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

In This Article


Reynolds Health Center is a community health center located in Winston-Salem, North Carolina. The health center is the principal venue for providing healthcare to indigent Forsyth County residents. The Adult Medicine Clinic typically logs 20,000 patient visits each year. The racial distribution is approximately 60% African American, 35% white, and 5% Hispanics, and the payer mix is 40% Medicaid, 16% Medicare, 4% private insurance, and 40% self-pay. Fewer than 100 managed care patients are currently in the practice, while the penetration of managed care in the county is approximately 37%.

A convenience sample of patients was selected from the waiting rooms of the Adult Medicine Clinic. Patients who were obviously psychoneurologically impaired or only Spanish speaking were excluded from the study.

Patients were accompanied by 1 of 2 facilitators (JLW, DC) to the patient education room where the computer was located. The purpose of the study was explained, and the patient was reassured that the activity would not interfere with his/her scheduled appointment. After the facilitator logged the patient on to the computer, the computer program presented an introductory segment containing pictures and voices of familiar clinic personnel. The patient was then instructed by the computer to click on a test button. This provided the facilitator the opportunity to observe the participant's familiarity with the computer mouse and to assist, if necessary.

A series of 4 multiple choice interactions/questions were then sequentially presented (Table 1). The facilitator was present in the room for the test button and the first interaction to ensure the participant could interact effectively with the computer. After the computer presentation, the same 4 questions were again asked directly by the facilitator in order to compare whether the verbal answers were the same as the answers chosen using the computer. In addition, the patients were asked whether there were difficulties using the computer presentation and how the patient felt that the computer might be helpful in patient education.

The computer presentation was created using Authorware 3.5 (Macromedia, Inc.). Audio clips were recorded directly into Authorware as 22 KHz quality recordings without modification. A red box surrounding an icon was used to denote areas that required a mouse click in order to answer the question posed. Voices and pictures of the clinic nurses, registration staff, and physicians were presented in the initial screen in an attempt to make the patient comfortable with the computer presentation. As an example, the second question presented to the patient is shown in Table 1. The software presentation was presented on a Macintosh Quadra 660 AV computer.

The study population was characterized by demographics (race, gender, and mean age). For subsequent analyses, age was categorized into 1 of 3 age groups (< 25, 26-65, and > 65 years of age). Patients were also categorized by level of prior computer use as shown in Table 1. The mean time in the computer presentation was characterized by demographic group and level of prior computer use.

The level of agreement between interview strategies was characterized by the proportion of questions for which the computer-based answers and subsequent verbal answers were the same, for each of the 4 questions and for all questions. Answer agreement was analyzed by question in order to examine the possibility of a training effect, and by demographics and by prior computer use.

Statistical testing was accomplished using SAS-JMP software (Cary, North Carolina). T-test and analysis of variance tests were used to test for differences in means of time in computer presentation.


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