Using bibliotherapy to promote consumer health information in a library setting

Abstract

In the light of increased focus on consumer health information and patient education, libraries are looking for innovative ways of delivering health information to patients and the public. The paper will address bibliotherapy as an effective method of health education and promotion. It will identify different ways of how self-help and creative bibliotherapy can be used to provide consumers with high quality and accessible health information. After a brief historical overview of bibliotherapy in a library setting, the paper will provide a detailed description of the most recent bibliotherapy-based projects successfully implemented in medical and public libraries to promote health and well-being to patients and the general public. The paper will also provide an overview of the development and implementation of the bibliotherapy program for children and women living with HIV/AIDS that the author has conducted at Nkosi’s Haven Village, Johannesburg, South Africa. The findings of the study show that bibliotherapy could be used as an effective tool in health promotion and education, particularly in a situation where a strong stigma is associated with a medical condition or disorder.

Full text

Using bibliotherapy to promote consumer health information in a library
setting
Natalia Tukhareli, MLIS, PhD
Health Sciences Library, Rouge Valley Health System, Toronto, Ontario, Canada
Abstract
In the light of increased focus on consumer health information and patient education, libraries
are looking for innovative ways of delivering health information to patients and the public. The
paper will address bibliotherapy as an effective method of health education and promotion. It
will identify different ways of how self-help and creative bibliotherapy can be used to provide
consumers with high quality and accessible health information. After a brief historical overview
of bibliotherapy in a library setting, the paper will provide a detailed description of the most
recent bibliotherapy-based projects successfully implemented in medical and public libraries to
promote health and well-being to patients and the general public. The paper will also provide an
overview of the development and implementation of the bibliotherapy program for children and
women living with HIV/AIDS that the author has conducted at Nkosi’s Haven Village,
Johannesburg, South Africa. The findings of the study show that bibliotherapy could be used as
an effective tool in health promotion and education, particularly in a situation where a strong
stigma is associated with a medical condition or disorder.
Key words: bibliotherapy; self-help; health literacy; health education; Acquired
Immunodeficiency Syndrome.
Introduction
In recent years, consumer health information and patient education have generated a wide
discussion in library circles. The discussion revolves around definitions, benefits for health care,
ways of delivery of health information to patients and the general public, challenges and barriers,
and roles of health libraries and librarians in promoting health information literacy in their
institutions. It has been widely acknowledged that engagement with health information is highly
beneficial for both patients and health care providers. According to the Patient Information
Forum (PiF) in its 2013 report, information is an intervention that impacts health and wellbeing
and it contributes to all three aspects of quality: clinical effectiveness, safety and patient
experience (1). At the same time, concerns have been expressed that patients may lack either
internet access or skills necessary to search, understand, evaluate, and utilize health information.
Approximately a third up to one half of the people in developed countries have low health
literacy. Individuals at high risk for low health literacy include the elderly, disabled, and
individuals with a poverty-level income and low literacy levels (2). On the other hand,
inadequate health literacy has been linked to poor management of long-term health conditions
(3). Furthermore, poor health knowledge is associated with more medication and treatment
errors, higher rates of hospitalization and emergency admissions, longer hospital stays, and a
decreased ability to make appropriate health decisions and use preventative services (1). In the
light of current financial pressure on the health care system, improving health literacy can reduce
health care costs. The survey of cost-benefit studies for patient education in managed care and
other settings shows that an average of three to four dollars is saved for each dollar spent on

patient education. Savings are attributed to the confidence with which patients manage their own
symptoms, thereby experiencing complications or exacerbations less frequently (4).
Within this context, finding effective ways of promoting health literacy becomes of special
importance for librarians. The library literature reports a higher percentage of hospital libraries
that provide quality consumer health information tailored to a wide range of cultural, educational
and language needs to help patients and the general public make informed choices about their
health (5-6). Patient Information/Consumer Health Information Centres have become an
essential part of hospital libraries. Librarians and health care providers realize the important role
that these resource centers pay in educating patients and families, thus helping them to
participate in decision making regarding their conditions and treatment. Our survey of hospital
libraries in the Greater Toronto Area (GTA) conducted in 2011 showed that 7 out of 10 hospitals
have a consumer health information center, typically located in a separate room or in a separate
section within the library. Furthermore, an internal survey of physicians and clinicians of the
Rouge Valley Health System (RVHS) conducted by the Health Sciences Library as a part of the
information needs assessment demonstrated an increased focus on patient information and
consumer heath among medical staff. The library survey data reports high demand in both online
and print patient education resources, 85.9% and 69.7% respectively.
Another recent trend is forming collaborations between medical and public libraries and health
care and social service providers. Within this context, bibliotherapy, in a variety of its
applications ranging from collaborative “information on prescription” and “books on
prescription” programs to read-aloud groups, has been generating interest among health care
professionals and librarians. The paper aims at providing an overview of the most recent
bibliotherapy-based projects successfully implemented in medical and public libraries to promote
health and well-being to consumers. Based on a comprehensive review of recent publications in
health librarianship and the author’s experience in implementing the “information on
prescription” program in a hospital library, the paper will highlight benefits of health information
literacy for patients and health care providers. Finally, the paper will discuss the findings of the
bibliotherapy program for children and women living with HIV/AIDS that the author developed
and delivered at the Nkosi’s Haven library in Johannesburg, South Africa, in 2010.
Methodology
The methodology included an extensive review of the academic and grey literature related to
consumer health information, information therapy, and bibliotherapy. The analysis of
bibliotherapy-based projects successfully implemented in medical and public libraries in the UK
and North America helped to identify the ways bibliotherapy could be used to help promote
health and well-being to consumers. Two case studies were included to describe the “Information
on Prescription” service implemented at the Rouge Valley Health System in Toronto, Canada,
and an innovative bibliotherapy program on HIV/AIDS piloted at the Nkosi’s Haven library in
Johannesburg, South Africa. The latter involved one-on-one and group interviews with the
participants of the program and observations in the form of reflective diaries maintained over the
course of the project.
Background: Bibliotherapy and its recent applications

Bibliotherapy, as a part of expressive therapy, involves the systematic use of books to help
individuals cope with mental, physical and emotional issues, combat social isolation, and
maintain health and well-being. The etymology of the term bibliotherapy (biblio-/biblos is the
Greek word for a book and therapy comes from therapeia, meaning curing or healing) aligns
bibliotherapy with some other similar practices, such as art therapy, dance therapy, music
therapy, and play therapy, emphasizing the idea of the healing and consoling power of art
through its various forms. The idea of bibliotherapy emerged out of the true nature of a book and
its power to influence human minds and souls. The power of the written word was discovered
and acknowledged during the very early periods in the “history of reading” and the history of
libraries.
It has been almost 100 years since the term bibliotherapy was introduced to describe the practice
of using literary materials to address mental health issues. Throughout its comparatively short
history, bibliotherapy has undergone significant changes in regards to its principal features, such
as goals and objectives, targeted client groups, settings and delivery modes. First introduced as
an adjunct to treatment and recreation for patients of psychiatric and general hospitals,
bibliotherapy soon expanded beyond the medical sphere to target diverse groups of people in a
variety of non-clinical settings, such as schools, public libraries, community centres, and prisons.
Throughout this expansion, the primary focus of bibliotherapy has shifted from helping
individuals regain their mental health to helping them maintain their mental and physical health
and well-being, thus helping them to take better control of their lives.
Since the beginning of the 21st century, the history of bibliotherapy has seen a rapid growth of
various clinical and non-clinical bibliotherapeutic interventions as well as the more creative
design and implementation of bibliotherapy schemes that address diverse client groups in a wide
variety of settings. While clinical bibliotherapy, primarily in its self-help model, has been
gaining recognition among clinical and primary health care professionals as an effective
approach to mental and physical health issues, the non-clinical (developmental, creative, or
social) bibliotherapy practised in schools, libraries, community organizations and prisons has
been viewed as an effective means of improving individual and community well-being.
Over the past two decades, self-help bibliotherapy, which involves the systematic use of self-
help materials as part of clinical interventions, has become the most prevalent form of clinical
bibliotherapy. It has been widely used to address a wide range of mental, physical and emotional
issues, from battling depression and anxiety, to coping with life-threatening diseases, to dealing
with life crises and difficult transitions. Furthermore, self-help bibliotherapy has been gaining
recognition as an effective, simple, and cost-effective way of promoting health to consumers,
thus empowering individuals to take better control of their health and well-being. This perception
has been supported by extensive evidence-based research in bibliotherapy. A comprehensive
review of 93 bibliotherapy studies including meta-analyses, randomized controlled trials,
controlled clinical trials, and systematic reviews published between January 2007 and January
2013 provides evidence of the efficacy of bibliotherapy in treating a wide variety of mental,
physical, and psychological conditions and disorders, such as depression, anxiety, stress,
hypochondria, obsessive-compulsive disorder (OCD), panic disorder, post-traumatic distress,
borderline personality disorder (BPD), hoarding, social phobia, sexual disorders, insomnia,
eating disorders, grief and bereavement, obesity, and alcohol-related disorders (7).

While clinical bibliotherapy tends to integrate self-help books and treatment manuals into
therapy, creative, or social, bibliotherapy capitalizes on a natural therapeutic potential of
imaginative literature to facilitate the change. It has been gaining recognition within the non-
clinical sector as an effective means of improving individual and community well-being. Given
that the focus of creative bibliotherapy is on “normality, communication and social interaction,”
this model is more flexible, allowing for a wider range of clients, reading materials, and settings.
(8). Creative bibliotherapy can be delivered in a wide variety of both clinical and community
settings, including hospitals, hospices, libraries, schools, nursing homes, community health
centres, shelters, and prisons. It has a potential to address a broad range of mental, emotional,
physical, developmental and social issues — from fighting a mild depression to living with a
chronic or life-threatening disease to dealing with bullying, poverty or relocation.
The literature shows that various applications of the creative bibliotherapy model have been
expanding quickly and becoming increasingly popular internationally (7). One of the most
promising approaches of creative bibliotherapy was introduced by the Reader Organisation in the
UK. Founded by Jane Davis in Liverpool University in 2002, the organization works in
partnership with local authorities and health trusts to deliver the Get into Reading program, an
innovative “shared reading” model run by trained facilitators through weekly read-aloud reading
groups. They take place in a variety of locations, including hospitals, mental health centres,
neurological rehab units, care homes, schools, libraries, corporate boardrooms, job centres,
hostels, shelters, prisons, and community centres.
A growing number of qualitative and quantitative studies provide evidence in support of “shared
reading” schemes. The literature has identified a number of benefits of the creative bibliotherapy
approach, including the flexibility of the model (it can be successfully adapted for different
settings and for the needs of different client groups), accessibility (attracts people with low
literacy or those who are not engaged with literature), and the improvement in mental, emotional,
psychological, and social well-being of the participants (8-12). The success of Get into Reading
groups has significantly contributed to the further development of creative bibliotherapy
nationally and globally. The “shared reading” bibliotherapy model is becoming a widespread
practice in the UK, Europe, Australia, and Canada. Canadian applications of the creative
bibliotherapy model include La Bibliothèque Apothicaire in Quebec and the Read to Connect
organization in Toronto, Ontario (7).
Discussion
An important change that has been observed in the recent developments of clinical and creative
bibliotherapy is an increased focus on collaborative projects. Medical and public libraries, in
partnerships with health care providers, introduce bibliotherapy-based programs to patients and
the general public to improve health information literacy and promote health and well-being.
During the last decade, a number of projects have been developed under the banner of
“information on prescription” and “books on prescription” schemes. On the other hand, creative
bibliotherapy model in the form of a “shared reading” group has been gaining recognition as an
effective tool of health education and promotion, particularly in a situation where stigma is
created around a disease or disorder. The following detailed description of bibliotherapy-based
schemes implemented in medical and public libraries will show three different ways of

delivering consumer health information in a library setting. The mechanics, benefits and
challenges of the schemes will be discussed.
“Information on Prescription”
The introduction of the “information prescription” concept provided further support for the
expansion of the idea of “information therapy” within the framework of patient-centred care,
which implies “the prescription of the right information to the right patient at the right time”
(13). Introduced in 1990-s and first defined as “the therapeutic provision of information to
people for the amelioration of physical and mental health and well-being” (14), information
therapy has become an essential part of health care. Although this is not a new concept, the
increasing emphasis on patient-centric care, the use of electronic information technologies, and
the interest of consumers in health information make the use of information therapy appear more
feasible than in the past (15).
The term “information prescription” generally refers to “the provision of a prescription of
information from a clinician to a patient in any format (hardcopy or electronic)” (16). The
concept of “information prescription” was presented in publications by the UK’s Department of
Health, setting strategies for health information for patients and the public. The white paper “Our
health, our care, our say: a new direction for community services” (17) has proposed an
“information prescription” service “for people with long-term health and social care needs and
for their carers.” The document outlined a strategy for health and social care professionals for co-
ordinating and developing information for individuals across health and social care. As stated in
the document, “The information prescription will be given to people using services and their
carers by health and social care professionals (for example GPs, social workers and district
nurses) to signpost people to further information and advice to help them take care of their own
condition (17).
In 2012, Ontario’s Action Plan for Health Care has identified a patient-centered approach as one
of the key priorities for health care. The document asserts that “keeping Ontario healthy” has
become the primary goal of health care and requires putting increased efforts into “promoting
healthy habits and behaviors” and “supporting lifestyle changes” (18). As Rick Ganderton, the
President and CEO of the Rouge Valley Health System, pointed out during the discussion of the
publication within the organization, the transformation of Ontario’s health care system set out in
the government’s plan implies shifting the focus from acute intervention “to managing wellness,
health, personal responsibility and management of disease at home with community support”
(19). Within this context, the Health Sciences Library has been looking for effective ways of
promoting consumer health information to patients, families and members of local communities.
After conducting an extensive literature review on consumer health and best practices in the area
of health promotion and education, the author has introduced the idea of the incorporating the
“information prescription” scheme into library services.
The literature review has shown that information prescriptions became an essential component of
patient-centred care. A growing number of health libraries provide consumer health information
by using an information prescription mechanism. A number of qualitative and quantitative
studies describe various applications of the information prescription scheme, highlight its
benefits for patients and health care professionals, and identify potential challenges and barriers

(4, 20-25). Based on existing evidence in the area of information prescription, the Health
Sciences Library has proposed the development of the “Information on Prescription” (InfoRx)
service for patients and staff of RVHS and outlined practical steps towards its implementation. In
June 2013, the library launched the service to assist physicians and nurses in providing patients
with the information about their conditions, treatments, and medications.
The InfoRx is being delivered through the Tom Leon Health Resource Centre (TLHRC), an
existing consumer health information centre run by volunteers and supported by the Health
Sciences Library. Founded in 1997, the TLHRC has been providing print and electronic health-
related resources to inpatients and outpatients of the RVHS and to the local community
members. The launch of the InfoRx provided an opportunity to expand the role of the Health
Sciences Library and TLHRC in educating patients and families on their conditions and
treatment options and encouraging healthy habits and lifestyle. Library staff and TLHRC
volunteers committed to creating a warm and welcoming environment where patients and
families can get emotional support and receive accurate up-to-date health information.
The InfoRx service is simple and easy to implement: a physician or a nurse fills out the
“prescription” form (available in both print and electronic formats) and refers a patient to the
TLHRC. A trained volunteer puts together the information package using all available print and
online resources. In situations where clients need more detailed information, a custom
information search can be done by library staff. Prior to the launch of the InfoRx service, the
librarian ensured that the TLHRC was equipped with high quality patient education and
consumer health materials written in plain language. Throughout the process of selecting patient
information resources, the criteria for assessing the quality of health information highlighted in
the report by the Patient Information Forum (PiF) were applied: the information should be
evidence based, comprehensive, current, clear, relevant, accessible, and readable (1).
The objectives for the InfoRx program were identified based on common benefits of information
therapy for both patients and health care providers described in the literature. It was anticipated
that the service would provide patients and family members with a sense of control, improve
their physical and psychological well-being, and enable people to utilize self-care. On the
clinical side, the InfoRx would save physicians time spent on providing patients with the
information about their conditions, treatments, and medications. The latter would contribute to
more efficient use of clinical time and hospital services and save the hospital’s dollars.
When identifying practical steps in the InfoRx implementation within the hospital, the author
took into consideration one of the challenges associated with information prescriptions. As
highlighted in the literature, a common barrier is the low awareness about health information
literacy and the benefits of “information prescriptions” among medical practitioners (20, 22).
Given that, the promotion of the program within the organization has received special attention.
In our promotional campaign at the RVHS, we have adopted a direct customized marketing to
clinical departments and programs. Based on marketing ideas collected from the literature, we
have identified and implemented the following marketing strategies: 1) targeted direct mail
(promotional flyers delivered to doctors’ offices/mail boxes; e-mail blasts to hospital groups); 2)
presentations at a hospital group’s regular meetings (presentations at the Medical Association
Committee (MAC), monthly meetings of clinical practice leaders (CPLs), morning huddles on
clinical floors and in the Emergency Department); 3) publications in print and electronic issues

of the hospital newsletter; and 4) internal network (partnering with clinical departments and
participating in their projects). In fact, the latter proved to be particularly effective and resulted
in an opportunity of incorporating the InfoRx service into the Care After the Care in Hospital
(CATCH) program, a new program implemented at the RVHS to help reduce readmission rates
for patients discharged from the hospital.
Currently, the InfoRx service supports the educational component of the CATCH program by
providing discharged patients with patient information handouts on specific medical conditions
and prescribed medications. The service is seen to be beneficial to both patients and health care
providers participated in the CATCH program. First, it saves the time that a nurse would
otherwise spend on accessing, retrieving, and evaluating health-related information for clients.
Second, it supports the overall goal of the CATCH program to help post-discharged patients
increase coping and disease management skills, and thus take better control over their health and
well-being. Furthermore, the implementation of the InfoRx service has expanded the hospital’s
focus on customer service, health promotion and education. It also increased the library’s
visibility and perceived value within the organization.
Overall, the implementation of the InfoRx service in a hospital setting shows a simple,
accessible, and cost-effective way of delivering high quality health information to consumers.
Also, it provides an example of a successful collaboration between the Health Sciences Library
and medical staff. It proves that by partnering with clinical departments and participating in their
programs, libraries can contribute to the promotion of patient education and consumer health
within a health care organization.
“Books on Prescription”
This model of self-help bibliotherapy is based on prescribing self-help books to patients and
involves a range of stakeholders, including health care professionals (mental health professionals
and general practitioners), community-based health workers (nurses and social workers), local
social welfare agencies, and local library staff (26). By participating in the “Book on
Prescription” scheme, health professionals can partner with public librarians and community-
service providers in educating patients and the general public about health-related issues and
healthy lifestyles. After health professionals select a number of self-help titles on various
medical conditions and disorders, the library service stocks a prearranged list of books. Doctors
and mental health professionals then issue a book prescription for a specific self-help book, with
the patient going to the library with the prescription rather than to the pharmacist (27).
As an adjunct to clinical bibliotherapy, “books on prescriptions” offer a promising way for
mental health professionals and general practitioners to address a variety mental, psychological,
emotional problems, and behaviour problems. The targeted individuals include children and
adults with depression, anxiety, stress, obsessive-compulsive disorder (OCD), social phobias,
eating disorders, panic disorders, sexual dysfunction, obesity, sleeping disorders, anger,
bereavement, problem drinking, and other issues (16, 26-29). Overall, this type of clinical
bibliotherapy provides a valuable alternative management for many patients with mild to
moderate mental health problems who prefer non-pharmacological treatment options. It also
supports the stepped-care model in a primary care, which has received increasing attention
recently. By providing mental health patients with an interim management option, “books on
prescriptions” bibliotherapy supports the goal of a stepped-care model “to begin one’s

therapeutic efforts with the least expensive and least intrusive intervention possible, and moving
to more expensive and/or more intrusive interventions only if deemed necessary to achieve a
desired therapeutic goal” (30).
Despite its comparatively short history, the “Books on Prescription” model of bibliotherapy has
gained wide recognition among health care providers and librarians and is supported by
evidence-based research. Health professionals involved in this type of clinical bibliotherapy
acknowledge numerous benefits of integrating self-help materials (from popular self-help books
to customized instruction manuals developed by expert health professionals for the purpose of
treating a specific problem area) into their mental health practices. According to the 2006
Bibliotherapy/Books on Prescription audit of bibliotherapy activity across England, benefits for
the health sector include the low-cost, relatively low-maintenance, and long-term sustainability
of the book prescription activity (31). For some practitioners, library-based bibliotherapy
represents a way to bring books to individuals who would not normally have either the financial
resources or the inclination to engage in therapeutic reading (29). Also, health professionals no
longer have to spend time to develop or buy their own resources or to photocopy other materials
(28).
From the program participants’ perspective, library-based bibliotherapy enables people to cope
with their mental health problems themselves thus encouraging and promoting self-help. The
users of the “Books on Prescription” bibliotherapy scheme reported an improved sense of
personal control over their health conditions. They particularly appreciated the
pharmacologically independent nature of this intervention (29). As for libraries, the inclusion of
bibliotherapy in public library services demonstrates the value of reading and libraries,
contributes to the development of the library’s audience, stock, and resources, and opens up new
partnerships and opportunities for libraries (27). Moreover, within the context of ongoing debates
around the ethics of bibliotherapy in a public library, the integration of the “Book on
Prescription” program into public library services helps dispel librarians’ concerns about
practising “therapy” without proper training (7).
On the other hand, research has revealed barriers to the implementation of book prescription
schemes in the health sector and libraries. Challenges for health professionals include lack of
knowledge of the content of the resources; time required to write the prescription and to explain
the process to people new to the concept of healthy reading; and the difficulty that some patients
might have in using the resources because of their illness (such as severe depression), their
cognitive skills, their motivation, or their reading ability. As for public libraries, the challenges
identified include library staff training and marketing and promotion (28).
The creative bibliotherapy reading group
Creative bibliotherapy also provides librarians with new opportunities in integrating consumer
health literacy into library programs. The following case study shows that it can be especially
beneficial in the situation when stigma is associates with a medical condition. The case study
presents a descriptive analysis of one of the aspects of the bibliotherapy program on HIV/AIDS
that the author developed for the residents of Nkosi’s Haven in Johannesburg, South Africa, in
2010. Nkosi’s Haven is a recognized NGO offering long-term residential care for destitute
mothers living with HIV/AIDS and their children, as well as orphans. The bibliotherapy program

aimed to meet the informational and recreational needs of the targeted group of children and
women, dispel the stigma associated with HIV/AIDS, and assist in breaking the isolation and
loneliness of the residents of the shelter. A total of 82 people — 59 children and young adults
(ages 6 to 19), both HIV-positive and HIV-free, and 23 adults (ages 20 to 58), all HIV-positive
— participated in reading groups over a period of three months.
Due to the well-recognized therapeutic value of a read-aloud group reading session, this
constituted the main component of the program delivery. The author has adopted an approach
taken by creative bibliotherapy schemes developed in the UK (the Get into Reading scheme
developed within the Reader organization and The Reading and You Service (RAYS) in public
libraries in Kirklees, UK) (8, 32). Each session included an introduction, a read-aloud
component, and a group discussion. After introducing the topic of the session, the facilitator
would read aloud a selection of literary materials. These would include a short story, an excerpt
from a novel, a poem, or a passage, or case study from a self-help book on HIV/AIDS. The
reading would be followed by a guided group discussion. During the discussion, participants
were encouraged to ask questions and share their stories relevant to the issues and situations
discussed (7, 33).
HIV education was identified as a primary goal of bibliotherapy with children. Thus, read-aloud
sessions designed for young participants of the program included an educational component to
increase their HIV awareness. The facilitator would explain the HIV/AIDS terminology and
teach related issues while reading a particular children’s book on HIV/AIDS. Within the
framework of HIV/AIDS, this becomes of special importance. The literature highlights the fact
that stigmatization associated with the disease puts enormous psychological strain on children
living with HIV/AIDS. In children experiencing stigma by association with their HIV-positive
mothers, stigma is exemplified by reduced social interaction or isolation and feelings of shame.
In addition, stigma by association is a predictor of adverse outcomes, such as depression,
loneliness, externalizing behaviour, and low self-esteem (34). Moreover, lack of open discussion
on HIV/AIDS within families and larger communities negatively affects the way children
conceptualize the disease and results in negative attitudes and a lack of empathy towards HIV-
infected people (35-36).
Due to the “secrecy” around HIV/AIDS, bibliotherapy was viewed as an effective way of
educating children on HIV-related issues and engaging them into active communication around
the disease. Children’s books selected for bibliotherapy sessions provided an effective channel of
delivering HIV/AIDS-related information to the young audience. The following criteria were
used to select appropriate bibliographic materials used during the bibliotherapy sessions:
accuracy and currency of the information on HIV/AIDS; relevance of the content (reading and
discussing the book provides insight into the problem to be solved); appropriateness of the
information to the children’s developmental level; a high level of sensitivity in approaching
terminal illness and death; literary value; good visual imagery; and accuracy of cultural details
and interpretations (7, 33).
The participant outcome analysis based on the data collected throughout the evaluation shows
that the program successfully met the informational needs of children affected by HIV/AIDS. By
the end of the program, approximately 92 percent of young participants (54 out of 59)

demonstrated increased knowledge about HIV/AIDS and related issues and increased
understanding of the universalities of difficulties they were experiencing. The fact that many
children acknowledged an increase in their comfort level in thinking and talking about
HIV/AIDS was considered one of the most important outcomes of the program.
The facilitator documented her observations on how the reading session on HIV prevention
helped teenage boys overcome their hesitation to ask questions related to sex education: “The
topic of the session was the transmission and prevention of HIV/AIDS. The readings were
followed by an intense discussion. Once again, children said that they never had open discussion
on AIDS at school. Their questions revealed a lack of basic knowledge about AIDS, including the
ways the HIV virus can be transmitted. For almost one hour, three 10-year-old boys kept asking
me questions about infected blood and unprotected sex, covering a broad variety of scenarios
that their imaginations would project. These questions revealed their fears of being infected,
which are rooted in a lack of HIV education. I was surprised that they did not hesitate to ask me
all these questions. I was moved when one of the boys said to me at the end, “Thank you for
answering our questions” (7).
It has been observed that participation in the bibliotherapy program helped children alleviate
their fears and anxieties around HIV/AIDS and change stereotyped attitudes towards the HIV-
infected people at Nkosi’s Haven. Moreover, it contributed to spreading a positive message far
beyond the shelter, thus fighting the stigma associated with the disease. The testimony of an
eight-year-old orphan, HIV-positive, was considered one the most valuable achievements of the
bibliotherapy program conducted at Nkosi’s Haven. After a few reading sessions, the girl said to
the facilitator, “Do you remember you were teaching us about HIV? I told my auntie what you
were teaching. I told her that if somebody has HIV, she should not be afraid of him. She can
touch and hug him” (7).
Conclusion
In conclusion, in the light of the current focus on health literacy, bibliotherapy is seen as an
effective way of promoting patient education and consumer health information within and
outside clinical settings. Bibliotherapy, in a variety of clinical and creative schemes, can be
widely used as a simple, accessible, and cost-effective way of health education and promotion
enabling individuals to increase control over their health and well-being. Bibliotherapy-based
programs can fill a unique niche within the context of services and programs traditionally offered
in a library setting. By developing and providing “information on prescription” and “books on
prescription” schemes and “shared reading” programs, public and special libraries may reinforce
their commitment to the communities they serve, demonstrate the value of books and reading in
addressing “living problems,” and strengthen relationships with the health care and social
sectors.
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