The introduction of a healthy reading scheme for people with mental health problems: usage and experiences of health professionals and library staff

Abstract

Objective This study aimed to explore utilisation of a ‘healthy reading’ service and to offer further insight into improving the processes and uptake of book prescribing so that more people have the opportunity to access this treatment.

Method Semi-structured interviews with librarians and prescribers. Collection of routine library data.

Results The scheme was thought to have been well organised, and borrowings by library users were high. A prescription was presented for 17% of borrowings. Health professionals who already used bibliotherapy in their practice were particularly positive about the scheme. There is potential to increase prescribing from other health professionals, especially general practitioners (GPs). Barriers to use included remembering the service, lack of knowledge about resources, concerns that patients would find resources difficult to use, and the time required within the consultation.

Conclusion This research showed that the healthy reading scheme provided a useful treatment option for patients with mild mental health problems and was also well used by library members. Regular reminders about the service and training for prescribers have the potential to increase patient access to resources. Further research is required to determine whether this model of bibliotherapy meets the needs of users of healthy reading materials in accessing the service.

Healthy reading has a place in stepped care models for improving mental health at both community and primary care levels. As well as being used as an adjunct therapy it could, in some cases, be an alternative to antidepressant prescribing and help reduce waiting lists for more staff-intensive psychological therapies.

Introduction

Background

Stepped care can be defined as ‘the practice of beginning one's therapeutic efforts with the least expensive and least intrusive intervention possible and moving on to more expensive and/or more intrusive interventions only if deemed necessary in order to achieve a desired therapeutic goal’,¹ and bibliotherapy, or healthy reading, increasingly features as a self-help option in stepped care programmes for people with mental health problems, although it is probably underutilised.²

Bibliotherapy (or healthy reading) has been defined as ‘using written texts, computer programs or audio/video-recorded material for the purpose of understanding or solving problems concerning a person's development or in meeting their therapeutic needs’.³ There is growing evidence that it is a modestly effective treatment for a range of mild to moderate mental health problems,^4–9 although the evidence is limited by the poor quality of many of the trials.^10,,11 Bibliotherapy resources include books and workbooks, CDs and DVDs, and access to internet sites, and usually contain information, descriptions of other people's experiences or a workbook or manual style approach to delivering cognitive behavioural therapy (CBT) techniques. They can be used with or without professional support.

An approach to providing access to bibliotherapy resources for people with mental health problems that is now common in the UK is through ‘books on prescription’ – this enables health professionals to direct their patients to an agreed collection of resources stocked in public libraries,^12–14 often with a paper prescription itemising the recommended material. Chamberlain and co-workers surveyed libraries in England and Wales and report on 21 existing schemes which varied in several aspects including the training given to library staff, geographic coverage, funding, automation of prescriptions, loan periods, publicity, partners involved, aims and objectives, and levels of optimism in continuing the service.¹²

There is some evidence to suggest that healthy reading prescribing by general practitioners (GPs) is low, ranging from 15%¹⁵ to 35%,¹⁶ and this study was conducted among health professionals and librarians, when Healthy Reading – East Lothian was introduced, to offer further insight into improving the processes and uptake of book prescribing so that more people have the opportunity to access this treatment.

Features of Healthy Reading – East Lothian

East Lothian is a relatively prosperous mixed urban/rural community (population 90 000) close to the city of Edinburgh. There are 12 libraries and approximately 67 GP principals working in 15 health centres.

Healthy Reading – East Lothian (HR-EL) was piloted at five medical practices and four libraries in a phased manner from March 2007, and the remaining libraries and medical practices entered HR-EL between October 2007 and December 2007. It is a partnership between library and community health services (run by the local authority) and the National Health Service (NHS) primary care and mental health services in East Lothian. Like many other similar schemes it was modelled on successful work in Cardiff.^13,17 Information and self-help techniques are provided in books, CDs, DVDs and internet sites (accessible free from the libraries) and cover the following mental health problems: addiction, anger, anxiety, depression, eating disorders, grief, head injury, mood swings, obsessive-compulsive disorder (OCD), self-esteem, suicide issues, trauma and childhood sexual abuse.

The library service developed a membership category allowing non-members of the library to access books on the recommended list on receipt of a prescription, and has adjusted the length of time books can be borrowed to 12 weeks and changed (softened) arrangements for pursuing overdue books.

Prior to implementation, the scheme was explained to the library staff by the local authority health improvement officer responsible for its introduction. A short, informal session was organised for each library to provide an opportunity to check staff were familiar with the procedures for HR-EL and to provide an opportunity to discuss any barriers that a person with psychological problems might have to overcome to successfully use the library.

Potential prescribers (general practice and community mental health team staff, psychologists and counsellors) were sent a pack which included a list of the recommended resources, a prescription pad, and guidance on using HR-EL. Each pack explained why the service had been developed and that an information session, led by public health staff and the local librarian, would be organised in each primary care centre.

The project has been developed as a resource for both professional use through prescription, and community use through promotion to the general public. Promotion has been in the form of events and leaflets available in libraries and health centres. All the literature about HR-EL has made it clear that the recommended books are available to borrow directly from the library and are suitable as self-help materials.

Objectives of the evaluation

This study aimed to explore:

• rates of borrowing of the resources and prescriptions presented to libraries

• the ease of use of the various features of HR-EL for those providing the service

• the need for training for librarians to deliver the scheme to people with mental health problems

• how useful the scheme was to prescribers

• what barriers there were, if any, to prescribing

• whether any aspects of HR-EL could be altered to improve usage of the scheme.

Method

Collection of routine data on uptake

Routine library service data were used to determine how often HR-EL resources were borrowed, and prescriptions presented to libraries were monitored.

Semi-structured interviews

Semi-structured telephone interviews were held with ten health professionals and four librarians or library assistants in March 2008 from the pilot sites, approximately one year after inception of the service. Limited project resources restricted the number of interviews and it was intended to explore the views of those using the scheme to determine what improvements could be made and what potential barriers might exist. However, some effort was made to include a small number of GPs who did not use the scheme, to contribute to the understanding of barriers to use, particularly within primary care.

Interviewees were selected as follows. Eight psychiatric staff (four community psychiatric nurses (CPNs), two day unit psychiatric nurses, two consultants), two counsellors and eight GPs wrote prescriptions which were presented at a library during the pilot phase. From these, two CPNs, one day unit nurse and one consultant, one counsellor and four GPs were randomly picked using the random function in SPSS. To include a perspective of some GPs who had not used the service, one was randomly picked from the remaining 28 GPs who had not used the service (or had no patients presenting with prescriptions), and one GP non-user was opportunistically recruited in place of one of the GPs sampled above (who had recently left the practice). A further GP non-user was approached from the only unrepresented practice in the study but did not respond to requests to participate. All health professionals were sent an invitation to participate from the scheme organiser and then contacted by the researcher. A purposive sample of library staff, to give perspectives from different libraries and different job roles, was also selected.

The characteristics of the interviewees are described in Table 1.

Table 1.

Characteristics of interviewees

Job title	Number	ID used with quotes	Usage of prescribing	Location
Counsellor	1	Co1	User of HR-EL
Community psychiatric nurse	3	CPN1 to CPN3	All users of HR-EL	Based in three different locations
General practitioner	5	GP2 to GP 4	Users of HR-EL	From four of the five early adopter practices (GP randomly picked from fifth practice declined to participate)
		GP5 and GP6	Non-users
Consultant psychiatrist	1	Con1	User of HR-EL
Librarians	2	L1 and L3	n/a	From three of the four early adopter libraries
Library assistants	2	LA2 and LA4	n/a

Interview topics, in line with the aims of the study, were agreed following reading of existing literature and discussion within the project team.

During the interviews, health professionals were asked about their initial thoughts on the book prescribing service and their experience of using HR-EL – the prescription, resource list and offering patients prescriptions. The interviews with the librarians focused on their initial expectations and concerns, training requirements, situation of resources in the library and their experiences of supporting people with prescriptions to borrow the books.

Interviews lasted between 5 and 21 minutes. All but one was recorded and transcribed. Interviews were analysed thematically based on an initial reading of paper transcripts to compile a list of key themes, which were then applied systematically using a computer package (NVivo7). All analysis was conducted by RR who presented key themes to the team for discussion.

Results

Uptake of Healthy Reading – East Lothian

Borrowing rates

Between May 2007 and May 2008, 844 items on the ‘healthy reading list’ were borrowed from libraries. Although these figures are for a one-year period they do not represent a full year of operation because of the roll-out period. When the service was fully operational, about 100 HR-EL items were borrowed each month. Of the items borrowed, 17% (144) were a result of a prescription being presented to library staff.

Prescribing information

Table 2 shows the number of prescriptions presented at libraries for each professional group. Thirty-six percent of GPs used the service at least once, issuing approximately three prescriptions each on average. Three practices made no use of the scheme.

Table 2.

Prescriptions (presented at libraries) by different health professional groups in a 12-month period

	Approximate number in East Lothian	Number (%) who wrote HR-EL prescription (presented at library)	Number of prescriptions (presented at library)	Average number of prescriptions (presented at library) by each prescriber
GPs	67	24 (36)	76	3.2
Psychiatric staff	24a	10 (41)	41	4.1
Counsellors	9	7(78)	22	3.1
Total	100	41 (41)	139	3.5
Othersb	unknown	–	5	–
Overall total			144

^aThis figure is an approximation of the number of staff in post when prescriber packs were sent out and is probably greater than the actual number, thus deflating the proportion of psychiatric staff writing prescriptions

^bFor example, child and adolescent mental health staff

Experience of health professionals and librarians

This section focuses on the experiences of health professionals and library staff and their perceptions of the benefits of the scheme for prescribers and barriers to prescribing. The codes used with quotations are explained in Table 1.

Introduction and training

The initial information about HR-EL was well received and all prescribers found the process readily understandable. Library staff incorporated HR-EL easily into their busy workload and appreciated the initial personal introduction to the scheme from the health improvement officer who discussed with them how to support people with prescriptions when they came to the library. The library staff felt confident that their experience and the general ethos of customer services would support people who brought a HR-EL prescription to a library. Further training in recognising and supporting people with depression had been available but was met with mixed views.

‘Well, we were offered a, sort of, open invitation to have some training in dealing with people who have … depression or mental health issues but some of us, myself included, refused that because I think that's taking it too far, you know, recognising somebody coming in the door that may have issues, we're not medical practitioners, we're librarians. I personally thought that was taking it too far.’ (L1)

‘I did go on a training course through the library [which] … just, kind of, summarised everything and made you understand the wider issues, and just to see it from other people's point of view.’ (LA2)

Use of prescription pads and the resource list

Interviewees who reported they had initially been sceptical about prescription pads had changed their minds about this and recognised that both the pads and the list of resources were important to the success of HR-EL. The presence of the prescription pad or the list of resources in the consulting room could act as a reminder of the HR-EL service.

‘I think … that it perhaps helps the prescriber to remember it [HR-EL], to take out the prescription pad and you have it there on your desk, beside your drug prescription pad and … perhaps just being there can remind somebody that there is an alternative.’ (Con1)

‘I have my list up in front of me and I have my book prescription now next to my prescription pad so it's a lot more obvious for myself.’ (GP4)

‘Well, it makes it easy for us to have a written list that we can choose from, although I haven't obviously read the books myself. But they have been recommended by other professionals, so that makes it easier, rather than just saying “why don't you go to the library and look through a few books”. So again, that makes it easier that there is a preordained list.’ (GP3)

The paper prescription made the prescriber feel as if they were giving something, added a more formal note to the concept of healthy reading, and possibly made people more aware that it was a serious treatment option.

‘It's good that, you know, not just to be writing on a scrap of paper. I think it looks more professional, more thought out, more like you're selecting something relevant to their treatment … Whereas quite often in the past I've written things on post-its, you know, “go and look out this book” or, you know, “there's this nice book that's got a yellow cover” [laughs] and I don't think that's as effective. I think it's far more effective to have it on a formalised bit of paper exactly what you're recommending that they look at.’ (CPN2)

One prescriber discussed with the patient whether they would like a paper prescription or not, outlining the advantages if they were not already a library user. This prescriber would also read through the synopsis of each relevant book with the patient to let them choose which one they thought best suited them.

The patient's name and address on the prescription acts as identification to provide an easy and legitimate way to become a library member and access the HR-EL resources.

‘It was funny because initially I didn't really see the point of it [the paper prescription] where you could just suggest a book to someone and they would be able to go and get it themselves. But I didn't realise there are so few people nowadays that are members of libraries. I don't think there was anybody that I did a prescription for that was a member of a library at all, so that was one thing that was helpful, that they didn't have to be a member. They could just go in with the prescription and get access to the book without having to go – I don't know what you need to do to join now, ID and all the rest of it. I think if that was the case then a lot of people wouldn't have bothered. So I think it may be easier for people to get access to literature.’ (CPN1)

Having a prescription was also thought to make people more confident about going to the library and make it easier in the library to get the book.

‘I was just thinking the thing about the prescription is that the person doesn't have to go into the library and not know what to do or where to go because they know that they just have to hand that over and the book will be given to them. And there's something probably quite safe about that for people, rather than going into a building they've never been in and thinking everybody's going to be looking at me because I'll be the only person that doesn't know what I'm looking for, etc. So I think that's quite a helpful aspect of it.’ (Co1)

Designing the prescription pad to make the space for the patient's name and address large enough for an address label was thought to be important as labels are often used for speed and clarity rather than writing the details by hand. Other suggestions included laminating the resource list to make it more attractive and professional looking, listing resources for each mental health problem on separate pages to enable copying this for patients who could then browse through the books in the library and borrow the one that they found most appealing, or having the list available electronically so it could be both readily updated and printed out by topic when needed.

In general, prescribers were satisfied with the range of HR-EL resources, although more resources for people with lower literacy skills were thought desirable.

‘That might just be the area that I work in because it's quite a deprived area so, you know, the reading age isn't brilliant … and the books on it [the list] are definitely recommended for people that are probably more intelligent … whereas, I think there are some books out there that are written a bit more for lower reading ages – stuff that could do with being on the list. (CPN2)

Offering patients bibliotherapy – advantages of the scheme and barriers to using it

The majority of interviewees thought they had a clear understanding of how the HR-EL service worked from the patients' perspective; one had even visited the local library to see exactly where the books were located so that she could describe this to people who were prescribed a resource. Prescribers described explaining the HR-EL scheme to potential recipients of prescriptions and found that people readily accepted the concept. They reassured their patients that it was an easy and discreet process.

‘I was quite surprised at the number of folk who really did go and get it [the book] and I think that the reason they did was because having explained the scheme to them and said you know, “you're not time limited in how long you can borrow this” and, you know, “you're not going to get hassle about returning it” and “… the librarian isn't going to say ‘hey! here's your book on depression’ and announce it to the whole library”. Because I've explained the scheme, the way that it's been set up, people have been a bit more reassured by that and I think they've gone and done it that way.’ (CPN2)

HR-EL made it easier for health professionals to suggest bibliotherapy to their patients because the resources could be used without cost. People could try different resources to see which suited them best so there was no risk that they were recommended to spend money on something that turned out not to suit them. Healthy reading also provided an alternative to taking antidepressant medication.

‘A lot of our patients couldn't afford to go a bookshop and buy one of these books and I think if they know that the library's got them in stock and that it will be a discreet service and they'll be able to keep the book for eight weeks or whatever, I think that's quite helpful and a lot of patients don't want medication you know, I've got patients mainly with mental health issues, they would rather, for example, get one of the workbooks and work through that than take medication. So I think it's replaced medication in some cases.’ (GP2)

HR-EL meant that health professionals no longer had to spend time to develop or buy their own resources or to photocopy other materials.

‘The fact that the libraries took it on was fantastic because just access to funding and the access to the actual books was something that was difficult for us to maintain.’ (CPN3)

Other advantages of HR-EL that were mentioned included its potential to help determine which patients might benefit most from more intensive psychological services and the provision of trusted resources in libraries for the general population which can give patients the information they need for ‘self-help’, thus obviating the need to consult a health professional.

‘But it's a good way of seeing how motivated someone is to do … psychological treatments; given the pressure on psychological services in this area it's a great way of … picking the ones that are going to use it usefully.’ (CPN2)

‘And if we can put in place things that help individuals in primary care … then that'll have an impact on them coming to secondary care. Hopefully we can even put in place things that enable individuals experiencing mental ill-health or disease or whatever, if they can find things that help them, even before having to go to their doctor.’ (Con1)

Although the introduction of the scheme was perceived to have many advantages, the data presented earlier suggest that many potential prescribers (especially GPs) did not use the service and those who did had not used the option frequently. The interviews highlighted several barriers.

The first obstacle to prescribing is extremely obvious, but merits outlining – it is remembering that the scheme exists. Memories of receiving the initial pack were sometimes vague or non-existent, and those who had used the scheme sometimes forgot if they had not used it for a while. GPs in particular suffer from this problem because they see people with a wider spectrum of diseases, which can result in information overload.

‘Well, in fairness, I think probably there was a brief synopsis sent out, but if it's not something I'm going to use on a regular basis, then I'm not going to retain that information, and I could have another bit of paper or another leaflet to put into my shelves beside my desk, that is just going to get mixed up with everything else that gathers dust … But a long big list, I'm just not going to either wade through or remember.’ (GP6)

GPs who did prescribe the library resources often mentioned a counsellor or CPN they knew who had used bibliotherapy enthusiastically in their professional practice, and this encouraged their use.

Another barrier mentioned was lack of knowledge of the content of the resources. Specialist mental health professionals were, understandably, more familiar with them than generalists. There were differing views on prescribing materials that the prescriber had not read or was not familiar with; some people were happy to prescribe books that other health professionals had sanctioned, others said they would not prescribe something they were not familiar with. To have a comprehensive knowledge of the content of every resource on the list was thought to be a major undertaking, even for specialists, and one that generalists were unlikely to achieve as their need for the service was more diluted. Another benefit of being familiar with the resources was being able to match people more easily to the various texts.

Health professionals who already used self-help resources for people with mental health problems appeared more likely to make use of HR-EL and were most appreciative of its introduction.

Another barrier that was frequently mentioned was the difficulty some patients might have using the resources because of their illness (such as severe depression), their cognitive skills, their motivation or their reading ability.

‘Obviously not everyone is going to have the cognitive capacity to sit down and read a book and process it, and come back and discuss it. And it's not always appropriate for everyone either, but for a big majority of folk it is.’ (CPN2)

‘For the core of my patients, I'm not sure how practicable it would be … as a GP we still do some house visits, and you're going into houses and there are no books, no magazines. You're seeing maybe the Daily Record [newspaper], and walls of videos and DVDs, but written literature is conspicuous by its absence. So that would be my only concern, that reading is just not part of the lifestyle or ways of getting better.’ (GP6)

Although a short, simple leaflet was available to explain the process of HR-EL to patients, some GPs felt that the time required to write the prescription (including deciding on which resource to prescribe) and to explain the process to people new to the concept of healthy reading was a barrier.

Library experience

Books were positioned differently in the libraries; in each case with the intention of being easily accessible and situated sensitively with regard to people being observed browsing them. They were either in a section of their own or on the shelves with others of the same category, arranged according to the usual classification. Staff were satisfied that the arrangement in their library worked well; they had anticipated that some borrowers might appear uncomfortable in locating these books but did not report any instances where this was apparent.

Borrowing a book through HR-EL allows people to keep the book for longer than regular library users and interviewees commented that people appreciated this.

‘They [HR-EL borrowers] all seem to welcome that they're getting the book for quite a long time … they're not having to rush to get through and get back, they've got lots of time to absorb the material that's there.’ (L3)

There had been no problem with books not being returned within the longer timeframe. Some titles were particularly popular and there was at least one instance of a popular book not being available despite multiple copies having been originally purchased. However, it had been possible to find a copy at another library for the patient to collect two days later, and further copies were ordered. Library staff expressed great enthusiasm for HR-EL and could only cite one problem – difficulty in finding shelf space for the new stock!

Advantages for the library were reported as being:

• greater stock for both HR-EL and regular borrowers

• external funding for the books

• more people using the library, borrowing healthy reading books, and discovering what the library has to offer

• new links with other community partners (primary care staff, community mental health teams).

‘… it's linking with other partners in the community which has been good. It's sort of widened our service and maybe making us more, I don't know, more prominent to other services.’ (L3)

‘It's always good to get other people in the door and I think it's perhaps getting people in that maybe wouldn't have had the confidence to come in on their own, but if they're told, you know by a counsellor or a doctor and given this prescription, it will you know, give them that added incentive to go in, in the first place and feel a bit more secure with that.’ (L3)

Initial concerns by library staff about people being nervous or uncomfortable coming with a prescription were not realised.

‘I think there was always a slight concern about how you would deal with – because obviously it's a public building, and there are other people, so sometimes you are always concerned that people might be uncomfortable with the scheme … It's actually not proved to be a concern. People are quite happy. They tend to just hand over the piece of paper. I think because they don't have to ask, they can just give the prescription. I think that's a lot easier.’ (LA2)

‘I've been surprised how many people have actually been quite happy to talk about why they want the book, or – I think that's good, that they feel that we are approachable in that way.’ (LA2)

Suggestions for improvements included making it easier for people to use library computers to access reputable internet sites and advertising healthy reading books clearly in the library and elsewhere in the community to encourage a wider range of people to use them before consulting a health professional.

‘I certainly think the library could be better utilised in many respects … patients will go for a good read but not necessarily think about going for a healthy read, you know, around their health. And I think the library should promote that more, ‘cause there's a huge number of books out there that would interest lots of different categories of people.’ (GP4)

Discussion

HR-EL was set up to increase accessibility to self-help resources for people with mental health problems. Although it has facilitated health professionals to recommend specific resources to patients and for members of the public to borrow the approved resources, it is likely that more people could have access to these resources by employing a variety of strategies such as: further publicity and training for health professionals to help overcome the identified barriers and raise awareness about the benefits of bibliotherapy; expanding prescribing to other professions such as occupational therapists, health visitors, district nurses, pharmacists, local voluntary agency mental health service providers, and social services staff; and wider advertising of the availability of library resources. This last strategy is important because bibliotherapy has the potential to enable people to cope with their mental health problems themselves.

Increasing the use of HR-EL by GPs is likely to require a variety of strategies that raise awareness of the service and highlight the evidence of its efficacy and ease of use. As well as more frequent information and reminders for both new and continuing staff, and provision of materials such as posters, prescription pads, resource lists and patient information leaflets, there is potential to investigate how integrating the prescribing of books into existing computer prescribing systems will facilitate and increase GPuse of the scheme. For example, reminders about book therapy could ‘pop up’ when antidepres-sants or other specific mental health pharmacotherapies are prescribed within the consultation, and the process of printing out a book prescription could be computerised. The experience of other schemes could be helpful with this.

Although some of the general public borrowers (without prescriptions) might have been directed to the resources by a health professional it seems likely, from the large numbers, that many people are borrowing HR-EL resources without first visiting a health professional. Other schemes have also found that the majority of users of the books are people who have not been given a prescription.^15,18,19 This may produce cost efficiencies if people access the materials of their own accord instead of a through/healthcare consultation, or if using the resources can be used to identify the type of patient who might be motivated to engage with other forms of CBT-based therapies.

It is interesting to note that the barriers to use are mostly located around healthcare professionals: in their ability to remember that such alternatives are available, their knowledge of the materials, and their perceptions of patient ability to engage with materials. The numbers of non-referral/non-prescription borrowers and the lack of reported problems in their use by library staff would indicate that these concerns may be largely unnecessary. The public seem to be able to borrow materials without much prior knowledge of their content although it is accepted that within the current scheme we have no knowledge whether they have selected the most appropriate materials or how effectively they have used the materials. Rogers et al highlight the importance of GPs discussing ‘the role of the individual in bringing about desired change’ during consultations to prepare patients for self care,²⁰ and it may be that training in this could facilitate greater GP use of healthy reading schemes.

HR-EL appears to provide a valuable alternative treatment or management option for many patients with a variety of mental health problems. For example, healthy reading could be particularly useful for patients with depression who are not keen or able to take antidepressants, or in cases of mild depression where the efficacy of antidepressants is doubtful.²¹ The Scottish Government has a target to prevent further increases in antidepressant prescribing, and healthy reading schemes have the potential to support this target.²² Psychological therapies often have long waiting lists, and for both patients with depression and those with other mental health problems HR-EL provides health professionals and patients with at least an interim management option. It also supports the stepped care agenda and can be used as an adjunct therapy with medication.

Limitations

The results of this evaluation are limited by the small number of interviews and their timing in the early stages of the scheme's operation. The identification of barriers may be limited by the inclusion of only a small number of GPs who did not use the service, although reasons for low levels of usage were also discussed by prescribers. The study has, however, been useful in highlighting the acceptability of the service to those already familiar with bibliotherapy and the potential to increase the use of ‘books on prescription’ by addressing the barriers identified and increasing the promotion of the service. Further in-depth qualitative research with a larger sample of health professionals from primary and secondary care is likely to determine other barriers to prescribing healthy reading and support expansion of its use. It was apparent from this work that library staff found it easy to assimilate the new service into their way of working. There is a lack of research evidence about the experiences and needs of people with mental health problems with respect to bibliotherapy, and a well-designed project to explore this is needed. As well as determining how best to support patients, it would be useful to know if people who access the resources themselves require any further support.

Conclusions

All library staff and the health professionals interviewed who had used HR-EL perceived the scheme to be a valuable addition to available services. They saw benefits for people with mental health problems and other members of the population and for their own occupations. For some health professionals, HR-EL made it easier and quicker to do what they have always done, and most liked the more formal approach which felt more professional.

The scheme appears to be well organised and operating without difficulty. No major changes were suggested by any of the interviewees. However, there is scope to increase the number of health professionals and members of the public using the scheme. It would be valuable to carry out further research to explore how this model of healthy reading could be improved for users themselves.

The decision to use a prescription pad in the HR-EL scheme seems to have been a good one. As well as prompting prescribers to use bibliotherapy, the prescriptions made it easy for prescribees to access the books in the library, particularly facilitating the membership they needed to borrow the book. The book list and synopsis were also important factors in the process.