Pamphlets in Medical Libraries

Alan Rees in the Consumer Health Information Source Book says that "the major intent" of health related pamphlets "is to provide a simple description of the signs, symptoms....and course of diseases."¹ In 1998, pamphlets were solicited from 10 health organizations, including the American Cancer Society and American Liver Foundation, and these pamphlets do many things besides describe diseases. The National Cancer Institute produces pamphlets, for example, that provide questions and answers about pain control and others that provide eating suggestions for cancer patients. Literature about pamphlets and interviews with several librarians about their libraries' pamphlet collections are discussed. The hypotheses are that pamphlets are collected in different ways by librarians, that pamphlets serve a variety of roles at distinct libraries, and that pamphlets play an important part in the delivery of health information to patient populations and the public. Pamphlets are important, but not necessarily better than the Internet, always up to date, or always free from limited, biased or inaccurate information. Rather, a pamphlet's use is related to the investment in it, they can be used without computer or Internet access, and some are valuable sources of information.

Methodology

The Library Literature database with the search term "pamphlets" was searched to learn what libraries do with pamphlets and to learn the advantages and disadvantages of pamphlets. Ten health related organizations were contacted to see what the pamphlets these organizations produced were like. The MEDLINE and CINAHL databases were searched under the search term "pamphlets'" to learn about the effects of pamphlets on behavior.

Librarians at the following libraries were interviewed:

1. National Library of Medicine

2. Northwestern University, Gaiter Health Sciences Library

3. University of Chicago, John Crerar Library

4. University of Illinois at Chicago, Library of the Health Sciences

5. Loyola University Medical Center Library

6. Rush Presbyterian St. Luke's Medical Center Library

In addition, a nurse educator at Northwestern University's Alberto Culver Women's Health Center and a business development specialist at the Canadian Consulate General's Office were interviewed. These interviews were conducted over the phone to determine the roles of pamphlets at libraries and shed light on the literature review with regard to some specific libraries.

Literature Review

The word "pamphlet" comes from the word "pamphilus" or "about love."² In the 14th century, the word pamphlet was used to distinguish a book from a booklet. In the 1500s, England, France, and Germany's critics of governments used pamphlets. By 1660, during the Restoration, pamphlets had lost ground to newspapers as sources of information. During the Glorious Revolution, circa 1688, pamphlets were used again.³ In the 1700s and 1800s, pamphlets were used by John Milton in the Areopagitica , Thomas Paine in Common Sense and by others for political purposes.⁴

Today, in the medical library, Alan Rees states that "many pamphlets are, in fact, consumer versions of research findings."⁵ He states further that few relate to physical fitness, exercise or prevention.⁶ Rees also states that these pamphlets must be updated regularly and that libraries are slow to get them. He lists roughly 1,400 pamphlets in his book.⁷ A debate has occurred in the library journal literature over whether or not pamphlet collections are beneficial. Pamphlets in libraries have disadvantages as well as advantages.

Disadvantages

1) Pamphlets yield a limited amount of information that is sometimes biased or inaccurate. L. Sherr and B. Hedge examined ante-natal leaflets about HIV infection and AIDS and discovered that all three of the

James Timothy Struck, Reference Librarian, Roosevelt University Library, Chicago.

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examined leaflets "were found to contain some errors and omissions." Also, Sherr and Hedge state that "bias was certainly perceived by observers with these examples."⁸ They conclude, "Leaflets are not a solution to AIDS and HIV counseling. They form one small component and run the risk of creating needs and anxiety rather than resolving these."⁹

2) Pamphlets are a "low-tech tool in a high-tech world" and do not have the appeal of computers.^10,11

3) Survey results from a study published in September 1995 revealed that maintenance of 32 and 37 vertical files, which sometimes contain pamphlets, was seen to be too time consuming. About 25 out of 37 respondents believed the vertical file would not be used enough, 19 thought the information was available elsewhere, and 16 didn't think they had the resources to start and maintain a file.¹²

4) Pamphlet collections are too labor intensive, can be stolen too easily, and are an outdated idea.¹³

5) Pamphlet collections are not current or accessible sometimes.¹⁴

6) Pamphlets can be difficult to access, deteriorate rapidly, and are labor intensive.¹⁵

7) Some health related pamphlets may "be to difficult for many Americans to read and understand since most of the booklets (55%) were written for individuals with grade 12 or higher reading skills."¹⁶

Advantages

1) Pamphlets provide information sometimes available nowhere else, and they are good to supplement a book collection.¹⁷

2) Pamphlets provide an inexpensive alternative source. Even though there is limited data in some pamphlets,"... they have the potential of providing valuable resources and data not found elsewhere in the library."¹⁸

3) The purpose of "public relations in its best sense is to inform and keep minds open... "and pamphlets serve this function.¹⁹

4) Pamphlets are timely, concise, convenient, accessible.²⁰

5) Pamphlets are timely, and the cite some data not anywhere else. A study at the University of Evansville reported that 29 out of 35 vertical file users reported finding the information necessary, and that the vertical file was useful as a supplement to other sources.²¹

6) Pamphlets are concise with unique data.²²

7) Pamphlets "contain data not found elsewhere in the library, which make vital contributions to academic research..."²³

The debate on pamphlet disadvantages and advantages is obviously a vigorous one. Still, there are other issues like how to organize and maintain a pamphlet collection.

Effects of Pamphlets on Health Behavior

The medical literature in MEDLINE and CINAHL were examined to determine the effects of pamphlets on behavior. L. Sherr and B. Hedge make it clear that pamphlets can create needs and anxiety and even perpetuate errors.

An article by Paul Cinciripini, et. al, studied 34 smokers who were treated with a smoking cessation program that involved either scheduled smoking or the use of the American Cancer Society's "I Quit Kit" (controls). "The results showed that 53 percent and 41 percent of the scheduled smoking group was abstinent at the six-and 12-month follow up points respectively." Controls who saw pamphlets against smoking averaged only a 6 percent increase in smoking cessation for the same periods. The conclusion is that scheduled smoking may be a "useful addition" to a smokers treatment program.²⁴

An article by Joanne Harrell, Alisa Cometto and Wanda Stutts discusses intervention with screening, nurse intervention, and an American Heart Association pamphlet on the proper diet to deal with cardiovascular disease among textile workers. The author found that, among the 544 workers studied, mean cholesterol levels increased after the intervention, some stopped and some started smoking and hypertension went down."²⁵

The effects of pamphlets then are mixed. Sherr and Hedge note errors and new anxieties. Cinciripini, et. al., note that the pamphlets alone were not as effective as a scheduled smoking program. Joanne Harrell, et. al., do note some improvement in health-a decrease in hypertension-from procedures like nurse intervention and pamphlets. Librarians should note that pamphlets have varied effects on those who use them because librarians play a role in collecting pamphlets.

Organizing and Maintaining a Pamphlet Collection

Michael Aked describes his experience at the University of Toledo where he put the pamphlets alphabetically by subject and entered them to be

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searchable in the catalog. He also states that dated information is bad and that he needed to date stamp the pamphlets.²⁶

Dorothy Jacobs describes her experience of storing pamphlets in manila folders with labels, date stamps, owner file id's, and mounting paper. She also describes her experience, explaining that time was the biggest cost and that only two libraries from her survey had vertical file funds. About the process of collecting pamphlets, Jacobs states that the Free Resource Builder for Librarians and Teachers can be used, but she also notes that the Vertical File Index is the most used source. Freebies Magazine can also be used to determine which organizations provide pamphlets. Jacobs also notes that of 34 librarians in a South Carolina survey, only one had a written collection development policy for its pamphlets. In South Carolina, 26 of 34 libraries allowed their pamphlets to circulate. More than 50 percent of libraries in this survey also kept statistics of pamphlet use. A survey Jacobs cites by Hodgson and Garoogian also reveals that 10 libraries used Library of Congress Subject Headings, six used Reader's Guide, five used popular headings, two used Vertical File Index, six used Reader's Guide, five used popular headings, two used Vertical File Index, one each used PAIS and Sears. Dorothy Jacobs also notes that one has to promote the pamphlet collection from the reference desk. She also cites work by Joy Thomas that publicity, weeding, and rigorous collection development standards resulted in a 65 percent increase in use.²⁷

Evelyn Payson did a survey of 171 libraries, 139 replied, and 102 or 73.4 percent had a vertical file. Payson also notes that the larger the collection, the more librarians reported that the collection was justified. Halfway efforts were not successful.²⁸

Barbara Alien noted that her primary collection tool was the Vertical File Index. She also noted that hanging files in a cabinet were useful to store the pamphlets. She also cites Hodgson and Garoogian's work that pamphlets may have "only a momentary value."²⁹ She argued that one needs similar collection rules to the general collection to collect pamphlets.³⁰

Much of the literature review discusses vertical files, so it could be argued that the data is not relevant to a paper on pamphlets. However, the Library Literature database included both formats under the subject "pamphlets." Also, it might be argued that pamphlets and vertical file material offers similar collection management challenges.

The Role of Pamphlets in Health Science Libraries: Summary of Interviews

The University of Illinois at Chicago Library of the Health Sciences does not collect pamphlets because it is difficult to keep them current, and much of the same information can be retrieved from the Internet. The head of Reference indicated that the library purchases the Health Reference Center, which contains some full-text pamphlets. It gets moderate use.³¹

The University of Chicago keeps pamphlets received through various depository programs in many areas of health. Five file drawers full of pamphlets, many from the NIH on cancer, are available and filed by general headings, such as breast cancer and prostate cancer. Topics in the pamphlet collection also can be accessed online at the Web site, http://www.lib.uchicago.edu. Then, one can click on the The Sciences, then Biomedical Sciences, then University of Chicago Resources, then Medical Pamphlet File at the Crerar Library. They do not pursue pamphlets by calling various organizations. The pamphlets were rarely used. They did not have a patient library and the pamphlets were patient oriented. The costs were space, processing, staff and storage. The library did not directly belong to the medical school, and there are departmental libraries at the hospital that may carry pamphlets. The National Cancer Institute maintains and funds a Patient Information Center on campus.³²

An interview was conducted with the Rush Presbyterian St. Luke's Medical Center Reference manager and Collection Development specialist will be discussed. She said there are pamphlets that are treated like books in the collection, which are added on a case-by-case basis, and that they were not a depository for government documents. The library subscribed, to the Health Reference Center, like the product that the University of Illinois at Chicago's Library of the Health Sciences had. She said that this was for patient education purposes and that it was not inexpensive. They had the CD-ROM and Web subscription to this resource and printing was available. They do not check out extra pamphlets unless they are catalogued and part of the collection. She also noted that some departments give out pamphlets, like the University of Chicago.³³

The Gale Group's Health Reference Center contains 500 or more resource pamphlets available on the database, 130 journals, and six reference books. The company representative also said this package costs about $2,500 a year in either the CD-ROM or online version.³⁴

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The Canadian Consulate was contacted to learn about the status of pamphlets in a country with a national health plan. A Business Development Specialist was interviewed. He said local governments in Canada decide which pamphlets to produce, and they are produced by the government, not by private organizations.³⁵

Next, Loyola University Medical Center's librarian in charge of the pamphlet collection was interviewed. She said they spend less than $200 a year, that they had no patient library, and that some nurses do collect pamphlets for patients. The library has a vertical file, which gets some use. They do not contact organizations-everything is mailed to them.³⁶

The Prentice Women's Hospital at Northwestern Memorial Hospital maintains a separate library called the Alberto Culver Women's Health Center. The nurse educator who runs the center said they have an average of 20-30 patients a day, mostly from Prentice Women's Hospital. She said the pamphlet collection supports prenatal classes, Lamaze, and breast-feeding classes. Unlike all other libraries, they give away extras. The Women's Health Center had many pamphlets on topics other than women's issues, such as food poisoning and the liver.³⁷

The Northwestern University Gaiter Health Sciences Library maintains a small Reference Department vertical file of tip sheets to answer frequently asked questions. However, the Gaiter Library, according to a librarian, does not have Alberto Culver's mission of providing consumer health education.³⁸

Lastly, a librarian at the National Library of Medicine was interviewed. She said pamphlets are included in the collection if they meet the criteria for collection and are treated and catalogued like books. Pamphlets are identified by title, author, or subject like all other non-serial print materials.³⁹

Conclusion

1. Pamphlet use is a function of investment - time, money and outreach. Librarians at the University of Illinois at Chicago and Rush noted moderate use while they also appeared to invest money for databases. Northwestern's Women's Hospital invested the most in print pamphlets and the nurse educator there noted moderate use.

2. Pamphlets provide a unique form of information. The Internet may have a lot, but pamphlets are able to be brought home. The also are useable by people not acquainted with all the skills or access points that might be needed to find everything on the Internet.

3. Some of the pamphlet producers do not target only consumers. The American Liver Foundation, for example, also provides information specifically for health services providers.

4. Separate collections are the norm, except at Rush and the National Library of Medicine. Rush and the National Library of Medicine integrate pamphlets into the collection. At these two institutions, there might be recognition of the idea that pamphlets are sometimes briefer forms of medical information, not just consumer health information. There might also be an appreciation that integration into the regular collection may result in increased usage.

5. Not all of the libraries attempt to catalog pamphlets, with the obvious exceptions of Rush and the National Library of Medicine. The University of Chicago catalogs onto the Internet by subject, but their collection is not integrated with the rest of their collection.

6. The University of Illinois at Chicago and Rush sometimes substitute online and CD-ROM services for print pamphlets in the form of the Gale Group's Health Reference Center. Rush again has some pamphlets with the rest of their collection, but the larger investment was in the Health Reference Center.

7. Nurses play an active role in collecting and distributing pamphlets at Rush, Loyola, Northwestern, and the University of Chicago. The consumer health emphasis of pamphlets is apparent.

8. Pamphlet collections in medical libraries have disadvantages—cost, the risk of getting lost or stolen, dated material and the cost of processing, but the advantages of pamphlet seem to outweigh these disadvantages. A nurse educator at Northwestern's Alberto Culver library sees the pamphlets used for programs at the Prentice Women's Hospital and 20-30 patients a day. I cannot comment on the psychological importance of getting information on health and disease, but it can be noted that patients at Northwestern's Alberto Culver Library, Rush, and University of Illinois at Chicago and, to a lesser extent, the other libraries can learn about their illness and health status. This is very important to people who don't always feel their health professionals spell things out about their illnesses and how to get well.

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Pamphlets may be biased in one direction, contain errors and manufacture acquiescence to procedures or drugs not accepted without the pamphlets. Pamphlets from competing drug manufacturers, for example, can be like advertisements simply promoting a certain drug, behavior or procedure. Still, pamphlets can disseminate helpful information about disease and, therefore, are valuable and important sources of consumer and medical health information.

NOTE: The author would like to thank Ramune Kubilius, Barbara Nadler, Dr. Cornelius Watson and the editors of the Bulletin of the Medical Library Association for their help in editing this paper.

FOOTNOTES

1. Rees, Alan M. The consumer health information source book. Phoenix: Oryx Press, 1998.

2. Gerhardt, Lilian. On pamphlets needed now. School Library Journal. 1992 Jan; 38:4.

3. Ellison, John W. and Patricia Ann Coty, ed. Nonbook media: collection management and user services. Chicago: American Library Association, 1987.

4. Ellison, op. Cit., 228.

5. Rees, op. Cit., 172.

6. Rees, op cit., 172

7. Rees, op. Cit., 172.

8. Sherr, L. and Hedge B. The impact and use of written leaflets as a counseling alternative in mass antenatal HIV screening. AIDS Care 1990 2(3):235-45.

9. Sherr, op. Cit., 235-45.

10. Aked, Michael. Building and maintaining an academic library pamphlet collection. Collection Building 15(3):22-31.

11. Payson, Evelyn. "The vertical file: retain or discard." College and Research Libraries 1995 Sept. 56:423-432.

12. Payson op. Cit., 427.

13. Payson op. Cit., 427.

14. Allen, Barbara. The information file in academic libraries: an unexploited resource. Collection Management 1992:16(3), 53-79.

15. Ellison, op.cit., 228-9.

16. Meade, Cathy, John Diekmann and Darlene Thornhill. Readability of American Cancer Society Patient Education Literature, Oncology Nursing Forum, 1992, 19(1), 51-55.

17. Ellison, op. Cit., 229.

18. Allen, op. Cit., 53.

19. Gerhardt, op. Cit., 4.

20. Aked, op. Cit., 23.

21. Jacobs, Dorothy S. The vertical file: an overview and guide. Collection Building 12 (1-2): 3-17.

22. Payson, op. Cit., 424.

23. Allen, op. Cit, 54.

24. Cinciripini, Paul M., Lynn G. Lapitsky, Annette Wallfisch, Richard Mace and Elahe Nezami. An evaluation of multicomponent treatment program involving scheduled smoking and relapse prevention procedures: initial findings. Addictive Behaviors. Jan-Feb. 1994: 19(1): 13-22.

25. Harrell, Joanne, Alise Cornetto and Wanda Stutts. Cardiovascular risk factors in textile workers prevalence and intervention, AAOHN Journal 1992 December: 40(12): 581-589.

26. Aked, op. Cit., 27.

27. Jacobs, op. Cit., 14-16.

28. Payson, op. Cit., 424-429.

29. Allen, op. City., 54-58.

30. Allen, op. Cit, 54.

31. Interview with University of Illinois at Chicago Librarian, Jan. 1998.

32. Interview with University of Chicago Biomedical Specialist, Jan 1998.

33. Interview with Rush University Medical Librarian, Jan. 1998.

34. Information Access Corporation Health Reference Center information package, 1998. NOTE: Health Reference Center is now owned by the Gale Group.

35. Interview with Canadian Consulate General Chicago Business Development Officer, Jan 1998.

36. Interview with Loyola University Medical Librarian, Jan 1998.

37. Interview with Northwestern University's Alberto Culver Library Nurse Educator, Jan 1998.

38. Interview with Northwestern University Medical Librarian, Jan 1998.

39. Interview with National Library of Medicine Librarian, Jan 1998.

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