Developing information services to promote evidence based practice in Norway: the librarians role in multidisciplinary teams.

Lena Nordheim & Sigrid Gimse
Research Librarians
National Institute of Public Health
Oslo (Norway)

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The HELSKO project was established spring 2000 at the Dept for Population Health Sciences at the National Institute of Public Health in Norway (1). The targeted groups of the project are the child health centres of Norway. The staff at these centres in Norway consists of health visitors/nurses, sometimes a midwife and a child physiotherapist, and some days of the week a GP. These centres are responsible for immunisation, screening and preventive health care for mothers and children, as well as counselling. Some of them are focused solely on adolescent health.

The school health service in Norway is also a target group for the project and consists mainly of the same groups of health personnel.The staff have up till now had little access to research-based information and library services. Computer literacy hasn't been crucial for delivery of the services they have given up till now, but things are changing. Some centres now do the registering of the child health records on PC, and this will soon set a standard throughout the country and will clear the way for PC's as a matter of course.

Another pilot project also initiated by the Norwegian Board of Health is now running. This project tries to broaden the access to professional secondary services of support for these centres in eight rural Norwegian municipalities. A consequence of this work has been the provision of computers and access to the Internet. Part of this project directs itself to help the staff with access to good information on the net as well as to connect them together in a professional network. This project is not staffed with a librarian, thus I have been responsible for teaching and advising the pilot project group about the practice of EBHC and about utilisation of the Internet. I am also a member of their steering board. The results and methods of this project are to be evaluated for implementation nation-wide.

The HELSKO project tries to meet the new needs and challenges that have arisen. We are providing the targeted health personnel throughout the country with good research based health information in order to enable them to make more informed decisions. We see the need for training them in net literacy as well, because it's a stepping stone to accessing EBHC resources in general. The project team at present consists of a public health doctor, physiotherapist, midwife, health visitor/nurse and librarian. We undertake this education through a website, which has been the librarian's foremost responsibility. The site focuses on evidence based practice. On the website health personnel have access to Norwegian information about the principles of EBHC; how to practice it, the different steps, with examples from their daily practice. We also provide links to external resources like the Centre for Evidence-based Child Health in London and other evidence based child health resources. In addition the website contains relevant Norwegian governmental information and some health regulating laws and guidelines, for the sake of training them in using the Internet. We also facilitate some relevant electronic journals, both primary and secondary.

We network the staff throughout the country together in three different discussion lists accessible from the website. One for health visitors, one for physiotherapists, one for midwifes. The different team members have different tasks. The midwife is responsible for drawing attention to good midwifery research articles, new relevant systematic reviews. In some cases critical appraisal of interesting new studies is undertaken on the discussion list for the purpose of teaching these skills to the list members. The librarian maintains an alert service to draw attention to new relevant Cochrane reviews of particular relevance for child health personnel. 

The project group has all been taking part in the courses given by the CASP International in Oxford (Critical Appraisal Skills Programme) in order to enable ourselves to teach Norwegian health personnel about the different steps of EBHC. In addition we keep going continuos internal workshops in critical appraisal of RTCs, systematic reviews and other study designs. 

The project team publish a newsletter, where the librarian takes part on the editorial board as well as publish the electronic version on the website. The letter focuses on good clinical practice, how to find and appraise research, and issues in child and adolescent health. We also have some self training material on the website on how to search PUBMED, and we will develop this more in the future.

The project group offers short EBHC courses. The courses include sessions on how to ask answerable questions, critical appraisal skills and implementation. The librarian takes part in all this, as well as running workshops on finding the evidence in Cochrane, PUBMED and some other internet resources. The short courses are widely asked for and most of them have a multidisciplinary approach. 

Our goal is that these health care workers soon will be proficient in the practice of EBHC, but we experience that they have long way to go before they reach this target. All the same we hope to spur and challenge them into this kind of practice by our combined efforts, and we also see that the project bears fruit. In one municipality near Oslo they have started their own CASP groups and is continuing independently from us. That is what we hope to obtain in the long run; cascades that will reach even further into the health communities of Norway.

Towards an evidence-based public health: information services for public health physicians 

The project Towards an Evidence-Based Public Health started in 1996 and finished December 2000. The main purpose of the project was to educate and stimulate public health physicians to make better use of medical knowledge, i.e. to implement evidence-based public health practice.

The early stages of the project investigated the practitioners' use of scientific information, the potential for using this type of information and the barriers against its use (2, 3). The last stage involved an intervention tailored to reduce the barriers identified. The intervention consisted of a multifaceted package containing the following components:

1) short courses on the principles and practice on evidence-based health care:

a) question formulation

b) information seeking skills 

c) critical appraisal

d) how to use the information in the local setting

2) access to relevant databases, such as The Cochrane Library and Medline

3) web pages containing educational materials, reports of summarised evidence, references to systematic reviews of particular relevance to public health and links to other sources of information on evidence based practice

4) a questions-and-answers service

5) newsletter

6) an e-mail discussion list

To develop and maintain the information service a multidisciplinary team was established, in which the team members participated/worked on a full- or part-time basis. In addition to the project leader and advisor, the team consisted of three public health doctors, a physiotherapist and a librarian. The librarian contributed to the different parts of the service, but was especially involved in supplying the questions-and-answers service and the development of the web pages. In the following these two components will be described more thoroughly.

 The question-and-answers service

To help public health physicians make use of scientific information a question-and-answers service was established. The q-and-a service could be compared to an extended library help desk, where not only literature searches were performed on a specific request, providing the user with references to potentially relevant articles. Additionally the evidence, if available, was critically appraised and summarised in a small report. The public health doctors were encouraged to pose questions to the project's discussion list. They also had the possibility to contact the librarians by phone or e-mail. In Norway the public health physician functions as the municipality's professional health counsellor in several different types of cases, which in its turn means that questions arises in a broad range of categories: environmental health issues, communicable diseases, effect of preventive and therapy interventions and organisation of health services. To be able to answer all questions different strategies were developed for the different categories. For questions about the effect of health care interventions or organisation of health services we conducted a literature search in a predefined set of databases. If good quality evidence was available a small report was written on the subject. Questions about communicable diseases or environmental issues were mostly forwarded to the Department of Bacteriology or the Department of Environmental Medicine respectively. If manageable, an additional literature search was performed in selected databases. There were mainly two reasons for using different strategies:

  1. Lack of resources. In spite of the modest number of questions received during the intervention period it was impossible to answer all of them writing reports. Most reports were written by one of public health doctor in the team, but the physiotherapist and librarian contributed to the writing process as well
  2. Lack of evidence. In some public health issues, in particular within the area of environmental medicine the supply of good quality evidence is more limited. Although using a predefined set of databases, searching for relevant evidence appeared to be much more time consuming and difficult.
The web pages

The research librarian had the main responsibility for developing and maintaining the web pages. The web pages consists of information about the project and important learning and information resources. In the following the main elements of the web service are described:

Evidence based learning tutorial

An introduction to the different steps of practising evidence based health care. 


Information about the library services


Access to relevant databases, i.e. Cochrane Library and Medline. 

Systematic reviews

Systematic reviews from the Cochrane Library considered being of particular interest and relevance for public health physicians. The reviews are organised into broad categories, i.e. 'Prevention and health promotion' and 'Psychiatric services' 

Questions and answers

All questions received from the public health doctors during the project period. Reports written by the project team can be found here

In focus

Larger reports about specific topics of particular interest for the larger groups of public health doctors. 

Other resources

Web resources elsewhere, mainly other evidence-based resources

Ongoing activities

The two projects described are now merging and the services will be offered to community health personnel in Norway on a permanent basis. We are now in the process of formulating a strategy for the extended project team.


1. Reinar L. Teaching EBHC to community health workers. Nordic EBHC newsletter 2000; 5: 20
2. Forsetlund L. Bjørndal A. Har samfunnsmedisinere tilfredsstillende tilgang til viktige informasjonskilder? [Do public health practitioners have satisfactory access to important information sources?]. Tidsskr Nor Laegeforen 1999; 119(17): 2456-62
3. Forsetlund L, Bjørndal A. Towards an evidence-based public health: a randomised controlled trial. Proceedings of the 8th International Congress on Medical Librarianship. London 2nd-5th July 2000.