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


Progress in computer-assisted patient education is perhaps better reflected in nonmedical literature. Articles published in the medical literature about computerized patient education in the clinical setting are surprisingly few and are of variable quality. The few available studies focus more often on the novelty of the computer software rather than on testing for efficacy or effectiveness.[20,21] A clear exception is the work of the shared decision making group whose rigorous testing of sophisticated multimedia products encompasses multiple clinical domains.[22,23]

Unfortunately, the quest for novelty on the part of software developers usually puts multimedia computer products beyond the reach of low-literacy patients. The extensive use of written text, the temptation to teach numeracy, and a content frequently focused on sophisticated medical topics (eg, genetic testing for cancer) usually undermine applicability to a low-literacy population.[24] Perhaps most important is the fact that the expense of software development effort demands a market that does not include disadvantaged populations. Contemporary software developers look toward the excitement of the Internet as a means of educating larger populations of technologically savvy end-users. However, less affluent members of society still have not been offered many of the basic benefits of electronic media. As a result, little is known regarding the value of computer-assisted education for low-literacy patients.

Early demonstration projects suggested that computers could be widely accepted by patients of different socioeconomic strata and could be used effectively by novices,[15,16,17,18] even without full advantage of contemporary computer strategies that can completely replace written text with audio, animation, or imagery. However, the idea that the multimedia computer is at least a partial solution for improving better patient education for low-literacy patients is still not recognized. The tolerance of a slower learning pace and the ability to avoid written text through the use of audio are particularly important advantages of the computer for low-literacy patient education. The privacy offered through a computer interaction may avoid the embarrassment of having to ask that a statement be repeated or of needing extra time to answer a question. Audio clips and images from familiar clinic personnel and settings offer advantages in making the patient receptive to and comfortable with the computer interactivity.

Pressures to increase office efficiency have already forced us to use multimedia presentations routinely for new patient orientation and diabetic education. The 85% level of overall agreement between computer and verbal questioning in this study convinces us that the computer's usefulness can be further extended to collecting patient information or preference, even with patients in an indigent care setting. Not surprisingly, older age and lack of prior computer experience were associated with slower performance. However, the level of agreement between computer and verbal questioning was high, even for these subgroups of patients. The ability to capture information through the computer from low-literacy patients should encourage accrediting organizations who now require documentation of the patient's understanding of educational efforts.[12] With new recommendations from the Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs of the AMA for better identification of and intervention on literacy problems, the stage may even be set for development of computer-based screening of literacy level, which then links immediately to educational content specific to the literacy level of the patient.[25]

Limitations of this demonstration project include the small sample size and single clinical setting for this study. A second limitation is that we did not actually assess the literacy level of patients undergoing the computer exercise. The high prevalence of inadequate literacy skills among patients has already been well demonstrated in the general population and in a variety of clinical settings. However, until the relationship between computer literacy and reading literacy is better established, future studies should actually measure the literacy level of patients in order to better determine whether the computer is best suited for those patient with inadequate, marginally adequate, or adequate literacy levels.

The daily routine of medical care involves multiple educational tasks that increasingly overwhelm providers, staff, and patients in a busy outpatient setting. Shifting these tasks to the multimedia computer has the potential advantage of reducing literacy barriers between healthcare provider and patient as well as improving office efficiency. Computer-assisted patient education offers a promising and practical alternative to bridging gaps in knowledge and understanding.


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