Partners in Information Access for the Public Health Workforce websitel
a
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed.
b
http://www.cdc.gov/.
c
http://lii.org/.
d
http://www.nyam.org/library/greylit/.
e
http://scout.wisc.edu/.
f
http://www.gpoaccess.gov/.
g
http://gateway.nlm.nih.gov/gw/Cmd.
h
http://www.cdc.gov/epo/dphsi/syndromic/.
i
http://library.umassmed.edu/ebpph/.
j
http://www.health.state.mn.us/library/infoneeds.html.
k
http://www.nlm.nih.gov/pubs/cbm/.
l
http://phpartners.org/.

Table 2
Search terms
Grey literature Information needs Information technology Public health
Health information systems Information resources Information use Public health informatics
Health sciences libraries Information seeking Information users Public health nursing
Human–computer interaction Information storage and retrieval Knowledge management Public health practice
Information access Information systems Public health workforce

4.1.2. Content sources health risks and preventive behaviors, emerging practices
In addition to filtered and summarized information, and programs, new interventions, and ‘‘best practice’’
four studies identified grey literature (e.g., policy docu- and evidence-based resources [7,12,15].
ments, government reports, legislative summaries, industry
group publications, and descriptions of best practices) as a 4.1.3. Data
source for needed information [7,17,19,20]. Other impor- Public health practitioners must implement and evaluate
tant sources included early reports of newly identified public health services, assess and monitor the health of
414 D. Revere et al. / Journal of Biomedical Informatics 40 (2007) 410–421

Fig. 1. Search and selection procedure.

their community, disseminate timely information, and 4.2.1. Other people

identify emerging threats. To do this they need current Thirteen studies report that colleagues are frequently the
national, state, and local information—which might information resource that public health professionals first
include data such as birth rates and emergency room visits, turn to with an information query [3,12,15,16,18,23,24,
practices and programs directed at specific health interven- 27–32]. This is similar to studies of information-seeking
tions, policies, and guidelines such as immunization sched- behaviors of other professionals—engineers, health care
ules—was also reported [13,14,17,21]. In addition, professionals, social scientists, lawyers, and life scien-
statistical and epidemiologic information [17,19,21,22] tists—that have repeatedly shown human resources are a
and metadata characterizing the content of data sets [7] primary source of information [33–35].
support the need to have the most current information Lee et al. conducted a comprehensive information needs
readily accessible whenever needed. survey of public health workers in Tennessee and found
that resources or categories of information that were rated
4.1.4. Access to needed information most highly in terms of daily use included colleagues and
Three papers observed that the decentralization, var- internal communications such as telephone calls, memo-
ied roles, and sheer enormity of information public randa, and personal conversations [27].
health practitioners necessitates a centralized information This finding does not appear to differ when specific pub-
service or ‘‘place to find out where to find out’’ lic health roles are studied. Public health clinicians [3,23]
[12,15,23], as well as directories and resources for con- and nurses [16,32] rank other people as a highly reliable
tacting experts [7] and a source for answers to clear, dis- and accessible source of needed information. For example,
crete research questions.[14,17] Providing multiple in the UK, public health ‘‘prescribing nurses’’ described
avenues of entry to information resources [8,21,24–26] networking, face-to-face consultation, and colleagues as
is also cited. invaluable information resources, both for support and
In summary, although public health information needs for keeping up to date, describing them as ‘‘the richest
may differ according to role (epidemiologist vs. nurse), set- source of information’’ [16]. Veterinary public health work-
ting (urban vs. rural), or availability of computer/Internet ers—an auxiliary workgroup concerned with diseases
access, the qualities associated with the information needs transmitted between people and animals (zoonoses)—seek
can be universally described as: vetted; high quality; gener- information first from colleagues and in a critical care sit-
ated by an authoritative content source; verifiable by a uation, nearly 60% are likely to consult other practitioners
trusted source; up to date and known to be regularly or university contacts [18].
updated; convenient; and accessible [7,12,15–17].
4.3. Access vs. barriers to meeting information needs
4.2. How information needs are being met
4.3.1. Environmental barriers
Numerous studies have looked at the type of informa- External characteristics, such as time, setting (urban,
tion public health professionals seek and how they access rural), staffing, and size of a public health department’s ser-
and use this information. While the ability to access infor- vice area can facilitate or hinder the public health practi-
mation across many disciplines is a necessary component tioner’s ability to meet information needs.
of public health work [16,24,27], a recurrent theme that Decentralization, unavailability of Internet services in a
emerges from the literature is the importance of col- rural environment, inadequate equipment, and lack of
leagues, peers, and other people for meeting information organized library services are cited as environmental barri-
needs. ers to meeting information needs [23,26,27].
 D. Revere et al. / Journal of Biomedical Informatics 40 (2007) 410–421 415

Table 3
Publications included in the review
Author, year Workforce segment Methods Outcome
Baker et al. (1995) [8] EPI, GEN REV Electronic resources: needs, reasons, types
Information: databases, needs, obstacles
Internet: needs
Bravata et al. (2002) [9] HO, PHMD, PHP REV Information: databases, needs, sources, types
Information-seeking: reasons
Cahn et al. (1998) [19] PHP REV Electronic resources: types
Information: databases, sources, types
Cash and Narasimhan (2000) [29] EPI (International) REV Information: needs, sources, types
Other people
Chambers et al. (1991) [24] GEN Q/SUR Electronic resources: types
Information: needs, sources, types, usage
Cheng and Lam (1996) [42] LIB (Hong Kong) Q/SUR Information: needs, sources, types, usage
Information-seeking: reasons
Cohen et al. (2006) [21] GEN REV Electronic resources: reasons, types
Information: databases, needs, obstacles, sources, types
Information-seeking: obstacles
Eldredge and Carr (2005) [41] GEN COM Information: types, usage
EHPC (2001) [37] ENV FOC Information: needs, obstacles
Forsetlund and Bjørndal (2001) [3] PHMD (Norway) FOC, OBS Information: databases, needs, obstacles, sources, types
Information-seeking: obstacles
Other people
Forsetlund and Bjørndal (2002) [23] PHMD (Norway) FOC, OBS Electronic resources: needs, types
Information: databases, needs, obstacles, sources
Information-seeking: obstacles, reasons, time spent
Other people
Forslund and George (2002) [11] CDS, EPI REV Electronic resources: needs, reasons, types
Information: databases, needs, obstacles, sources, types
Friede et al. (1993) [25] EPI REV Electronic resources: needs, reasons, types
Information: databases, types
Information-seeking: time spent
Internet: needs, skills
Friede et al. (1995) [43] GEN REV Electronic resources: needs, types
Information: databases, needs, obstacles, sources, types
Internet: needs, skills, obstacles
Friedman et al. (2001) [22] GEN REV Electronic resources: needs, types
Information: databases, needs, obstacles, types
Information-seeking: obstacles
Internet: needs
Garrett and Yasnoff (2002) [40] PHMD PIL Electronic Resources: needs, types, usage
Information: databases, needs, sources, types
Internet: needs, obstacles
Gray (1998) [38] PHP REV Information: databases, needs, sources, types
Information-seeking: obstacles
Hall et al. (2003) [16] PHN (England) INT, QUAL Information: needs, obstacles, sources, types, usage
Information-seeking: reasons
Other people
King et al. (2004) [45] VET REV Information: needs, obstacles, sources, types, usage
Knight et al. (2001) [26] LIB Q/SUR Information: needs, types
Information-seeking: reasons
Lee et al. (2003) [27] GEN QUAL, Q/SUR Information: databases, needs, obstacles, sources, types,
usage
Information-seeking: obstacles, reasons
Other people
Martin et al. (2005) [12] and GEN QUAL, INT, Q/ Electronic resources: needs, obstacles, types, usage
LaPelle et al. (2006) [15] SUR, FOC, OBS Information: databases, needs, obstacles, sources, types,
usage
Information-seeking: obstacles, reasons
Other people
O’Carroll et al. (1998) [17] HO, PHMD REV Information: databases, needs, sources, types, usage
Internet: needs, skills, obstacles, usage
Pappaioanou et al. (2003) [36] EPI (International: REV Information: obstacles, sources, types
Bolivia, Cameroon, Information-seeking: cost, obstacles
Mexico, Philippines)
(continued on next page)
416 D. Revere et al. / Journal of Biomedical Informatics 40 (2007) 410–421

Table 3 (continued)
Author, year Workforce segment Methods Outcome
Pelzer and Leysen (1991) [18] VET Q/SUR Information: sources, types
Other people
Rambo (1998) [13] GEN QUAL, INT, Information: needs, sources, types
FOC
Rambo et al. (2001) [14] LIB REV Information: databases, needs, sources, types, usage
Information-seeking: reasons
Rambo and Dunham (2000) [7] ENV, EPI, GEN, HO, FOC Information: databases, needs, sources, types
PHN Other people
Scheiber et al. (1998) [30] GEN (Germany) Q/SUR Electronic resources: needs, obstacles, types
Information: obstacles, sources, types
Information-seeking: obstacles
Internet: skills, obstacles, usage
Other people
Schulte et al. (2003) [44] OH REV Information: sources, types, usage
Telleen and Martin (2003) [31] GEN, LIB COM, Q/SUR, Electronic resources: needs, types, usage
FOC Information: databases, needs, types
Information-seeking: obstacles
Internet: needs, obstacles
Other people
Turner (2005) [20] GEN PIL Information: needs, obstacles, types
Information-seeking: obstacles
Turner et al. (2005) [32] PHN INT Information: needs, obstacles, sources, types
Information-seeking: obstacles

Abbreviations used: Workforce: CDS, communicable diseases; ENV, environmental health; EPI, epidemiology; GEN, general/public health ‘‘workforce’’;
HO, health officer; LIB, librarian; OH, occupational health; PHN, public health nurse; PHMD, public health doctor; PHP, public health policy maker/
analyst; VET, public health veterinarian. Methods: COM, comparative study; FOC, focus group; INT, interview; OBS, observation; PIL, pilot study; Q/
SUR, questionnaire and/or survey; QUAL, qualitative study; REV, review.

Table 4
Summary of public health information needs
Category of information need Description
Access to varied resource formats Availability of grey literature, reports, guidelines, practices, programs, interventions, datasets, epidemiologic data
Availability of information from both public (e.g., government institutions, CDC) and private (e.g., industry
associations) sources
Authority Vetted
Generated by an authoritative content source
Verifiable by a trusted source
Centralized access A ‘‘place to find out where to find out’’ answers
Improved access/availability of Convenient
information Multiple avenues of entry to information sources
Improved delivery Portal to information and resources
Quality High quality information and resources
Reduced barriers to information Reduce time to find resources. Reduce ‘‘information overload’’ of both relevant and irrelevant information.
Improve access to people/public health experts who are critical source of information
Reliability Persistent resources, both in content and availability
Trustworthiness/credibility of information
Synthesized/collated information Summarized, pre-digested, filtered information
Timeliness Up-to-date information that is known to be regularly updated

4.3.2. Psychological barriers not act on that need because of the perception that the
The information seeker’s preferences, prejudices, self- information may not be found [3,23].
evaluation of knowledge and skills, interests, and knowl- Pappaioanou et al. identified several barriers known to
edge of the subject are all potential psychological barriers affect the use of epidemiologic data in decision making,
to meeting information needs. including the failure of epidemiologists to: analyze and
In Norway, Forsetlund and Bjørndal conducted a series frame issues in a policy context for decision makers;
of focus groups, observations, and interviews of public package and present data in an understandable and
health clinicians. They report that while the practitioner compelling format; lack of trust on the part of decision
may have recognized an information need, s/he still may makers in the accuracy of data which has resulted in their
 D. Revere et al. / Journal of Biomedical Informatics 40 (2007) 410–421 417

discounting the information; and fear of social or economic government documents; literature reviews and journal
consequences [36]. abstracts; and to network and interface with other clinics
and agencies [31].
4.3.3. Source characteristics
An information source’s accessibility, relevance, trust- 4.4.2. Internet portals for meeting information needs
worthiness, currency, quality, and reliability can determine Anecdotal evidence (Madhavan A. personal communi-
whether an information need is met or is not fulfilled. Lim- cation, 2006) suggests that Google is the primary tool used
ited access to needed information is a major obstacle for by public health practitioners to locate relevant informa-
public health practitioners, including access to research- tion. However, there is recognition of the need among pub-
based information sources, medical literature, electronic lic health practitioners for a centralized information service
full-text journal articles, conference websites, and grey lit- or ‘‘place to find out where to find out.’’ Four approaches
erature [12,15,23,27]. In addition, access to relevant infor- to using the Internet to provide access to information
mation found in resources that are outside traditional resources and tools are highlighted.
public health (e.g., marketing literature, organizational The MassCHIP (Massachusetts Community Health
behavior, etc.) is another barrier to obtaining needed infor- Information Profile) system is an online data query system
mation [12,15]. that resides locally on the public health practitioner’s hard
Information overload when searching or evaluating the drive or network server. It provides access through multi-
information found presents further obstacles [23,37]. Addi- ple avenues of entry to a database of public health informa-
tional barriers include the complication of different inter- tion that includes data sets from Massachusetts and other
faces for different resources; widely dispersed information state agencies to reflect a broad view of public health.
resources; quality of information; gaps in information; MassCHIP also has the capacity to retrieve data for multi-
and barriers to overcoming gaps [23,37,38]. ple levels of geography, from the neighborhood through
the state, including planning districts and hospitals. Access
4.3.4. ‘‘Unique’’ barriers is tailored by public health domain so a wide variety of
Global disease surveillance, particularly in countries users—students, community workers, epidemiologists,
which do not have adequate disease-monitoring infrastruc- nurses, academic researchers, journalists—can build que-
tures, can be hampered by fear of sanctions, inaccurate ries, download data, and build maps and charts on the
reports and rumors, concern over social disruption on a basis of the data (e.g., national, state and local data; census
national level and unwarranted international panic that data; data generated by the state’s Departments of Educa-
can lead to economic losses [29]. The need for timely, reli- tion, Social Services, Employment and Training; births;
able, and accurate information early in an outbreak is crit- hospital emergency department visits; etc.). Users can cre-
ical for preventing harsh international reaction against ate customized, user-defined geographies to examine need,
countries that report disease outbreaks, especially poorer generate statistics that apply to the custom aggregate geog-
countries that are more economically vulnerable in the raphy, and design interventions for target areas [21].
event of an outbreak. CDC WONDER was developed in response to the large
Data set ‘‘overload’’—the consequence of increasingly data sets generated by surveys, questionnaires, etc. It was
large data sets generated by surveys and other data collec- designed to simplify the management of data by placing
tion tools—has forced many epidemiologists to become timely, action-oriented information in the hands of public
data managers, making it more difficult to analyze data health professionals. WONDER provides data sets with
from a variety of sources in order to detect disease out- online documentation regarding how the data were collect-
breaks at an early stage [11,25]. ed, how questions were phrased, sampling methods, known
biases and errors, and references; ability to conduct full-
4.4. Use of the Internet by public health practitioners text searches of textual databases and data sets of prefor-
matted tables. In addition, WONDER provides access to:
4.4.1. Role-based Internet use numerical data sets (AIDS, Behavior, Cancer, Census,
Telleen and Martin found that Internet use varied Hospitalization, Mortality, Notifiable disease, STDs); tab-
depending on public health work segment. For example, ular databases (Alcohol, BRFSS, Diabetes, General US
they report that public health workforce roles influence health); text databases (ASTHO, CDC Resource Index,
what information needs are met by using the Internet. ICD-9, Documentation, MMWR, NACHO/CDC Nation-
For example, public health nurses use the Internet for al Profiles of Local Health Departments); and SAS data
access to clinical treatment information; patient education sets [25].
materials; network with other clinics; and abstracts and Another CDC system, NEDSS (National Electronic
full-text journal articles. This is in contrast to nurse admin- Disease Surveillance System), is a major component of
istrators/clinic coordinators who go online to find: grant the Public Health Information Network (PHIN). NEDSS
requests for proposals (RFPs); grant writing help; commu- integrates information between healthcare providers and
nity demographics; national norms for various health indi- epidemiologists by providing electronic transfer of infor-
cators; health outcome studies and other comparative data; mation from clinical information systems in the health care
418 D. Revere et al. / Journal of Biomedical Informatics 40 (2007) 410–421

industry in order to promote early detection of disease out- and smart search systems that can navigate complex, mul-
breaks. The goal is an integrated and interoperable surveil- ti-layered websites [22].
lance system at the state and local levels. Part of this effort Customized information ‘‘toolkits’’ for practitioners are
is development of the Public Health Conceptual Data needed. These could be developed for different work
Model, a high level conceptual model which provides the groups, for example, or in conjunction with the Healthy
foundation for standardization of public health data collec- People 2010 objectives. A toolkit would consist of source
tion, management, transmission, analysis, and dissemina- documents (e.g., practice guidelines), news and announce-
tion [11,39]. ments, legislative updates, search interfaces to relevant
CDC generates a large body of information that is pub- data sets, directory and contact tools, and preformatted
lished in various forms, but not always in the form most searches to selected databases [14].
accessible to end users [14]. CDC Recommends is a com- Public health practitioners meet their information needs
pendium of prevention guidelines with CDC recommenda- by using information resources that are easy to access and
tions and guidelines for the prevention, control, treatment use, up-to-date, flexible, free or low cost, pre-digested or
and detection of infectious and chronic diseases, environ- summarized, stable, and are focused on the practitioner’s
mental hazards, natural or human-generated disasters, particular field(s). Public health professionals rely on time-
occupational diseases and injuries, intentional and uninten- ly, up-to-date information. Therefore, information systems
tional injuries and disabilities, and other public health con- should support frequent regular updates [12,16,17].
ditions [40]. Programs such as CDC’s Information Network for Pub-
lic Health Officials, the Health Alert Network, and the
National Library of Medicine’s Partnership in Information
5. Discussion Access for Public Health Officials are designed to strength-
en the information infrastructure of state and local public
This literature review focused on the information needs health agencies. The success of these initiatives will depend
of public health professionals prior to developing system not only on technology but also on the information content
requirements to inform the design and development pro- being delivered, how it used, and on a workforce trained to
cess of an interactive digital knowledge management sys- effectively use these new tools and resources. Further
tem that will support the collection, management, and research is needed to determine optimal development,
retrieval of public health documents, data, learning objects, structure, delivery, and marketing of public health infor-
and tools. What do the cumulative findings from this mation to specific public health workforce segments [7].
review tell about the effective system design for public The common theme of people as public health knowl-
health information? edge resources points to the need to provide timely access
Given the variety of roles and background of public to public health experts via up-to-date directories that are
health workforce, a one-size-fits-all system cannot meet organized by content area, as well as reliable information
public health information needs. Ideally, the development mediators such as librarians and information specialists.
of online public health information resources should reflect
the complexity and diversity of the public health workforce 6. Limitations of the review
itself [7,20]. Public health job functions and disciplines are
variable and influence not only selection of information There are several limitations to the findings of this liter-
resources but also information needs that must be met. ature review. The focus of this review is the information
The roles of public health vary widely and different seg- needs of public health professionals (not public health
ments of the public health workforce have different infor- researchers in academic settings) in the United States.
mation needs [7,27]. Also, information needs within Although some studies from non-USA publications are
workgroups vary by level of training (e.g., graduate degree included, our limitation to publications in English may
in public health vs. associate degree vs. certification, etc.) have introduced a bias in inclusion to those studies con-
[14,20] and some groups of the public health workforce ducted in the USA. Another limitation is the focus on
are more used to incorporating external information the public health workforce in general. Given the numerous
resources in their work than others [17]. disciplines represented by the label ‘‘public health’’ it is
To best serve public health professionals, the design of possible that pertinent studies were missed in the compre-
knowledge management systems should offer ready access hensive search that was performed. In addition, given the
at the point of need, with a minimum of security barriers very elusive nature of public health publications, it is pos-
(e.g., logon and password). Information system design sible that searches may have overlooked a pertinent
must be intuitive and take into consideration public health publication.
workflow. Our results suggest that many of the information needs
While much valuable public health information is locat- assessments focused on public health professionals involved
ed on governmental websites navigating these websites to in clinical care. However, clinicians make up only a small
find specific answers to questions is problematic. System percentage of the public health workforce in this county.
design should focus on providing user-friendly interfaces Only a few studies have investigated the information needs
 D. Revere et al. / Journal of Biomedical Informatics 40 (2007) 410–421 419

of diverse aspects of the public health workforce. It is very Useful information, while theoretically available, is bur-
likely that the information needs of local health profession- ied within voluminous and difficult-to-search local, state,
als, particularly in rural areas may differ from their urban national, and international websites. In addition, there
counterparts. Filling these gaps should help direct future remains much critical information buried in print reports,
systematic information needs assessments of public health publications of policies and procedures, and databases
professionals. which lack useful search and retrieval interfaces.
This literature review is limited to published accounts of Regardless of category of information need, public
information needs assessment and consequently, it is likely health role, setting (urban vs. rural), or availability of com-
that many unpublished public health information needs puter/Internet access, the information sources used to meet
assessments exist. For example, the joint NLM and Nation- a public health information need can be universally
al Network of Libraries of Medicine (NN/LM) ‘‘Partners in described as resources that are: vetted; high quality; gener-
Information Access’’ program has funded a number of out- ated by an authoritative content source; verifiable by a
reach projects with the goal to: (1) increase public health trusted source; up to date and known to be regularly
professionals’ awareness of NLM, NN/LM and CDC ser- updated; convenient; and accessible [16,17]. Systems devel-
vices; (2) assist public health professionals in getting con- oped for public health agencies must take into consider-
nected to the Internet; (3) provide information technology ation the users’ needs, role and tasks. Given the diversity
and information services training; and (4) increase aware- of public health activities it may be necessary to design cus-
ness of public health information needs and resources tomizable interfaces. Systems design and implementation
among NN/LM members (for a list of projects see http:// need to incorporate: coordination; national facilitation;
phpartners.org/nnlm_projects.html). Although 18 pro- interstate and inter-county collaboration; and standards
grams have been funded since 1999, few have published for data content, data format, and statistics [22].
the results of their needs assessments. In addition, over Peers, administrators, program personnel, and state con-
the last ten years several public health information needs tacts are critical sources of public health information. Col-
assessments have been performed through NLM’s Regional leagues, peers and other people are the most reliable,
Medical Libraries (RMLs) that remain unpublished. available and commonly used information resources for
Hopefully this review, which highlights the need for training and carrying out the day-to-day work of public
more systematic evaluations of the information needs of health. Information systems to provide access to public
public health professionals, will encourage publication of health resources need to be designed to enable human com-
such efforts. munication and not interfere with this critical public health
resource [32]. As mentioned previously, information systems
7. Conclusion can assist in this need for human networking with directories
to subject experts and other contacts. In addition, public
While there have been other reviews of public health health librarians and other information specialists can serve
information needs, to the best of our knowledge this is a significant role in helping public health professionals meet
the first review that has searched beyond traditional biblio- their information needs with human-mediated searching
graphic databases to include the diversity of information and training to use information delivery systems.
resources public health practitioners routinely use or have
need to use—for example, grey literature, conference pro- Acknowledgments
ceedings, government reports, websites, etc. This innova-
tive methodology has produced a richer and more useful We wish to acknowledge the contributions and helpful
picture of the information needs of the public health work- feedback of our collaborators in the Center for Public
force than previous literature reviews. Health Informatics and School of Public Health, Universi-
There are four consistent findings from this study: (1) ty of Washington: Yuki Durham, Patrick O’Carroll, Mark
although much progress has been made in developing Oberle and Bryant Karrass, as well as our anonymous
online web resources to support the work of public health reviewers for their comments and insights. This work was
professionals, the problem of rapidly finding the needed supported in part by the Centers for Disease Control and
answer (no more and no less) continues to expand; (2) Prevention Award Number 1 P01 CD000261-01, the
few formal studies of information needs and information- Health Sciences Libraries, and the Center for Public Health
seeking behaviors of public health professionals have been Informatics at the University of Washington.
reported; (3) major barriers to information access include
time, resource reliability, trustworthiness/credibility of References
information, and ‘‘information overload’’ of both relevant
and irrelevant information; and (4) people are a critical [1] Hewins ET. Information need and use studies. Annual review of
information science and technology, vol. 25. Washington,
source of information in public health—therefore, informa-
DC: American Society for Information Science; 1990. pp 145–72.
tion system design needs to include avenues that support [2] Wilson TD. Information needs and uses: fifty years of progress. In:
access to human communication networks (e.g., providing Vickery BC, editor. Fifty years of information progress: a journal of
accurate directories, listservs, etc.). documentation review. London: Aslib; 1994. p. 15–51.
420 D. Revere et al. / Journal of Biomedical Informatics 40 (2007) 410–421

[3] Forsetlund L, Bjørndal A. The potential for research-based infor- [24] Chambers LW, Haynes RB, Pickering R, McKibbon A, Walker-
mation in public health: identifying unrecognised information needs. Dilks CJ, Panton L, et al. New approaches to addressing information
BMC Public Health 2001;1:1. needs in local public health agencies. Can J Public Health
[4] IOM. Who will keep the public healthy: educating public health 1991;82(2):109–14.
professionals for the 21st century. Washington, DC: Institute of [25] Friede A, Reid JA, Ory HW. CDC WONDER: a comprehensive
Medicine, National Academies Press; 2002. on-line public health information system of the Centers for
[5] Alpi KM. Expert searching in public health. J Med Libr Assoc Disease Control and Prevention. Am J Public Health 1993;83(9):
2005;93(1):97–103. 1289–94.
[6] Armstrong R, Jackson N, Doyle J, Waters E, Howes F. It’s in your [26] Knight B, Pedersen L, Bina L, Anderson K. Information access for
hands: the value of handsearching in conducting systematic reviews public health professionals in North Dakota. Midwest Chapter/MLA
of public health interventions. J Public Health (Oxf) 2005;27(4): and Wisconsin Health Science Library Association; 2001. Available
388–91. from http://undmedlibrary.org/pdf/ReportQ8.pdf. Accessed 02/01/
[7] Rambo N, Dunham P. Information needs and uses of the public 2006.
health workforce–Washington, 1997–1998. MMWR Morb Mortal [27] Lee P, Giuse NB, Sathe NA. Benchmarking information needs and
Wkly Rep 2000;49(6):118–20. use in the Tennessee public health community. J Med Libr Assoc
[8] Baker EL, Friede A, Moulton AD, Ross DA. CDC’s Information 2003;91(3):322–36.
Network for Public Health Officials (INPHO): a framework for [28] Blackwelder MB, Dimitroff A. The image of health science librarians:
integrated public health information and practice. J Public Health how we see ourselves and how patrons see us. Bull Med Libr Assoc
Manag Pract 1995;1(1):43–7. 1996;84(3):345–50.
[9] Bravata D, McDonald K, Owens D, Buckeridge D, Haberland C, [29] Cash RA, Narasimhan V. Impediments to global surveillance of
Rydzak C, et al. Bioterrorism preparedness and response: use of infectious diseases: consequences of open reporting in a global
information technologies and decision support systems. Report No.: economy. Bull World Health Organ 2000;78(11):1358–67.
Evidence Report/Technology Assessment No. 59, AHRQ Publication [30] Scheiber A, Schneemann R, Wischer R. Assessment of information
No. 02-E028. Rockville, MD: Agency for Healthcare Research and needs in public health in Germany: results of a nationwide survey.
Quality; 2002. Info Res 1998;3:2. Available from: http://informationr.net/ir/3-3/
[10] Choi BC, Orlova A, Marsh M, Issa N, Morrison H. Two information paper43.html>. Accessed 12/10/2005.
dissemination approaches for public health decision makers: ency- [31] Telleen S, Martin E. Improving information access for public health
clopaedia and fire alarm. J Epidemiol Community Health professionals. J Med Syst 2002;26(6):529–43.
2004;58(8):634. [32] Turner AM. From the ground up: determining the information
[11] Forslund DW, George JE. A service-based approach to integrating needs and uses of public health nurses in an Oregon County
epidemiological information in public health departments. AMIA Health Department. Seattle, WA: University of Washington;
Annu Symp 2002:1020. 2005.
[12] Martin ER, Simpson EH, Luckmann RL, Telleen S, La Pelle NR. [33] Gorman PN, Helfand M. Information seeking in primary
Evidence-based practice for public health project. Report No.: Final care: how physicians choose which clinical questions to pursue
Report, Project TS-0734. Worcester, MA: Lamar Soutter Library, and which to leave unanswered. Med Decis Making 1995;15:
University of Massachusetts Medical School; 2006. 113–9.
[13] Rambo N. Information resources for public health practice. J Urban [34] Hertzum M, Pejtersen AM. The information practices of engineers:
Health 1998;75(4):807–25. search for documents as well as for people. Inf Process Manage
[14] Rambo N, Zenan JS, Alpi KM. Public Health Outreach Forum: 2000;36(5):761–78.
lessons learned. Bull Med Libr Assoc 2001;89(4):403–6. [35] Leckie GJ, Pettigrew KE, Sylvain C. Modeling the information
[15] LaPelle NR, Luckmann R, Simpson EH, Martin ER. Identifying seeking of professionals: a general model derived from research on
strategies to improve access to credible and relevant information for engineers, health care professionals, and lawyers. Libr Qtrly
public health professionals: a qualitative study. BMC Public Health 1996;66(2):161–93.
2006;6:89. [36] Pappaioanou M, Malison M, Wilkins K, Otto B, Goodman RA,
[16] Hall J, Cantrill J, Noyce P. The information sources used by Churchill RE, et al. Strengthening capacity in developing countries
community nurse prescribers. Br J Nurs 2003;12(13):810–8. for evidence-based public health: the Data for Decision Making
[17] O’Carroll PW, Cahn MA, Auston I, Selden CR. Information needs in Project. Soc Sci Med 2003;57(10):1925–37.
public health and health policy: results of recent studies. J Urban [37] Environmental Health Policy Committee. Environmental health data
Health 1998;75(4):785–93. needs: an action plan for Federal Public Health Agencies; 1999.
[18] Pelzer NL, Leysen JM. Use of information resources by veterinary Available from: http://web.health.gov/environment/DataNeeds/hili-
practitioners. Bull Med Libr Assoc 1991;79(1):10–6. tes.htm. Accessed 02/01/2006.
[19] Cahn MA, Selden CR, Auston I. Web-based resources for retrieving [38] Gray BH. Sources used in health policy research and implications
health policy information: NLM and beyond. J Urban Health for information retrieval systems. J Urban Health 1998;75(4):
1998;75(4):826–41. 842–52.
[20] Turner AM, Liddy ED, Bradley J, Wheatley J. Modeling public [39] CDC. Public Health Conceptual Data Model; 2002. US Department
health interventions for improved access to the public health grey of Health and Human Services, Centers for Disease Control and
literature. J Am Med Libr Assoc 2005;93(4):487–94. Prevention. Available from: http://www.cdc.gov/nedss/DataModels/
[21] Cohen BB, Franklin S, West JK. Perspectives on the Massachusetts phcdm.pdf. Accessed 02/01/2006.
Community Health Information Profile (MassCHIP): developing an [40] Garrett NY, Yasnoff WA. Disseminating public health practice
online data query system to target a variety of user needs and guidelines in electronic medical record systems. J Public Health
capabilities. J Public Health Manag Pract 2006;12(2):155–60. Manag Pract 2002;8(3):1–10.
[22] Friedman DJ, Anderka M, Krieger JW, Land G, Solet D, Durch J. [41] Eldredge JD, Carr DA. Evidence-based public health informatics
Assessing population health information through interactive systems. training for public health practitioners. In: 3rd International evidence
Pub Health Reports 2001;116(2):132–47. based library conference; 2005. Available from: http://conferenc-
[23] Forsetlund L, Bjørndal A. Identifying barriers to the use of research es.alia.org.au/ebl2005/Eldredge.pdf. Accessed 02/01/2006.
faced by public health physicians in Norway and developing an [42] Cheng GY, Lam LM. Information-seeking behavior of health
intervention to reduce them. J Health Serv Res Policy professionals in Hong Kong: a survey of thirty-seven hospitals. Bull
2002;7(1):10–8. Med Libr Assoc 1996;84(1):32–40.
 D. Revere et al. / Journal of Biomedical Informatics 40 (2007) 410–421 421

[43] Friede A, Blum HL, McDonald M. Public health informatics: how components in occupational safety and health. Am J Ind Med
information-age technology can strengthen public health. Annu Rev 2003;44(5):515–31.
Public Health 1995;16:239–52. [45] King LJ, Marano N, Hughes JM. New partnerships between animal
[44] Schulte PA, Okun A, Stephenson CM, Colligan M, Ahlers H, health services and public health agencies. Rev Sci Tech
Gjessing C, et al. Information dissemination and use: critical 2004;23(2):717–25.