Abstract

MJA 1997; 167: 579-581  

Introduction

A United Kingdom study has evaluated the impact of establishing a patient library.⁷ A 200-book library covering 107 topics was established by a general practitioner and librarian at a cost of $1600. Each book contained a questionnaire, to be completed when the book was returned. Over 15 months, 243 books were borrowed; 163 questionnaires (67%) were returned. Sixty-five per cent of respondents in this UK study would not have sought the information elsewhere, and 98% found the books useful or very useful. Forty-four per cent felt their anxiety levels had reduced as a consequence of reading the book.⁷

My purpose was to replicate this work in an Australian setting, aiming to determine the value of providing health information by means of a patients' library in an Australian general practice, and to examine the effects of such information on patient knowledge, anxiety and behaviour.  

Methods

The library was available to all patients based on both the recommendation of items by their doctors and on personal selection from a catalogue in the waiting room. The loan period was two weeks and a $2 lending fee was used to cover loss and damage.

The study period was 24 months, during which time the number of items borrowed was recorded. Library items were classified into 22 subject categories and the number of items borrowed from each category was also recorded. Items were available for loan from 1 May 1994.

During the first 15 months (i.e., until 31 July 1995) patient questionnaires were provided with each item when issued. To assess patients' usual reading habits (and modelled on the UK study) the questionnaire asked about their use of the public library service and whether or not they read books or articles on health matters. Patients were also asked how useful they had found the item from the library and whether they or their doctor had selected it. They were asked about their perceptions of their anxiety, knowledge and behaviour after borrowing an item from the library, and whether they would have sought health information elsewhere if it had not been so readily available in the practice library. Finally, they were asked to record the title, and to comment on the item they borrowed.

At the end of the 24 months, the doctors in the practice were asked to complete a short questionnaire which sought information about their impressions of the library, how they used it, the problems they encountered, and the ways in which it could be improved.  

Results

At the end of 15 months, 229 items had been lent and 164 questionnaires returned (response rate, 72%). The findings, in comparison with the UK study, are summarised in Box 1. During the 24 months of the study, 322 items were borrowed, while the practice generated 52 076 consultations, giving a borrowing rate of one item for every 174 consultations. Box 2 illustrates the frequency of borrowings from the 22 categories of items available, and Box 3 lists the 10 most popular books.  

Patient questionnaire

Doctors' questionnaire

The doctors' use of the library varied. One doctor liked to use the books to reinforce a message, another to use the books to increase the patient's understanding of their condition and so improve compliance, and another used the books for areas he personally found difficult to deal with. At times, books were used as a way of providing a second opinion. In so doing it was felt that the book reduced the need for a referral, investigation or prescription.

The biggest frustration reported by the doctors was finding books out on loan or missing when they were required.

With over 200 books in the library, it was not possible to be familiar with all the items in the library and their philosophies. One doctor commented that it was awkward when patients came back knowing more than the doctor.

On one occasion, having become aware of the significance of her scaly scalp condition through reading a book on arthritis, a patient was able to raise the possibility of psoriasis. This was a symptom that had been overlooked by both doctor and patient in previous consultations.  

Discussion

Although this study was based on patient self-report and cannot verify these reported changes, findings of other studies suggest that they may have occurred. Roland and Dixon found that an educational booklet on back pain significantly improved knowledge and patient behaviour up to a year after it had been issued.⁸ Similarly, Sorby et al. demonstrated that an anxiety management booklet significantly reduced anxiety.⁹

However, the value of using health information as a way of changing patient behaviour has been challenged. In a comprehensive review of health education material, Gatherer et al. commented that "written instructions appear to be inferior to most other sorts of instructions".¹⁰ Further, changes in behaviour as a result of the distribution of books may not always be desirable. A randomised controlled study evaluating a booklet for parents on childhood illnesses found that the number of day-time consultations in the intervention group fell by 28% but home visits rose by 173%!¹¹

A possible source of bias in this study is that patients were able to borrow more than one item, and therefore might have completed more than one questionnaire. My intention was to evaluate specific items of health information and their effects on individuals rather than to evaluate individual patients. Only one book was deemed inappropriate and removed from the library.

My findings were very similar to those of the Stevenage study,⁷ indicating that a patient library is an equally acceptable concept to Australian patients. A major difference between the studies was in the use of public libraries, with comparatively few Kincumber patients (13% v. 77% in Stevenage) reporting using the public library as a place to seek health information. This may reflect a different attitude towards public libraries in Australia, but may also be the result of the inaccessibility of public libraries in Kincumber, with the nearest public library about a 20-minute car journey away. As 47% of Kincumber patients saw their GPs as their main source of health information, a practice library seems an ideal way to help fulfil this need as well as to improve the profile of the practice within the community.

As in the Stevenage study, the main users of our library were women (88%). This is no surprise as women attend surgeries more often than men. It does, however, raise the concern that men may be missing out on health information and that other strategies may need to be employed in communities to provide men with health information.

Both doctors and staff found the exercise of running the patient library very satisfying, even though one staff member needed to spend time chasing up overdue books. Ten items were lost during the two years of the study, mostly because patients failed to register them with the reception staff after having had the item selected by their doctor. The $2 loan charge more than covered these losses and has enabled us to update and expand the library. A card index system, as used by most public libraries, proved an effective system for monitoring borrowing and was more acceptable to staff than a computerised database.

The qualitative impression generated by the responses to the doctor questionnaire was that the library offered the doctors another option in their clinical management of patients. Although research has shown that simply increasing doctor (and patient) knowledge does little to improve patient care,^12-14 a process that empowers patients to take control of their illness and reinforces a message presented by their GPs may be effective. A more sophisticated study would be required to determine if a practice library actually influenced management, compliance and outcomes.

Practices wishing to establish a library may find our list of "top 10 books" helpful. Such was the demand for these books that three copies of each title were required. Other titles, such as Cleft lip and palate, were used only once in the two years of the study, but made a tremendous difference to a mother whose baby had been born with a cleft lip. As might be expected, the Stevenage practice had a different top 10 (menopause, cystitis, stress, Alzheimer's, bereavement/death and dying, child care, phobias, women's health, candidiasis, and diabetes), although a number of the topics were popular in both study groups.

Our practice would recommend the patient library and we now wonder how we managed without it. We were fortunate to be able to purchase library items as part of a research project, although it would be possible to build up a collection without straining the practice finances by applying a borrowing fee. The outlay of $2000, with a $644 return over two years, together with the time it took one of our staff to administer the borrowing list, could not be seen as profitable. Nevertheless, the status the library gave to the practice and the help the library gave to both doctors and patients was worthwhile. Notably, we received only one complaint about the borrowing fee during the two years.  

Acknowledgements

References

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Health Link was established at Westmead Hospital in 1984 as a drop-in centre supplying patients, carers and staff with health information from a medically reviewed collection of resources.
In late 1995, Health Link relinquished this role, turning instead to providing PC-based electronic directories for practising GPs of accurate information about health-related services throughout Australia as well as details of a range of publications on health topics written for consumers.
For more information, telephone: 02 9845 7307