In this section I present the research approaches I used, along with the HISP India team.
Action research
During the fieldwork I was part of the HISP team, which applies action research approaches in their attempt to develop a IS, which may eventually improve health services to the poor and marginalized. HISP seems to fall into the ‘Southern’ tradition of action research (ref. section 4.1.1), although it is difficult to categorize HISP as it expands to different countries with different contexts and different levels of participants.
The action research approach relates to e.g. the participatory design of Minimum dataset, prototyping and different on-site training methods. We had the health workers enter health data into the system, which we then analysed and presented to the Department of Family Welfare. The
information need was defined through interacting with the users in workshops and meetings.
The HISP India team
The HISP team in India during my stay existed of Trude Larssæther, Jørgen Darre and Maria Røhnebæk, my co-students at University of Oslo (UiO), Zubeeda Quraishy, an Indian anthropologist, Usha Srinath, an Indian medical doctor and Jørn Braa (Norwegian) and Sundeep Sahay (Indian), ISs professionals at UiO. The team was towards the end of my stay supplied with two more students from UiO and one Indian informatics professional.
Both professionals from UiO have several years of experience in implementing and studying the use of ISs in various global contexts, especially with a focus on health. The medical doctor was responsible for medical related issues, like the minimum data set and the data dictionary.
The anthropologist is the program coordinator of HISP India, while Braa is the project coordinator of HISP international. Trude and my role were to get involved as much as possible in the HISP project, mostly by conducting training and helping with initial implementation of the system. Flanked by this involvement, we naturally acted as researches as well. As we had knowledge of DHIS we acted as professionals and advisors, but worked closely with the stakeholders involved in the project.
As part of the HISP team I took part in all actions involved in developing the HIS Project. I participated in meetings and discussions with different stakeholders, and within the team, more informal meetings and talks.
Working in a team gave me several advantages, like access to meeting reports, letters and summaries. The fieldwork implied a great amount of travelling around to the different health facilities and stakeholders. After leaving the fieldwork, I still conducted meetings and discussions with the HISP team through mail and meetings in Norway.
Most of the people I met were excited about the fact that we were foreigners and came all the way to India to work on the project. They were eager to talk with us, but we had sometimes problems concerning the language. The project was situated in a small town in a rural area, where most people did not have much education, and had poor knowledge of English.
The training process
Referring to action research, the researchers and the stakeholders interact and work closely together to define and solve the problems. We were part of the second training program attended by the health staff. HISP hired a computer education centre to support the training. Before the training program started, the hired staff attended several days of training by the HISP team.
In addition to the classroom training, many on-site training sessions were performed. Having a background in informatics and not health, it was necessary for us to learn the meaning of the data elements and how they were intended to be used. The team consisted of a doctor who knew the terminology, but the actual use and understanding of the data elements had to be taught to us by the health workers. This mutual learning was important in levelling out the “differences” between us, the researchers, and the local users, with whom we aimed at collaborating with on “equal” terms. This training took place during workshops, in the primary health centres or wherever we met the Multipurpose Health Worker (female), or field worker, which I have labelled them, who collected data.
Data collection
When the computers had been in use for some weeks, we made the health workers enter health data, which they had collected for the previous year into the computer. I finished my field work before the data entering was finished, but another student working in the HISP team brought home a CD with the data, which we have analyzed together in Chapter 8. We have used both a quantitative and qualitative method. Examples of qualitative aspects was to go back to the primary health centres, present the data, and together with the staff try to understand the result of the data analysis. The analysis is based upon numbers, but we also try to understand the outcome in relation to the social and institutional context.
Observations
Going around to the different health centres and observing the health workers was very useful. The HISP team paid frequently visits to the primary health centres, usually unannounced. This gave us the opportunity to check whether the computers were in use, and by whom. Most important, I got to see how the health workers used the computer, and the progress in learning how to use it. Observing the trainers was also useful in order to see how they performed the training. We were also allowed study data registration forms and reports at primary health centres.
Interviews
I conducted a number of informal and semi-structured interviews of health workers and some more formal and more structured interviews of the HISP team members in India and other participants of HISP international. These interviews enlightened issues that were unclear, both concerning the work of HISP, but also matters of the team itself. Considering that several of the members had worked with health in developing countries for numerous years, the interviews provided us with highly valuable information.
Interviewing health workers was done in an informal manner, often when they dropped by the health centres in between their fieldwork. The language was a hindrance, which sometimes resulted in short and limited answers.
Our presence, knowing that we were part of HISP, seemed to influence the answers they gave. Indians are known for respecting higher authorities, and the fear of insulting someone might have affected the answers the health workers gave. Having informal conversations felt more natural and valuable than performing interviews.
Number of interviews; field workers: 16, HISP members: 5, Officials: 4 Questionnaires
During the period I spent in Kuppam, we carried out two surveys by means of questionnaires. The first was an evaluation of the three day training program, which the health staff had attended. This was handed out at the end of the training and included questions regarding the training, the software and how they felt about the computerization of the primary health centres. English is the secondary language in India, but many of the health workers do not speak or read it very well, or not at all. The participants were therefore given a choice of answering in English or their local language, Telegu.
The second questionnaire contained open-ended questions and was handed out after the system had been in use for a month. This was not only meant as a follow-up, but as an opportunity to also reach the health workers who did not attend the training program, but still used the software. I felt this was a good opportunity to receive feedback, since the health workers were mostly on fieldwork, and not present at the primary health centres. The trainers stayed there the whole day, and the staff dropped in occasionally during their fieldwork. If I would interview the users myself, I would have to stay at one primary health centre the whole day, and maybe be able to perform one or two interviews. Being eight primary health centres, and health workers dropping in at unscheduled times; this would take too much time to carry out since the process took place for approximately one month.
Literature and other sources
We worked in the rural area, Kuppam, and access to facilities, like libraries, computers and Internet, was poor. Most of the information we got hold of was in paper form that we only could borrow and copy. There were a few Internet cafes in the town, but using the Internet was a trial of patience. The site went down, you could not get it up in the first place, or the power was cut. Either way, Internet was the best way to communicate with the other HISP team members, because of the high frequency of travelling. It was also the only way of sharing experiences with other HISP members in the world. When implementing the software, we especially needed support from people situated in South Africa. Internet has also been helpful when writing the thesis. The Internet provides several informative sites on India, Andhra Pradesh and health information, i.e. the Indian census.
During this study, a rather extensive literature study has been performed. It has been absolutely necessary for our understanding of the context and to gain background knowledge. The literature consists mostly of academic books and articles, but also papers and folders that we got our hands on during the fieldwork. The topics of the literature range from HIS and developing countries to organizational change.
Possible misinterpretations of my own data
When interacting with other persons there are always possibilities for misunderstandings and misinterpretations. Working in a different cultural, social and political context, made me especially aware of these risks. I will say that the language was the most obvious obstacle; both because many of the health staff were poor in English, and concerning the answers in both questionnaires. My connection to the HISP may also have influenced their behaviour and answers. Responding on the evaluation of training at the very same day as the training program where we were present might have influenced the answers the participants gave. Although, that we were foreigners might also be an advantage; we are outsiders, which may have reduced any possible political and hierarchical constraints towards us.
5 Health Information Systems Programme - HISP
This chapter gives a background of the project I have worked within, the Health Information Systems Programme (HISP).