health literacy and health information behavior of florida public library users: a mixed methods...

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published online 17 April 2014Journal of Librarianship and Information ScienceYong J. Yi

Health literacy and health information behavior of Florida public library users: A mixed methods study

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Introduction

With frequent changes in the healthcare environment and demands for more health-related information, people are relying heavily on consumer health information (Fox and Duggan, 2013). Although a majority of Americans seek consumer health information on the Internet (Mayer et al., 2008), about 6% of American adults perceive public librar-ies as their primary or valuable source for health informa-tion (Kwon and Kim, 2009), and still look for print sources, such as books and magazines (Zickuhr et al., 2013). Public libraries have provided people with health information for over 40 years (Baker et al., 1998). A user referred to as a consumer is anyone who looks for health-related informa-tion on any subject, including self-treatment, health insur-ance, or how to lead a healthy lifestyle (Medical Library Association and the Consumer and Patient Health Information Section, 2003). Thus, consumer health infor-mation is limited to the health information available to lay people, rather than health professionals.

Consumer health information delivered by public libraries has been presented in a variety of formats, includ-ing brochures, posters, print books, serials (e.g. maga-zines), journal articles, audio-visual (e.g. CD-ROM, DVD) materials, databases, online resources, etc. The library ser-vices that users engage with include reference services

(either on-site or by mail/email and phone), interlibrary loans, various types of online services (e-book, Ask a Librarian, mobile services), etc. Many people use public libraries as their frequent point of access for seeking health information (Zickuhr et al., 2013), in part because public libraries are perceived as an ‘unobtrusive and inexpensive channel’ (Khalil, 2001: 93). However, little attention has been paid to the users’ health information behaviors within public libraries. Instead, most previous research discusses users’ health information behaviors in health science libraries or hospital libraries (Bryant, 2004; Gray et al., 2012; Scherrer, 2004; Weightman and Williamson, 2005; Zach et al., 2012).

With regard to health information behavior, many stud-ies have found that inadequate health literacy is one of the major barriers to using such services in public libraries (Alpi and Bibel, 2004; Bibel, 2008; Brown, 2008; Burnham and Peterson, 2005; Gillaspy, 2005; Hourston, 2008; Orban,

Health literacy and health information behavior of Florida public library users: A mixed methods study

Yong J. YiSungKyunKwan University, South Korea

AbstractThe study aimed to examine users’ self-perceived health information behavior according to their health literacy ability. The proficiency levels for health literacy were measured by scores on the Short Test of Functional Health Literacy Ability (S-TOFHLA). The study conducted self-administered surveys with 131 public library users and semi-structured intensive interviews with 20 users as a follow-up. Surveys found that most participants had proficient levels of health literacy, and there was an association between health literacy and some demographic characteristics such as gender and educational level. The majority assessed their health information behavior as high. Interviewees identified critical barriers to seeking, evaluating, and using health information delivered by public libraries. Findings provided insights into public libraries for better assistance for their users’ particular needs such as preferred resources or services. Above all, the findings acknowledged the challenges of current services, and suggested the strategies for coping with them.

KeywordsHealth information, health literacy, information behavior, mixed methods, public library

Corresponding author:Yong J. Yi, Institute for Knowledge and Information Management, School of Library & Information Science, SungKyunKwan University, 53 Myung Ryun Dong 3 Ga, Jong No Gu, Seoul 110-745, South Korea. Email: [email protected]

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2005). Health literacy is ‘the ability to identify relevant sources of information, use them to find the necessary information, assess the quality and appropriateness of the information, and finally to analyze, comprehend, and use the retrieved information to make an informed healthcare decision’ (Medical Library Association, 2003: para. 4). It is obvious, by definition, that inadequate health literacy hin-ders library users in effectively finding, evaluating, and using consumer health information. However, few empiri-cal studies have focused on health literacy in the context of public library use; it is hard to find research that measures the health literacy ability of public library users, or that investigates users’ perceptions of their own health literacy.

In order to fill this gap, the present study explores how public library users’ health literacy, measured by the Short Test of Functional Health Literacy Ability (S-TOFHLA), is related to their behavior in finding, evaluating, and using consumer health information in daily practice. Investigating the characteristics of health information behavior associ-ated with the users’ health literacy can provide insights for libraries considering enhanced assistance for their users’ particular needs by acknowledging the challenges of cur-rent library services or the users’ preferred resources or ser-vices. Therefore, understanding the relationship between health literacy ability and health information behavior can translate to improvements in health information services.

Literature review

The origin of consumer health information can be found in bibliotherapy, which used books to help calm patients (Cheu, 2001). Wannarka (1968) discussed the growth and development of medical collections in libraries. In the late 19th century, medical collections were included as resources in public libraries. By 1898, a collaborative effort had developed between a public library and the med-ical profession, resulting in the Colorado Medical Library Association, with a collection consisting of 5322 volumes. During this period, the medical collection mainly served medical students and healthcare professionals. By the 1950s, the Medical Library Association limited a librari-an’s role to making health-related information available. As early as 1969, however, a hospital library extended its services to patients: the Kaiser Permanete Health Library in Oakland, California was the first hospital-based library to provide health information services to lay people (Wannarka, 1968). These services included reference ser-vices, audio-visual programs, and loaning materials. This trend continued during the 1990s and early 2000s, as changes in the healthcare environment have driven public libraries to deliver health information to their users. This section will discuss the key concepts, health literacy, and consumer health information behavior in public libraries, and next, self-perception theory which is employed for a theoretical framework of the present study.

Health literacy

Previous studies have shown that health literacy is one of the greatest barriers to consumer health information ser-vices in public libraries (Bibel, 2008; Brown, 2008; Gillaspy, 2005; Hourston, 2008; Kars et al., 2008). Many studies have defined health literacy (US Department of Health and Human Services, 2000; World Health Organization, 1998; Zarcadoolas et al., 2006). The World Health Organization’s (1998) broad definition of health lit-eracy is ‘the achievement of the cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand and use information in ways that promote and maintain good health’. The American Medical Association Council of Scientific Affairs defined it more narrowly, as ‘the ability to read and comprehend prescription bottles, appointment slips, and the other essential health-related materials required to successfully function as a patient’ (American Medical Association, 1999: 552). According to Centre for Advancement of Learning (2000, cited in Speros, 2008: 636), the compo-nents of health literacy consist of ‘reading and numeracy skills, comprehension, the capacity to use information in health care decision-making, and successful functioning in the role of health care consumer’. Other sources define it as ‘the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions’ – Healthy People 2010 (US Department of Health and Human Services, 2000: 3) and The Health Literacy of America’s Adults (Kutner et al., 2006).

Prior to defining health literacy, the Medical Library Association (MLA) (2003: para. 5) defines health informa-tion literacy as:

the set of abilities needed to: recognize a health information need; identify likely information sources and use them to retrieve relevant information; assess the quality of the information and its applicability to a specific situation; and analyze, understand, and use the information to make good health decisions.

The key element of health information literacy is the recog-nition of a need for health information. By adding the key concept, MLA (2003: para. 4) defined health literacy as:

the ability to identify relevant sources of information, use them to find the necessary information, assess the quality and appropriateness of the information, and finally to analyze, comprehend, and use the retrieved information to make an informed healthcare decision.

Since the MLA’s definition specifically describes the key concepts of health literacy that the present study focuses on – finding, evaluating, and using it – the MLA’s defini-tion is most appropriate for the present study.



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Consumer health information behavior in public libraries

Previous studies highlight that consumer health informa-tion plays a vital role in reducing people’s anxiety by help-ing them understanding their health issues, and empowers them to make informed health-related decisions (Bolton and Brittain, 1994; Pifalo et al., 1997). Since one of the first places laypeople seek health information is the public library, the role of these institutions has grown rapidly (Gillaspy, 2000; Tu and Hargraves, 2003). Above all, pub-lic libraries have provided complementary services, which healthcare professionals may not provide due to lack of time or expertise (Yi et al., 2012).

The majority of users seek health information regarding the diagnosis of and available treatments for physical ail-ments (Alpi and Bibel, 2004; Kars et al., 2008; Yi et al., 2012). According to Rees (1982, cited in Allcock, 2001: 22), users seek health information in order to ‘identify, alleviate, and remedy diseases and ailments; … to preserve health and prevent disease; and … to access supporting services in their communities that can assist them in cop-ing with the financial, social, and economic impact of ill-ness’. While consumers have diverse health information needs, their needs and behaviors differ from those of phy-sicians, nurses, and allied healthcare professionals. For example, consumers quite often seek the experiences of others who share the same health problems (Stvilia et al., 2009). In addition, individual’s situations, including lack of health insurance or expensive healthcare services, lead consumers to independently seek out consumer health information (Yi et al., 2012).

Consumers perform a variety of health information behaviors within libraries. They may seek health informa-tion for themselves or others (e.g. family, friends, or col-leagues) by searching libraries’ collections or databases (e.g. Gale’s Health Reference Center, EBSCO’s Health Source Plus). Furthermore, consumers use the Internet to find health information at libraries. They also seek infor-mation through face-to-face meetings with librarians, vir-tual reference services (e.g. Ask a Librarian, Internet Public Library), phone, and email reference services. With regard to health information behavior, previous studies aforementioned highlight that consumer health informa-tion needs to be easy to understand and available in diverse formats, in order to provide better services for users with different literacy levels.

Self-perception theory

The present study applies self-perception theory for its conceptual framework. Previous studies discuss self-perceived information literacy skills, and associate them with anxiety related to information-seeking behavior (Collins and Veal, 2004; Kuhlthau, 1991; Morris et al.,

1992). Self-perception theory, developed by psychologist Daryl Bem (1972), addresses the relationship between an individual’s attitude and their behavior. The theory sug-gests that people may judge their own internal states, such as attitude or emotion, by monitoring their own behavior. It is the opposite of traditional ideas that behavior is an exter-nal expression of attitudes or beliefs, meaning that behavior is dictated by internal states. According to self-perception theory, individuals rationally assess their own knowledge or skills by observing themselves through experience.

Measuring self-perception has its limitations, since it relies solely on self-reporting. However, it has been utilized to study people’s behavior. Kuhlthau (1991) investigated users’ self-perception of affective and cognitive aspects of the information-seeking process. Gross and Latham (2007) addressed the gap between users’ self-assessment of infor-mation-seeking skills and their actual skill levels. Collins and Veal (2004) discussed self-perception’s relationship to library anxiety. They assessed staff barriers (users’ self-perception of staff’s approachability), affective barriers (users’ self-perception of skills), comfort with the library, knowledge of the library (familiarity with the library), and mechanical barriers (self-perception of skills related to library equipment). Norman and Skinner (2006) developed the measure of eHealth literacy based on the concept of self-efficacy, which Bandura (1977) employed as one’s belief in his/her ability to successfully perform specific tasks or goals. Bandura highlights that self-efficacy is influ-enced by self-perception and external experiences. The self-efficacy concept, thus, employed for eHealth literacy is closely related to, and even similar to the self-perception concept of the present study. Norman and Skinner (2006) assessed eHealth literacy by measuring self-perceived skills or self-efficacy at finding, evaluating, and using health information on the Internet.

Research questions

The purpose of the present study is to investigate the asso-ciation between public library users’ health literacy ability and their self-perceived health information behavior, and the relationship between their health literacy ability and their actual health information behavior. Health literacy skills were classified into three levels: inadequate (0–53), marginal (54–66) and adequate (67–100) based on the S-TOFHLA scale (Baker et al., 1999; Nielsen-Bohlman et al., 2004). In this study, inadequate and marginal levels (0–66) are defined as below proficient, and adequate levels (67–100) are defined as proficient. Measuring the self-perceived skills assumes that library users have honest sense of assessing their own experiences and abilities. This study is guided by the following research questions:

1. What is the current status of health literacy for pub-lic library users? Is there any association between




the users’ health literacy ability and demographic characteristics?

2. How do public library users perceive their ability to seek health information in public libraries? How do they find health information resources?

3. How do public library users perceive their ability to evaluate health information? How do they eval-uate health information?

4. How do public library users perceive their ability to use health information? How do they use health information?

5. What barriers to finding, evaluating, and using health information do public library users report encountering?

Methodology

The study employed mixed methodology incorporating quantitative and qualitative methods in order to triangulate the findings. The data sets collected from both methods are likely to ‘enhance, elaborate, or complement’ each other (Creswell, 2003: 563). This research, among mixed meth-ods, chose an explanatory design employing sequential data collection; first, the study collected quantitative data from surveys, a primary method, since it needed to inves-tigate the results of the S-TOFHLA and self-perceived health information behavior from many users, and then collected follow-up qualitative data through interviews among the sample. Since the self-perception theory, a the-oretical framework of the study addresses the relationship between an individual’s attitude/ability and behavior, the study needed to ask in-depth and specific questions which are hard to ask with surveys.

For the quantitative study, 200 surveys were distributed in Florida public libraries between March 2011 and May 2011, and 131 responses were collected; thus, the response rate was 65.5% – 14 pilot study participants were excluded. The main library, along with two branch libraries, serves the majority of users (Leon County Public Library System, 2009, 2010). The users in the two branch libraries came from different ethnic groups: At one branch, over 70% of users were African-American, and at the other more than 55% were white (Florida State University, 2002–2011). The study sampled from these two branches, in addition to the main library, in order to include users from as many

backgrounds as possible. The survey participants were composed of 55 males and 76 females. Most of them were black (69 users) or white Americans (57 users), and 5 eth-nic minorities, including 3 Latinos, 1 Native American, and 1 Asian. The sample included adult library users only, since S-TOFHLA is designed to measure adults’ functional health literacy abilities. Survey participants were compen-sated by being entered into a drawing for one of ten $20 Wal-Mart gift cards.

As a follow-up to surveys, semi-structured intensive interviews were conducted between April and May 2011. The study selected 20 interviewees among survey respond-ents, based upon gender, race, educational level, and age, as presented in Table 1. The interviews employed the criti-cal incident technique, which is appropriate for qualitative analysis of special events/instances that people have expe-rienced (Flanagan, 1954). The present study asked inter-viewees to recall and describe specific health information activities, including their health information needs, situa-tions causing health information seeking, obstacles/diffi-culties encountered. The interviewees were actively involved in seeking, evaluating, and using consumer health information at the time of the study. All of the interviewees were compensated with $20 Wal-Mart gift cards.

Study instruments

The survey questionnaire was composed of measures compiled from previous studies (Aguirre et al., 2005; Baker et al., 1999; Emory University, 1995; Norman and Skinner, 2006; Pifalo et al., 1997). They were categorized into three different parts: (1) S-TOFHLA (Emory University, 1995), (2) Health information behaviors, with questions slightly modified from eHEALS (Norman and Skinner, 2006) and Pifalo et al.’s (1997) study, and (3) library user profile. Part 1 measured health literacy, Part 2 asked about users’ self-perception of health information behaviors, and Part 3 collected users’ demographic infor-mation. Note that the present study borrowed eHEALS to employ verified questions to measure health information behavior, rather than using its original scale; eHEALS scale treated health information behavior on the Internet as a single factor, whereas the present study categorized health information behavior into three: finding, evaluat-ing, and using health information.

Table 1. Demographics of interviewees.

Gender Race Education Age

Female (n=13) White (n=11) High school (n=2) 18–24 yrs old (n=2)Male (n=7) Black (n=8) College (n=10) 25–34 yrs old (n=2) Native American (n=1) Graduate (n=9) 35–44 yrs old (n=1) 45–54 yrs old (n=7) 55–64 yrs old (n=6) 65yrs & older (n=2)



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In measuring health literacy, the S-TOFHLA assesses both numerical and reading abilities and takes up to 12 minutes to administer. Reading comprehension is meas-ured by 36 questions, and 4 are reserved for the numerical abilities test. The test items of The S-TOFHLA are drawn from medical field. Numerical ability questions aim to assess ‘an ability to understand monitoring blood glucose, keep a clinic appointment, obtain financial assistance, and understand directions for taking medicines using an actual pill bottle’ (Nielsen-Bohlman et al., 2004: 48). Reading comprehension questions were drawn from ‘instructions for preparation for an upper gastrointestinal series, the patient “Right and Responsibilities” section of a Medicaid application, and a standard informed consent form’ (Nielsen-Bohlman et al., 2004: 48).

Regarding interviews, the study employed content analy-sis using open coding, axial-coding, and theory notes. Specifically, open coding identified some categories (e.g. situations that caused health information seeking, emotional status, health information needs, information behaviors, self-perceptions of health literacy, information barriers, etc.) that characterized health information behaviors that occurred in public libraries. After open coding was done, axial coding was conducted in order to analyze the relation-ship or interaction between variables, for instance, the links between categories that consist of health information behav-ior, and between health information barriers and self-perceptions of health literacy. Based on the connection between the categories, lastly, the researcher created theoreti-cal notes which contributed to identifying meanings that rela-tionship between the categories implied and drawing cohesive ideas regarding health information behavior of users.

Findings

Research question 1

The first research question focused on the current status of public library users’ health literacy, and if health literacy ability (measured by the S-TOFHLA) was related to demo-graphic variables – gender, race, age, and educational level. Scores for the S-TOFHLA range from zero to 100 points. Each numerical ability question is worth seven points, for a total of 28 possible points. Each reading com-prehension question is assigned two points, for a total of 72 possible points. As presented in Table 2, the S-TOFHLA scores of the current study are overall high: the mean is 95; the median is 98; and the mode is 100.

Most participants (98.5%) had proficient health literacy (67–100 points), while only 1.5% of the study participants

had below proficient (0–66 points) health literacy ability. Therefore, the study concluded that it was not appropriate to divide the study participants into two different levels of health literacy groups by applying the standard of the S-TOFHLA. Note that the current study focused on ana-lyzing health information behaviors of proficient users, because of the characteristics of the sample.

Associations between health literacy and gender. The result of the Mann-Whitney test between health literacy and gen-der in the Table 3 presents that the difference in health lit-eracy ability between males and females is statistically significant. The mean ranks of male and female partici-pants provide more accurate depiction of difference between the two groups. The mean rank of females was 72.44, and the mean rank of males was 57.10, which indi-cated that female users were likely to have greater health literacy abilities than male users.

Association between health literacy and race. According to Table 4, the Kruskal-Wallis test between health literacy and race indicated that there was no significant association between health literacy ability and race.

Association between health literacy and educational level. All participants except two people (unknown) had high school education or higher. According to Table 5, there is signifi-cance between health literacy ability and the level of edu-cation. While mean rank of high school graduates is 39.94, mean ranks of college and graduate school graduates are 65.63 and 73.70, respectively.

Table 2. Descriptive statistics of health literacy.

S-TOFHLA Minimum Maximum Mean Median Mode Std. deviation

Points 44.00 100.00 95.03 98.00 100.00 8.62

Table 3. Mean difference of gender.

Gender N (=131) Mean rank Mean

Female 76 72.44 96.697Male 55 57.10 92.745

(p = .017).

Table 4. Mean difference of race.

Race N Mean rank Mean

Health Literacy White 69 68.20 97.029 Black 57 57.82 92.429 Other 5 96.899 Total 131

(p = .097).




The findings indicate that college graduates are likely to have higher health literacy ability than high school grad-uates. There is, however, no significant difference of health literacy ability between college graduates and graduate school graduates.

Association between health literacy and age. As presented in Table 6, the study divided the sample into six homogeneous groups based on age. The result of Kruskal-Wallis test between health literacy and age indicates that there is no sig-nificant association between health literacy ability and age.

Research question 2

Research question 2 asked about users’ self-perception of their ability to find health information in public libraries. When asked about the importance of their ability to access health resources, as presented in Table 7, only 8 (6.1%) and 16 participants (12.2%) responded that it was not important at all or it was not important, respectively. While 19 participants (14.5%) were unsure of its importance, 51

participants (38.9%) felt it was important, and 37 partici-pants (28.2%) indicated that it was very important.

According to Table 8, only six participants (4.6%) strongly disagreed with the statement, ‘I know what health resources are available in the library’. Thirty-two (24.4%) users disagreed, and 31 (23.7%) were undecided. The larg-est number of respondents, 47 (35.9%) users, agreed with the statement, and 15 (11.5%) users strongly agreed.

Table 9 presents the responses to the statement, ‘I know where to find helpful health resources in the library’. Only seven (5.3%) users strongly disagreed, and 24 (18.3%) users disagreed. 21(16.0%) were ‘undecided’. In comparison, 70 (53.4%) and nine (6.9%) participants agreed or strongly agreed, respectively.

As presented in Table 10, when asked if they knew how to find resources, only six (4.6%) among 130 respondents strongly disagreed, and 12 (9.2%) users disagreed. Ten (7.6%) users responded ‘undecided’. A large number of the respondents, 80 (61.1%) users, agreed, and 22 (16.8%) users strongly agreed.

Interestingly, there were significant differences between answers for questions regarding finding behavior. Table 11 presents the results of paired T-tests for it. Study partici-pants rated higher on their ability of ‘how to find helpful health information in the library’ than the abilities of ‘where to find helpful health information in the library’, or knowledge of ‘what health resources are available in the library’, which asked more specific abilities. The findings indicated that survey participants might not be familiar with health information resources or services delivered in public libraries, which will be discussed in the section on research question 5.

Table 12 presents frequency of the resources or services which public library users would look first to find health information. The largest number of the participants, 101 users (77.7%) would start their health information search with the Internet, and then 69 participants (53.1%) with printed books, 65 participants (50.0%) with reference ser-vices, 58 participants (44.6%) with printed journal articles, and so on. Respondents could choose multiple resources or services applied to their preferences.

Table 13 presents preference of reference services which public library users would choose when looking for health information. Quite a lot of respondents, 86 users (65.6 %), relied on face-to-face reference services, where 52 participants (39.7%) chose email reference services as

Table 5. Mean difference of educational level.

Education N Mean rank Mean

Health Literacy High 17 39.94 87.647 College 68 65.63 96.088 Graduate 44 73.70 97.318 Missing 2 Total 131

(p = .004).

Table 6. Mean difference of age.

Age N Mean rank Mean

Health literacy 18–24 22 61.93 94.545 25–34 22 72.34 96.182 35–44 20 62.95 94.450 45–54 34 64.60 95.353 55–64 20 70.68 97.550 65 ≤ 11 51.09 94.636 Missing 2 Total 131

(p = .649).

Table 7. Perception of ability to find health information – 1.

Not important at all

Not important

Unsure Important Very important

N= 131 8 16 19 51 37% 6.1 12.2 14.5 38.9 28.2

Responses to a survey question: ‘How important is it for you to be able to access health resources in the library?’.



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the second preference, 29 participants (22.1%) chose tele-phone reference services, and so on.

Regarding the question asking what types of materials/formats the users prefer for obtaining health information in the library, the largest number of respondents, 97 partici-pants (74.0%), would want to get health information from the Internet as presented in Table 14. Next, 74 users (56.5%) wanted it in the format of printed journal articles, and 69 users (52.7%) in the format of printed books.

Research question 3

Research question 3 asked the survey participants about their ability to assess the quality of the health information they located. As presented in Table 15, only one (0.8%) participant strongly disagreed or disagreed, respectively, with the statement that they had the skills to evaluate the health resources they found in the library. Fifteen partici-pants (11.5%) were undecided, where more than half of the respondents, 74 users (56.5%) agreed, and 40 participants (30.5%) strongly agreed.

Table 16 presents the responses to the survey question, ‘I can tell high quality health resources from low quality health resources in the library’. In the responses, only one participant (0.8%) strongly disagreed, and 10 users (7.6%) disagreed, where 36 participants (27.5%) were ‘unde-cided’. Sixty-one participants (46.6%) agreed, and 23 par-ticipants (17.6%) strongly agreed.

The paired T-test result presented in Table 17 indicated that the study participants rated higher on their skills to


Strongly disagree

Disagree Undecided Agree Strongly agree

N=131 6 32 31 47 15% 4.6 24.4 23.7 35.9 11.5

Responses to a survey question: ‘I know what health resources are available in the library’.


Strongly disagree


N=131 7 24 21 70 9% 5.3 18.3 16.0 53.4 6.9

Responses to a survey question: ‘I know where to find helpful health resources in the library’.


Strongly disagree


N=130 6 12 10 80 22% 4.6 9.2 7.6 61.1 16.8

Responses to a survey question: ‘I know how to find helpful health resources in the library’.Missing = 1(0.8%).

Table 11. Paired samples test – finding behavior.

Mean Std. deviation Std. error mean T df Sig.(2tailed)

Pair 1 How - What .52344 1.04214 .09211 5.683 127 .000Pair 2 How - Where .38281 .82406 .07284 5.256 127 .000

(95% Confidence Interval of the Difference).

Table 12. User preferences: first search.

Printed brochures

Printed books

Printed j_articles

Printed serials

Audio-visual

DB Internet Reference services

Other services

None

N=130 34 69 58 41 25 50 101 65 7 2% 26.2 53.1 44.6 31.5 19.2 38.5 77.7 50.0 5.4 1.5

Missing =1(0.8%).

Table 13. User preferences: reference services.

Face-to-face Telephone Email Postal mail Other services None

N=131 86 29 52 13 17 16% 65.6 22.1 39.7 9.9 13.0 12.2




evaluate the health information they found in libraries than their ability to distinguishing high quality and low quality health information. Discrepancy between the two responses, in other words, indicated that the study partici-pants might not have clear ideas about discerning quality health information, which will be discussed in research question 5 reporting health information barriers.

Research question 4

Research question 4 asked the participants about their ability to use or apply health information they found in public libraries to their health questions. First, the study asked the usefulness of public libraries in making healthcare decisions. For this question, as presented in Table 18, 50 (38.2%) users reported that they felt the library was very useful in helping them in making deci-sions about their health, where the smallest number of respondents, 10 (7.6%) users responded that it was not useful at all.

Participants responded to the statement, ‘I know how to use the library to answer my questions about health’, as shown in Table 19. Only three participants (2.3%) strongly disagreed, and four (3.1%) participants disagreed. In com-parison, more than half of respondents, 76 participants

(58.0%) agreed, and 32 participants (24.4%) strongly agreed.

Regarding the survey question, ‘I know how to use the health information I find in the library to help me’, accord-ing to Table 20, only two (1.5%) and three (2.3%) partici-pants strongly disagreed or disagreed, respectively, where the largest number of participants, 86 users (65.6%) answered that they agreed.

In response to the survey question, ‘I feel confident in using information from the library to make health deci-sions’, only two (1.5%) participants strongly disagreed, and seven participants (5.3%) disagreed, where more than half of participants, 72 users (55.0%) agreed, and 20 par-ticipants (15.3%) strongly agreed. Table 21 presents the responses.

When comparing the answers regarding behavior of using health information, there were significant differ-ences as presented in Table 22. According to the paired T-test results, the participants rated lower on their ability to use the library to answer their questions about health than using the health information they find in the library, or using information from the library to make health decisions. The findings indicated that the participants were less confident in using consumer health information services provided in public libraries than applying such information to their health issues, which will be specifi-cally discussed later in the section of health information barriers.

In order to get better insight into using behavior, the study asked the survey participants about the impacts of health information that they found in public libraries, in terms of knowledge extension, actions taken (e.g. health behavior/lifestyle changes), and a change of feelings. First, regarding knowledge extension, as shown in Table 23, 101 participants (77.1%) answered that they learned more about the health issues, and 105 participants (80.2%) answered that they would better understand information that their doctor provided.

Second, the study asked if the survey participants would take, or had taken such actions as change of health behav-ior or lifestyle after using health information. Table 24 pre-sented that a majority of them (108 users) answered that they would ask their doctor more questions about the health information that they found, or they (106 users) would bring more pertinent health information to their doctor, after using health information than before. Similarly, 109 participants (83.2%) answered that they

Table 14. User preferences: actual use.

Printed brochures

Printed books

Printed j_articles

Printed serials

Audio-visual

DB Internet Reference services

Other services

None

N=131 42 69 74 44 34 40 97 48 6 3% 32.1 52.7 56.5 33.6 26.0 30.5 74.0 36.6 4.6 2.3

Table 15. Perception of ability to evaluate health information – 1.

Strongly disagree


N=130 1 1 15 74 40% 0.8 0.8 11.5 56.5 30.5

Responses to a survey question, ‘I have the skills I need to evaluate the health resources I find in the library’.Missing =1(0.8%).

Table 16. Perception of ability to evaluate health information – 2.

Strongly disagree


N=131 1 10 36 61 23% 0.8 7.6 27.5 46.6 17.6

Responses to survey question, ‘I can tell high quality health resources from low quality health resources in the library’.



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would make better decisions about treatment, whereas only 78 users (59.5%), answered that they would more easily change their lifestyle (e.g. stop-smoking/alcohol, lose weight, start work-out) after that than before.

Third, the study asked if the survey participants would experience, or had experienced, a change of anxiety after using health information provided in public libraries. According to Table 25, quite a few respondents, 86 users

(65.6%), answered they would more easily reduce their anxiety about the health issues after that, while 28 users (21.4%) responded ‘unsure’ for the question, and 17 users (13.0%) responded they had, or would have no change of anxiety.

Research question 5

Answers for research question 5 were provided from in-depth interviews. With regards to barriers to finding health information, they reported limited collections, difficult healthcare terminologies, unskilled search, the barriers with staff, and a lack of awareness for health information resources or services. These barriers corroborated the sur-vey results; the survey participants were not clearly aware of what health resources are available, or where to find helpful health information in the library. Such barriers connected to their perceived ability to use the library to answer their questions about health, which survey partici-pants rated lower than the other abilities to use health information in surveys. Most interviewees shared the importance of public awareness about health information services, mentioning promotion (e. g. seminar or work-shop) for drawing public attention.

As for the barriers to evaluating health information, likewise, interviewees reported that they were not famil-iar with the quality criteria/indicators/markers that should be applied to discern reliable or trustworthy health infor-mation. This finding confirmed the results of the surveys. In addition, participants reported difficulty in judging contradictory treatments: which treatment options were right or wrong. When applying health information to them, the interviewees had particular difficulty in under-standing health terminology, or changing their health behavior or lifestyle. They also reported that they were confused when encountering conflicts between conven-tional medicine and complementary and alternative medicine.

Discussion

According to self-perception theory, individuals may assess their own knowledge or skills by observing their experience. Study participants rated their ability to find, evaluate, and use health information based on their percep-tion of what they have performed in public libraries. The findings from this study corroborate that theory; overall, participants’ self-perceived abilities tended to be high, and

Table 17. Paired samples test – evaluation behavior.


Pair 3 Skill- Quality .43411 .80860 .07119 5.683 127 .000


Table 18. Perception of ability to use health information – 1.

Not useful at all

Not useful Unsure Useful Very useful

N=131 10 17 36 50 18% 7.6 13.0 27.5 38.2 13.7

Responses to a survey question, ‘How useful do you feel the library is in helping you in making decisions about your health?’.


Strongly disagree


N=131 3 4 16 76 32% 2.3 3.1 12.2 58.0 24.4

Responses to a survey question, ‘I know how to use the library to answer my questions about health’.


Strongly disagree


N=131 2 3 14 86 26% 1.5 2.3 10.7 65.6 19.8

Responses to survey question 32, ‘I know how to use the health infor-mation I find in the library to help me’.


Strongly disagree


N=131 2 7 30 72 20% 1.5 5.3 22.9 55.0 15.3

Responses to survey question 35, ‘I feel confident in using information from the library to make health decisions’.




most of them had proficient or even advanced health liter-acy as well. In other words, the study participants’ high rating of their health information behavior connected to the high scores they obtained on S-TOFHLA.

There are possible reasons for the high results on S-TOFHLA in the current study. First, the high scores may stem from characteristics of the study participants. Compared with the general public, public library users are likely to have a higher functional literacy; according to Pew Internet & American Life Project, people with college or higher level of education are more likely to have used public librareis than those with lower levels of education (Zickuhr et al., 2013). Previous studies indicated that edu-cation attainment is associated with functional health lit-eracy (Kars et al., 2008). Therefore, a majority of public library users with higher educational level are likely to demonstrate higher levels of health literacy.

Regarding S-TOFHLA, there was a consistent pattern indicating that the study participants would provide

incorrect answers to certain questions (such as questions 19 and 24); only a few items may differentiate health lit-eracy abilities among them. Otherwise, it seemed that pub-lic library users were likely to get a high score, usually more than 90 points. In addition, the scores may have been high because the questions of the S-TOFHLA are written in simple language, and include a little health care termi-nology. Therefore, the study findings suggested that S-TOFHLA needs to be modified or a different test should be considered to better assess the levels of health literacy.

According to the findings for first search and actual use, while more than 70% of the survey participants identified the Internet as the first resource for both, over 50% of them indicated that they also relied on printed books or journal articles, respectively. From the interviews, the users reported that printed books were easy to browse, and printed journal articles were appropriate resources to get in-depth health information. Compared to the responses for the first search, the preference for brochure and audio-visual materials for actual use apparently increased by six and seven percents respectively. The difference of prefer-ence for the first search and actual use suggested that users were likely to start searching for information using certain types of resources or services, but they actually want to look at it in a different format. As for reference services, survey participants relied more on face-to-face services rather than email, phone, or postal mail services.

The findings from interviews provided further evidence of users’ lack of knowledge of quality criteria. However, interviewees often mentioned ‘credential’ as an indicator for authority and ‘duplication’ as an indicator for accu-racy. Interviewees tended to trust health information pro-vided by authoritative healthcare professionals. For them, the more frequently repeated information was considered more worthy to be believed, since reiterated information indicated agreement or reputation among others.

With regard to the impact of health information, study participants reported that the health information had helped them become more conscious or cautious by learning about the causes or the nature (symptoms or progress) of health issues. Some interviewees highlighted that health informa-tion obtained from their own self-research was helpful in finding specific treatments for their particular health issues that even their doctors could not provide appropriate pre-scription or treatments. Increased knowledge motivated their actions – asking more questions, bringing pertinent questions to their doctors, making treatment decisions, and

Table 22. Paired samples test – using behavior.


Pair 4 Decisi – Lib. .63566 1.13838 .10023 6.342 128 .000Pair 5 Health – Lib. .62791 1.26287 .11119 5.647 128 .000


Table 23. Knowledge extension.

Learn more Better understand

Yes 101 (77.1%) 105 (80.2%)No 8 (6.1%) 8 (6.1%)Unsure 21 (16.0% ) 17 (13.0%)

(N = 130, Missing = 1 (0.8%)).

Table 24. Actions taken.

Ask more Bring information

Treatment decision

Behavior change

Yes 108 (82.4%) 106 (80.9%) 109 (83.2%) 78 (59.5%)No 10 (7.6%) 6 (4.6%) 7 (5.3%) 18 (13.7%)Unsure 13 (9.9%) 19 (14.5%) 15 (11.5%) 35 (26.8%)

(N = 131).

Table 25. Anxiety decrease.

Anxiety decrease

Yes 86 (65.6%)No 17 (13.0%)Unsure 28 (21.4%)

(N = 131).



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changing lifestyle/health behavior. However, the survey participants identified change of lifestyle/health behavior most challenging among the actions, which suggested that the relationship between health literacy and behavior change was not likely linear.

Regarding a change of feelings, a relatively smaller number of the survey participants reported that their anxi-ety decreased, whereas a relatively larger number of the survey participants, 34.4%, responded that they were unsure about a decrease of anxiety, or had not experienced it. According to Kuhlthau (1991), people would feel relieved if the search was successful, or disappointed if it was not. However, some interviewees in the current study experienced an increase in anxiety when they found what they wanted. For example, after discovering severe pro-gress or medical limitations (no treatment available) of a disease or an inevitable step (e.g. surgery) for a treatment, people would become more anxious than before they had found the health information. This finding, therefore, sug-gests that the characteristics of a task influence the affec-tive aspects of the information search process; while the information search process (Kuhlthau, 1991) can be applied to neutral queries (e.g. academic task), it cannot be applied easily to healthcare-specific queries, particularly to those which are related to personal health issues.

In the in-depth interviews, the participants identified critical barriers. They had experienced confusion from encountering health information which recommended contradictory treatment or remedies, suggesting there are limitations to functional health literacy which focuses mainly on reading and understanding the information, but little on assessing it. Similarly, interviewees reported chal-lenges in choosing healthcare treatments because of con-flicts between conventional medicine and complementary and alternative medicine. This addresses the dilemma of public library services; although users frequently ask such questions, librarians should not provide these information services, since which violate reference ethics. According to the code of ethics, a librarian’s role is not answering their health or medical questions (including recommenda-tions about medications, treatments, health professionals), but guiding users to health information. In the same vein, neither should they interpret the health information for users nor give health care advice to users based on their personal knowledge. Therefore, effective collaboration or referral services between the librarians and healthcare pro-fessionals need to be set up in order to provide the users with authentic answers for such healthcare queries, and thereby improving user satisfaction.

Conclusion

Self-perception theory brought a paradigmatic change in classic findings in which one’s attitude or belief is the pre-dictor of his or her behavior. In other words, self-perception

theory contends that there is a reverse relationship between cause and effect; people can identify their ability or belief from their behavior. The findings from this study support Bem’s theory, and furthermore, extend the application of the theory to LIS field by addressing the association between health literacy and health information behavior. Self-perception theory can be integrated into training/edu-cation for librarians as well; it can be explored whether librarians are likely to shift their attitude or perception of library users after participating in repeated programs to improve library services for users

The results of S-TOFHLA indicated that most of the study participants had proficient health literacy, and there was an association between health literacy and demo-graphic characteristics such as gender and educational level. Above all, the findings from this study highlighted that proficient users tended to assess their health informa-tion behavior positively. Interestingly, the participants heavily relied on printed resources as well as the Internet, and identified public libraries as a source to obtain printed health information.

Public libraries need to take into account user prefer-ences, in particular the resources that users frequently request, when developing health information collections. For instance, audio-visual materials are good candidates for users who have trouble seeing or reading. Even if most of the study participants were proficient, libraries need to assume below proficient users. Better understanding of the relationship between health literacy abilities and health information behavior may provide insights into effective consumer health information services to public libraries. Based on the insights, public libraries can support the par-ticular needs of below proficient users as well as proficient users. Meeting their different preferences may contribute to lowering information barriers of public library users, who are either proficient or below proficient.

Even interviewees with proficient health literacy indi-cated difficulty understanding healthcare terminology. It is, thus, desirable to provide health information at multiple reading levels and in different kinds of formats to meet different literacy levels and various learning styles, so that users have the choices to best fit their needs without expe-riencing the embarrassment of asking for low-literacy materials (Orban, 2005).

Regarding barriers to consumer health information ser-vices, the interviewees considered a lack of public aware-ness one of the biggest challenges. What might be done in the context of public libraries to lower the barriers? A sim-ple endeavour can increase public awareness: for instance, public libraries can attract users with interesting healthcare topics such as frequently asked seasonal or local health questions (e.g. flu, pollen allergies) and inform them that libraries can support such healthcare concerns. It will be helpful to add more and clearer signs informing users that health information resources are available in the libraries,




around the facilities or the places (e.g. entrance door, front desk, and restroom) people visit often. These efforts will enhance the social role of public libraries as a valuable health information source in a community, thereby making a contribution to public health.

Funding

The author would like to acknowledge the 2011 Beta Phi Mu Eugene Garfield Dissertation Scholarship Committee for their financial support of this research study.

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Author biographyYong J. Yi MLIS, PhD, is a Senior Researcher and Adjunct Professor in the Institute for Knowledge and Information Management, School of Library and Information Science, SungKyunKwan University, Seoul, South Korea. She completed a PhD in the School of Library and Information Studies, College of Communication and Information at Florida State University.



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