Factors affecting the provision of consumer health information in public libraries: the last five years.

ABSTRACT

BETWEEN 9000 AND 2005 SEVERAL CHANGES have created an impact on libraries that provide consumer health information to the public. They include increased Internet connectivity; quality and amount of consumer health information available; realization that American lifestyles are leading to health problems; maturation of the consumer health movement and greater acceptance of it among health care professionals; emphasis on health literacy; and September 11th. Some changes were notable in 2000 but remain issues for providers of consumer health information. They include the number of health news items available in all media; the aging baby boomers and their impact on health care financing; less time for physicians and nurses to provide health information and patient education during regular office visits; and the popularity of complementary therapies. The impact of these issues on the provision of health information in U.S. public libraries is discussed.

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In 2000 this author published an article entitled "Starting a Consumer Health Information Service in a Public Library" (Gillaspy, 2000). The present article expands on the basic information provided in the original document, noting especially what has and has not changed in the intervening five years that potentially affects consumer health information in the public library setting.

Walter Broadnax, who in 1995 was the deputy secretary of the Department of Health and Human Services, stated that families in 2015 will be health literate, by which he meant, "They make informed decisions about health issues. They understand the link between behavior and health.... We have a moral imperative to make health information available to every American" (Broadnax, 1995; italics mine). Fulfilling such a goal demands that public libraries be part of the network of health information delivery, and the phrase "moral imperative" implies urgency. However, in too many communities, public libraries are struggling with slashed budgets, reduced staff, and competing priorities. How can they meet yet another demand?

The truth is that as many as 20 percent of reference requests received by a sample of public libraries in the late twentieth century were health related (Wood et al., 2000), and that number may be far less than the actual total of people who search on their own rather than request reference assistance. Public libraries are critical to diminishing the "digital divide" in the United States; since in 2004 a full 95 percent of public libraries in this country offered Internet access. Significantly, 80 percent of library systems in the United States are located in rural areas, where access to quality health information might be limited without online systems. To illustrate how rapidly public libraries have become wired, only 28 percent of systems had Internet access in 1996 (Bill and Melinda Gates Foundation, n.d.), compared to the near-total access only eight years later. In other words, public libraries are meeting challenges, especially for economically disadvantaged citizens. The Gates report states that families with incomes of less than $15,000 per year use computers in public libraries at rates two to three times greater than families with annual incomes of more than $75,000 (Bill and Melinda Gates Foundation, n.d.).

This being said, there is little doubt that public libraries can enhance their consumer health services. An examination of trends and events that impact consumer health information (CHI) services in public libraries can elucidate areas where enrichment or improvement might occur.

WHAT HAS CHANGED IN THE PAST FIVE YEARS, AND WHAT Do THE CHANGES MEAN FOR PUBLIC LIBRARIES?

Seven trends or events have occurred between 2000 and 2005 that significantly impact the delivery of consumer health information in all settings, but particularly in public libraries, the institutions most invested in serving the information needs of all citizens in a community. These items include the following: (1) increased access to the Internet; (2) increase in the quality of health information available on the Internet; (3) realization that American lifestyles are leading to serious health problems, even in the young; (4) maturation of the consumer health movement; (5) increase in high-quality print resources for consumer health; (6) emphasis on health literacy; and (7) September 11th. Certainly other factors could be listed as having had an impact, but these seven are notable for the breadth and depth of change that has occurred because of them.

Increased Internet Connectivity and Access

Many more people have access to the Internet in their homes than was true five years ago; moreover, the Internet is far more ubiquitous in society generally than it was at that time. In a 2003 report the Pew Internet Project reported that 93 million Americans, comprising 80 percent of adult Internet users, had used the World Wide Web to search for health information (Fox & Fallows, 2003). This is a change from the 52 million Americans who had relied on the Internet to make health decisions in 2000 and the 73 million in 2002 (Fox & Rainie, 2002).

These data are contradicted, however, by a study from the Center for Studying Health Care Change. These researchers, who conducted a survey of U.S. households in 2001, found that 62 percent of American adults sought no health information at all, from any source, during the previous twelve months. Of the 38 percent who indicated they had searched for health information, a mere 16 percent of them used the Internet as their source. (They preferred books, periodicals, friends, or family members as sources.) Moreover, this group was overwhelmingly young, female, and well educated (Tu & Hargraves, 2003). The authors of the report note that these results portend "significant challenges ... ahead in educating consumers about trade-offs among the cost, quality and accessibility of care" (Tu & Hargraves, 2003, p. 1).

Where does the truth lie? In fact, in terms of providing consumer health information in public libraries, it may not matter. Adults learn at the point of need, when learning is relevant to their life situation, and certainly health issues become pertinent to almost everyone at some point in their lives. Of the Internet users who do search for health information, the implication for services in public libraries is clear: computers with fast, reliable Internet access must be available for citizens who do not have personal computers or online access in their homes, who prefer anonymity, or who need professional guidance in using a computer or accessing quality information.

Quality of Information

The quality of Web-based health information is arguably much higher than it was five years ago, and it is also easier to evaluate and use. However, just because evaluation tools are more obvious and usable, it does not follow that users pay attention to items such as the authority of the source and the currency of the information. In fact, the report Internet Health Resources states that fully half of health information seekers check authority and timeliness "only sometimes," "hardly ever," or "never" (Fox & Fallows, 2003, p. 32). The Medical Library Association (MLA) posted the "Top Ten Most Useful Web Sites" for health consumers in 2002 (MLA Net, 2004). The Web abounds in authoritative, excellent health information, and educated consumers have learned to look for such signs of quality as the HONcode, assigned by the Health on the Net Foundation; (1) federal government, academic medical center, or nonprofit organization sponsorship; and similar imprimaturs of quality. Public libraries can help point their users to authoritative, reliable sources by linking to MLA's "Top Ten" page or directly to the recommended sites themselves, as well as to others that are appropriate for local needs. They can also offer classes to help users learn how to evaluate Internet information or provide Web-based tools for imparting standard protocols for judging the worth of the information they find.

Health Effects of American Lifestyles.

The Healthy People 2010 initiative lists ten leading health indicators that are being used to measure the health of United States citizens over ten years. At the top of the list are physical activity and overweight and obesity (Healthy People 2010, n.d.). Other lifestyle factors, such as tobacco use, substance abuse, and responsible sexual behavior, follow the first two. Although health care professionals and both private and government programs have targeted physical activity and weight management in the past, these issues have received far greater attention in recent years, perhaps because of the growth of obesity in the young. "Youth Risk Behavior Surveillance: United States, 2003" illustrates both the nutrition and the exercise issues: in the week preceding the survey, only 22 percent of high school students had eaten five or more fruits and vegetables per day. Moreover, fewer than two-thirds of high school students had participated in vigorous or moderate physical activity in the week preceding the survey (Centers for Disease Control and Prevention, 2004). The American Academy of Pediatrics notes that the "prevalence of overweight and its significant comorbidifies in pediatric populations has rapidly increased and reached epidemic proportions [and that] prevention of overweight is critical, because long-term outcome data for successful treatment approaches are limited" (Krebs &Jacobson, 2003, p. 427).

Adults are significantly affected as well. Evidence of the deleterious effects of poor lifestyle choices in the area of nutrition and physical activity may be observed based on many factors, including the addition of the medical subject heading (MESH) Metabolic Syndrome Xin 2002. This newly recognized syndrome is characterized by any combination of insulin resistance (a MeSH heading only since 1996), hyperlipidemia, hypertension, obesity, noninsulin-dependent diabetes mellitus, and increased risk for adverse cardiovascular events such as stroke or heart attack.

What does this mean in the context of public libraries? The implications for collection development are obvious. Additionally, programming for children and adolescents can include positive health messages, and parents who search for information on how to help their children and teens cope with issues of weight management, healthy eating, and exercise should be able to find current resources in their local public libraries.

Consumer Health Movement Matures

Another feature of the past five years is that the consumer health movement has become more mainstream and more accepted within the medical community. Indeed, increasing numbers of physicians communicate with their patients via e-mail, though this trend is far from including a majority of physicians, who in the main are reluctant to venture into such potentially risky territory. Moreover, not all consumers are interested in having any portion of their personal medical information online, even within "secure" Web sites, since the danger of its being misused is certainly present.

An article in the Oncologist features statements by both a medical oncologist and a thoracic surgeon about the use of e-mail with patients, which they both view as a positive development, if it is used appropriately. The oncologist notes, "As we negotiate the future of communication, it's not a question of whether you want to communicate with people by e-mail, it's a question of how" (Penson, Benson, Parles, Chabner, & Lynch, 2002, p. 561). The surgeon explains his belief in the positive nature of e-mail communication with patients by saying, "It requires some participation by the patients in their care, which is very important" (Penson et al., 2002, p. 561). Both BMJ ("Best Treatments," since 2004) and the Annals of Internal Medicine ("Summaries for Patients," since 2001) now include special features that interpret the results of key treatment studies for patients. BMJ features a "click through" to relevant points in the actual article, should a consumer wish to explore a topic in depth. These tools complement the JAMA Patient Pages, which have been a staple of that journal since 1998.

Not only are some physicians communicating with their patients via e-mail and personal Web sites, but consumers are also actually seated at the table in some health decision-making scenarios. For example, the Cochrane Collaboration, which is an international organization that "produces and disseminates systematic reviews of healthcare interventions" (Cochrane Collaboration, 2004) and their effectiveness, and is a key player in the move toward evidence-based medicine, has included a consumer component since its inception in 1993. CCNet--the name of the Cochrane Collaboration's consumer network--has members in more than fifty countries. The collaboration encourages all Cochrane groups to include consumers in their deliberations and communications, partly so that research topics that are important to the general public but get overlooked by the health professionals are identified and that outcome measures that are important to laypersons are noted (CCNet, n.d.). Entwistle, Refrew, Yearley, Forrester, & Lamont wrote about the advantages of involving consumers in health research, noting that lay people's views can be identified through reading what they have written about specific health topics; consulting through surveys, focus groups, and related formats; conducting consensus conferences with consumers; integrating consumers into the assessment phase of research study proposals and reports; and including health consumers on working groups (Entwistle et al., 1998, p. 465).

In England the "expert patient program" has been in existence since 2002 (About expert patients, n.d.). Here laypersons are trained to become partners with their physicians in managing their own health. The goal of the training is to develop "the confidence and skills to improve quality of life and work in partnership with health professionals" (Shaw & Baker, 2004, p. 723).

Many other examples of these types of consumer inclusion exist. The examples illustrate the international nature of the consumer health movement and how it has become a part of health care entities as it has matured. Once again, public libraries have an opportunity to expand services to this population, which currently comprises a "minority of patients who have the resources [and will] to find out about their illness and ... take an active part in managing their own care" (Shaw & Baker, 2004, p. 724). Not only do consumers like these, many of them dealing with a chronic condition, require a computer and the Internet, they also require medical textbooks to acquire in-depth knowledge of specific conditions and treatment options. Public libraries with an array of levels and formats in their consumer health collection, including the current editions of key medical texts, will be able to serve this population. The public library is the place that most of these consumers will use, since many of these people are located in rural areas and otherwise have little access to medical textbooks.

Quality of Print Materials

The fourth change has to do with print resources available in lay language. While some of these materials have been available for many years, the quality and choice has expanded greatly in the past half decade. The first edition of the Gale Encyclopedia of Medicine (Longe, 2001) was published in 1999; the second edition has been available since 2002. Following the success of this excellent consumer health resource, Gale Group published a number of other works, including the Gale Encyclopedia of Alternative Medicine (Krapp and Longe, 2001), the Gale Encyclopedia of Cancer (Thackery, 2001), the Gale Encyclopedia of Genetic Disorders (Blachford, 2002), the Gale Encyclopedia of Mental Disorders (Thackery, 2003), and the Gale Encyclopedia of Surgery (Senagore, 2004). The first edition of the consumer version of the Merck Manual was published in 1997; the second edition appeared in 2003, and it is available on the Web (Beers, 2003).

Two consumer health series that are particularly notable for their format, accuracy, and helpfulness are O'Reilly's "patient-centered guides" (the first titles appeared in 1999), and Marlowe's "first year," which began publication in 2003. A group of outstanding books whose titles begin with Mayo Clinic on ... also began publication in 1999. Though they are not listed as a series, they are recognizably the same in format, accuracy, and currency. Other good print resources exist as well, but these examples represent some of the finest available, and the majority of them have appeared since the year 2000. Public libraries, especially those in rural areas, should own as many of these works as the budget allows and their client base demands.

Emphasis on Health Literacy

A fifth trend that has dramatically changed the landscape of consumer health information is the emphasis on health literacy, which stems from the alarming rate of functional illiteracy in the United States. Widely considered the most statistically valid and reliable data set of its kind, the massive National Adult Literacy Survey (NALS) of 1992 reported that between 40 and 44 million Americans functioned at the lowest level of literacy (level 1) and are able to engage in only the most rudimentary tasks requiring reading, writing, and computational skills. For example, while people in this group can sign their names and add up a bank deposit entry, they cannot find an intersection on a street map or enter information beyond their name on a social security application. Though 15 percent of the total level 1 group were born in another country, and 5 percent had documented learning disabilities, all the rest were lifelong residents of the United States and, presumably, passed through some portion of its public school system (National Institute for Literacy, n.d.).

Functional health literacy is defined both as "the ability to understand basic health care communications, such as prescription instructions and insurance forms" (American Medical Association, 2003) and as "the ability to read, understand, and act on health information" (Andrus & Roth, 2002, p. 283). Even the most basic health information is generally much more difficult to read and interpret than a street map or a simple form. As early as 1980 JAMA published the results of a study that compared informed consent forms from five national cancer clinical trial groups for readability and concluded that "informed consent documents may not be understood by a substantial portion of patients who sign them" (Morrow, 1980, p. 56). By 2004 the Institute of Medicine had quantified the number of people who "have difficulty understanding and using health information" (Institute of Medicine of the National Academies, 2004) as 90 million people, or nearly one half of all adults in the United States. The grave effects such poor literacy can have on patient compliance with treatment plans, let alone simply understanding their diagnosed disease or condition, is both obvious and well documented.

Public libraries can make a significant impact on improving this situation in two ways. First, they can include easy-to-read health materials in their collections, perhaps through linking to quality Web sites like the National Institute of Digestive, Diabetes, and Kidney Diseases (NIDDK). In May 2004 the front page of this Web site (http://www.niddk.nih.gov/) contained a prominently placed link to twenty-three "Easy-to-read Publications" about such common topics as hepatitis, peptic ulcer, and diabetes. Healthfinder (http://www.healthfinder.gov/), a particularly simple site to use, can be searched for "easy-to-read" and has the advantage of linking to information that is not limited to certain diseases or body systems. The health topics page on MedlinePlus (http://www.nlm.nih.gov/medlineplus/healthtopics. html) includes a link to easy-to-read pages as well. Even if print materials for adults with low literacy cannot be obtained because of budget constraints, the Internet offers viable alternatives, at least for common problems, and many of the pages are available in both English and Spanish.

A second way that public libraries can address the health literacy crisis in the United States is through continuing adult literacy programs. Many other agencies besides public libraries offer literacy programs, especially in urban areas; however, the public library is ideally the prime advocate for literacy and learning in a community. A U.S. Department of Education report from 2002 states that 17 percent of all public libraries offered some sort of literacy program conducted by their staff and using their resources. The larger the library, the more likely it was that they would offer at least one literacy program.

The most common such program, offered by 63 percent of the libraries, was adult basic literacy skills, which teaches adults reading at the fourth grade level and below (Fast Response Survey System, n.d.). Yet most of the simplest patient education materials are generally geared to a fifth-grade reading level, with a range that goes well beyond what a college student would find easy to understand (Davis, Crouch, Wills, Miller, & Abdehou, 1990). This situation is at the core of Secretary Broadnax's moral imperative and demands attention across institutions, agencies, and disciplines. Public libraries that address health literacy--through collections, programs, and special events and promotions--are doing their part to alleviate the burden imposed on a large percentage of citizens by lack of language skills.

September 11th

Finally, the horrific events of September 11th have affected all aspects of global society. Certainly they have affected the provision of health information to the public, in that public librarians may be confronted with consumer health questions that have not arisen to any significant degree since the Vietnam era. A small but growing body of literature discusses health events and observations in various populations since September 2001. Deleterious health effects can be observed across populations in a time of global upheaval, which certainly describes the early years of the twenty-first century.

Two years after 9/11, a group of researchers published a consensus statement on what are called unexplained symptoms following exposure as a combatant or support staff in a war theatre. Since unexplained symptoms, defined as "physical symptoms that provoke care-seeking but have no clinically determined pathogenesis after an appropriately thorough diagnostic evaluation" (Clauw et al., 2003, p. 1041), have been formally studied since World War I, the authors conclude that there is a "near certainty" (Clauw et al., 2003, p. 1040) that such symptoms will occur in the aftermath of the attack in New York City and subsequent military action abroad. One of the most helpful conclusions in the consensus statement is the finding that well-intentioned interventions often cause more harm than good, and the most hopeful is that "symptoms are likely to resolve with time" (Clauw et al., 2003, p. 1046). This powerful public health message is one that can be conveyed through public libraries, in addition to other communication channels, to an anxious public, particularly in areas where citizens have been personally affected by 9/11 and its aftermath. While the consensus statement examines primarily combatants, wars from the twentieth century forward have routinely targeted civilian populations as well as military forces. Vulnerable segments of the population, especially children and the aged, experience extreme psychosocial trauma that may heal slowly or not at all. Indeed, discounting psychological trauma, studies show that the "adverse consequences of physiological stressors are ... [most serious] when individuals lack: 1) control; 2) predictability; 3) direction; and 4) social support" (Clauw et al., 2003, p. 1044).

Of course, the loss of these four entities is felt most keenly by people who are actually participating in or are part of war or terrorist events, but anyone who lacks these important qualities is subject to negative health effects. Many Americans have felt the loss of one or more of these qualities since September 11th.

Children are at particular risk, especially if they have directly experienced war or terrorism. Depending upon their developmental stage, they may blame themselves for events they do not understand; regress to an earlier stage; or become irritable, defiant, or violent (Joshi & O'Donnell, 2003, p. 277). Overcoming the trauma requires multiple levels of support from families, communities, and government. Additionally, graphic images of war released by the media may have significantly adverse effects on some children.

One need not be directly affected by war or a terrorist act, however, to suffer symptoms of post-traumatic stress and loss. A longitudinal study conducted in the first six months after 9/11 examined the adjustment process among adults who did not directly experience the event. Although symptoms of post-traumatic stress declined over time, they remained elevated six months later (Silver, Holman, McIntosh, Poulin, & Gil-Rivas, 2002, p. 1242). Events since that time may have exacerbated stress levels and symptoms, particularly among families who have relatives serving abroad in either a military or a civilian capacity.

In the face of dramatically altered global priorities, public libraries occupy a unique position with regard to an existing communication infrastructure. More than 16,000 public libraries exist in communities across the United States, and they are trusted sources of information for their patrons. Indeed, in the immediate aftermath of the Twin Tower attacks, the New York Public Library began fielding reference requests for topics as diverse as Islam, Nostradamus, and particulars of the Arabic language (Matthews & Wiggins, 2001). Enterprising public librarians built miniportals to direct users to quality information.

In November 2001 staff from the Illinois State Library and the University of Illinois Library Research Center initiated a study to determine how public libraries in the state had reacted to the events of September 11th. At that time, only 25 percent had initiated any special programming, and fewer than 8 percent had participated in community panels. However, more than half had mounted special exhibits, and nearly 60 percent had created and supplied resource lists to patrons (Library Research Center, 2002). Three years out from 9/11, an initiative called the September Project is recruiting libraries to host events large and small where "people across the country will come together at public places like local libraries to discuss ideas that matter. Through talks, roundtables, and performances, people will share ideas about democracy, citizenship, and patriotism" (September Project, 2004).

Whether or not public libraries choose to participate in this national event, the health implications of September 11th and its aftermath are profound. From helping parents assist their children with understanding confusing events and gruesome images in the media, to providing information to returning veterans and their families, to adding items to collections that will record the health effects of this era for posterity, public libraries have a vital role to play in meeting the September 11th-related health information needs of their customers.

WHAT HAS NOT CHANGED, AND HOW ARE PUBLIC LIBRARIES AFFECTED?

As much as the world has changed since 2000, some trends that were observable at that time continue today. Health news remains ubiquitous; it is a staple of television news shows, newspapers, and magazines. The United States continues to be an aging society; yet, even with the first wave of the baby boom generation approaching retirement, the United States is facing significant challenges in the area of health care reimbursement. The health care environment in the United States continues to be one in which physicians and nurses, traditionally the purveyors of patient education, have less and less time to answer the questions posed by patients and caregivers. Finally, consumers continue to be interested in alternative, complementary, and integrative approaches to health care.

Health in the News

The explosion in biomedical information has, not surprisingly, translated into press releases, health segments on television and radio news programs, special weekly or daily newspaper sections, and Internet sites. This activity represents a trend that is more than five years old. Methods of disseminating the information have become more sophisticated, but the practice of creating news from health advances is not new.

One of the challenges inherent in the early release of information is helping the public understand that the nature of scientific advancement often means that research must be repeated in order to verify results. For example, Judah Folkman first envisioned the idea of angiogenesis at the beginning of his career, more than forty years ago, yet neither endostatin nor angiostatin, the potent antiangiogenesis drugs he developed, nor others in this category that have been developed by other researchers, had been approved by the Food and Drug Administration in mid-2004. Consumers do not always understand how important it is to prove both safety and efficacy and to determine optimal dosage and method of administration before making a drug widely available. The tension that exists between the need for safety and the possibility of a cure is nothing new in medicine. Any librarian who deals with consumers searching for health information will confront this issue at some point. Basic resources on the conduct of scientific inquiry cut across disciplines and are an important part of a public library's collection.

Baby Boom Generation

In 2004 a member of the baby boom generation turns age fifty every 7.6 seconds; by 2023, 20 percent of the population--one in five Americans--will be older than 65 (Callimachi, 2004). This phenomenon is occurring at the same time as dramatic changes in health care delivery and financing in the United States. A balanced discussion of a single-payer system versus private insurers, government programs, or a combination is beyond the scope of this article. However, the health care financing conundrum facing the United States definitely affects the provision of consumer health information in public libraries.

The record-breaking number of births beginning in the United States in 1946 and extending through 1964, what is now called the boom generation, has altered every aspect of American life. Even if what some pundits perceive as a looming crisis in funding for both Social Security and Medicare turns out to be an exaggeration, no doubt this group's retirement years will be vastly different from those of their parents and earlier generations. Although they are arguably healthier, fitter, and better educated than previous generations, the boomers will still face the health issues that arise with aging and may demand low-cost options for their care and minimally invasive therapies. Moreover, as the practice of medicine is changing to include innovative treatment options and patients as partners in care, their need for quality health information may exceed that of any previous group of elders. Given that public libraries are central to their communities and easily accessible by all, their administrations will need to assess the information needs within this demographic and plan ahead for the queries that will inevitably come their way.

The impact of a large aging population on care-giving structures merits particular attention, especially as it affects consumer health information. Medicare is a system that was designed to address acute health care conditions, not chronic, long-term conditions like Alzheimer's disease, Parkinson's disease, diabetes, arthritis, some forms of cancer, and related maladies. Yet, these are the sorts of health problems that will affect an ever-increasing number of patients and families, as medical technology becomes even more sophisticated and effective than it is now (Edlund, Lufkin, & Franklin, 2003).

What can public libraries do to assist customers who find themselves needing to make decisions about care for a relative with a chronic, progressive condition? They can start by assuring access to government and private insurer information about long-term care insurance, what Medicare and Medicaid will and will not cover, and what the laws are in their states regarding living wills, durable powers of attorney for health care, and related economic and legal issues. If families opt to care for a family member at home, then the public library can assure a current collection in setting up a home health care situation, from the type of equipment needed, to cookbooks, to formation of a respite team, and more. The public library could even form a partnership with medical agencies (like home health), faith-based institutions, or senior centers to secure a support net for families who are caregivers. The models from community to community will be different, but assuring that the groundwork is laid in advance will lessen the impact of an increasing need for information associated with long-term care.

Time Crunch for Health Care Professionals

Physicians and nurses are unquestionably the best possible sources of health information and education for their patients. They remain the front line purveyors of such information. However, a number of factors--including specialization, vocabulary, literacy, language, and time--mitigate against these two groups of professionals being able to respond to all of the health information needs of their patients and families. In some states, such as Illinois, high rates for malpractice insurance are actually driving some physicians out of the profession, leaving rural areas bereft of specialties such as obstetrics and neurosurgery (Parsons & Chase, 2004). While librarians can never diagnose or prescribe or recommend one course of treatment over another, they can provide the expertise in health information resources that will direct consumers to trusted sources that will aid them to work with their health care providers in making decisions about their care.

Alternative, Complementary, and Integrative Approaches to Care

What is today known as integrative medicine was, not so very long ago, derided as "alternative" medicine. However, Americans spend significant sums of money on various herbal formulations, chiropractic, homeopathy, and related therapeutic approaches. In 1992 Congress indicated that, in the interests of public health, it wanted alternative therapies to be studied. The National Institutes of Health established the Office of Alternative Medicine and began doing just that (Marwick, 1992, p. 957). Today there is a National Center for Complementary and Alternative Medicine, as well as an Office of Cancer Complementary and Alternative Medicine. The purpose of all this infrastructure is to subject various substances and systems (such as traditional Chinese medicine) to the rigor of the clinical trials process.

Today more information about safety and efficacy, especially of herbals, is known than ever before. Good safety profiles for the majority of herbals have, so far, been verified, though much research remains to be done regarding the effect of long-term use of these substances. Some herbs, however, in particular St. John's wort, are now known to have serious, potentially fatal effects if taken with certain commonly prescribed medications like anticoagulants, antidepressants, and others (Williamson, 2003, p. 1075).

Despite the lack of concrete scientific evidence, Americans are using complementary therapies in increasing numbers. In fact, more than two-thirds of American adults report having used a complementary therapy and, of this number, nearly half continue to use one or more therapies over a period of years (Kessler et al., 2001, p. 267). Scientists are working to establish safety, efficacy, dosage, and administration, since the use of these remedies has persisted over more than fifty years and profoundly affects the delivery of health care in the United States.

Public libraries undoubtedly receive many requests for information about this topic. Mounting the best possible Web sites available on this subject, purchasing evidence-based databases like the Natural Medicines Comprehensive Database (http://www.naturaldatabase.com/), and partnering with medical libraries and pharmacists with knowledge of this field will assure that patrons will have access to the information they need to make safe, effective use of complementary therapies.

CONCLUSION

Is there a moral imperative to make health information available to every American? And, if there is, how exactly should this be done?

Given the great complexity of the issues connected to health care that affect people in the United States and around the world today, the importance of providing such information is clear. Thanks to the Internet and the World Wide Web, availability to wired consumers is also a given. However, while almost everyone in this country theoretically has Internet access, through public libraries if not at home, the reality is that there are still at least two generations of Americans alive today who are unfamiliar with computers and are often unwilling to master the skills necessary to access information online. Moreover, people learn differently and require multiple formats and channels of communication to acquire knowledge effectively.

While the number and nature of individuals who actively seek health information is disputed, the number is almost certain to rise given the ubiquity of what is available, the ease of access, the health care financing dilemma, and the needs of an aging population balanced against a younger, "sandwich" generation confronted with numerous economic and social challenges. Making current, accurate health information available in multiple formats, where and when customers require it, remains the goal for which all libraries answering health-related questions must strive. A combination of strategic partnerships and carefully built collections is the best assurance that public libraries will meet the consumer health information needs of their customer base and satisfy the moral imperative for such a service.

NOTE

(1.) Details of this quality indicator can be found at http://www.hon.ch/home.html. Retrieved May 29, 2004, from this address.

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Fox, S., & Rainie, L. (2002). Vital decisions: How Internet users decide what information to trust when they or their loved ones are sick [Pew Internet and American Life Project Report]. Retrieved September 9, 2004, from http://www.pewinternet.org/reports/toc.asp?Report=59.

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Thackery, E., ed. (2003). Gale encyclopedia of mental disorders. Detroit, MI: Gale Group.

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Mary L, Gillaspy, Manager, Health Learning Center, Gaiter 3-304, Northwestern Memorial Hospital, 251 East Huron Street, Chicago, IL 60611