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Providing health information to community members where they are: characteristics of the culturally competent librarian.

ABSTRACT

SINCE ALL PEOPLE MAKE HEALTH DECISIONS, all people need health information. Currently most people do not get health information from libraries; nevertheless, librarians can play an important role in the provision of health information if they listen carefully to community needs, develop cultural competence, and work with community partners. Librarians must collaborate to provide services where people are: physically, culturally, linguistically, educationally, and in many other senses. An example is given of a partnership between the librarian at Mars Hill Graduate School and the African Americans Reach and Teach Health Ministry that provides information services to faith communities in the Puget Sound area. Concepts discussed are summarized in a proposed list of cultural competencies for librarians.

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Health information is distinctive in its universal necessity. When asked how frequently reference desk questions are health related, one public librarian quipped that they were "second only to automotive related" requests. While not everyone owns an automobile, 100 percent of our actual and potential patrons have bodies and minds, and 100 percent of those patrons make decisions about health. We may well be able to generalize about the individuals who are currently pursuing information in our libraries, but not everyone who needs health information is coming into our libraries. In fact, Tu and Hargraves (2003) found that in 2000 the majority of a sample of Americans (62 percent) never sought information about a health concern; instead they were passive recipients of health information (from the media, etc.). Thus, in the provision of consumer health information we, as librarians, might have our greatest opportunity to affect every member of the community. This article will focus on universal service to individuals and communities.

How do librarians meet health information needs of individuals and their communities? By meeting people where they are, not where we want them to be. We cannot fulfill everyone's health information needs if we set criteria for who should be served, where and when the service should take place, what information should be provided, and who should provide it. M1 parameters of library service should be questioned in the light of who is served--the community and its individuals. Once we understand the "who," the answers to "where and when," "what," and "who serves" follow naturally.

The authors are involved in a partnership that can serve as an example of health information provision to a new community. The library at Mars Hill Graduate School (a graduate-level divinity and counseling school) is partnering with the African Americans Reach and Teach Health (AARTH) Ministry to help faith communities in the Puget Sound area fulfill the health information needs of their congregations. The librarian in this case is white and the community members are African American, but the principles to be discussed in this article apply whenever a librarian seeks to provide service to a patron who identifies with a different community.

In the AARTH-Mars Hill collaboration, the questions and answers are as follows:
 Who should be served? Members of African American faith communities
 in the Puget Sound area, along with their families, friends, and
 anyone else who affiliates with those communities.

 Where and when should information services be offered? In churches
 On Sunday mornings, at evening faith meetings, at church-sponsored
 Health fairs and health classes, and whenever someone looks on
 AARTH's and the various churches' Web sites for health information.

 What information should be provided? Information on the specific
 health issues that disproportionately affect African Americans,
 short health articles to go on the back of church bulletins,
 culturally appropriate information, links to programs that will
 read Web pages aloud, information on how to find good health
 information, etc.

 Who should provide the information? Not the librarian; instead,
 community leaders, pastors, health professionals, and volunteers
 have the direct information-sharing role. The librarian is critical
 but in the background.


Since outreach to this extent might be unfamiliar for some librarians, we can learn from other professions that also are reaching out to every person in the community. Two pertinent professions are health care and public education, the first because of the shared subject matter of health, and the second because educators, like librarians, enable access to information. Health care and education already have extensive outreach literatures that can be of value to librarians embarking on universal service. Most of the research cited in this paper comes from the literature of those two fields.

WHO IS SERVED?

When we provide health information, whom are we serving? Within the United States, "between 1985 and 2030, the proportion of children from non-white, non-Anglo-European groups will rise from 28% to 41%" (Lynch & Hanson, 1998, p. 8). The population we are serving now--and will be serving in the years ahead--gets more diverse every day. Moreover, the foregoing statistic just covers the aspects of race and country of origin; it does not take into account language, culture, religion, reading ability, sexual orientation, health practices, learning style, disabilities, critical thinking style, information assimilation preference, and decision-making methods--to mention just a few characteristics. These characteristics may be shared by entire communities, may pertain only at the individual level, or may be both communal and individual. With our usual patrons, those who have been entering our libraries for years, we may have known exactly how to provide service. When we enlarge our service to encompass everyone in the community, we can no longer make assumptions about either the individuals or the community from which they come. As an example, the racial disparity in information use is marked; African American women use printed news media on health 50 percent less than average and computer-based resources 60 percent less than average (Nicholson, Grason, & Powe, 2003).

One of the oldest principles in educational theory (dating back to the Greeks) is that people learn and remember best when new information is related to current knowledge and experience (Wittrock, 1986). Therefore, to provide health information in the most effective way, we must relate the health information we provide to our patrons' own health experience and knowledge, which may be entirely different from our own.

Some librarians have become extremely knowledgeable about certain ethnic, racial, or cultural groups. An excellent example of this refined knowledge is offered by Ellen Howard in EthnoMed (ethnomed.org), a Web site that describes characteristics that impact health care for a variety of refugee and immigrant communities in the Seattle area: Amharic, Arab, Cambodian, Chinese, Eritrean, Ethiopian, Lao, Mexican, Mien, Oromo, Somali, Soviet Jewish, Tigrean, Ukrainian, and Vietnamese. The Web site discusses health beliefs, languages, family and kinship structure, etiquette, immigration issues, domestic conventions, and experience with Western medicine, among other issues. We can, and should, use such sources to become knowledgeable about the various cultures in our communities; however, even such a remarkable Web site only touches a corner of all cultural characteristics and obviously only covers a few of the thousands of world cultures. The lesson is that we will never know as much about a person or community as that person or community knows. The study of a variety of cultures simply enables us to understand that a wide range of differences exist: "Cultural sensitivity cannot mean knowing everything there is to know about every culture that is represented in a population to be served. At its most basic level, cultural sensitivity implies, rather, knowledge that cultural differences as well as similarities exist" (Anderson & Fenichel, 1989, pp. 8-9).

The first step is to acknowledge that we do not know much about others. In light of our infinite ignorance, what can we do to be sensitive and respectful of our patrons? The next step is to be aware of our own values and biases, and the third is to work with our patrons to find acceptable methods and materials. For example, librarians are fond of (or are biased toward) drawing Venn diagrams to explain Boolean logic and search strategy. The educational system taught us that our profession values two-dimensional representations of complex concepts on rectangular surfaces; the use of maps is another example. Once we understand and accept that we are biased toward two-dimensional, rectangular representations, we may then be more understanding of a patron who shuns the two-dimensional representation and says, "Can you just tell me what this is all about?" or "Can you just show me how to use that search box?" or merely has a confused and frustrated look when presented with a Venn diagram. In order to perform the search, the patron does not necessarily need to understand Venn diagrams. Fortunately, most librarians have other teaching methods ready: we can perform a sample search so that the patron sees, in practice, what results are obtained with the various Boolean operators; or we can make up some simple, verbal rules like "putting an 'and' between words means you will get fewer things; putting an 'or' between words means you will get more." Venn diagrams are merely our educational system's culturally biased means of representing a concept that can be represented in a variety of different ways. We need to rid ourselves of the criterion that only patrons who understand Venn diagrams can be taught how to use search boxes in databases or that only patrons who can read maps can find their way to the clinic.

Once we acknowledge and accept our ignorance and biases, the next step is to ask questions. This step, often called community assessment (Burroughs, 2000), can start with research such as that in EthnoMed, but eventually it needs to involve personal contact with the community through questionnaires, interviews, focus groups, or simple conversations. With the African Americans Reach and Teach Health Ministry, we sent out questionnaires that asked about the demographics and needs of each congregation. The results gave us comparable information for the various groups. Then we interviewed at least one church leader, usually the pastor, to find out how he or she characterized the community--what needs, strengths, and interests were present, as suggested by SWOT theory (Strengths, Weaknesses, Opportunities, Threats, n. d.). For example, one church sponsors a regular workshop called "Undoing Racism," offered by the People's Institute for Survival and Beyond, indicating a strong interest in, and probable knowledge of, racial justice in the health care field. Another pastor mentioned several times the need for a Web page reader on the AARTH home page so that people who cannot read can still hear every page, which was a signal that nontextual media of many varieties might be useful in the community.

While questionnaires and planned interviews are invaluable, so are direct, immediate questions and answers. Before a project planning meeting, the librarian asked if it would be all right to invite a colleague to accompany her. AARTH's director told her that this was not appropriate at the beginning of the partnership. Because the librarian asked, and because the director answered forthrightly, a mistake was avoided. The reason for the director's response brings to light the importance of respect for cultural differences and similarities in relationship building. It was necessary for AARTH to establish its presence as a strong community player before bringing in other institutional partners.

Finally, in the process of developing mutual understanding with individuals and communities, we must also develop a trusting relationship. Howell even emphasizes the importance of a "pleasant" interaction as a crucial setting for honest and trusting discussions of health (Howell, 2003). An effective way of developing trust is to find similarities or mutual values. Institutionally, Mars Hill Graduate School, as a seminary and counseling program, and AARTH, as a health ministry, both emphasize the faith-health connection. Individually, the librarian and the AARTH leaders found unity in the belief that faith communities should go beyond prayer to action when the health of the community is threatened.

Therefore, in order to understand whom we serve we must

1. Acknowledge that we do not know as much about other people or communities as they know about themselves

2. Recognize our own and our community's biases

3. Open ourselves up to learn about and from other people and other communities

4. Work to develop a trusting relationship with individuals and communities

Once we increase our understanding of people in our community, the other questions follow more easily.

WHERE AND WHEN IS INFORMATION OFFERED?

Our next question is, Where and when should we provide health information services? The majority of Americans are not getting their health information in libraries. Some of the most important sources of health information are families, friends, health care professionals, the Internet, television, radio, newspapers, magazines, and books (Hudson & Watts, 1996; Tu & Hargraves, 2003; Diaz, Griffith, Reinert, Friedmann, & Moulton, 2002). Few studies of health information-seeking patterns of the general public mention libraries.

The public health field has long recommended that, in order to reach new people, institutions must go where they are--do not expect them to come to you. Public health educators regularly communicate with people in beauty parlors (Booker, 2000), at food banks, at needle exchange sites, on billboards, on television, on the job site, etc.

Librarians often express the bias that it is "good" to use a library, but limiting health information services to those who want to and can use a library sets up a barrier. In our work with the African American faith communities, we find that it is "good" to go to the church for information. Information of all kinds received at church has a higher chance of being culturally appropriate and of blending with community values and way of life. When information is provided in a way that is compatible with current values and patterns, it has a greater chance of being used (Rogers, 2000).

Especially in the African American community, barriers exist between the usual information sources and consumers (Matthews, Sellergren, Manfredi, & Williams, 2002). We must find ways to remove those barriers (Zarcadoolas, 2000) and must never blame people for not using (to our biased eyes) perfectly fine resources that are inaccessible for others. One way of reaching across the information-access barrier is the faith community. Churches have been shown to be particularly effective sites for health education (Winett, Anderson, Whiteley, Wojcik, Winett, & Rovniak et al., 1999), since African Americans look to their churches for community resources more than people in other communities.

The AARTH-collaborating churches have already taken responsibility for health issues; most have health ministries or means by which members of the congregation who are health-care professionals share their expertise in the church. The AARTH director recommends that librarians make sure information is provided in an environment that is comfortable for the community--a place that is accessible so that people do not have to dress up, get in the car, or take a bus. For the AARTH community, that is often the church, where people feel more comfortable asking questions about health and can get answers in their own language. Not only did we expect the information to be shared where people already are, but even the partnership meetings were held at sites suggested by AARTH rather than by the librarian (except when specific resources in the library were needed). In other words, the librarian went to the community and did not expect the community to come to the library.

Given the growing use of the Web and media for health information (Diaz et al., 2002; Tu & Hargraves, 2003), the place where health information may best be provided is in every individual's own home. One might postulate that a librarian could make the greatest impact on the quality of health information in many communities by providing excellent library services to the health reporter at the local TV station, the local newspaper, or a health Web site developer. Certainly, librarians who are involved in the creation of excellent health Web sites, such as NOAH, MedlinePlus, or EthnoMed, have a long reach.

We have a choice: Do we attempt to change the information-seeking traditions of every community member, or do we offer learning opportunities to the current providers of health information? The chances for effectiveness are infinitely greater when we help a few people do better what they already want to do well rather than attempt to change everyone.

In order to understand where and when to provide health information services we need to

1. Find out where individuals and communities are currently seeking health information

2. Encourage those information-seeking patterns

3. Improve current sources of information where people already are

WHAT HEALTH INFORMATION?

What health information should we make available? Needs assessments are perhaps more effective in this area than any other. However, we must be sure our needs assessments are broad, not just asking what information people need but digging deeper to ask if people even feel a need for information. Using the Stages of Change model, if the community does not perceive a need for information, any information provided is useless until we help people go from precontemplation to contemplation and onward (Rogers, 2000). Since only 38 percent of Americans seek information for a health condition (Tu & Hargraves, 2003), in a needs assessment we might very well find that the need is to inspire the desire to seek information rather than to actually provide any information. The role of the librarian is then as a change agent.

AARTH and its partner churches had already perceived the need for information. The AARTH pastors and congregations were concerned about the health disparities of African Americans and saw information as one means to address the problems. Steps can be taken to influence a community to recognize need (Witte, 2000), but we will be more effective if we start with needs that are already expressed by the community. In our needs assessments with AARTH partners, the same health topics arose again and again. By creating Web pages that address those topics, we show the compatibility of the AARTH Web site with current need.

An unexpected need that arose during our needs assessment was for a specific form rather than specific content. Churches need short (half-page to one-page) health information pieces that can fit on one page of the church bulletin. Many topics were of interest, if only they could be effectively and appropriately covered briefly. In addition, the information had to come from an agency that would not require permission or payment for reproducing.

Librarians tend to be effective seekers and finders of whatever information is needed. Recent work in New York Online Access to Health (NOAH, www.noah-health.org) and MedlinePlus (www.medlineplus.gov) has greatly enhanced the variety of materials available in terms of reading level, language, and format. Somewhat more difficult to find is culturally appropriate information. For example, African Americans experience greater morbidity and mortality for many diseases than their white counterparts; therefore information written for African Americans should recognize the more serious nature of diseases.

In finding health information for AARTH Web pages, it was often necessary to forego librarians' standard inclusion criteria (such as that used by MedlinePlus) and instead find Web sites written by and for African Americans. For example, MedlinePlus requires that a "list of advisory board members or consultants is published on the site" (U. S. National Library of Medicine, 2004), but for AARTH, authority may be more appropriately established by the endorsement of African American community organizations. In the case of the AARTH project, the librarian published, on the Web, a treatise on HIV/AIDS by a respected and well-loved local African American physician; the actual content could have been found on many sites, but since Dr. Moses has the ear of the community, his words can make a much greater impact.

At times the information needed is not readily available. At that point the role of the librarian expands beyond finder and collector to creator or advocate for creation (Alpi & Bibel, in press). For example, Ellen Howard of EthnoMed wrote successful grants that paid for the translation of materials.

Therefore, to provide the needed information, librarians should

1. Use a variety of methods for discovering information needs--in terms of topic, level, format, etc.

2. Seek out current materials that match those needs

3. Where needed materials are not extant, advocate or arrange for the creation of materials or compilations

WHO PROVIDES HEALTH INFORMATION?

The final question is, Who should serve the health information needs? Randall-David (1989, p. 26) has listed therapeutic agents or people whose help is sought in various communities:

Mainstream White American Counselors, Psychiatrists, Psychologists, Social workers, Ministers

African American Ministers, Root workers, Voodoo priests

Native American Medicine men, "Singers"

Mexican American Curanderos

Puerto Rican Espiritistas, Santerios

Cuban Santerios

Southeast Asian American Herbalists, Family/friends, Diviners

Haitian Voodoo priests

Note that librarians are not on the list; librarians are not necessarily seen as people to whom one should look for health information. If our goal is to ensure the provision of good health information, it may not be necessary for librarians ever to be seen by the broad community as the source of health information. Librarians may be the best people at discerning information need and finding appropriate information to fulfill that need, but others may be better at interfacing with the individual or the community. The method by which librarians can help communities is through partnerships, where a community sees the librarian as a help in fulfilling community needs, and the librarian sees the community's organizations and individuals as a means of carrying out the library's goals. Community partnerships such as this form the backbone of public health interventions (Briggs, 2003; Strategies for Success, 2001). Community leaders and respected members of a community are the most effective facilitators for the adoption and learning of information-seeking skills (Rogers, 2000). An individual learns best when the person imparting the information is similar to the learner and can model behavior and skills using methods and materials that are mutually familiar (Witte, 2000).

In the case of AARTH, a community organization recognized the need for better information and recognized that a librarian would be an important asset to the organization. The librarian has been involved in developing and using needs assessments, creating a Web site that helps the community explore topics of interest, finding culturally appropriate resources that fulfill stated needs, developing curricula for training sessions, and training representatives from each faith community who will, in turn, train the rest of their congregations. But at no time is the librarian the "face" of the information. The needs assessment is printed on the community organization's letterhead; the Web site where information is shared is the organization's Web site, not the library's; and training within congregations is carried out by community members, not by the librarian.

Perhaps the most critical role for the librarian in a community partnership for health information is to champion universal access and help lower the barriers. For example, normal agency policies and procedures can be barriers for people who are not familiar with the bureaucratic culture (Press et al., 2003). National Library of Medicine (NLM) funding provided for computers for the AARTH project. However, the funding agency required that AARTH buy equipment, then submit receipts for reimbursement, which can take several weeks. The AARTH director was stymied because AARTH had no cash in hand to pay for equipment in the first place. At that point, it was the partner librarian's cue to see what other arrangements could be made. In this case, the library advanced funding for some of the equipment from the library budget and, more critically, the librarian lobbied--even hounded--the funding agency to change the funding mechanism. While the librarian may not be the direct provider of health information in a universal access setting, advocating for the community and negotiating with bureaucracy are necessary alternate functions.

Therefore, in determining who should provide health information, librarians should

1. Determine who is currently providing health information

2. Partner with those people or organizations in such a way that the partners are the direct community contacts

3. In the partnership, act as advocate as well as information expert

CONCLUSION

We librarians are ideally placed to provide health information effectively to all members of our varied communities:

* We know how to carry out the necessary research to learn about new communities and people.

* We tend to be sensitively responsive rather than prescriptive.

* We instill trust.

* We know information literacy theory and practice.

* We regularly think of alternative methods (for example, synonyms) rather than single answers.

* We can find the varied information to fulfill a wide variety of needs.

* We have a strong service orientation that accepts others getting credit for the information we find.

By mixing together these strengths with methods and skills described in the literature on health and on education, librarians can

* Serve every member of the community

* Provide information where and when it is most needed and best assimilated

* Find the best information to fulfill needs

* Ensure that the information is offered by those most able to ensure its use

Speaking to individuals or groups about their personal health and physical well-being is an exercise in humility and honor. When a partnership works, and when the librarian approaches the community with humility, the community grants the librarian permission to ask questions and provide answers that lead to a deeper understanding of the social-cultural fabric of people without being considered intrusive. The librarian is in the unique position of being a conveyer of information and facilitator of relationships and partnerships. For the librarian, a community partnership can bestow the honor of mutual trust, understanding, and regard.

CHARACTERISTICS OF THE CULTURALLY COMPETENT LIBRARIAN

Many fields have codified cultural competence. It may be time for librarianship to adopt a similar code, such as that suggested below. Since the health field already has developed several codes, the following has been adapted from the health literature (Health Resources and Services Administration, 2002; National Center for Cultural Competence, 1999-2004; U.S. Department of Health and Human Services, 1999; Sue & Sue, 2003; Sue, Arredondo, & McDavis, 1992; American Psychological Association, 1993; Sutton, 2000).

I. Attitude

1. The culturally competent librarian is one who is becoming culturally aware and sensitive to his or her own heritage, along with the cultural heritage of others.

2. The culturally competent librarian can conduct self-assessment and is aware of how his or her own values, biases, attitudes, and beliefs may affect different or minority patrons.

3. Culturally competent librarians are comfortable with differences that exist between themselves and their patrons.

4. The culturally competent librarian values

a. Individual identity: what makes individuals unique

b. Group identity: reference base that may incorporate family, race, ethnicity, gender, religion, age, etc.

c. Universal identity: common aspects that all share as human beings.

II. Knowledge

1. The culturally competent librarian seeks to possess specific knowledge and information about the particular group with which he or she is working.

2. The culturally competent librarian seeks to understand the sociopolitical system with respect to its treatment of minorities.

3. The culturally competent librarian has knowledge and understanding of characteristics of information seeking and information use.

4. The culturally competent librarian is aware of institutional barriers that prevent minorities from gaining information.

III. Skills

1. The culturally competent librarian generates, sends, and receives a wide variety of verbal and nonverbal responses.

2. The culturally competent librarian develops and implements institutional strategies in partnership with communities, including setting goals, assessing need, developing a diverse work force, and evaluating services.

3. The culturally competent librarian can incorporate his or her values and knowledge into aspects of policy-making, administration, practice, and service delivery.

4. The culturally competent librarian is able to play a variety of partner roles:

a. consultant--serving as resource person to other professionals and/or minority populations

b. outreach--moving out of libraries and into patrons' communities

c. ombudsman--accompanying partners and patrons through bureaucratic mazes and procedures

d. facilitator of indigenous support systems--structuring activities to supplement, not supplant, existing information-seeking systems.

ACKNOWLEDGEMENTS

This work was partially supported by funding from the National Library of Medicine, through the Pacific Northwest Regional Medical Library.

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Nancy Ottman Press, Library Director and Associate Professor, Mars Hill Graduate School, 2525 220th St. SE, Suite 100, Bothell, WA 98021, and Mary Diggs-Hobson, Co-founder and Executive Director, African Americans Reach and Teach Health Ministry, 7728 Rainier Avenue South, Seattle, WA 98118.
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Consumer health information from both sides of the reference desk.

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