1. 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
journal homepage: www.intl.elsevierhealth.com/journals/ijmi
Using digital videos displayed on personal digital assistants
(PDAs) to enhance patient education in clinical settings
Tina Penick Brock a,∗ , Scott R. Smith b
a The University of London, London, UK
b The Center for Outcomes & Evidence at the Agency for Healthcare Research and Quality, Rockville, MD, USA
a r t i c l e i n f o a b s t r a c t
Article history: Objectives: To evaluate the effects of using an audiovisual animation (i.e., digital video) dis-
Received 3 May 2006 played on a personal digital assistant (PDA) for patient education in a clinical setting.
Received in revised form Methods: Quasi-experimental study of a prospective technology intervention conducted in
18 August 2006 an outpatient infectious diseases clinic at an academic medical center. Subjects responded
Accepted 27 September 2006 to questions immediately before, immediately after, and 4–6 weeks after watching a digital
video on a PDA. Outcome measures include participant knowledge of disease, knowledge of
medications, and knowledge of adherence behaviors; attitudes toward the video and PDA;
Keywords: self-reported adherence; and practicality of the intervention.
Handheld computers Results: Fifty-one English-speaking adults who were initiating or taking medications for
Literacy the treatment of HIV/AIDS participated in the study. At visit one, statistically significant
Patient nonadherence improvements in knowledge of disease (p < 0.005; paired t-test), knowledge of medications
(p < 0.005; paired t-test), and knowledge of adherence behaviors (p < 0.05; ANOVA) were mea-
sured after participants watched the PDA-based video. At visit two (4–6 weeks later), sta-
tistically significant improvements in self-reported adherence to the medication regimens
(p < 0.005; paired t-test) were reported. Participants liked the PDA-based video and indicated
that it was an appropriate medium for learning, regardless of their baseline literacy skills.
The video education process was estimated to take 25 min of participant time and was
viewed in both private and semi-private locations.
Conclusions: Technology-assisted education using a digital video delivered via PDA is a con-
venient and potentially powerful way to deliver health messages. The intervention was
implemented efficiently with participants of a variety of ages and educational levels, and in
a range of locations within clinical environments. Additional study of this methodology is
warranted.
© 2006 Elsevier Ireland Ltd. All rights reserved.
1. Introduction ing to medication regimens [3–6]. Tailored, theory-based,
clinician-led counseling with feedback regarding performance
Informed patients are better at engaging in positive health is an ideal method for achieving this [1,6,7], yet as office visits
behaviors [1], participating in health decisions [2], and adher- get shorter [8], clinicians have less time to provide educational
This project was completed at the University of North Carolina at Chapel Hill in Chapel Hill, NC, USA where both authors hold adjunct
faculty appointments.
∗
Corresponding author at: Department of Practice & Policy, University of London School of Pharmacy, BMA House – Door A, Mezzanine,
Tavistock Square, London WC1H 9JP, UK. Tel.: +44 20 7874 1273; fax: +44 20 7387 5693.
E-mail address: tina.brock@pharmacy.ac.uk (T.P. Brock).
1386-5056/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijmedinf.2006.09.024

2. 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 ) 829–835
services [9]. Even when time is available, clinicians struggle to Visual CE® version 7.0) were used to maximize sound/viewing
find appropriate tools to deliver health messages [10], partic- quality and to create data collection instrumentation for the
ularly to patients with low literacy skills [11], multiple chronic handheld computing platform.
disorders [12], or diseases requiring complex regimens and The video message provided information to maximize self-
high levels of adherence such as HIV/AIDS [2]. 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 [13]; however, due to their dition of his/her disease [30]. The outline for this message
size and expense, their convenience for use in many set- was adapted from a study in which pharmacists provided live
tings is not ideal. Several recent reviews and reports of the instructions to patients [6] and the key themes have been
use of smaller (i.e., handheld) computers or personal digi- described previously [29]. A depiction of the device, the video
tal assistants (PDAs) suggest that these devices are not only message, and a portion of the survey instrument as viewed on
portable, inexpensive and easy to operate [14], 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 design
vices [15–27]. In addition, preliminary evidence indicates that
patients feel comfortable with their physicians using PDAs Eligible patients were identified by the research screener in the
in practice [28,29]. Despite this potential, however, the use clinic and were briefed on the project by their primary health
of PDAs to augment the patient education process has not care provider. If the patient expressed interest, a researcher
been 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 and
2. 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 [31]. At the end of the visit, the participant was
opment and review by clinicians and patients. Phase two given a card containing an identification number. At their
included testing the feasibility of using the PDA device and the next regularly scheduled clinic visit, a paper-based follow-up
video by clinic subjects. Results of these preliminary phases questionnaire (data collection point 3) was administered to
have been described in a previous publication [29] and were assess self-reported adherence and retention of key concepts
subsequently used to refine the intervention and instrumenta- from the video. The flow of participants through the study is
tion for Phase three, pre-/post- and follow-up testing in clinic depicted in Fig. 2.
subjects. The procedures for the entire project were reviewed
and approved by the University’s Committee on the Protection 2.5. Outcome measures
of 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 the
eases clinic in a teaching hospital. Participants were recruited intervention.
through clinician referral and were eligible if they were
English-speaking, aged 18 years or older, had a confirmed diag- 2.6. Statistical considerations
nosis of HIV disease, were initiating or continuing on HIV
medications at the first visit, and were willing to give informed After data collection was completed, the responses to the
consent. three surveys and the literacy assessment were synchronized
and imported into a database. All data were verified prior to
2.3. 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 the
sive (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 items
Microsoft® 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 at
available 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.

3. 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.

4. 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 were
3. Results invited to provide additional comments not addressed in the
surveys. These responses were transcribed and are shown in
3.1. 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 adherence
outside the home (53%), and did “not have enough money to behaviors
make ends meet” at the end of the month (65%). They ranged
in age from 25 to 70 years, with an average age of 42.1 years. Paired samples t-tests were conducted to evaluate the impact
This was consistent with results from previous studies in this of the PDA video on participants’ self-assessed knowledge of
clinic 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 medications
remaining were switching therapy, restarting therapy after a (p < 0.005) following the video. Likewise, 84% of participants
drug 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 or
high 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 improvement
participants 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. In
type of computerized device before (96%). addition, after watching the video, all participants were able
to respond correctly to an item about the appropriate timing
3.2. 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 PDA
video, 96% strongly agreed or agreed with a statement giving 3.4. Self-efficacy
the 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 that
and that listening to the video made the information easier they were at least very sure they would be able to take all or
to remember. When questioned about specific attributes con- most of their HIV medicines as directed, 89% were at least
tributing to the quality of the video (e.g., speed, pace, and very sure that the medicines would have a positive effect on
interest) responses were consistently positive. Fig. 3 depicts their health and 96% were at least very sure that if they did
the means, standard deviations, and ranges for each of the not take the medicines as instructed, the HIV in their bodies
component review elements on a visual analogue scale simi- would become resistant to HIV medicines.

5. 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 at
Paired samples t-tests were conducted to evaluate the impact the opportunity to optimize the use of time typically spent in
of 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 and
also completing the follow-up survey, there was a statistically 4. Discussion
significant increase in self-reported adherence to their medi-
cation regimen (p < 0.005). 4.1. Principal findings
3.6. Practicality The results from this study indicate that PDA-based videos
are an acceptable approach for teaching patients about health
Raw data describing the time necessary to implement the care. This is supported by several findings. First, participants
intervention was trimmed for extremes, leaving a mean time liked the PDA-based video and felt that it was an appropriate
of 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 watching
clinician 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 was
requirements for privacy for patients, yet useful in a variety improved. And finally, the intervention could be implemented
of 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 clinical
exam 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 the
infectious diseases clinic waiting room (12%), and the labo- concern that using PDAs directly with patients will lead to
ratory 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 Braddy
vacy; although, some participants opted to allow a partner or [34], 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

6. 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 ) 829–835
but pathogenic contamination was less common. Just as is
the case with other clinical tools, a good infection control Summary points
plan 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 the
PDAs 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 using
parisons to other research are not possible. What is known PDAs for educational interventions.
from previous study is that efficient educational tools are
needed to help clinicians educate patients at high risk of dis- What this study adds:
ease progression, particularly those patients with barriers to
traditional instructional methods (e.g., low literacy skills). We • Digital videos delivered on PDAs are a feasible and
also know that clinicians are rapidly adopting PDAs into their convenient complement to clinician-led educational
daily 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 uses
densome. In fact, a recent review suggests that patients will (e.g., clinical information repository, scheduling) show
continue 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 transitions
clinicians will influence the use of these media to improve toward the adoption of electronic health records and
the quality of care provided [9]. computerized prescribing to improve the quality of
care, policy makers should investigate incorporating
4.2. Limitations electronic educational tools into national health infor-
mation technology portfolios.
When comparing this study to the evidence about the
strongest research methods, there are a few limitations
and 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 by
recruitment. 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 is
disease (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 larger
tion, knowledge and self-efficacy are important, but not exclu- numbers of participants randomized to technology-enhanced
sive determinants of positive health outcomes. And finally, and standard care groups and followed over time are needed
because the period of observation was limited to two clinic to verify the results and better understand the effects of
visits, 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. Conclusions
Technology-assisted education using a digital video delivered Acknowledgements
via PDA is a convenient and potentially powerful complement
to clinician-led educational sessions. The intervention was Lynda Bell, Amanda Corbett, Ariel Shumaker-Hammond, and
implemented efficiently with participants of a variety of ages Rosa Yeh for assistance with recruitment of subjects. This
and educational levels, and in a range of locations within research was funded by the University of North Carolina
the 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 #9P30
first 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 either
common handheld devices (e.g., mobile telephones, MP3 play- the Agency for Healthcare Research and Quality (AHRQ) or the
ers) increases the opportunity for the ideal scenario, i.e., US Department of Health and Human Services (DHHS). The
the 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 be
the portability of new media players, the growing ownership inferred.

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references [16] D.C. Baumgart, Personal digital assistants in health care:
experienced clinicians in the palm of your hand? Lancet 366
(2005) 1210–1222.
[17] S. Fischer, T.E. Stewart, S. Mehta, R. Wax, S.E. Lapinsky,
[1] 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’ [18] 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. [19] A.S. McAlerney, S.B. Schweikhart, M.A. Medow, Doctor’s
[2] 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) [20] J.R. Barrett, S.M. Strayer, J.R. Schubart, Assessing medical
805–809. residents’ usage and perceived needs for personal digital
[3] 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. [21] K.E. Keplar, C.J. Urbanski, D.S. Kania, Update on personal
Care 40 (2002) 794–881. digital assistant applications for the healthcare provider,
[4] 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 [22] 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.
[5] S.M. Edworthy, G.M. Devins, and the patient education study Inform. 75 (7) (2006) 553–563.
group. Improving medication adherence through patient [23] 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. [24] W.W. Boonn, A.E. Flanders, Informatics in radiology
[6] 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 [25] J. Rodgriguez, A. Goni, A. Illarramendi, Real-time
(2003) 187–199. classification of ECGs on a PDA, IEEE Trans. Inf. Technol.
[7] 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 [26] 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.
[8] D. Mechanic, D.D. McAlpine, M. Rosenthal, Are patients’ [27] 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. [28] T.K. Houston, M.N. Ray, M.A. Crawford, T. Giddens, E.S.
[9] 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. [29] S.R. Smith, T.P. Brock, S.M. Howarth, Use of personal digital
[10] 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. [30] A. Bandura, Self-Efficacy: The Exercise of Control, W. H.
[11] S.C. Kalichman, E. Benotsch, T. Suarez, S. Catz, J. Miller, D. Freeman & Company, New York, 1997.
Rompa, Health literacy and health-related knowledge [31] 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
[12] 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 [32] 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.
[13] W. Sumner 2nd., Computer assisted patient education, Fam. [33] H. Viswanathan, R. Anderson, J. Thomas III, Nature and
Med. 22 (1990) 92–93. correlates of SF-12 physical and mental quality of life
[14] 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.
[15] C.E. Kuziemsky, F. Laul, R.C. Leung, A review on diffusion of [34] 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.