{"subscriber":false,"subscribedOffers":{}} Beyond Books: Public Libraries As Partners For Population Health | Health Affairs

Research Article

Culture Of Health

Beyond Books: Public Libraries As Partners For Population Health

Affiliations
  1. Anna U. Morgan is a Robert Wood Johnson Foundation Clinical Scholar at the Perelman School of Medicine, University of Pennsylvania, in Philadelphia.
  2. Roxanne Dupuis is a research program manager at the Center for Public Health Initiatives, University of Pennsylvania.
  3. Bernadette D’Alonzo is a research assistant at the Center for Public Health Initiatives, University of Pennsylvania.
  4. Andria Johnson is a lecturer in the Department of History and Sociology of Science at the University of Pennsylvania.
  5. Amy Graves is a research assistant at the Center for Public Health Initiatives, University of Pennsylvania.
  6. Kiahana L. Brooks is a research assistant at the Center for Public Health Initiatives, University of Pennsylvania.
  7. Autumn McClintock is strategy coordinator for the Strategic Initiatives Department at the Free Library of Philadelphia.
  8. Heather Klusaritz is director of community engagement at the Center for Public Health Initiatives and associate director of the Center for Community and Population Health in the Department of Family Medicine and Community Health at the Perelman School of Medicine, University of Pennsylvania.
  9. Hillary Bogner is an associate professor in the Department of Family Medicine and Community Health at the Perelman School of Medicine, University of Pennsylvania.
  10. Judith A. Long is a core investigator at the Veterans Affairs Center for Health Equity Research and Promotion and the Sol Katz Professor of Medicine at the Perelman School of Medicine, University of Pennsylvania.
  11. David Grande is an assistant professor of medicine at the Perelman School of Medicine, University of Pennsylvania.
  12. Carolyn C. Cannuscio ( [email protected] ) is director of research at the Center for Public Health Initiatives and an assistant professor in the Department of Family Medicine and Community Health at the Perelman School of Medicine, University of Pennsylvania.
PUBLISHED:Free Accesshttps://doi.org/10.1377/hlthaff.2016.0724

Abstract

Public libraries are not usually included in discussions about improving population health. They are, however, well positioned to be partners in building a culture of health through programming that addresses the social determinants of health. The Healthy Library Initiative, a partnership between the University of Pennsylvania and the Free Library of Philadelphia (the public library system that serves the city), has undertaken such efforts in Philadelphia. In this article we report findings from an assessment of how ten highly subscribed programs address the social determinants of health, as well as results of interviews with community residents and library staff. Of the 5.8 million in-person Free Library visits in 2015, 500,000 included attendance at specialized programs that addressed multiple health determinants, such as housing and literacy. Library staff provided intensive support to vulnerable populations including homeless people, people with mental illness and substance use, recent immigrants, and children and families suffering from trauma. We found that public libraries are trusted institutions that have broad population reach and untapped potential to improve population health.

TOPICS

As the nation searches for ways to improve population health, public libraries are rarely discussed. However, several hallmarks of public libraries make them well-positioned partners for building a culture of health. First, the US public almost universally supports libraries and believes they are vital to community well-being. 1 Second, libraries have tremendous population reach. With more than 9,000 public library systems serving 95 percent of the US population, approximately 50 percent of Americans visit a library every year. 2,3 Third, libraries play a critical role in promoting child and adult literacy—keys to predicting health literacy, adherence to preventive health care services, and overall health outcomes. 4,5 Finally, libraries have long been sources of consumer health information, 611 places of shelter, and sites of socialization across diverse groups. 12 They have even served as venues for preventive health efforts. 8,1317 In this study, our objective was to identify additional untapped opportunities for public libraries to advance population health.

The work was conducted by the Healthy Library Initiative, a partnership between the University of Pennsylvania and the Free Library of Philadelphia (the public library system that serves the city), which hosts more than 5.8 million in-person and 9.9 million online visits annually, in a city of 1.5 million residents. 18 This initiative aims to integrate evidence-based health efforts throughout the Free Library’s fifty-four branches, with an emphasis on programming to support the new South Philadelphia Community Health and Literacy Center, which includes a health-focused library branch, public and private health clinics, and a recreation center. 19 We investigated how the daily work and specialized programs of the Free Library address the social determinants of health, such as employment, education, and housing, which are widely acknowledged drivers of health disparities. 20 As an example of a successful partnership among public libraries, public health, and health care systems, 10,21 this work aligns with the Robert Wood Johnson Foundation’s mission to promote innovative cross-sectoral partnerships in building a culture of health. 22

Study Data And Methods

Data for this study include information provided by the Free Library about its largest programs; interviews with local residents regarding community health needs; and interviews with library staff about their work and its relationship to the social determinants of health.

Program Scan And Logic Model

We examined how current library programming addresses the social determinants of health using a modified logic model, a method used to illustrate the pathway by which resources and activities translate to desired outcomes. 23 We assessed ten of the Free Library’s most highly attended programs, documenting threats to health, programs, activities, attendance, and expected impact on the social determinants of health.

Needs Assessment

In fall 2015 we conducted an assessment of library staff and local community needs, informed by the principles of community-based participatory research, in which all participants are considered experts on local needs, assets, and resources. 24 We worked with a street photographer as well as with trained interviewers (photographs available online at http://www.healthylibrary.org and through Appendix A1). 25 We used purposive sampling to select participants. The interviewers engaged with diverse residents in semistructured daytime interviews within a walkable distance (one mile) from at least one of the six library branches in South Philadelphia, the neighborhood where the new Community Health and Literacy Center is located. The protocol was repeated in spring 2016 in West Philadelphia, identified by the Free Library as a priority location for health programming. We asked community members about the assets and challenges in their neighborhoods, their health concerns, and how the Free Library could help. Contemporaneously, we interviewed library staff with work experience in the same catchment areas as the residents to understand their professional practice, focusing on the social determinants of health.

We interviewed ninety-five people, including eighteen library staff (44 percent male, ages 24–68) and seventy-seven community residents (43 percent male, ages 18–90). Among the fifty-three community residents who reported their race/ethnicity, 38 percent identified as white, 32 percent as black or African American, 15 percent as multiracial or other, 9 percent as Asian, and 6 percent as Hispanic.

Analysis

Interviews were recorded and transcribed verbatim. We developed a coding structure using line-by-line reading of transcripts to specify recurrent concepts. Three assistants coded interviews using NVivo 11.0 software, with 95 percent agreement. The research team summarized findings in memos that guided group discussions and iterative interpretation of the data to identify cross-cutting themes. 26

Limitations

Our study had several limitations. The community health issues reported reflect current conditions in Philadelphia and would be expected to vary elsewhere. Additionally, library staff were recruited with assistance from library administrators, and staff might have been concerned about reporting socially desirable information despite assurances of confidentiality. The daytime street interview strategy disproportionately included a high-need (for example, unemployed) population, but purposive sampling was conducted to mitigate bias and achieve diversity by race/ethnicity and socioeconomic status.

Study Results

Our analysis of programs, coupled with community resident and library staff interviews, suggests that the Free Library is highly responsive to community needs.

Libraries Address Social Determinants Of Health

The Free Library has fifty-four branches located throughout the city of Philadelphia ( Exhibit 1 ). Of the 5.8 million in-person library visits in 2015, 500,000 were for specialized programs, which reach residents of all ages and socioeconomic backgrounds. 18 Programs address multiple social determinants of health, including early childhood and adult literacy, youth leadership skills and healthy behaviors, job readiness, nutrition, and support for the elderly ( Exhibit 2 ). All programs are designed to foster social interaction, itself beneficial to health. 12,27

Exhibit 1 Free Library of Philadelphia branches and percentage of families living below the federal poverty level

Exhibit 1
SOURCES American Community Survey 2014 five-year estimates; City of Philadelphia. NOTES Poverty data include percentage of families living below federal poverty level in 2013 by census tract. Library location data are from 2012 and include all library branches.

Exhibit 2 Impact of Free Library of Philadelphia programs on the social determinants of health, fiscal year 2015

Exhibit 2
SOURCES W. K. Kellogg Foundation. Logic model development guide (Note  23 in text); additional data sources are in online Appendix A3 (Note  25 in text).

Libraries Are A Safety Net For Vulnerable Populations

With clean, safe, and free-to-access branches citywide, staffed with well-informed personnel and accessible programs, libraries serve as welcoming havens for all Philadelphians. Our interviews suggest, however, that libraries are disproportionately frequented by vulnerable populations, including those experiencing mental illness, substance use, and homelessness, as well as recent immigrants and children (Appendix A2). 25

Mental Health And Substance Use:

Staff reported spending significant time aiding patrons experiencing mental illness (for example, identifying mental health resources). Both library staff and community participants perceived that substance use in the community is ubiquitous. Participants identified a need for enhanced community education, including substance abuse prevention and related programs promoting school success and job readiness. Library staff also expressed alarm that “patrons come in who are overdosed on drugs,” and “people…shoot up in our bathroom,” leaving staff feeling frustrated and helpless.

Homelessness:

The library provides physical shelter and resources for patrons experiencing homelessness and housing insecurity. As one librarian described, “In the summer, we’re cool for them. In the winter, we’re warm.” Staff reported routinely assisting patrons with locating a shelter, completing applications for housing or social services, and navigating complex legal housing challenges (for example, breaking a lease, bedbugs, and so forth).

Residents expressed concerns about gentrification, explaining that new housing developments, rising taxes, and increasing rents push families out of their homes, contribute to food insecurity, and threaten community well-being. Residents also noted that the library could provide housing and employment assistance to people transitioning out of incarceration.

Recent Immigrants:

Community residents and librarians viewed the library as a valuable resource for new immigrants. Library staff explained how they serve as de facto health and social service system navigators, assisting new immigrants in accessing insurance and health care; completing job applications; communicating with lawyers, landlords, and schools; and applying for citizenship. Staff explained the difficultly conveying to new immigrants that the library is free, open to them, and not a place where they will “get in trouble.” Once that connection is made, library staff note that trust grows, and “we [can] communicate, probably because there [is] less stress.”

Staff noted that classes in English as a second language are highly subscribed, with as many as fifty regular participants in weekly classes at neighborhood branches. Still, according to residents, the demand for classes far exceeds the supply. New immigrants with young children also seek reading and homework assistance at the library (for example, “requests to even just read with their kids so that they learn how to pronounce things with an American accent”).

Beyond the practical assistance it provides new immigrants, the library serves as “common ground” for people of all ethnic/racial backgrounds. Programming is adapted to allow for cross-cultural interchange, with innovative programs such as multilingual story hours, cooking classes emphasizing traditional dishes from residents’ cultures of origin, and a knitting club, drawing women who otherwise are discouraged from leaving home alone. Community residents felt that the library could serve an even greater role, offering neutral space and programming to foster dialogue across traditionally segregated racial/ethnic groups. In these ways, for new immigrants in particular, the library serves as a critical site for community integration.

Children And Families:

Community residents quickly identified children and families as a neighborhood asset, stating that “the number one strength” is family. However, residents observed a dearth of opportunities for young people and expressed a desire for additional programming to engage youth. Librarians also identified children as a priority, explaining that some popular offerings (story time, homework help) are so well attended that library staff feel overwhelmed, especially after school.

Particularly troubling for participants was the perceived prevalence of child and family trauma, such as witnessing violence or losing a parent to incarceration, illness, or violence. Staff also reported neighborhood trauma (for example, fights or bullying) spilling into the library. Given that library staff have sustained interaction with residents, and especially with children, staff discussed the stress they feel as mandatory reporters of suspected child abuse. Both community residents and library staff recognized that the library remains one of the few community resources to welcome children with extensive social, educational, and health needs.

Librarians Are Committed To Public Service

Library staff expressed that they were “honored” to be “entrusted with [patrons’] confidence,” providing patrons with much needed support. They believe they have “an opportunity to get to the heart of what the person needs” and that patrons often need “not just a book, but an ear.” Being of service to highly vulnerable people, however, can be a stressor, and library staff lament that they “sometimes become a default social worker.” Staff requested further training on “social issues and how to better answer questions and deal with the public.”

Discussion

With the Free Library of Philadelphia, we identified key strengths of public libraries as partners for addressing social determinants of health. Public libraries are trusted institutions with broad geographic and demographic reach. Since they are free and open to all, and present in many neighborhoods, public libraries often disproportionately serve vulnerable populations, including people with mental health and substance use concerns, new immigrants, and disadvantaged youth. 13,14 These strengths are tempered by community needs that often outstrip librarians’ professional training and staff capacity. Below we raise several challenges and opportunities, aiming to stimulate a national conversation about public libraries and population health.

Increasing Library Capacity For Advancing Population Health

Foundational to the work of public libraries is an emphasis on equity. 28 In the library setting, equity translates to creating opportunities and removing barriers for disadvantaged groups. While the library serves all residents as a much-needed “third place,” fostering informal and program-driven social interaction, 12 we have demonstrated that it also serves as a lifeline for the most vulnerable. Our findings are consistent with historical evidence that libraries have long served as a refuge from extreme conditions and a haven for the homeless. 29,30 Library staff indicated that their formal training inadequately prepared them to serve high-need populations. Led by an interdisciplinary group of health and social service professionals, the Healthy Library Initiative recently trained community health specialist librarians to recognize, engage, and refer to appropriate services patrons experiencing homelessness, mental illness or substance use, immigration challenges, and childhood or family trauma. Incorporating findings from the pilot program, we plan to disseminate a scalable model to be used for training focused on the social determinants of health. Other programs addressing homelessness and consumer health have been piloted in Minnesota and through the National Network of Libraries of Medicine. 31,32 We are fielding a nationwide study to assess variation in public libraries’ work on social determinants.

Building Cross-Sectoral Partnerships To Advance Population Health

Even with additional training, library staff cannot replace highly skilled health or social service professionals. By strengthening cross-sectoral collaborations, the library can become an even more effective health hub. 10,15 Such a hub exists at Philadelphia’s newly launched South Philadelphia Community Health and Literacy Center ( Exhibit 1 ), which includes medical clinics, a library, and a recreation center. One goal is to foster referral of patrons and patients to the most appropriate resources available at the site or elsewhere. The center might also reduce stigma associated with help-seeking by offering a street-level library, open to all, as its point of entry. In addition, in a small pilot program, the Free Library is experimenting with the placement of a social worker and a nurse in the central branch of the library. In other models, libraries could serve as locations for “pop-up” clinics or as digital gateways to support telemedicine. With strategic investments from public health and health system partners, these models might be transferable to other settings and adapted to local needs.

Leveraging Librarians’ Role As Trusted Community Sentinels

Our interviews revealed that public librarians serve as “sentinels” in their communities, identifying the most pressing needs by responding to daily requests from patrons. In this role, libraries contribute two particular strengths to advance a culture of health: accessibility and trustworthiness. In addition to libraries’ being freely accessible, library staff ask no questions of patrons. Anyone is free to participate in a shared social environment, acclimate to that environment, and approach staff when assistance is desired. Moreover, the institution capitalizes on this close community connection by developing programming that is highly responsive to local needs. Local control of libraries allows for adaptation of programming across sites, over time, and in partnership with health and social service systems, 10 based on evolving community needs and feedback.

Throughout this project, the public’s trust in the library was a consistent theme. Library staff affirmed a profound commitment to patrons and their privacy, as codified in the American Library Association’s “Library Bill of Rights” as early as 1939. 33 This commitment undoubtedly undergirds public confidence in libraries but also presents challenges, both as librarians field health-related questions 9,10 and in the evaluation of libraries’ health impacts, especially if such assessments rely on individual data.

Conclusion

Results from this study demonstrate how public libraries are well positioned to influence population health. While social observers have signaled that the digital era is a death knell for public libraries, 34,35 we instead concur with the overwhelming majority of Americans who still see libraries as vital community assets and visit public libraries 1.5 billion times each year. 1,3 Indeed, as our results show, public libraries are dynamic, socially responsive institutions, a nexus of diversity, and a lifeline for the most vulnerable among us. Policy makers, public health agencies, and health care systems should maximize these attributes by investing in strong relationships with public libraries, supporting them in their work by bolstering infrastructure, training, and programming. While health has not historically been at the center of their missions, libraries occupy a unique place in public life, making them powerful partners for building a culture of health.

ACKNOWLEDGMENTS

The authors thank Eliza Davenport Whiteman for her contributions to the Healthy Library Initiative and for configuring the map used for Exhibit 1 . They also thank photographer Nema Etebar and the dedicated University of Pennsylvania students who supported the project through data collection and analytic assistance. They are grateful to the interview participants and training attendees, who generously shared their time and thoughts, and to their partner, the Free Library of Philadelphia. They thank the Center for Public Health Initiatives, the Office of the Dean at the Perelman School of Medicine, and the University of Pennsylvania Prevention Research Center for support of the Healthy Library Initiative. This article was partially funded by the Centers for Disease Control and Prevention (CDC) (Grant No. 1U48DP005053-01). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or the Department of Health and Human Services.

NOTES

   
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