This is an excerpt from an April 2020 paper examining the role of Public Libraries as providers of Consumer Health Information

Introduction

Public libraries have evolved far beyond the cloistered rooms filled with book-lined shelves, card catalogs, and signs which prohibited eating and required silence. Today’s libraries are vibrant information hubs providing their communities with everything from meeting rooms, maker spaces, to computer labs. In addition to expanding their technology and information services,  many public libraries are establishing social work partnerships (ex: Long Branch Free Public Library) (Long Branch Free Public Library, n.d.).  Others are creating internet platforms like Health InfoNet of Alabama, which combines the resources of the state’s medical and public libraries, to provide residents with consumer health information (CHI). As Fallows  (Fallows, n.d.)  cited, public libraries have a history of being “second responders” by serving as coordination points and providing vital services and places of solace during natural and man-made disasters.

On April 9, 2020, the Public Library Association (PLA) released a survey that provided a representative sampling (28%) of how libraries are responding to the COVID-19 crisis. The study found that while the majority of libraries have closed their doors to the general public, most are continuing to serve their communities by providing Wi-Fi, expanding online services, adding virtual programming, using 3-printers to create PPE, and continuing to connect with their customers by chat, text, email, and phone (How Public Libraries Are Responding to the Pandemic, n.d.).  Also, more than 70% are using social media to share information about COVID-19 (How Public Libraries Are Responding to the Pandemic, n.d.)

This paper examines how public libraries are providing CHI to their communities during this COVID-19 Coronavirus Pandemic, and how they can  prepare themselves for future crisis events.

Why Public Libraries Should Be A Provider of Consumer Health Information

During a recent lecture,  Robert Shapiro (R. Shapiro, personal communication, March 4, 2020), Public Health Librarian, University of Kentucky Medical Library, shared that in his view, the most important thing about CHI is that it is the right information, at the right time.  This statement is never more valid than during a pandemic when CHI must be disseminated to the public to encourage their participation in efforts to prevent, contain, and recover from the health emergency. Vaughan (Vaughan & Tinker, 2009, p. 324) explains that the quality of the societal response to a pandemic depends partly on meeting the specific communication needs of diverse populations, especially those most vulnerable to the risks and most likely to experience communication gaps. The strength of public libraries is that they can bridge the digital divide in communities. Libraries can also reach vulnerable populations such as homeless persons, recent immigrants for whom English is a second language, and those who may need assistive technologies (such as braille or closed-captioned video). As Vaughan (Vaughan & Tinker, 2009) states, lessons learned from historical and recent public health crises suggest that inappropriate communications and insufficient planning can significantly compromise risk reduction and lead to adverse or deadly outcomes for vulnerable populations.   During a pandemic, communities need health information that is accessible, credible, and timely. Information seekers also need the “right information” for their reading level ( functional literacy),  and appropriate cues to action. (R. Shapiro, personal communication, March 4, 2020).

Spatz (2014) cites a 2013 study released by the Pew Internet and American Life Project that found that 72% of adults in the US used the Internet to find health information.  However, the study also showed that while overall 85% of American adults used the Internet, percentages varied between high school graduates (78%), those without a high school education (59%),  household incomes less than $30,000 year (76%), and only 56% for adults over age 65 years of age.  As the following chart shows, 70% of Americans have searched online for information about the COVID-19 coronavirus (NW et al., n.d.)

As Spatz (2014) cites, the use of CHI websites and tools require various levels of cellular or broadband internet access as well as a certain degree of health, information, and computer literacy.  These are all areas that can be addressed by public libraries.

The National Network of Libraries of Medicine cites the definition of “health literacy” found in the Institute of Medicine report, Health Literacy: A Prescription to End Confusion.” It is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (NNLM, 2020).    Health literacy requires a complex group of reading, listening, analytical, and decision-making skills, as well as the ability to apply these skills to health situations (NNLM, 2020).  Public librarians can direct customers to evidence-based knowledge resources and teach information seeking techniques and skills for using technology.

Spatz (2014, p. 58) recommends that librarians follow the guidelines established by the  National Library of Medicine and the Office of Disease Prevention and Health Promotion when developing or evaluating patient website information.  Both recommend that CHI resources be written at a sixth- or seventh-grade reading level to ensure that the information will be understandable to a large proportion of users. Materials should be organized as short, segmented pieces focusing on a limited number of concepts, avoid abstract or vague statements, and instead offer clear and executable instructions (2014, p. 58).

Librarians may also want to consider CHI, which uses infographics and comic-style illustrations. As Shapiro (personal communication, March 4, 2020) shared, while there are conflicting opinions about the benefits of graphical or illustrated health information, it’s generally accepted that the more formats you can provide information in, the better, especially if you’re trying to reach a population that might be averse to text.

Public libraries are also well positioned to provide information on community services, which may impact their customers during a pandemic. As Shapiro (R. Shapiro, personal communication, March 4, 2020) points out, “something like transportation needs or where to find temporary funding to get your electricity turned back on aren’t typically what we would consider ‘health information’ but we know now that the social determinants of health are equally as important as the health services that an individual receives.”

A Model for Developing a Strategy for Responding to the Public’s Need for Information During a Pandemic

In 2006 and 2007, researchers  Natalie Henrich, Ph.D. MPH, and Bev Holmes, MA, conducted a study in Vancouver, Canada, to evaluate the communication needs of the general public as well as health care workers during an emerging infectious disease outbreak. While this study was not designed as a guide for libraries,  it could be easily adapted by a library that wished to formulate a public health crisis response plan. The study is relevant to libraries for two reasons: a.) it provides insights into the type of health information that the general public looks from in a public health crisis as well as their preferred sources of information, and 2.) It provides a model for community engagement and involvement in pre-crisis planning.

Henrich (Henrich & Holmes, 2011, p. 610) explains that a crisis communication plan needs to be developed well in advance of an event because it is critical for saving lives and achieving an efficient resolution.  As the authors explain, during a health crisis, various subpopulations (such as the elderly, youth, persons with pre-existing conditions)  will have specific concerns and questions that warrant consideration during pre-crisis planning. During the pre-crisis phase, public health officials should engage the community in discussions to identify: the type of information members want to receive, whom they trust to deliver the information; and, how the information should be provided (Henrich & Holmes, 2011, p. 610).  Henrich (2011, p. 611) suggests that by involving the community in these types of pre-crisis discussions, there would be an increased receptiveness to the emergency communications and the probability of acceptance of control, prevention, and treatment recommendations provided by health officials.

The study consisted of eleven focus groups, comprised of between 8-10 participants, who were selected using a targeted sampling approach to represent sets of key populations within the Vancouver community (2011, p. 612).  The group employed a “decision-theoretic” approach to examine: (a) information needed to assess risk from an emerging infectious disease (EID);  (b) information required to make decisions about the use of new vaccines and drugs developed for a pandemic; and, (c) from whom people want to receive information and preferred methods of information delivered (Henrich & Holmes, 2011, p. 611).   Peterson (Peterson, 2011) defines “decision theory” as the theory of rational decision making where given a “decision-problem,” a decision-maker chooses what to do from a set of alternative acts, where the outcome of the decision depends on which scenario reflects the actual given. For example, applying decision theory to the current COVID-19 crisis, a focus group participant might have been various time frames from self-quarantining, or asks to choose between various experimental treatments.

Focus groups were scheduled at convenient times and locations for the participants, lasted approximately an hour and a half and were videotaped (2011, p. 613).  After the preliminary introductions, a group leader read a scenario describing a fictitious disease, asked questions and guided a discussion on  (a) perceptions of the risk as the disease moving out of the country of initial detection and arriving in Vancouver, and (b) concerns, questions, and attitudes about, and willingness to use, hypothetical new vaccines and drugs developed to prevent and treat the disease (2011, p. 613).

After the feedback was coded and analyzed, it was determined that:

• What people want to know about pandemics, and the drugs and vaccines used to combat them is:
  •  Who has been infected (socio-demographics, etc.), and where? How is it spread? How can I avoid infection?
  •  If I get infected, how sick will I get, and for how long? Can I die from this? And,
  • How effective and safe are the drugs and vaccines? What are the side effects? How has safety been tested, and how can you reassure me that safety hasn’t been compromised due to the pressures of the crisis? How do the risks of side effects and the unknown long-term effects compare to the risks from the disease?    (2011, p. 617)
• Almost all participants said that after learning about a health crisis from the news, they would go to more trusted and preferred sources for additional information such as a are their family doctors and the Internet. (2011, p. 615)

These results are not surprising and indicate that one of the roles that libraries can play during a public health crisis is to help their customers identifying credible sources of consumer health information.

Librarians Share Their Insights on Providing Consumer Health Information in a Public Library.

On March 27, 2020, I spoke with Kay H. Smith, MLS, MPH, regarding the evolution of Health InfoNet of Alabama. As she explained,  the 200+ public libraries in Alabama are the “front lines” because they have the most frequent contact with non-health professionals seeking health information. My question for was, how do you think public libraries should prepare their librarians for addressing questions about health reference resources, especially in light of the fact that many are downsizing their Reference Desks? 

“Staffing is definitely a concern for libraries of all types, perhaps especially public libraries. Another guiding principle behind the founding of Health InfoNet of Alabama was the recognition of the need for support on the part of public librarians fielding these questions at their libraries. The medical libraries in the state are committed not only to help in training public library staff in appropriately and knowledgeably responding to health questions but also to act as referral points for those questions that might require resources beyond their collections. I think, considering the fact that folks are going to seek help from their local librarians with these questions regardless, this training and backup are essential to supporting limited public library staffing.”  (K. H. Smith, personal communication, March 27, 2020)

On April 17, 2020, I had the opportunity to conduct an email interview with Harold Escalante, a Branch Manager for Charlotte Mecklenburg Public Library. I asked him to share his thoughts on ways that his branch could provide CHI to its customers.

“As a Library Manager what is important to me is not just the best way to provide credible health information safely to our customers but doing it in a way that is, above all else, done with the safety of staff in mind. Staff in public branches are very much at high risk because we deal with the gamut of people. Really the best, most immediate way to provide any type of library service is online through sources like online chat and virtual programming. I am grateful that during this time, our library system quickly brought back our online chat service. This was a service that we had discontinued because it was not being utilized but has since become essential.  Through online chat we have been able to communicate with customers and introduce many of them to the wonder of e-resources (H. Escalante, personal communication, April 17, 2020).

Conclusion

Due to a pre-existing relationship of trust with their customers,  public libraries can serve as a critical conduit of information to vulnerable communities during a public health crisis.  However, as Spatz (2014, p. 122) cites, librarians are not licensed to practice medicine and should not do so, even when patrons persist.   

The National Network of Libraries of Medicine (The Consumer Health Reference Interview and Ethical Issues | NNLM, n.d.)  explains that CHI questions present special challenges to the reference interview process:

• Consumers may have incomplete information about their health condition, or they are unfamiliar with medical terminology.
• The information needed may be about a sensitive health issue, such as a mental health or sexual health condition.  In the case of Pandemic, customers may fear stigmatization, job loss or other negative consequences. 
• The health concerns may be serious, life-altering, or life-endangering. In addition, the patron may be nervous, embarrassed, upset, and emotional. Often the individual or their loved one has been newly diagnosed with a condition.
• Consumers may have unreasonable expectations about the information available.  During an emerging pandemic, there is often limited or frequently updated information about a disease, its cause, and its treatment. 
• Consumers may be concerned about confidentiality, anonymity, and security, especially about personal health information transmitted electronically.  A homeless person may fear that a diagnosis of a disease will cause them to be evicted from a shelter, or an undocumented person may fear deportation. 
• Consumers may be confused about the role of the library staff. They might assume that the librarian can advise them on making health care decisions.
• Library staff may be afraid of providing the wrong answer to the health information question.
• Library staff may be concerned about providing negative information to the patron.

Because of the aforementioned concerns, public libraries will need to form strong partnerships with medical libraries and offer regular cross-training opportunities in medical librarianship. 

Works Cited

Escalante, H. (2020, April 17). The Role of Public Libraries In Providing Health Related Information [Email Interview].

Fallows, D. (n.d.). Public Libraries’ Novel Response to a Novel Virus—The Atlantic. Retrieved April 22, 2020, from https://www.theatlantic.com/notes/2020/03/public-libraries-novel-response-to-a-novel-virus/609058/

Henrich, N., & Holmes, B. (2011). Communicating During a Pandemic: Information the Public Wants About the Disease and New Vaccines and Drugs. Health Promotion Practice, 12(4), 610–619. https://doi.org/10.1177/1524839910363536

How Public Libraries Are Responding to the Pandemic. (n.d.). American Libraries Magazine. Retrieved April 23, 2020, from https://americanlibrariesmagazine.org/blogs/the-scoop/public-libraries-responding-pandemic/

Long Branch Free Public Library. (n.d.). Long Branch Free Public Library. Retrieved April 23, 2020, from https://www.longbranchlib.org

NNLM. (2020). Health Literacy Definition. National Network of Libraries of Medicine Initiative. https://nnlm.gov/initiatives/topics/health-literacy

NW, 1615 L. St, Suite 800Washington, & Inquiries, D. 20036USA202-419-4300 | M.-857-8562 | F.-419-4372 | M. (n.d.). Americans turn to technology during COVID-19 outbreak, say an outage would be a problem. Pew Research Center. Retrieved April 23, 2020, from https://www.pewresearch.org/fact-tank/2020/03/31/americans-turn-to-technology-during-covid-19-outbreak-say-an-outage-would-be-a-problem/

Peterson, M. (2011). Decision Theory: An Introduction. In M. Lovric (Ed.), International Encyclopedia of Statistical Science (pp. 346–349). Springer Berlin Heidelberg. https://doi.org/10.1007/978-3-642-04898-2_23

Shapiro, R. (2020, March 4). The Role of the Public Health Librarian [Class Lecture].

Smith, K. H. (2020, March 27). Preparing Public Libraries for Providing Consumer Health Information [Class Lecture].

Spatz, M., & Medical Library Association. (2014). The Medical Library Association Guide to Providing Consumer and Patient Health Information. Rowman & Littlefield Publishers. http://ezproxy.uky.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=777921&site=ehost-live&scope=site

The Consumer Health Reference Interview and Ethical Issues | NNLM. (n.d.). Retrieved April 22, 2020, from https://nnlm.gov/initiatives/topics/ethics

Vaughan, E., & Tinker, T. (2009). Effective Health Risk Communication About Pandemic Influenza for Vulnerable Populations. American Journal of Public Health, 99(S2), S324–S332. https://doi.org/10.2105/AJPH.2009.162537