Introduction

What is the definition of “good health,” and what does being “healthy” mean to the average layperson? How can public libraries and consumer health librarians assist patrons with finding vetted health information, at appropriate reading levels, on a variety of topics? What are some potential obstacles to finding and understanding health information at the layperson level and, ultimately, helping eradicate or lessen health disparities among the population of the United States in the 21 st century?

The role of the public library in making available and disseminating authoritative health information, at reading levels patrons understand and are comfortable with, is important because it supports, reinforces, and builds upon instructions patrons have received from their healthcare providers. Patient education and consumer health are not interchangeable concepts, but can complement each other and guide patients/patrons in making better, more informed healthcare decisions about medical conditions, medications, herbal supplements, and procedures, as well as referring them to appropriate support groups, both locally and nationally.

Patient education is usually performed in a clinical setting by a nurse educator who specializes in teaching the patient and/or the patient’s caregivers, in a systematic way, methods to improve their health outcomes. This, in turn, helps reduce hospital readmissions, now tied to pay-for-performance measures for federal reimbursement to hospitals. Typical topics include making sure patients understand their discharge instructions, adequate blood-sugar control, and proper use and dosages of medications upon leaving the hospital, as well as medication reconciliation to reduce errors, a Joint Commission national patient safety goal in 2005.

This patient education is carefully documented in the health record, on paper, or, increasingly, in the patient’s electronic health record (EHR). Many hospitals are using MedlinePlus Connect, a free service of the National Library of Medicine (NLM), National Institutes of Health (NIH), and the Department of Health and Human Services (HHS), to link patient EHR portals to consumer health information for ease of use by physicians and nurses right at the bedside, or point of care, with just a few clicks.

The New Hanover County Public Library (NHC-PL) in Wilmington, North Carolina, is among the approximately 200 public libraries in the U.S. with a designated consumer health library and a librarian who deals specifically with the community’s health information needs. New Hanover County is located in the southeastern part of North Carolina and serves a population of approximately 206,189 people, according to the U.S. Census Bureau, with 15.9% living below the poverty level.

The consumer health library is a full member of the National Network of Libraries of Medicine through 2016, and is a sublibrary within the main library’s branch in downtown Wilmington. The NHC-PL system consists of one main library and three satellite branches, serving a diverse population from all educational and socioeconomic backgrounds. The consumer health librarian also has access to the North Carolina AHEC (Area Health Education Center) Digital Library, paid for with an annual fee, giving access to MEDLINE® and other clinical databases. At this time, it is the only consumer health department within a public library in the state of North Carolina. The medical librarian has an MLS, the AHIP credential at the senior level, and the nonhospital, level-1 Consumer Health Information Specialization (CHIS) from the Medical Library Association (MLA) consumer health and patient information section, CAPHIS.

Patrons need not be library card holders to get assistance from the consumer health librarian, who answers questions by phone, email, and in person. As with clinical librarianship services, consumer health librarians perform literature searches, when applicable, and keep and report monthly statistics on the number of searches. Statistics are also kept on the number of contacts the consumer health librarian makes with the public when doing outreach.

There is a reference collection of core clinical titles in the consumer health library, access to subscription-based online medical encyclopedias, onsite and remotely, such as the Gale Health Series, and, through NCLive.org, North Carolina’s statewide online library service, access to CINAHL w/Full Text, Consumer Health Complete, and various nursing and allied health eBooks. The consumer health librarian also orders or prints out many free or low-cost materials from a variety of sources, such as MedlinePlus bookmarks, and materials from various health associations. Book-and-poster displays on thematic health topics are assembled on a bimonthly basis, both in the consumer health library and on a kiosk on the ground floor of the library.

Googling for Health Information

The evolving patient-centered care model has patients and patients’ families more involved in healthcare decisions. In the past, there was a more hierarchal model of top-down, doctor-knows-best flow of information from the clinician to the patient. Patients are more active now in researching health conditions, diseases, and medications, especially those advertised in magazines and the media, with a more diffuse, horizontal model emerging that incorporates the doctor, nurse, nurse practitioner, and the patient in healthcare decisions collaboratively.

The evidence-based medicine (EBM) model of healthcare, of course, includes patient values, along with best-evidence practice guidelines, and clinicians’ expertise. A better informed patient assists in the EBM care process, in tandem with the coordinated healthcare team.

According to the Pew Internet & American Life Project, patients hit the pay-for-access firewall when they simply Google for health information, as opposed to being steered to free, quality resources like MedlinePlus.gov, Health Finder (sponsored by the National Health Information Center), or PubMed Health-Clinical Effectiveness. PubMed Health has a “For Consumers” section under the “Contents” tab at the top of the page with easy-to-read summaries of clinical effectiveness research, both beneficial and harmful. PubMed Health is provided by the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM).

Statistics relating to the use of the Internet for health information searching reveal that 59% of U.S. adults have used the Internet to find information about health topics, with 35% going online to attempt to diagnose health conditions for themselves, friends, and family. Doctors, however, are still the primary source of health information.

The public is also now moving towards using mobile devices to search for health information, with roughly half of smartphone owners using their devices to search out health information. MedlinePlus has a mobile site for ease of use on these devices.

The Challenge of Low Health Information Literacy and “Plain Language” Initiatives

Pfizer’s website provides a useful online tool called the Prevalence Calculator, which can quickly assess what percentage of your, or a doctor’s, community may have difficulty reading and understanding health information. Low literacy rates in general, and low health literacy rates in particular, are not interchangeable concepts. Low health literacy, according to the Institute of Medicine’s (IOM) Consensus Report, “Health Literacy: A Prescription to End Confusion,” is described 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,” with 90 million Americans being unable to do so without some difficulty.

The Agency for Healthcare Research & Quality’s Report (AHRQ), “Health Literacy Interventions and Outcomes: An Update of the Literacy and Health Outcomes Systematic Review of the Literature,” outlines how the inability to understand complex concepts like proper medication dosages or instructions, unsurprisingly, leads to higher mortality rates and emergency room visits, flooding the U.S.’s overburdened emergency departments with nonemergent medical issues.

Americans who can function on a day-to-day basis with basic literacy skills may have low literacy reading comprehension with medical and health information (http://nnlm.gov/outreach/consumer/hlthlit.html#A3). There are options for patrons with lower than average health literacy levels, defined on the MedlinePlus Easy-To-Read page as a 5 th-to-8 th-grade reading level. Below are some helpful websites:

• Easy-to-Read Drug Facts – From the National Institute of Drug Abuse, information about drugs, addiction, recovery, and prevention in an easy-to-understand format.

President Obama signed the Plain Writing Act of 2010 (H.R. 946/Public Law 111-274) on October 13, 2010. The National Institutes of Health (NIH) have adopted plain writing to communicate health and disease prevention information, in a grammatically correct way, with accurate word usage and complete sentences. The NIH’s mission is to “reach all Americans with health information they can use, and to communicate in a way that helps people easily understand research results.” Plain language is not “dumbed-down” writing, but clear, concise writing that saves time and money.

For those interested in learning more, online training in plain-language writing is available at: http://plainlanguage.nih.gov/CBTs/PlainLanguage/login.asp

Providing Vetted Health Information

What can a public library and an experienced consumer health librarian offer patrons to support their values when it comes to their healthcare decisions? Vetted consumer health websites, preselected for quality, on the discrete page the library uses just for consumer health (the NHC-PL uses LibGuides). Other indicators of quality health websites are those with the Health On the Net (HONcode) certification. Created in 1995, the Health On the Net Foundation promotes the proliferation of online quality health information, and is a nonprofit institution accredited by the Economic and Social Council of the United Nations. This is a voluntary certification, and once a site is certified, it is given a regular check-up to ensure the quality of the information is upheld.

Also offered in the consumer health library is a core reference collection of clinical titles (online and hardcopy) and reviewed, “best-of” popular health titles, Dewey Decimal sections 610-618.92, and the critical appraisal skills and experience medical and consumer health librarians can bring to patrons wading through the plethora of information and disinformation available on the Internet. Sadly, the New York-based New York Online Access to Health (NOAH) website has now closed down, after 16 years of providing excellent online information, but MedlinePlus is recommended for use in its place. North Carolina has a GoLocal Health site. One watchdog website that deals with “quackery,” Quackwatch.com, is included as a recommended page on many consumer health web pages, as is the Medical Library Association’s Top Ten Most Useful websites, at: http://www.mlanet.org/resources/medspeak/topten.html

The Affordable Care Act and Patient Empowerment

The U.S. spends more, per capita, on healthcare than other industrialized nations; data from the year 2010, the most recent available, revealed that U.S. spending on health was 70% higher that healthcare spending in comparable countries, with little evidence that higher spending leads to better outcomes for patients.

With the passage of The Affordable Care Act in 2010, more Americans should begin to gain access to healthcare and, in theory, the need for consumer health information will grow. Especially important is making available the link to HealthCare.gov, which has information about what will change for consumers as the law is implemented through 2015.

Outreach and Community Partnerships

Increasingly, public libraries are bringing information and programming to the people, and embedding in their communities with a variety of cultural and educational outreach. At the NHC-PL, the consumer health librarian attends ongoing health fairs and other events, sometimes with New Hanover County divisions, bringing appropriate materials and marketing the consumer health services. The response is always positive, with patrons voicing appreciation that such a resource is available to them for their health information needs beyond doctors, nurses, and pharmacists. Many patrons are comfortable approaching their local public library with their queries first and then, armed with information provided by the library, feel they can make better informed decisions and have meaningful discussions about their care with their doctors or nurse practitioners.

Other potential outreach opportunities for libraries are having a presence at the annual American Cancer Society’s “Relay for Life” event held around the U.S.; working with schools, farmers’ markets and local-food initiatives, veterans’ health fairs, and the LGBT community.

The NHC-PL also does a great deal of programming, including having health education speakers come in to speak on popular topics, such as keeping New Year’s weight-loss resolutions, handling the stresses of the so-called “sandwich generation,” who are caring for aging parents and their own children, and end-of-life planning. Speakers have included RNs, doctors, psychologists, and social workers. Potential outreaches may include a health fair, working with the local county health department for basic screenings.

Librarians must make it clear that they can make no diagnosis or treatment recommendations, but they can give information to patrons to take to their providers for further discussion. There is a clear written disclaimer on the front page of the consumer health web page spelling this out and recommending that patrons discuss any concerns with their doctors or other healthcare providers.

Conclusion

Good health can mean different things to different people, and consumer health librarians can aid in the search for better health by making the process of finding quality information easier, quicker, and more transparent. The first-century BC Latin writer, Publilius Syrus wrote, “Good health and good sense are two of life’s greatest blessings.” We, as consumer health public librarians, can provide our patrons quality, sensitive, confidential health information at a reading level they can understand, thus empowering them to move within the U.S.’s complex healthcare system easily and with more confidence so that their holistic health needs are met.

References

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Collins, L., & , (2013). Dr. google? americans go online for health info, but pew says doctor still primary . Retrieved from Deseret News website: http://pewinternet.org/Media-Mentions/2013/Dr-Google.aspx

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Fox, S., & Duggan, M. (2013). Health online 2013. Retrieved from Pew Internet & American Life Project website: http://pewinternet.org/Reports/2013/Health-online.aspx

Glassman, P. National Network of Libraries of Medicine, (n.d.). Health literacy. Retrieved from website: http://nnlm.gov /outreach/consumer/hlthlit.html

Health on the net foundation . (2011). Retrieved from http://www.hon.ch/

National Institutes of Health, (n.d.). NIH plain language training. Retrieved from website: http://plainlanguage.nih.gov/CBTs/PlainLanguage/login.asp

National Institutes of Health, U.S. National Library of Medicine. (2013). Easy-to-read medlineplus. Retrieved from website: http://www.nlm.nih.gov/medlineplus/all_easytoread.html

National patient safety foundation . (2013). Retrieved from http://www.npsf.org/for-healthcare-professionals/

Prevalence calculator . (2012). Retrieved from http://www.pfizerhealthliteracy.com/physicians-providers/PrevalenceCalculator.aspx

U. S. Department for Health & Human Services, Agency for Healthcare Research & Quality. (2010). Health literacy interventions and outcomes: An update of the literacy and health outcomes systematic review of the literature. Retrieved from website: http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=392

U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality. (2012). Medication reconciliation. Retrieved from website: http://www.psnet.ahrq.gov/primer.aspx?primerID=1

U.S. Department of Health & Human Services, National Institutes of Health. (2012). Clear communication: A nih health literacy initiative. Retrieved from website: http://www.nih.gov/clearcommunication/plainlanguage.htm

United States National Academies, Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Retrieved from website: http://www.iom.edu/Reports/2004/Health-Literacy-A-Prescription-to-End-Confusion.aspx