The Multimedia Computer for Low-Literacy Patient Education: A Pilot Project of Cancer Risk Perceptions

James L. Wofford, MD, MS, Dorothy Currin, MPH, Robert Michielutte, PhD, Marcia M. Wofford, MD

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In This Article

Abstract and Introduction

Objective: Inadequate reading literacy is a major barrier to better educating patients. Despite its high prevalence, practical solutions for detecting and overcoming low literacy in a busy clinical setting remain elusive. In exploring the potential role for the multimedia computer in improving office-based patient education, we compared the accuracy of information captured from audio-computer interviewing of patients with that obtained from subsequent verbal questioning.
Setting: Adult medicine clinic, urban community health center
Patients: Convenience sample of patients awaiting clinic appointments (n = 59). Exclusion criteria included obvious psychoneurologic impairment or primary language other than English.
Intervention: A multimedia computer presentation that used audio-computer interviewing with localized imagery and voices to elicit responses to 4 questions on prior computer use and cancer risk perceptions.
Measurements and Main Results: Three patients refused or were unable to interact with the computer at all, and 3 patients required restarting the presentation from the beginning but ultimately completed the computerized survey. Of the 51 evaluable patients (72.5% African-American, 66.7% female, mean age 47.5 [± 18.1]), the mean time in the computer presentation was significantly longer with older age and with no prior computer use but did not differ by gender or race. Despite a high proportion of no prior computer use (60.8%), there was a high rate of agreement (88.7% overall) between audio-computer interviewing and subsequent verbal questioning.
Conclusions: Audio-computer interviewing is feasible in this urban community health center. The computer offers a partial solution for overcoming literacy barriers inherent in written patient education materials and provides an efficient means of data collection that can be used to better target patients' educational needs.

Recent studies emphasize that low reading literacy is highly prevalent in the general population and in many different patient populations.[1,2,3,4,5,6] The prevalence of inadequate functional health literacy (ability to read and comprehend commonly used healthcare instructions) may reach 80% in some medical settings.[4] Not only is low literacy prevalent, but it is also costly to the healthcare system. Persons with lower reading literacy levels have a greater likelihood of hospitalization and higher expenses for healthcare than those with better reading skills.[3,7,8] As an example, Medicaid recipients who read at the lowest grade level have average annual healthcare costs r4 times that of the overall Medicaid population.

Because of the high prevalence of low literacy, healthcare professionals should feel obligated to adjust their patient education materials to the literacy level of the patient. However, most patient education materials are written, and written at a reading level beyond that of the usual patient. Handouts used to educate patients, including those from professional organizations, are typically written at the tenth grade level or higher.[9,10] By contrast, the average reading level of Medicaid enrollees is at the fifth grade level. Text simplification of printed materials is the strategy that has received the most attention for improving patient education materials in healthcare settings, but there is a limit to how much simplification can be done without losing meaning.[11] To make matters worse for the office-based clinician, accrediting organizations now insist that clinicians not only offer educational materials but that they be understood by patients.[12] For the busy healthcare professional faced with a shrinking amount of face-to-face time with the patient, new office strategies for identifying and providing the low-literacy patient with understandable education materials are necessary.

The multimedia computer is a new vehicle for delivering health education to those with low literacy skills. Advantages of the multimedia computer for patient education include the ability to use audio, animation, video, and interactivity that can be tailored to the literacy level of the patient. Translation of patient materials to other languages is easier than through printed text by using computerized audio recording. Because health information presented through the multimedia computer avoids barriers inherent in printed material, an obvious next question is whether low-literacy patients can use a computer effectively. While it may seem intuitive that low-literacy patients might have more difficulty using the computer, reading literacy is not synonymous with intelligence.[13] Studies suggest that socioeconomically disadvantaged persons often perform well with computers.[14,15,16,17,18] This pilot study sought to determine whether use of the multimedia computer is feasible for a low-literacy population in a clinic setting and whether capturing information from the patients through the computer is accurate compared with verbal questioning.

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