Promoting health information literacy.

Abstract

The recent development of public health informatics as an interdisciplinary field, and the dissemination of this body of knowledge, have brought forth new opportunities for collaboration between the faculty of health sciences and academic library. This paper explores the potential areas for collaboration, describes empirical collaborative projects between these two parties in enhancing the information literacy of public health discipline in a major health science center, and discusses the lessons learned, including the opportunities and challenges associated with the collaboration.

Background

1.1 Information literacy and health literacy

According to the Association of College and Research Libraries, information literacy is a set of competencies that enables individuals to recognize needs for information, and have the ability to locate, evaluate, and use the needed information effectively. [1] General information literacy is an important attribute in achieving lifelong learning, because it contributes to informed decisions based on critical reasoning and thinking. On the health spectrum and as a subset of information literacy, health literacy relates to the degree to which people can obtain, understand and process basic health information and services, and then act on appropriate health decisions. It is one of the crucial, enabling capabilities that could contribute to the realization of the goals of Healthy People 2010 as stipulated by the Center of Disease Control and Prevention (CDC). [2] By comparison, both definitions of literacy address the acquisition of information when needed, assessment of information with scientific facts and expert advice as the knowledge base, and utilization of the results of the combined actions to execute knowledge-based strategies leading to informed decisions, such as the choice of a healthy lifestyle.

1.2 Public Health Informatics

Closely related to health information sciences, the National Library of Medicine (NLM) defines public health informatics as the systematic application of information and computer sciences to public health practice, research, and learning. [3] The literature suggests that effective dissemination of public health literacy play an important role in the decision of the general public in seeking preventive health measures and healthcare services. For seeking preventive health, one study found that patients who had inadequate reading skills did not know that mammography was associated with diagnosing breast cancer. Conversely, women with adequate literacy skills who read on at least a 9th grade level appeared to be adequately informed about mammography. [4] Another study found that increased access to self-care books, telephone advice nurses, and Internet-based health information was associated with decreases in reported pediatric healthcare utilization. [5]

In terms of literacy and health care, research results of two separate hospital studies have suggested that the literacy skills of patients with diabetes, hypertension, and asthma were the strongest correlates of knowledge about their illness and disease management skills, even after statistical adjustments were made for conventional sociodemographic co-variables. [6] [7], The results of the studies also suggest that the interventions (of enhanced health literacy) were associated with a decreased reliance on health professionals for information. These findings suggest that improved literacy is a critical component in improving public well being, and in the context of public health, improved literacy is crucial in the pursuit of preventive health and appropriate management of diseases.

Public health informatics is a discipline that applies information technology to public health science. [8] By this definition, the faculty of the School of Public Health (SPH) conducts teaching, research and community services widely involving public health informatics. These may include using relational databases to store the results of survey questions, presenting epidemiological data using the Geographic Information Systems (GIS), analyzing various potential socio-biological risk determinants of health disparities, and recommending scarce health resources allocation based on computer-assisted analysis. For formally structured graduate courses, the training modules of health informatics are usually prepared for graduate students in a classroom setting. The training modules are not specifically designed to transform discipline-specific attributes of knowledge to general competencies, nor to deliver the terminology-ridden scientific research to an audience of general literacy level. Therefore, it is desirable to strengthen the collaboration between full-time public health faculty and library faculty, in order to disseminate technically-oriented training modules to a wider audience.

1.3 Collaboration: bridging the great divides

By convention, classroom faculty members have not been interacting with academic library faculty at an extensive level until recently. Articles have been written about the "tension" between academic librarians and classroom faculty. Carpenter [9] contends that an "enmity" exists between classroom faculty and academic library faculty. Kotter [10] claims that the tension and the lack of interaction are the "great divides" to be bridged. In seeking potential causes of such tension, Ren [11] observes that the phenomenon arises from classroom faculty perceiving library faculty as inexperienced in conducting research and teaching and not as "academic equals" at work. Owusu-Ansah [12] attributes the "latent tension" in the relationship to the observation that teaching faculty "would have little to do with the library and have little respect for the academic librarians". Notwithstanding these contestable arguments, collaboration could expand the synergistic opportunities that would further the mission of academic enterprise. In his proposal to "bridge the great divide", Kotter [10] suggests that the improved association between faculty and library faculty would enhance librarians' ability to promote and support research among classroom faculty, while allowing the librarians to actively participate in the enterprise of scholarship. Farber perceives that the true benefits of collaboration are the mutually reinforced and shared visions between classroom faculty and librarians. [13] The classroom faculty objectives are to help students attain a better understanding of the course subject matter. The library faculty objectives are to enhance the students' ability to find and evaluate information which in turn enhances the students' understanding of the subject matter and contributes to their life long learning skills.

The expanded opportunities--brought forth by both the promotion of health informatics knowledge and the dissemination of the literacy programs, warrant strengthened collaboration between the faculty of health sciences and academic librarians. The following sections seek to identify potential areas for collaboration and calls for action. The remainder of this paper presents recent cases on how public health informatics literacy are implemented in practice, specifically with reference to the acquisition and assessment of knowledge components. It then describes the potential areas for collaborative work and presents a recent intitiative in a Health Science Center (HSC) that underscores this collaboration. The last section discusses how such initiatives may expand the collaboration between the faculty of health sciences and academic librarians.

2. Public Health Informatics Literacy In Action: Two Recent Initiatives

This section examines two essential competencies of information literacy, namely the acquisition and assessment of health information. It describes how these competencies are addressed in the public health informatics discipline, and explores the opportunities for interdisciplinary collaboration.

2.1 Web Portals of Health Information

According to Ferguson, the increased adoption of Internet technology affords at least four major sources of health information that take advantage of the information highway. [14] These include commercial services, on-line mailing lists, Internet newsgroups (also known as USENET newsgroups) and the World Wide Web. The expanded channels for distributing health information have introduced new challenges and opportunities. A recent study sought to characterize health-related portal websites has found that while many Internet users are surfing the Web, they are likely to encounter advertisements that are usually promoting products that are unsupported by scientific research, such as those of "weight-loss supplements". [15] Therefore, a major challenge confronting consumers in the acquisition of health information, is herhaps how to distinguish accountable health information from mis-information (or infomercials).

One case illustrating opportunities to enhance health information acquisition and assessment on the information highway is the recent proliferation of public health "portal websites" or "toolboxes". At the federal level, there are several initiatives of health literacy portal websites pertinent to general consumer health or thematic health interests. Among these productions, CDC Wonder, healthfinder.gov and health.gov are examples of current general health portals to the websites of a number of multi-agency health initiatives and activities, including those of the U.S. Department of Health and Human Services and other federal agencies. Other websites have been produced for specific public health interests. For example, in response to the recently heightened alert of potential terrorist activities, CDC [16] produced the "bioterrorism" portal website to provide information associated with frequently asked questions on bioterrorism agents and preparedness, organizations that are dedicated to readiness training advisories, alert and bulletin, and on late-breaking news. Similarly, the University of North Carolina produced a "toolbox" website as a repository of public health data management instruments. [17]

The National Library of Medicine (NLM) and medical librarians have also recently focused attention on the public's need for health information. As mentioned previously, portal websites have been developed that provide reliable health information from the government. In addition, NLM provides free access to MEDLINE plus[R] that includes MEDLINE and quality, up-to-date drug information, encyclopedias, dictionaries, directories and clinical trials. To emphasize consumer health information, NLM provides consumer health and public health information grants through its National Networks of Libraries of Medicine (NN/LM), a network of 4,500 health science libraries. NLM's online training programs prepare medical librarians to use its products and services and in turn the medical librarians train others--public health professionals, hospital medical staff, residents and interns, and public librarians.

Portal websites/toolboxes offer convenient access to reliable health information at the users' fingertips, as they provide "one-stop-shopping" convenience for accessing and acquiring accountable health information with ease. These websites allow quick updates on reliable and time-sensitive health information. These strengths are particularly crucial in time of urgency, and may therefore reduce the public's anxiety in the events of uncertainty.

2.2 Community health monitoring systems

Community health monitoring systems demonstrate another initiative in promoting health information literacy. Community Health Monitoring System (CHMS) are a continued set of performance measurement activities that involve the selection and use of quantitative measures of health program capacities, processes, and outcomes to inform the public or a designated public agency about critical aspects of a program. [18] Performance monitoring has evolved over the past 20 years and has been termed in the literature as: Community Health Monitoring Systems (CHMS), Community Health Information Networks (CHINs), Community Health Information Management Systems, Community Health Information Systems (CHIS), Community Health Report Cards, Community Care Networks, and Health Information Networks, [19] among other derivative appellations with a similar focus on community health.

In the United States, concerted interests are matched by rigorous efforts to develop health information systems for monitoring purposes at both the national and local levels. According to Furukawa, there were about 500 Community Health Information Networks that closely monitored health across the nation in 1996. [20] A survey conducted by the UCLA Center for Healthier Children indicated that nationwide at least 115 Community Health Report Cards were profiling community health in 1999, [21] including the Community Health Status Indicators that are provided by CDC. [22] To make the community health profile more accessible to the general public, some CHMS also present health outcomes in a Web-based or GIS-enabled format (examples include Community Health Information Systems of Houston [23] and MICA in Missouri [24]). CHMS emphasize various determinants of health ranging from environmental factors, income, and race to motor vehicle crash prevalence. [25] The CHMS intend to provide accountable health information, including health indicators and outcome measures to quantify community health performance and to promote public awareness. The systems help the public to access community health profiles, provide a knowledge-base for community health initiatives, and seek to narrow health disparities in the nation.

2.3 Areas of collaboration for health librarians and faculty

The collaboration between public health faculty and academic library faculty seems both logical and intuitive. Both focus on public interest, and seek to fulfill teaching and service roles to enhance health literacy delivery and utilization. The relationship between both parties may be improved by joint involvement in promoting health informatics literacy in at least three levels of professional interactions: curriculum development, instructional design, and classroom instruction. In delivery of public health informatics literacy, faculty members are qualified content-providers in their respective subject disciplines, so they can focus on the information assessment. Librarians can contribute professional assistance in instructional design, such as polishing course modules to be more content-and-setting specific, and clarifying the vocabulary and concepts for the general public to digest and utilize.

Thus, the aforementioned two public health informatics initiatives underline the need and opportunity for a collaborative effort: in acquiring accountable health information and the production of portal websites/toolboxes, faculty members may serve as content-providers; while many academic librarians are comparatively well-versed with web-authoring technology, they may provide assistance on instructional design, such as web development and maintenance. In the case of producing CHMS, faculty members may be responsible for assessing health data and conducting analysis, while academic librarians may assist in teaching the outcomes databases, querying data or results in response to users' request, prioritizing and presenting information in a content-specific and culturally-appropriate manner to the general public. In terms of utilization, librarians also may facilitate the process of information delivery. The goal of a public service librarian is to identify pertinent information based on the specific consumer requests and supply the most relevant materials regardless of format, as well as current bibliography of additional items for the consumers' judgment.

3. Collaborative projects in action in a health science center

The following outlines two collaborative projects between SPH faculty and academic library faculty in a major Health Science Center (HSC). The collaboration intends to make health information more accessible to the general public and to strengthen existing graduate programs.

3.1 Center for Health Informatics and MPH in Health Informatics

In 2001, the HSC President requested that the HSC plans an initiative to create a Center for Health Informatics. This collaborative project involved a team of health information practitioners, including faculty in the Library and SPH faculty members. The purpose of the Center is to support teaching, interdisciplinary research, and community services of the academic enterprise. The Center seeks to improve student education by articulating and efficiently fulfilling their information needs, and to augment current instruction efforts at HSC by offering separate courses in information seeking and informatics. The Center seeks innovative methods of information integration and provision, and serves as a focal point for collaboration between the Library, Graduate School of Biomedical Sciences, Medical School and SPH. The Center serves as a community outreach center for other organizations in the Dallas-Ft. Worth Metroplex area, and as a center for health informatics research and outreach in a multistate region.

In addition to the Center, an MPH program with a concentration in health informatics was established in SPH. The new MPH program joins thirteen other health informatics programs in this country. This program enrolled its first cohort of students in fall 2002. Major teaching and research areas include public health data analysis and interpretation, the GIS and spatial analysis in public health, and the design and evaluation of hospital information systems. Central to the program is the adoption of the courses jointly offered by the SPH and the Library.

3.2 Information Access for public health professionals

In the summer of 2002, the Library, SPH, Office of Professional and Continuing Education (PACE), and local health department responded to a National Library of Medicine (NLM) RFP ("Information Access for Public Health Professionals") with a proposal to improve public health information literacy. The project proposal seeks to assess the needs of public health professionals who would be best served by NLM and CDC products, to enhance the accessibility of health information through training development and delivery, and to produce a public health website portal.

Needs Assessment In this project, a statistically significant sample of public health department directors in target Public Health Regions will be surveyed to assess users' familiarity and accessibility of NLM, CDC and other public health databases. The survey will 1) establish what information resources are of interest, and 2) if users are interested in a free or low cost training program targeted at public health officials focusing on accessing reliable and authoritative health information and research. The survey will serve to publicize the development of the Public Health Informatics Training Program and to build enthusiasm among relevant parties. The survey will be jointly developed by PACE, SPH, and will be conducted by the local health department.

Training Program Development and Delivery A training program will be developed based on the results of the needs assessment. Different educational formats that incorporate adult learning principles will be included in the curriculum. The Library, PACE, and local health department will jointly develop the program. Once developed, the training modules will be offered to health departments throughout north Texas. The four hour session will be conducted at departments with training centers and incorporated into PACE activities. A suitable education facility will be sought for departments without training centers, and three sites will be chosen. Training activities will be accredited to award continuing education credit for certified health educators, registered sanitarians, physicians and nurses by PACE.

Web-based Portal A web portal will be developed to provide access to all databases and resources discussed in the Training Program. The web portal will allow registration into an optional email list and monitored bulletin board. Those participating in the email list will receive updates and notices about the website and will be emailed continuing education vignettes that will require visiting the website to claim credit. Officials from the local health department, SPH faculty members and others will create training emails/alerts. The first will cover NLM and CDC resources. The monitored bulletin board will allow registered professionals the ability to post questions related to public health and to receive replies from pre-screened and authorized health officials. The local health department will monitor the bulletin board and the web portal will be maintained beyond the project period by PACE. Training Program Promotion/Publicity The Public Health Informatics

Training Program will allow information access for public health professionals. It will be promoted through 1) the initial Needs Assessment Survey interaction, 2) exhibits and educational sessions at Public Health Meetings, 3) listing on the PACE website and calendar, 4) letters of invitation to Public Health Department Directors, 5) the elective Track in selected CE activities by PACE, 6) existing Health Alert Networks, 7) Department of Health "Resources and Information Digest", and 8) health educators email lists.

4. Lessons learned: opportunities and challenges

The above examples demonstrate recent initiatives in promoting public health informatics, and illustrate how faculty and academic library faculty may work together to enhance information acquisition and assessment. After completing the collaborative projects, we identified additional areas for collaboration and potential challenges in practice. One potential area includes adding literacy programs such as introductory informatics courses for first year students of health sciences. Another includes the need for establishing a Writing Center to prepare students in academic communication and to assist local health authorities to prepare for grant writing. The functions may be efficiently carried out with a faculty-librarian synergistic collaboration. Challenges are primarily the motivation for faculty involvement. In designing collaborative activities, consideration needs to be given to the tenure and promotion criteria (i.e., teaching, research or community services) of faculty members so that faculty participation as an institutional commitment can be assured, and sufficient release time be requested and dedicated to participation.

In summary, the enhancement of public health informatics literacy is an endeavor of substantial magnitude. Since health literacy has been shown to be associated with population health outcomes, it therefore warrants strengthened collaborative effort between academic librarians and classroom faculty to address the unmet needs. The collaborative projects are mutually-rewarding, and hold promise to take the health information literacy and well-being of the general public to the next level.

References

[1] Information Literacy Competency Standards for Higher Education (2000). Chicago: IL: Association of College and Research Libraries.

[2] Healthy people 2010. http://www.health.gov/healthypeople Retrieved: September 13, 2002.

[3] Public health informatics. Current Bibliographies in Medicine 2001-2. National Library of Medicine. http://www.nlm.nih.gov/pubs/cbm/phi2001.html Accessed: March 27, 2003

[4] Davis TC, Michielutte, R., Askov, EV et al. (1996) Practical assessment of adult literacy in health care. Health Education and Behavior, 25(5), 613-624.

[5] Wagner TH, Greenlick MR (2001). When parents are given greater access to health information, does it affect pediatric utilization? Medical Care. 39:848-55.

[6] Williams, M.V., Baker, D. W., Honig, E.G., Lee, T.M., & Nowlan, A. (1998) Inadequate literacy is a barrier to asthma knowledge and self-care. Chest, 114, 1008-1015.

[7] Williams, M.V., Baker, D. W., Parker, R. M., Nurss, J.R. (1998). Relationship of functional health literacy to patient's knowledge of their chronic disease: A study of patients with hypertension or diabetes. Archives of Internal Medicine, 158, 166-172.

[8] Yasnoff, WA (2001). The promise of public health informatics. Journal of Public Health Management and Practice: JPHMP, 7 (6). p iv-iv.

[9] Carpenter KE (1997). The librarian-Scholar. The Journal of Academic Librarianship. 24(3). p 398-401.

[10] Kotter WR. (1999). Bridging the great divide: improving relations between librarians and classroom faculty. The Journal of Academic Librarianship 25(4). p 294-303.

[11] Ren WH (2000). Attending to the relational aspects of faculty citation search. The Journal of Academic Librarianship, 26(2). p 119-123.

[12] Owusu-Ansah EK (2001). The academic library in the enterprise of colleges and universities: toward a new paradigm. The Journal of Academic Librarianship.27(4). p 282-94.

[13] Farber E (1999). Faculty -librarian cooperation: a personal retrospective. Reference Services Review, 27(3). pp 229-234.

[14] Ferguson T and Madara ET (1996). Health Online: How to Find Health Information, Support Groups, and Self-Help Communities in Cyberspace. Perseus Publishing.

[15] Slater MD and Zimmerman, DE (2002). Characteristics of health-related web sites identified by common internet portals. JAMA, 288 (3):pp 316-317.

[16] Public health preparedness and response. Centers for Disease Control and Prevention. http://www.bt.cdc.gov Retrieved March 27, 2003.

[17] Data Skills Online. University of North Carolina Chapel Hill--SPH. http://www.sph.unc.edu/toolbox Retrieved March 27, 2003

[18] Pen-in EB, Jane S. Dutch Skillman SM eds. (1999). Health performance measurement in the public sector. Principles and policies for implementing an information network. National Research Council. National Academy Press. pp. 19.

[19] Kralovec JO and Kennedy R (1994). A new vision of health care delivery. Community Health Information Networks. American Hospital Association. pp 3-21.

[20] Stipe SE (1996), "Health Information Networks: A connection to an efficient future." Best's Review in life and health. 96(10) pp. 28-31.

[21] Fielding JE, Sutherland CE, and Halfon N (1999). "Community Health Report Cards--Results of a national survey." Am J Prev Med 17(1) pp 79.

[22] Community Health Status Indicators. http://www.communityhealth.hrsa.gov Retrieved March 27, 2003.

[23] Community Health Information Systems. http://www.slehc.org Retrieved March 27, 2003

[24] Missouri Information for Community Assessment. Missouri Department of Health. http://www.dhss.state.mo.us/MICA/nojava.html Retreived: March 27, 2003.

[25] Public Health Foundation (1998). Inventory of public/private health information initiatives. http://www.phf.org/data-infra.htm. Retreived: March 27, 2003.

Chiehwen Ed Hsu, University of North Texas
Lynn F. Johnson, University of North Texas
Ann N. Brooks, University of North Texas

C. Ed Hsu, PhD, is assistant professor of health management and policy. He coordinates the Master of Public Health in Health Informatics. Lynn F. Johnson is the special projects librarian with the GDL Library and an instructor in the Department of Education. She serves as Project Director for the OSTMED[R] database project. Ann N. Brooks is assistant professor with the department of education and associate director of public services for the GDL Health Science Library.