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


Of these 59 patients asked to participate in the study, only 3 were unable to initiate or respond to the initial instructions about the computer presentation despite exclusion criteria of obvious psychoneurologic impairment. The results from 1 patient who was called away for his scheduled appointment while in the middle of the computer presentation but returned after the appointment to complete the presentation were not included. Three patients, who upon presentation of the test button acted as if they did not understand the task, accepted the offer to repeat the presentation from the beginning and ultimately succeeded in completing the computer presentation. Demographic data were not available for 4 patients, leaving a total of 51 evaluable patients. By our estimation, demographic characteristics of the final study population (Table 2) were similar to those of the clinic population except for the fact that persons who spoke Spanish only (5% of our clinic population) were excluded.

Most participants were African American and female (Table 2). The mean age of the population was 47.5 (± 18.1) years of age. A majority of participants (60.8%) had not used a computer in the previous month, but 17.6% had used a computer frequently in the last month. The mean time in the computer presentation, 6 minutes overall (358.9 seconds), did not differ significantly by gender or race (Table 2). However, older age group was significantly associated with an increased amount of time with the computer presentation (analysis of variance P = .002). Participants with no prior computer use in the previous month also took significantly longer with the computer presentation (analysis of variance P < .001).

For any individual question, the average level of agreement was 88.7%. The lower level of agreement for all 4 questions (66.7%) reflects that disagreement was dispersed among the 4 questions with no obviously lower level of disagreement for any 1 question (Table 2). There was no apparent increase in the level of agreement with successive questioning, which would have suggested a training effect. However, the highest level of agreement coincided with the last question, which also arguably has the most clear-cut answer (smoking as a cause of lung cancer). While there was no association between level of agreement and gender, age, or prior computer experience by chi square testing, differences in race were statistically significant (P = .008).

Although it was not a response category in the question/interaction on previous computer use, many of the patients had never operated a computer. Still, the overwhelming majority succeeded in completing the presentation. Many patients not only enjoyed participating in the project but appeared to leave the room feeling more confident and proud of that accomplishment (even joking that they might buy a computer now). However, a variety of skill levels in our population sample was obvious. Repetition and clicking instructions that slowed the presentation made the experienced operator at times somewhat impatient. Introducing the mouse as the means of interacting with the computer was necessary with the presentation of the initial test button. The computerized instruction to click on an icon sometimes visibly startled participants with the alert that the presentation would require action on the participant's part. An offer to restart the presentation resulted in a more attentive participant on the second attempt but was necessary with only a few participants. Once the patient was attentive to the need for action, explanation of the mouse was most easily done by taking the patient's hand and placing it on the mouse with the facilitator's hand on top of the participant's hand, calling attention to the motion of the cursor that resulted from mouse dragging. Specific instructions to lift the mouse off the pad and replace it on another part of the pad were sometimes necessary.

While we initially thought that only an initial test button would be needed for instruction for mouse operation, by the time the first question/interaction was encountered, some participants were still not completely facile in mouse navigation. However, by the second question/interaction, even the novice user was comfortable with mouse navigation. As a result, it was decided during the course of the study that the facilitator should stay in the room with the patient until after the first question/interaction was successfully navigated.

The shame factor that has been noted in the literature on low-literacy patients encouraged our careful attention to novice computer users.[19] Framing the exercise as a project to help the clinic and explaining that no prior computer skills were required was helpful in assuring patients. Asking the patients if they could move their index finger and telling them that the tasks ahead were no more complicated seemed to help relieve anxiety for some. These findings are consistent with our belief that computer-based patient education should complement rather than replace the health professional in providing education. (One patient asked politely if the computers were going to replace doctors now).

Comments on difficulties using the computer presentation and on the relevance of computers for health education in our clinic were solicited after the computer experience. Despite the fact that the majority required help with operating the mouse initially, even those participants reported no problems with the computer. Comments on the potential usefulness of the computer for health education in the clinic were generally positive, with no meaningful insights derived from this question. The combination of graphics and audio in the pilot presentation was considered by the participants to be an important feature.


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