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J Med Libr Assoc. Oct 2004; 92(4): 495–497.
PMCID: PMC521522

Updating hospital reference resources in the United States–associated Pacific Basin: efforts of the Pacific Islands Continuing Clinical Education Program (PICCEP)*

Karin E. Johnson, PhD, Research Associate, Susan M. Skillman, MS, Deputy Director, Kathleen E. Ellsbury, MD, MSPH, Associate Professor, Matthew J. Thompson, MBChB, MPH, DTMH, Associate Professor, and L. Gary Hart, PhD, Professor and Principal Investigator


This article describes a project by the Pacific Islands Continuing Clinical Education Program (PICCEP) at the University of Washington (UW) to supplement hospital reference materials in six jurisdictions in the US-associated Pacific Islands. It outlines a model for cooperatively developing a suite of clinical reference materials suitable to low-resource settings.

The US-associated Pacific Islands encompass the US flag territories of American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), and Guam, as well as the independent countries, “freely associated with the United States,” of the Federated States of Micronesia (FSM), the Republic of the Marshall Islands (RMI), and the Republic of Palau. The region contains 104 inhabited islands that cover an area of the Pacific that is larger than the continental United States. Nearly 500,000 total residents live in the jurisdictions. Gross domestic product per capita in 2000 varied from $1,600 in RMI to $21,000 in Guam. English is an official language throughout the region, although many people speak one or more other languages [1]. The United States serves as the region's primary funder of social and health services. Each jurisdiction has one or more secondary hospitals, with bed sizes ranging from under 50 to over 200. Only a few of them offer advanced specialty services.

In 1998, the federal Institute of Medicine (IOM) found numerous health care challenges in the region: deteriorating health infrastructure, high health care costs, serious health problems on some islands such as high rates of substance abuse and infant mortality, and particularly “shortages of adequately trained health care personnel” [2]. The IOM recommended an emphasis on health workforce improvement, in large part through continuing medical education (CME). The federal government responded, in part, by funding PICCEP, a four-year effort implemented by the UW Center for Health Workforce Studies.

PICCEP conducted a needs assessment and concluded that, among other problems, the region's health care providers lacked current clinical reference materials [3]. Most hospitals did not have libraries or librarians. They all had at least a small collection of reference materials, but most physicians felt these materials were too limited to help solve specific clinical problems or maintain skills. Personal computers were few in number and not readily available for most clinicians. In addition, limited, slow, and expensive Internet access made computerized references impractical in all but the most developed jurisdictions, such as Guam and the Republic of Palau.


Given the need for reference materials expressed by regional physicians and observed by PICCEP staff, PICCEP sought to improve access to key clinical reference resources as part of its overall CME program. During 2000–2001, it obtained $40,000 for this purpose. Because most health systems in the US-associated Pacific Islands were divided distinctly into a central hospital and a public health system, PICCEP targeted hospitals, where most physicians were based. To distribute available resources equitably in the region, PICCEP divided the funding roughly equally among the eleven major hospitals. PICCEP sought to coordinate its program supplementing reference materials with other organizations engaged in similar efforts. An investigation revealed no preexisting programs in the region and only one documented program in the world, the Blue Trunk Program run by the Library of the World Health Organization (WHO). This program provided African district health centers with about 100 books on medicine and public health and a few medical journal subscriptions [4]. WHO worked with local trainers to help deliver, publicize, and monitor the collection.

Book donation programs can fail for reasons including materials that do not reach their intended audience or are inappropriate to local conditions, placement of materials where few potential users know about them, materials that are removed for personal use and not returned, resources for updating that are missing, and recipients who are unaccustomed to using books and journals as information sources [5]. Aware of these potential pitfalls, PICCEP resolved to develop a program that would ensure long-term access to useful reference materials.

PICCEP wanted to involve each hospital in the selection of suitable materials. But given the limited and one-time availability of funds, PICCEP sought to guide each hospital in creating a package of resources that would suit the needs of a variety of health professionals in clinical settings ranging from urgent care to patient counseling. Program physicians consulted with a medical librarian to develop a reference resource catalog (available from the authors). The Brandon/Hill list for small medical libraries served as the basis for the catalog of recommended resources [6]. The final selection differed slightly due to availability and suitability for hospitals located outside of the United States. The catalog was divided into “core references,” material which was determined to be essential for the hospitals, and “supplemental resources,” additional options from which respondents could choose, and was further categorized by topic. Hospitals could add their own requests for additional items.

PICCEP identified a key contact at each hospital and asked that contact to consult with physicians, nurses, and allied health staff about their preferences in reference materials. Respondents were instructed to rank the priority of each item in the catalog. This method of assessing preferences worked extremely well; all hospitals returned a carefully considered list that encompassed a wide range of materials suited to a range of clinical topics and professions.

PICCEP attempted to purchase all of the identified materials as “very strongly desired” and as many other requested materials as possible. Because the requests from the jurisdictions far exceeded the project budget, PICCEP staff analyzed each hospital's choices to put together a comprehensive package of materials. Staff prioritized core items and materials most relevant to each hospital's resources and community. PICCEP purchased some electronic journal subscriptions for hospitals with greater technical capacity. To help minimize the loss of materials over time, PICCEP gave each hospital a personalized rubber stamp, so they could indicate ownership of each item.

Most selections were purchased through a bookstore in Seattle that offered a discount and free shipping to PICCEP. Most items were shipped to the hospitals and insured by private carrier. Delivery expenses were significantly higher than anticipated. Similar programs in the future should budget 5% to 10% above purchasing costs to cover the high costs associated with shipping to remote regions.

The American Academy of Family Physicians (AAFP) Medical Education Materials Clearinghouse, which channels donations of medical reference resources to needy hospitals around the world, contributed additional materials. PICCEP staff selected appropriate materials from the fund's catalog and distributed them to each hospital based on their most appropriate use. University colleagues offered a variety of additional materials. PICCEP accepted many for distribution after screening for relevance and currency.

PICCEP followed up with each hospital to ensure that all items arrived. Two hospitals required a letter from PICCEP indicating that the shipped items were donated, so that they were not assessed import duties. Otherwise, all of the materials reached their intended destinations without difficulty, and PICCEP received enthusiastic feedback about them.

During subsequent PICCEP-provided courses, faculty assessed program success. Most of the reference materials were located in secured areas of the target hospitals, such as a designated room or an area in the doctor's lounge. Specific texts were assigned to individual doctors or wards, where the specialty was most appropriate. Some PICCEP faculty referred to the materials in their sessions to help encourage use of the resources.


Ideally, personnel and funding would be available to encourage access to and use of resources over a longer period. Initiatives such as the Health InterNetwork [7] may help poor countries do so. WHO and several publishing companies established the Health InterNetwork Access to Research Initiative (HINARI) in 2000 to ensure equitable access to health information around the world. Its first phase makes a large range of scientific publications available for free or at reduced costs to selected countries, depending on their income. Where applicable—FSM and the RMI became eligible in 2003—this initiative, combined with global efforts to increase telecommunications capacity, logically extends efforts such as PICCEP's to provide clinical reference materials on a limited budget.

PICCEP's initiative overcame many of the challenges facing efforts to donate references. While goals such as fully evaluating the use of reference materials and updating them when they are outdated or lost remain, PICCEP did establish a suite of suitable materials accessible to a variety of clinicians in 11 hospitals at an average cost of under $4,000 per site.


The authors greatly appreciate the contributions to this program by the University Book Store (Seattle, Washington) and the AAFP Office of International Activities and assistance in distribution from Heather Deacon, editing from Alice Porter, and word processing from Martha Reeves. The AAFP Office of International Activities sponsors the AAFP Medical Education Materials Clearinghouse, which is happy to accept contributions of medical books, audiotapes, videotapes, and complete volumes of journals that are less than five years old. It distributes these materials free of charge (recipient is requested to cover shipping) to organizations outside of the United States whose works are related directly to family medicine. Persons interested in making contributions to the AAFP Medical Education Materials Clearinghouse, or requesting materials from it, should contact Ms. Terry Smalley, senior program coordinator, AAFP Office of International Activities, 11400 Tomahawk Creek Parkway, Leawood, Kansas 66211-2672; 800.274.2237 x4512; gro.pfaa@tni. The AAFP Medical Education Materials Clearinghouse would appreciate advance notification of the titles of any materials contributors would like to donate.


* This study was conducted by the University of Washington's Pacific Islands Continuing Clinical Education Program, in the Center for Health Workforce Studies, and was funded by the Bureau of Primary Health Care and the Bureau of Health Professions, US Health Resources and Services Administration.

 When these previous trust territories gained independence in 1986 (Federated States of Micronesia and the Republic of the Marshall Islands) and 1994 (Palau), they negotiated a special status that gives their citizens the right to travel freely to the United States and the United States the right to exclude any foreign power from having a military presence in the region.


  • Central Intelligence Agency. The world factbook. [Web document]. The Agency, 2004. [cited 24 Jun 2004]. <http://www.cia.gov/cia/publications/factbook/>.
  • Institute of Medicine. Pacific partnerships for health: charting a new course. Washington, DC: National Academies Press, 1998.
  • Thompson MJ, Skillman SM, Johnson K, Schneeweiss R, Ellsbury K, and Hart LG. Assessing physicians' continuing medical education (CME) needs in the US-associated Pacific jurisdictions. Pac Health Dialog. 2002.  Mar; 9(1):11–6. [PubMed]
  • World Health Organization. Blue trunk libraries. 2001. [Web document]. The Organization, 2001. [cited 24 Jun 2004]. <http://www.who.int/library/country/trunks/index.en.shtml>.
  • Ibid.
  • Hill DR. Brandon/Hill selected list of books and journals for the small medical library. Bull Med Libr Assoc. 1999.  Apr; 87(2):145–69. [PMC free article] [PubMed]
  • Health InterNetwork Access to Research Initiative. Health InterNetwork. 2003. [Web document]. [cited 24 Jun 2004]. <http://www.healthinternetwork.net>.

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