DOI: 10.1111/j.1471-1842.2007.00744.

User library service expectations in health science vs.

Blackwell Publishing Ltd

other settings: a LibQUAL+® Study

Bruce Thompson*, Martha Kyrillidou† & Colleen Cook*, *Texas A&M University and Baylor College
of Medicine, College Station, Texas, USA, and †Association of Research Libraries, Washington DC, USA

Abstract
Objectives: To explore how the library service expectations and perceptions of
users might differ across health-related libraries as against major research
libraries not operating in a medical context; to determine whether users of
medical libraries demand better library service quality, because the inability of
users to access needed literature promptly may lead to a patient who cannot be
properly diagnosed, or a diagnosis that cannot be properly treated.
Methodology: We compared LibQUAL+® total and subscale scores across
three groups of US, Canadian and British libraries for this purpose.
Results: Anticipated differences in expectations for health as other library
settings did not emerge.
Conclusions: The expectations and perceptions are similar across different
types of health science library settings, hospital and academic, and across other
general research libraries.

In this environment, as Danuta Nitecki has

Introduction
LibQUAL+® is a ‘total market survey’ intended
to help library staff understand user perceptions,
and thereby improve library service quality and
better meet users’ information needs. A total-
market survey is one of the 11 ways of listening to
users elaborated by Leonard Berry1 and implies
benchmarking against the service performance of
alternative service providers.
As Rowena Cullen indicated, ‘focusing more
energy on meeting ... customers’ expectations’2 is
critical in the contemporary environment, in part
because:
‘the emergence of the virtual university, supported
by the virtual library, calls into question many
of our basic assumptions about the role of the
academic library, and the security of its future.’2 p.663
Correspondence: Martha Kyrillidou, Director, Statistics and Service
Quality Programs, Association of Research Libraries, 21 Dupont Circle
NW, Suite 800, Washington, DC 20036, USA. E-mail: martha@arl.org
observed, ‘A measure of library quality based
solely on collections [counts] has become obsolete.’3
Librarians have come to realize the wisdom of the
words of French philosopher and moralist François
de La Rochefoucauld, ‘Il est plus nécessaire d’étudier
les hommes que les livres’4—in English, ‘it is more
important to study people than books’.
The LibQUAL+® protocol evolved out of the
SERVQUAL model, and the use of SERVQUAL
in library settings.5 Within the service quality
orientation, as the developers of SERVQUAL
noted, a major premise is that ‘only customers
judge quality; all other judgements are essentially
irrelevant’.6 Furthermore, in the words of Bruce
Thompson, ‘We only care about the things we
measure’7 so we do not seriously care about service
quality unless we listen to library users in various
systematic ways.
LibQUAL+® has three primary components:
‘First, LibQUAL+® consists of 22 core items
measuring perceived service quality with respect

© 2007 The authors

38 Journal compilation © 2007 Health Libraries Group. Health Information and Libraries Journal, 24 (Suppl.1), pp.38–45
 LibQUAL+® in health science libraries, Bruce Thompson et al.
Figure 1 Sample screen of the LibQUAL+® survey
to (a) Service Affect, (b) Library as Place, and
(c) Information Control. Each item is rated
with respect to (a) minimally acceptable service
expectations, (b) desired service expectations, and
(c) perceived level of actual service quality ...
Second, the LibQUAL+® protocol solicits open-
ended comments from users regarding library
service quality ... These comments are crucial,
because here the participants elaborate upon
perceived strengths and weaknesses, and sometimes
offer suggestions for specific actions to improve
service. Third, libraries using LibQUAL+® have
the option of selecting five additional items from
a supplementary pool of 100+ items to augment the
22 core items to focus on issues of local interest.’9
There are two key aspects in understanding
LibQUAL+®: (i) what LibQUAL+® measures
and (ii) how LibQUAL+® measures. Affect of
service includes elements of empathy, responsiveness,
assurance and reliability; information control
measures the scope of collections, timeliness,
© 2007 The authors
Journal compilation © Health Libraries Group 2007 Health Information and Libraries Journal, 24 (Suppl.1), pp.38–45
39
convenience, ease of navigation, and the availability
of modern equipment; and last, library as place
measures the availability of utilitarian space,
symbolic aspects of the library structure and the
notion of library as refuge. The ‘how’ these things
are measured has roots in the disconfirmation
theory that has shaped the development of the
SERVQUAL instrument, by emphasizing the gap
between expectations and perceptions. Expectations
are viewed as existing in a continuum of tolerance,
with the lowest point defining minimum expectations,
up to the other end of the zone of tolerance where
desired expectations are found. To illustrate this
framework, Fig. 1 shows a screenshot of the
LibQUAL+® survey demonstrating that, for
each concept measured, we have three scales
(i) minimum, (ii) desired and (iii) perceptions of
actual service delivery.
The additional availability of the comments box
has been a rich source of contextual information.
In our experience, a strikingly high percentage—
about 40%—of participants consistently across
40 LibQUAL+® in health science libraries, Bruce Thompson et al.
institutions provide open-ended comments using
the LibQUAL+® comments box. Libraries have
been able to act immediately on some issues as
they receive feedback in real time and as users are
providing reasonable and constructive suggestions.
One unique feature of LibQUAL+® as a service
quality assessment tool is that LibQUAL+® data
can be evaluated using any combination of three
interpretation frameworks: (i) location of percep-
tions within the ‘zones of tolerance’ defined by
minimally acceptable and desired expectations, (ii)
benchmarking against peer institutions, and (iii)
by comparing changes in a given institution’s data
longitudinally over time.
In the 8 years since its inception in 20005,
LibQUAL+® is on track to be used to collect data
in 2007 from the one millionth library user from
the 1000th institution! LibQUAL+® now has
been used in the USA, Canada, Australia, New
Zealand, the UK (England, Scotland, Wales),
France, Ireland, the Netherlands, Switzerland,
Germany, Denmark, Finland, Norway, Sweden,
Egypt, the United Arab Emirates, and South
Africa. A Chinese version is being implemented
in Hong Kong in the autumn of 2007. Currently,
the system supports 12 languages: Afrikaans, US
English, UK English, Chinese (traditional),
Danish, Dutch, Finnish, French (Canadian), French
(European), German, Norwegian, and Swedish.
Library participants believe that LibQUAL+®
data have been useful in improving library service
quality.9,10 But this vast trove of data from across
continents and library types also is a major
resource for understanding the contemporary
library users’ perceptions of the modern library.
As library users are exposed to more international
information delivery systems, their expectations
are shaped by the same forces. They end up having
similarly high expectations, whether they are using
institutional resources in North and South America,
Europe, Asia, Africa or Australia. The conclusions
from a detailed institutional study in Sweden state that:
‘Library users in Sweden have indicated that the
information control dimension is an important
one to them and this is the one dimension where
libraries are not faring well.... The “new library
user” may be a highly self-sufficient researcher who
navigates the Internet and identifies information
Journal compilation © Health Libraries Group 2007 Health Information and Libraries Journal, 24 (Suppl.1), pp.38–45
resources on his or her own. The ability to
effectively use information resources in a self-
sufficient manner may make it easier for many
users to by-pass the library and is an international
phenomenon that may be affected by the global
nature of information exchange and dissemination.
The possibility of a link between modernization
and self-sufficiency may also exist and may be felt
more acutely in areas with longer history behind
them, for example European settings. The
desire of researchers to move forward faster and
“modernize” may affect their perceptions and
expectations in those settings.’11
Health science libraries
In 2004, the first academic Swedish library
participated in LibQUAL®, and the first group of
three Swedish hospital libraries also participated
that year, in addition to seven hospital libraries
from the USA. This was the first group to
implement LibQUAL+® in the hospital library
environment.
Academic health science libraries have par-
ticipated in LibQUAL+® since 2001. They make
up 62 institutions among a total of 1036 primarily
academic and other types of libraries. The
Association of Research Libraries (ARL) has
closely collaborated with the Association of
Academic Health Science Librarians (AAHSL)
group in North America to modify LibQUAL+®
for the academic health science library environment.
In 2006, a group of 10 libraries from the National
Health Service (NHS) England also experimented
with a pilot implementation. In summarizing the
benefits of the AAHSL/ARL partnership, Tamera
Lee highlights the following:
‘The AAHSL/ARL partnership effected numerous
qualitative benefits aside from the data results.
For ARL, it assisted in furthering the applicability
of LibQUAL+® as a qualitative assessment tool
across different types of institutions. The special
[AAHSL] cohort assisted ARL with promotion,
training, and increased participation. For AAHSL,
the partnership created a heightened awareness
of the viability of outcomes assessment and a
cost-efficient protocol for listening to users. The
additional five questions allowed AAHSL to
© 2007 The authors
 LibQUAL+® in health science libraries, Bruce Thompson et al.
include constructs for issues perceived as unique
or more significant to health science libraries. It
prompted further interest in testing the instrument’s
feasibility for a new cohort of hospital libraries.
And, perhaps most importantly, with a strong
service orientation already in place, implementing
a national survey contributed to the advancement
of a culture of assessment and placed the academic
community at the centre of that assessment.’12
Additional information on specific libraries’
implementation activities are summarized in
articles describing the implementations at Mercer
University School of Medicine13, at the University
of Colorado Health Sciences Center14, at Duke
University15 and at the Galter Health Sciences
Libraries at Northwestern University.16
The NHS pilot
The NHS pilot with the LibQUAL+® survey
was a natural outgrowth of the successful
implementation of LibQUAL+® with the academic
libraries in the UK as they have been coordinated
by Stephen Town through the Society of College,
National and University Libraries (SCONUL).17
NHS is the largest organization in Europe, with
1.3 million staff (and the third-largest organization
in the world). They have different types of Trusts:
Acute Trusts which are hospital-based, Primary
Care Trusts (PCTs) which are mainly community
based, Mental Health Trusts that combine elements
from the first two, Ambulance Trusts, and NHS
Direct which comprises telephone and online
services. At the local level they are organized under
Strategic Health Authorities (SHA) which may have
multiple service providers under their jurisdiction
(for example, in 2003, the Avon Gloucestershire
and Wiltshire SHA included 25 different service
providers and more than 20 000 staff).
The quality agenda was one of the major drivers
in the NHS pilot, as they are focusing on patient-
centred NHS and evidence-based practice. The
focus on the quality agenda clearly has implications
for library staff in delivering high-quality informa-
tion and summarized evidence to library users.
One of the attractive features of LibQUAL+® for
the NHS group is the ability to benchmark
across sites and the facilitation of sharing of best
© 2007 The authors
Journal compilation © Health Libraries Group 2007 Health Information and Libraries Journal, 24 (Suppl.1), pp.38–45
41
practices with the ultimate goal of improving
service quality. The NHS pilot was part of the
work programme developing the National Service
Framework that attempts to define what users
should expect from library services.
Increased competition for resources has moved
libraries more forcefully towards assessment and
the evidence-based movement. Evidence-based
librarianship, for example, has influenced a large
part of the health science library field. Performance
measurement, service quality improvement and
service quality assurance are some other ways
that information providers are more consciously
examining the impact of their work on their
communities and the value they bring to their
professional environments.18
Purpose of the study
The present study was undertaken to use
LibQUAL+® data to explore how the library
service expectations and perceptions of users
might differ across health-related libraries as
against major research libraries not operating in
a medical context. We compared LibQUAL+®
total and subscale scores across three groups of
libraries for this purpose.
Theoretically, it might be expected that users of
medical libraries demand better library service
quality, because the inability of users to access
needed literature promptly may lead to a patient
who cannot be properly diagnosed, or a diagnosis
that cannot be properly treated. Such failures may,
indeed, have life-threatening consequences. Such
demands might lead to (i) higher minimum service
quality expectations, (ii) higher desired service
quality expectations, and (iii) narrower zones of
tolerances. Furthermore, if medical libraries obtain
greater resources in light of these expectations,
user average perceptions in such settings may also
be more favourable than the perceptions of users
working in other environments.
Results
The samples consisted of (i) 697 participants from
10 libraries from the NHS operating within the
UK, (ii) 4330 participants from US institutions
belonging to the Association of Academic Health
42 LibQUAL+® in health science libraries, Bruce Thompson et al.
Science Libraries (AAHSL), and (iii) 21 302
participants from US and Canadian non-health
libraries that are members of the Association of
Research Libraries (ARL). ARL is an organization
of the leading 123 research libraries in the USA
and Canada. AAHSL is a similar institutional
association that encompasses about 130 academic
health science libraries as members. NHS is one of
the largest organizations in the world and, within
this large National Health Service, a small group
of libraries experimented implementing LibQUAL®
during 2006.
Score reliabilities
Researchers typically report evidence that scores
are trustworthy, prior to subjecting their data to
substantive analyses. One consideration evaluates
whether scores fluctuate randomly, or systematically,
which is the psychometric consideration called
score reliability.19 Reliability allows us to answer the
question of whether the scores measure anything.
As we have said before:
‘The criterion for acceptable score reliability is
context specific. When we are using scores to
decide which hospitalized patients to disconnect
from life support, we will accept very, very little
randomness. When we are deciding which pre-
schoolers will have gold vs. silver stars pasted on
their foreheads as they leave school each day, our
standards may be somewhat relaxed, because the
consequences of misjudgement are much less
severe. Of the many coefficients that can be used
to quantify score reliability, the most commonly
used is the coefficient called Cronbach’s alpha....
In social science research, alpha coefficients of at
least 0.70 are often considered acceptable.’20
The Cronbach’s alpha coefficients for the scores
analysed in the present study are reported in
Table 1. These score reliabilities are quite high for
all three dimensions of LibQUAL+® (the lowest
coefficient is 0.88), sufficient to support subsequent
substantive analysis, and also comparable with the
coefficients for LibQUAL+® scores reported in
numerous prior studies.21–25 Having established
that the LibQUAL+® scores are reliable in the
three library settings we are analysing, libraries
Journal compilation © Health Libraries Group 2007 Health Information and Libraries Journal, 24 (Suppl.1), pp.38–45
Table 1 Cronbach’s α coefficients for total and scale scores
British American ARL
Score NHS Health Non-health
Information Control 0.90 0.93 0.90
Service Affect 0.95 0.95 0.94
Library as Place 0.88 0.91 0.88
Total 0.95 0.96 0.96
ARL, Association of Research Libraries; NHS, National Health
Service.
within the NHS, Academic Health Science Libraries,
and ARL libraries, we can now examine if there
are differences among these groups.
Group comparisons
Table 2 presents the means on LibQUAL+®
total scores, and the three subscale scores (i.e.
Information Control, Service Affect, and Library
as Place). All four of these scores are scaled 1 to 9,
with ‘9’ representing the highest possible score, such
that these scores can be compared apples to apples.
Second, the table also presents the standard
deviation (i.e. SD) about each of the means. The
standard deviation is a measure of dispersion or
heterogeneity of the scores. The SD will be zero
if every score equals the mean (i.e. the scores are
perfectly homogeneous), and will become an
increasingly larger positive number as ratings
become more disparate from each other.26
Third, Table 2 presents the ‘zone of tolerance’
for each set of means. This was computed as the
mean for desired service ratings minus the mean
for the minimally acceptable service expectations.
Fourth, a quasi-standardized ‘adequacy gap’
score is reported for each scale. The ‘adequacy
gap’ equals the service quality perception rating
minus the rating for minimally acceptable service
expectations. This was then divided by the zone
width to take into account differences in zones of
tolerance widths across the service dimensions.
Discussion
Our results suggest several conclusions with respect
to user perceptions of library service quality. First,
© 2007 The authors
 LibQUAL+® in health science libraries, Bruce Thompson et al. 43

Table 2 Means (and standard deviations) for LibQUAL+® total and subscale scores across the three library types

Minimum Perceived Desired Zone Adequacy

Group M (SD) M (SD) M (SD) width gap/zone width

British NHS (n = 697)

Information Control 6.84 (1.29) 6.91 (1.33) 8.03 (0.93) 1.19 0.06
Service Affect 6.81 (1.36) 7.62 (1.18) 7.91 (0.97) 1.10 0.74
Total Score 6.70 (1.25) 7.13 (1.16) 7.84 (0.90) 1.14 0.38
Library as Place 6.21 (1.51) 6.52 (1.52) 7.38 (1.34) 1.17 0.26
American Health Science (n = 4330)
Information Control 7.03 (1.37) 7.21 (1.26) 8.26 (0.88) 1.23 0.15
Total Score 6.79 (1.37) 7.24 (1.20) 8.03 (0.92) 1.24 0.36
Service Affect 6.75 (1.49) 7.41 (1.29) 7.97 (1.07) 1.22 0.54
Library as Place 6.41 (1.70) 6.97 (1.56) 7.69 (1.40) 1.28 0.44
North American ARL (n = 21 302)
Information Control 6.85 (1.36) 7.03 (1.21) 8.24 (0.90) 1.39 0.13
Total Score 6.51 (1.35) 6.91 (1.17) 7.93 (0.93) 1.42 0.28
Service Affect 6.37 (1.49) 6.98 (1.33) 7.79 (1.12) 1.42 0.43
Library as Place 6.12 (1.68) 6.56 (1.53) 7.62 (1.39) 1.50 0.29

Scores are sorted in descending order using the desired means.

ARL, Association of Research Libraries; NHS, National Health Service; SD, standard deviation.

the Table 1 results suggest that LibQUAL+®
provides reliable scores, even in specialized health
libraries, such as some of the libraries of NHS
England. The tabled reliability coefficients are
comparable with those obtained in other
psychometric studies.21–25 Thus, the LibQUAL+®
protocol is at least one reasonable assessment
candidate for use in the health library context. Of
course, user-orientated library staff listen to users
in multiple ways, and triangulate the messages
they hear across the ways of listening to users.
So, LibQUAL+® should be viewed as one way
of measuring service quality available to health
libraries among many other methods that can also
be deployed.
Second, anticipated differences in expectations
for health as against other library settings did not
emerge, as reflected in the Table 2 results. In all
three groups, the Information Control dimension
had the highest means on the desired ratings (8.03,
8.26 and 8.24 for the NHS, AAHSL and ARL
data, respectively). In all three groups, the ‘ade-
quacy gap divided by the zone of tolerance width’
scores were appreciably lower on the Information
Control scores (i.e. 0.06, 0.15 and 0.13, respectively)
than on the other two subscales (i.e. Service Affect
and Library as Place). Thus, users had highest
expectations but relatively the least satisfaction
with respect to Information Control.
These results reflect the inescapable reality that
the Web has fundamentally altered the way that
users think about libraries, and their expectations
regarding ubiquity of access to comprehensive
information, in the form they want, with the
immediacy they demand. This evolution was
presaged within the qualitative studies providing
the initial grounding of LibQUAL+® within the
mindset of library users. As one user commented
in describing how he thinks about library staff:
‘Well, first of all, I would turn to the best search
engines that are out there. That’s not a person so
much as an entity. In this sense, librarians are
search engines [ just] with a different interface.’27
Similarly, the qualitative comments published
from the Swedish Lund Institute of Technology
resonate similar issues from the library users who
provided comments to the survey: ‘My requirements
for library services have changed considerably in
the last 10 years. Earlier I used to visit [the library]
at least once a week and got the information on
paper. During the last 3 or 4 years I haven’t been in
the library.’11
In all three groups, participants had the lowest
means on desired ratings of Library as Place (i.e.

© 2007 The authors

Journal compilation © Health Libraries Group 2007 Health Information and Libraries Journal, 24 (Suppl.1), pp.38–45
44 LibQUAL+® in health science libraries, Bruce Thompson et al.
7.38, 7.69 and 7.62, respectively), and were also
most heterogeneous in their perceptions (i.e. SDs
were 1.52, 1.56 and 1.53, respectively). In all three
groups, the most favourable adequacy gap ratings
occurred on Service Affect (i.e. ‘adequacy gap
divided by the zone of tolerance width’ means of
0.74, 0.54 and 0.43, respectively). Library users
want to be understood and be well treated by
library staff, but they primarily want information:
information, whenever they want information,
and in whatever form they want.
The type of library, whether it is a hospital
library, an academic health sciences library, or a
general comprehensive research library, does not
affect the level of ratings of service expectations
and perceptions. Library users may want infor-
mation delivered immediately irrespective of the
urgency or impact of the use of the information
sought. Their affective personal information needs
seem to be the same irrespective of the contextual
settings for the different types of libraries examined
in this study. These findings imply that strong
collaborative relations are useful to libraries
irrespective of type of library.
Key Messages
Implications for Policy
• Service quality evaluation is an important
activity for hospital and academic health
libraries.
• Delivering services that satisfy users, enabling
their users to seek information in a self-
sufficient way, and providing a space where
users’ can interact with information resources
are key service criteria for health libraries.
• Hospital and health library services should
consider collaborative assessment with other
research libraries.
Implications for Practice
• Applications such as LibQUAL+® enable
libraries to listen to their users by systemat-
ically examining users’ perceptions and
expectations.
• The LibQUAL+® protocol performs in a
reliable fashion in hospital, academic health
science as well as general research settings.
Journal compilation © Health Libraries Group 2007 Health Information and Libraries Journal, 24 (Suppl.1), pp.38–45
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Received 6 June 2007; Accepted 13 September 2007