830 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 829–835services . Even when time is available, clinicians struggle to Visual CE® version 7.0) were used to maximize sound/viewingﬁnd appropriate tools to deliver health messages , partic- quality and to create data collection instrumentation for theularly to patients with low literacy skills , multiple chronic handheld computing platform.disorders , or diseases requiring complex regimens and The video message provided information to maximize self-high levels of adherence such as HIV/AIDS . efﬁcacy, or the patient’s belief that he/she could take the Computerized patient education systems can help to antiretroviral medications as required to improve the con-address some of these challenges ; however, due to their dition of his/her disease . The outline for this messagesize and expense, their convenience for use in many set- was adapted from a study in which pharmacists provided livetings is not ideal. Several recent reviews and reports of the instructions to patients  and the key themes have beenuse of smaller (i.e., handheld) computers or personal digi- described previously . A depiction of the device, the videotal assistants (PDAs) suggest that these devices are not only message, and a portion of the survey instrument as viewed onportable, inexpensive and easy to operate , but also that the device screen are shown in Fig. 1.they are already being used widely by clinicians for access-ing references, collecting information, and documenting ser- 2.4. Study designvices [15–27]. In addition, preliminary evidence indicates thatpatients feel comfortable with their physicians using PDAs Eligible patients were identiﬁed by the research screener in thein practice [28,29]. Despite this potential, however, the use clinic and were briefed on the project by their primary healthof PDAs to augment the patient education process has not care provider. If the patient expressed interest, a researcherbeen fully explored. The objectives of the study were to assess obtained their consent to participate. Following this, the sub-the effects of using an audiovisual animation (i.e., digital ject was shown the PDA device, instructed brieﬂy on its use,video) displayed on a PDA for patient education in a clinical and asked to complete survey 1 (data collection point 1)setting. directly on the PDA. In order to accommodate participants with low literacy skills, an electronic button allowed the par- ticipant to hear a narrator read the survey questions and2. Methods responses. After the completion of survey 1, the investiga- tor activated the 17-min video on the PDA. Following this,2.1. Study design and phases the investigator activated survey 2 (data collection point 2) on the PDA. After completing survey 2, the researcher adminis-The project encompassed a prospective, interventional study tered the Rapid Estimate of Adult Literacy in Medicine (REALM)conducted in three phases. Phase one included media devel- instrument . At the end of the visit, the participant wasopment and review by clinicians and patients. Phase two given a card containing an identiﬁcation number. At theirincluded testing the feasibility of using the PDA device and the next regularly scheduled clinic visit, a paper-based follow-upvideo by clinic subjects. Results of these preliminary phases questionnaire (data collection point 3) was administered tohave been described in a previous publication  and were assess self-reported adherence and retention of key conceptssubsequently used to reﬁne the intervention and instrumenta- from the video. The ﬂow of participants through the study istion for Phase three, pre-/post- and follow-up testing in clinic depicted in Fig. 2.subjects. The procedures for the entire project were reviewedand approved by the University’s Committee on the Protection 2.5. Outcome measuresof the Rights of Human Subjects, and all subjects provided ver-bal consent to participate. The main outcome measures were participant knowledge of HIV disease, knowledge of HIV medications, and knowl-2.2. Setting and participants edge of adherence behaviors. Secondary measures included attitudes toward the video and device, self-reported adher-The study was conducted in an outpatient infectious dis- ence to the medication regimen and practicality of theeases clinic in a teaching hospital. Participants were recruited intervention.through clinician referral and were eligible if they wereEnglish-speaking, aged 18 years or older, had a conﬁrmed diag- 2.6. Statistical considerationsnosis of HIV disease, were initiating or continuing on HIVmedications at the ﬁrst visit, and were willing to give informed After data collection was completed, the responses to theconsent. three surveys and the literacy assessment were synchronized and imported into a database. All data were veriﬁed prior to2.3. Multimedia intervention (device and video) analysis with SPSS for Windows® (version 11.5). Distributions of important variables were graphed and descriptive statis-The PDA device selected to deliver the video was inexpen- tics calculated. Paired samples t-test was used to compare thesive (i.e., less than $300 in FY 2003) with a color, 16-bit, before and after results within the different thematic areas.touch-sensitive display and a vertical orientation of 3.5 inches. Reliability analyses were performed on certain groups of itemsMicrosoft® Pocket PC version 3 was pre-installed by the manu- to determine the internal consistency and feasibility for scal-facturer on the two devices used for the study. Commercially- ing in subsequent analyses. A Cronbach’s alpha value of atavailable software programs (i.e., Macromedia® Flash® version least 0.70 was set as the a priori level of consistency for com-6.0 for Pocket PC, Real Player® using a Pocket TV viewer, and bining items.
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 829–835 831 Fig. 1 – Screen shots from PDA video and surveys. Fig. 2 – Flow of participants through the study.
832 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 829–835 Table 1 – Participant comments about the PDA video •“This was a good video because it put the facts on the line. People need to know that if they don’t take the medicine, they are going to get sick and they are going to die.” •“I liked the part where patients were talking to you. I felt like they knew what it was like to have to take all these medicines but not want anyone to know you are sick.” •“This was a good video and it helped me a lot. Maybe it should be scarier, though. What I mean is, maybe you should show pictures of sick patients. We’re vain. . . and we don’t want to look like sick people with AIDS. Seeing ugly people on the movie – all skinny, with no hair and sores all over them – could scare some people into taking the medicines right.” •“I wish someone had shown me this when I ﬁrst got AIDS. No one told me all this stuff and now some of the medicines won’t work for me. I’ll keep trying to ﬁnd some, though.” •“At ﬁrst I was scared about using the little computer, but it was fun. I wish I could keep it!” •“When I ﬁrst got diagnosed I was so scared. I didn’t have any idea there were so many options. It was nice that my mother got to watch the movie, too. She has a lot of questions but she’s going to help me stay on track.” •“Nobody tells you that these drugs aren’t like other medicines. I like the video because it made it clear, you have to take them every day even if you feel sick.” •“I do good during the week but on the weekend it’s hard to keep the same schedule. I didn’t think it was that bad as long as I took it most of the time. I guess I was wrong!” •“I liked the woman on the video who talked about her kids. Sometimes it gets to be too much trying to keep up with them and keep my medicines straight. I used to be scared to tell the doctor I was having trouble, but now I know he can’t help me if he doesn’t know what’s wrong.” •“It was nice to learn more about the disease and how you catch it. I still don’t know how I got it and that makes me scared, but I know I need to take these medicines if I want to live!” •“When you feel good, it doesn’t seem like you need the medicines, but I guess you really do.” •“I am going to remember the people in the video. . . and the computer, too.” •“I was scared about all the effects of the medicines. Some of them can make your looks change and then people know something is wrong. But I need to talk about that with the doctor, not just stop taking them. Maybe other medicines won’t work for me!” lar to the one used by study participants. All participants were3. Results invited to provide additional comments not addressed in the surveys. These responses were transcribed and are shown in3.1. Demographics Table 1.Fifty-one subjects consented to participate in the study. Partic-ipants were primarily male (51%), Black (77%), working for pay 3.3. Knowledge of disease, medications, and adherenceoutside the home (53%), and did “not have enough money to behaviorsmake ends meet” at the end of the month (65%). They rangedin age from 25 to 70 years, with an average age of 42.1 years. Paired samples t-tests were conducted to evaluate the impactThis was consistent with results from previous studies in this of the PDA video on participants’ self-assessed knowledge ofclinic population. disease and treatment as depicted on two visual analogue During the ﬁrst clinic visit, approximately one quarter of scales. There was a statistically signiﬁcant increase in knowl-participants were beginning medication therapy for HIV; the edge of HIV (p < 0.005) and knowledge of HIV medicationsremaining were switching therapy, restarting therapy after a (p < 0.005) following the video. Likewise, 84% of participantsdrug holiday, or continuing therapy as prescribed. Approxi- strongly agreed or agreed that the video increased their knowl-mately 60% of participants reported that they had ﬁnished edge of HIV disease and 90% of participants strongly agreed orhigh school or the equivalent, but 55% still demonstrated a agreed that the video increased their knowledge of HIV med-reading ability below eighth grade level (deﬁned as low liter- ications.acy) as evidenced by score on the REALM. A majority of all In almost every case, participants showed improvementparticipants indicated that it is easier for them to learn from from baseline by responding correctly to all items concern-videos than it is from books (94%) and that they had used some ing appropriate adherence behaviors on the second survey. Intype of computerized device before (96%). addition, after watching the video, all participants were able to respond correctly to an item about the appropriate timing3.2. Reviews of the video and PDA device of medications, which was the most commonly missed item from the ﬁrst survey.Of the 50 participants who provided feedback on the PDAvideo, 96% strongly agreed or agreed with a statement giving 3.4. Self-efﬁcacythe video an overall rating of “excellent.” In addition, 94% indi-cated they liked using a handheld computer to watch the video After watching the video, 96% of participants responded thatand that listening to the video made the information easier they were at least very sure they would be able to take all orto remember. When questioned about speciﬁc attributes con- most of their HIV medicines as directed, 89% were at leasttributing to the quality of the video (e.g., speed, pace, and very sure that the medicines would have a positive effect oninterest) responses were consistently positive. Fig. 3 depicts their health and 96% were at least very sure that if they didthe means, standard deviations, and ranges for each of the not take the medicines as instructed, the HIV in their bodiescomponent review elements on a visual analogue scale simi- would become resistant to HIV medicines.
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 829–835 833 Fig. 3 – Participant reviews of the video (N = 50).3.5. Adherence ticipants expressed hesitancy about the location where they watched the video. In fact, most articulated appreciation atPaired samples t-tests were conducted to evaluate the impact the opportunity to optimize the use of time typically spent inof the video on participants’ self-reported adherence to HIV idle waiting.medication regimens using a nine-item validated scale [32,33].Among those participants taking medications at visit one andalso completing the follow-up survey, there was a statistically 4. Discussionsigniﬁcant increase in self-reported adherence to their medi-cation regimen (p < 0.005). 4.1. Principal ﬁndings3.6. Practicality The results from this study indicate that PDA-based videos are an acceptable approach for teaching patients about healthRaw data describing the time necessary to implement the care. This is supported by several ﬁndings. First, participantsintervention was trimmed for extremes, leaving a mean time liked the PDA-based video and felt that it was an appropriateof 51.1 min (SD = 11.3 min). It is estimated that by using the medium for learning, regardless of their literacy skills. Second,PDA strictly for educational (and not research) purposes, the knowledge of disease, knowledge of medications, and knowl-total usage time would be approximately 25 min, although the edge of adherence behaviors were all improved after watchingclinician would not need to be present during the 17 min while the video. Third, self-efﬁcacy to adhere to HIV medication reg-the patient watches the video. imens was high following the video and at the follow-up visit, The video process was designed to be compliant with US self-reported adherence to the HIV medication regimen wasrequirements for privacy for patients, yet useful in a variety improved. And ﬁnally, the intervention could be implementedof environments. Participants viewed the PDA-based video in efﬁciently with patients of a variety of ages, educational lev-a variety of locations, including the infectious diseases clinic els, and backgrounds in a range of locations within the clinicalexam room (35%), the general clinical research unit (GCRC) environment.clinic exam room (27%), the pharmacy waiting area (16%), the One important concept not addressed in this study is theinfectious diseases clinic waiting room (12%), and the labo- concern that using PDAs directly with patients will lead toratory waiting room (10%). Each participant was offered the device contamination, which could be particularly devastat-opportunity to use a new set of headphones to assure pri- ing in the immunocompromised patient. A study by Braddyvacy; although, some participants opted to allow a partner or , however, suggests that during tests at one institution,family member to watch the video along with them. No par- multi-use PDAs were colonized with typical skin organisms
834 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 829–835but pathogenic contamination was less common. Just as isthe case with other clinical tools, a good infection control Summary pointsplan is important for preventing infections in individuals par-ticipating in PDA-based patient education programs. In addi- What is already known on this subject:tion, although there were no cases of theft or damage to thePDAs used in this study, this remains a potential limitation • Efﬁcient and effective tools are needed to help clini-of portable devices as compared to larger appliances. Finally, cians educate patients with chronic diseases and com-because the device was not tested speciﬁcally in patients with plex medication regimens; particularly those with lit-impairments to sight and/or manual dexterity, the results eracy challenges.should not be generalized to these audiences. • Clinicians are rapidly adopting PDAs into their daily This is the ﬁrst contemporary study to assess the use of practice for a variety of uses.PDA-based digital videos for patient education, so direct com- • There have been few published investigations usingparisons to other research are not possible. What is known PDAs for educational interventions.from previous study is that efﬁcient educational tools areneeded to help clinicians educate patients at high risk of dis- What this study adds:ease progression, particularly those patients with barriers totraditional instructional methods (e.g., low literacy skills). We • Digital videos delivered on PDAs are a feasible andalso know that clinicians are rapidly adopting PDAs into their convenient complement to clinician-led educationaldaily practices for a variety of uses, so the prospect of using sessions.these devices for clinical education should not be overly bur- • Technologies that are already common for other usesdensome. In fact, a recent review suggests that patients will (e.g., clinical information repository, scheduling) showcontinue to be the driving force behind the incorporation of promise for patient education applications.consumer technology into health care and that innovative • As health care in both the US and UK transitionsclinicians will inﬂuence the use of these media to improve toward the adoption of electronic health records andthe quality of care provided . computerized prescribing to improve the quality of care, policy makers should investigate incorporating4.2. Limitations electronic educational tools into national health infor- mation technology portfolios.When comparing this study to the evidence about thestrongest research methods, there are a few limitationsand cautions that should be explained. First, the quasi-experiential study design relied upon clinician referrals for by patients and providers and the reduced costs possible byrecruitment. These referrals may have inﬂuenced the size and developing the tools for multiple platforms permits educa-composition of the sample. Second, clinical indicators for HIV tional videos to be used in most settings in which care isdisease (e.g., viral load, CD4+ cell count) were not collected, delivered.so severity of illness could be a confounder. Third, satisfac- Future studies in different practice settings with largertion, knowledge and self-efﬁcacy are important, but not exclu- numbers of participants randomized to technology-enhancedsive determinants of positive health outcomes. And ﬁnally, and standard care groups and followed over time are neededbecause the period of observation was limited to two clinic to verify the results and better understand the effects ofvisits, it is unknown whether the high levels of knowledge, PDA-based video education on health outcomes. Further-self-efﬁcacy and adherence were sustained. more, the development of educational tools that are linguis- tically appropriate for diverse patient populations should be explored.5. ConclusionsTechnology-assisted education using a digital video delivered Acknowledgementsvia PDA is a convenient and potentially powerful complementto clinician-led educational sessions. The intervention was Lynda Bell, Amanda Corbett, Ariel Shumaker-Hammond, andimplemented efﬁciently with participants of a variety of ages Rosa Yeh for assistance with recruitment of subjects. Thisand educational levels, and in a range of locations within research was funded by the University of North Carolinathe clinical environment. Since multiple interventions over Program on Health Outcomes. In addition, support was pro-time are the most effective way to positively inﬂuence health vided by the University of North Carolina at Chapel Hill Cen-behaviors, the PDA-based video may actually be just a good ter for AIDS Research (CFAR), an NIH funded program #9P30ﬁrst step in the educational process. In addition, the grow- AI50410.ing number of options for displaying digital videos through Disclosure: This paper does not represent the policy of eithercommon handheld devices (e.g., mobile telephones, MP3 play- the Agency for Healthcare Research and Quality (AHRQ) or theers) increases the opportunity for the ideal scenario, i.e., US Department of Health and Human Services (DHHS). Thethe availability of a variety of cost-effective, multi-platform views expressed herein are those of the authors, and no ofﬁ-tools for improving communication with patients. Indeed, cial endorsement by AHRQ or DHHS is intended or should bethe portability of new media players, the growing ownership inferred.
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 829–835 835references  D.C. Baumgart, Personal digital assistants in health care: experienced clinicians in the palm of your hand? Lancet 366 (2005) 1210–1222.  S. Fischer, T.E. Stewart, S. Mehta, R. Wax, S.E. Lapinsky,  V.E. Stone, J.W. Hogan, P. Schuman, A.M. Rompalo, A.A. Handheld computing in medicine, J. Am. Med. Inform. Howard, C. Korkontzelou, et al., Antiretroviral regimen Assoc. 10 (2003) 139–149. complexity, self-reported adherence, and HIV patients’  Y.C. Lu, Y. Xiao, A. Sears, J.A. Jacko, A review and a understanding of their regimens: survey of women in the framework of handheld computer adoption in healthcare, HER study, J. Acquir. Immune Deﬁc. Syndr. 28 (2001) Int. J. Med. Inform. 74 (2005) 409–422. 124–131.  A.S. McAlerney, S.B. Schweikhart, M.A. Medow, Doctor’s  C.K. Fairley, R. Levy, C.R. Rayner, K. Allardice, K. Costello, C. experience with handheld computers in clinical practice: Thomas, et al., Randomized trial of an adherence qualitative study, BMJ 328 (2004) 1162–1165. programme for clients with HIV, Int. J. STD AIDS 14 (2003)  J.R. Barrett, S.M. Strayer, J.R. Schubart, Assessing medical 805–809. residents’ usage and perceived needs for personal digital  M.R. Di Matteo, P.J. Giordani, H.S. Lepper, Patient adherence assistants, Int. J. Med. Inform. 73 (1) (2004) 25–34. and medical treatment outcomes: a meta analysis, Med.  K.E. Keplar, C.J. Urbanski, D.S. Kania, Update on personal Care 40 (2002) 794–881. digital assistant applications for the healthcare provider,  J.M. Simoni, P.A. Frick, D.W. Pantalone, B.J. Turner, Ann. Pharmacother. 39 (2005) 892–907. Antiretroviral adherence interventions: a review of current  C. Fuchs, L. Quinzio, M. Benson, A. Michel, R. Rohrig, B. literature and ongoing studies, Top. HIV Med. 11 (2003) Quinzio, G. Hempelmann, Integration of a handheld-based 185–198. anaesthesia information management system, Int. J. Med.  S.M. Edworthy, G.M. Devins, and the patient education study Inform. 75 (7) (2006) 553–563. group. Improving medication adherence through patient  W.D. Pace, E.W. Staton, Electronic data collection options for education distinguishing between appropriate and practice-based research networks, Ann. Fam. Med. 3 (2005) inappropriate utilization, J. Rheumatol. 26 (1999) S21–S29. 1793–1801.  W.W. Boonn, A.E. Flanders, Informatics in radiology  S.R. Smith, J.C. Rublein, C. Marcus, T.P. Brock, M.A. Chesney, (infoRAD): survey of personal digital assistant use in A medication self-management program to improve radiology, Radiographics 25 (2005) 537–541. adherence to HIV therapy regimens, Patient Educ. Couns. 50  J. Rodgriguez, A. Goni, A. Illarramendi, Real-time (2003) 187–199. classiﬁcation of ECGs on a PDA, IEEE Trans. Inf. Technol.  C. Goujard, N. Bernard, N. Sohier, D. Peyramond, F. Lancon, J. Biomed. 9 (2005) 23–24. Chwalow, et al., Impact of a patient education program on  S. Hirani, J. Hodgkins, S.D. Chen, G. Lucas, Current products adherence to HIV medication - a randomized clinical trial, J. and practices: personal digital assistants in orthodontics, J. Acquir. Immune Deﬁc. Syndr. 34 (2003) 191–194. Orthod. 32 (2005) 61–68.  D. Mechanic, D.D. McAlpine, M. Rosenthal, Are patients’  P.P. Taylor, Use of handheld devices in critical care, Crit. Care ofﬁce visits with physicians getting shorter? N. Eng. J. Med. Nurs. Clin. North Am. 17 (2005) 45–50. 344 (2001) 198–204.  T.K. Houston, M.N. Ray, M.A. Crawford, T. Giddens, E.S.  J.L. Wofford, E.D. Smith, D.P. Miller, The multimedia Berner, Patient perceptions of physician use of handheld computer for ofﬁce-based patient education: a systematic computers, Proc. AMIA Symp. (2003) 299–303. review, Patient Educ. Couns. 59 (2005) 148–157.  S.R. Smith, T.P. Brock, S.M. Howarth, Use of personal digital R.E. Glasgow, S.S. Bull, J.D. Piette, J.F. Steiner, Interactive assistants to deliver education about adherence to behavior change technology: a partial solution to the antiretroviral medications, J. Am. Pharm. Assoc. 45 (2005) competing demands of primary care, Am. J. Prev. Med. 27 625–628. (2S) (2004) 80–87.  A. Bandura, Self-Efﬁcacy: The Exercise of Control, W. H. S.C. Kalichman, E. Benotsch, T. Suarez, S. Catz, J. Miller, D. Freeman & Company, New York, 1997. Rompa, Health literacy and health-related knowledge  T.C. Davis, S.W. Long, R.H. Jackson, E.J. Mayeaux, R.B. George, among persons living with HIV/AIDS, Am. J. Prev. Med. 18 P.W. Murphy, et al., Rapid estimate of adult literacy in (2000) 325–331. medicine: a shortened screening instrument, Fam. Med. 25 E.A. Bayliss, J.F. Steiner, D.H. Fernald, L.A. Crane, D.S. Main, (1993) 391–395. Descriptions of barriers to self- care by persons with  D.E. Morisky, L.W. Green, D.M. Levine, Concurrent and comorbid chronic diseases, Ann. Fam. Med. 1 (2003) predictive validity of a self-reported measure of medication 15–21. adherence, Med. Care. 24 (1986) 67–74. W. Sumner 2nd., Computer assisted patient education, Fam.  H. Viswanathan, R. Anderson, J. Thomas III, Nature and Med. 22 (1990) 92–93. correlates of SF-12 physical and mental quality of life J.J. Cimino, S. Bakken, Personal digital educators, N. Engl. J. components of low-income HIV adults using an HIV service Med. 352 (9) (2005) 860–862. center, Qual. Life Res. 14 (2005) 935–944. C.E. Kuziemsky, F. Laul, R.C. Leung, A review on diffusion of  C.M. Braddy, J.E. Blair, Colonization of personal digital personal digital assistants in healthcare, J. Med. Syst. 29 (4) assistants used in a health care setting, Am. J. Infect. (2005) 335–342. Control 33 (2005) 230–232.