Patient Educational Media

PATIENT EDUCATIONAL MEDIA

Patient educational media include a wide range of programs and materials delivered by health care organizations and designed to help patients achieve or maintain an enhanced state of health and recovery. Examples include printed materials (e.g., brochures, booklets, pamphlets), videotapes, audiotapes, and most recently, electronic programs and resources such as web sites, kiosks, or other interactive multimedia programs. While health education and the use of educational media occurs in many settings, there are at least two characteristics unique to health care settings that make it especially appropriate for such activities. First, improved health is the primary objective of activities that occur in this setting. Unlike worksites, communities, or schools, people go to a doctor's office expecting to deal with issues related to their own health. Second, health care providers are generally considered to be credible sources of health information. This combination of factors— people who are more than usually receptive and attentive to health information (e.g., patients) interacting with professionals who are trusted and respected (e.g., health care providers)—creates an environment conducive to effective patient education.

Patient educational media are typically designed to meet one of two types of objectives: (1) to inform and educate; and (2) to assist and support. Addressing the first of these objectives involves translating scientific and medical knowledge into lay terms that patients can understand. Addressing the second objective involves helping patients solve problems, cope with difficulties, or modify health-related risks and behaviors. Both types of objectives can be relevant to a broad spectrum of patient education needs, including raising awareness, changing attitudes and beliefs, motivating and supporting behavior change efforts, promoting screening, enhancing adherence to a disease prevention or treatment regimen, and guiding rehabilitation efforts.

Historically, patient educational media has consisted almost exclusively of printed pamphlets and brochures. These materials tend to use a general, rational, informational, and didactic (GRID) style of presenting health information. The GRID approach typically involves writing in the second or third person, from the perspective of one who is not personally involved in the topic of interest. It explains health-related processes and phenomena in terms that are often simplified in language, emotionally neutral, broad in scope, but short on detail. This approach seems especially well suited to meet "inform and educate" objectives like explaining risk factors, causality, biological processes, disease etiology, and surgical or other treatment procedures. Printed, massproduced pamphlets also have the advantage of being relatively inexpensive to produce. But they have important limitations, too. Such "one-size-fits-all" materials are created for general populations, and therefore don't really consider specific characteristics of the different patients who might use them.

In order for patient educational media to stimulate changes in knowledge, attitude, or behavior, certain intermediary steps must occur. These include patients' paying attention to the materials and understanding their content. Some patient educational media are more likely to have these effects than others. For example, Petty and Cacioppo's elaboration likelihood model suggests people will process information more thoughtfully and carefully if they perceive it to be personally relevant. Information processed in this way (e.g., "elaborated" upon) tends to be retained for a longer period of time and is more likely to lead to permanent change. Thus, it can be expected that those educational programs and materials that address patients' needs most specifically will be more successful in reaching their objectives.

Targeted patient education materials are those intended to reach a specific subgroup of the general population, usually based on some set of characteristics shared by its members. For example, there are cessation programs and materials designed especially for pregnant women who smoke. Because these materials take into account the unique needs of a specific group of patients, they represent an incremental improvement over generic materials. An even more advanced approach to patient educational media is customization at the level of the individual patient. The first widespread attempt to do this began in the 1970s with the advent of computerized health-risk appraisals (HRAs). For decades since then, the HRA has been one of the most widely used health-education tools for promoting individual behavioral change in health care settings. To participate in an HRA program, individuals typically complete an assessment to provide information about their health-related behaviors (e.g., smoking, seat belt use), health-status indicators (e.g., blood pressure, cholesterol level), and other personal characteristics related to mortality risk (e.g., age, gender, weight, present disease status). This information is fed into a computer-based risk estimation algorithm that weights each of these factors according to its relative contribution to different disease states, establishes a health profile for each participant, and then looks at population mortality rates experienced by others of the same age and sex with a similar profile. HRA feedback originally appealed to patients because its quantification of personal risk status was novel and interesting. It has also appealed to health care providers, who can use its data in aggregate to help identify the patient education and health promotion needs of patients.

During the 1990s, patient educational materials began to adopt the same approach to behavioral change that HRAs use to communicate risk information. These "tailored" patient-education materials include any combination of information and behavior-change strategies intended to reach one specific person, based on characteristics that are unique to that person, that relate to the outcome of interest and that are derived from an individual assessment. The process of tailoring patient-education materials is much like the process an actual tailor uses to make custom clothing. A tailor takes a customer's measurements, asks about preferences for fabric, color, and style, and uses this information to create clothing to fit that customer. Likewise, a tailored health-communication program measures a participant's needs, interests, and concerns; and uses that information to create health messages and materials to fit that person. Studies conducted among patients in health care settings have shown that tailored messages are more effective than non-tailored messages in promoting changes in a range of health-related behaviors.

Another new approach to patient education involves multimedia strategies that may be interactive and delivered through video or electronic channels. While traditional mass media campaigns have limited effectiveness in changing behavior, the Internet and other computer-based communications have the potential to reach a very large audience with what is more like an interpersonal communication. The rapid development of technologies and the expansion of the Internet provide widely available opportunities to obtain interactive information, education, and support, tailored to individual needs and preferences.

A media-based health-education program could take the form of a web site, an interactive computer kiosk in a doctor's office, a videotape or audiotape mailed to a patient's home, telephone counseling, a printed newsletter, a self-help booklet, a brochure, or any number of other executions, either singly or in combination. Advanced technologies, such as interactive multimedia and World Wide Web programming, have several obvious advantages over printed and other traditional kinds of health education materials. First, they are less dependent on user literacy, and thus may be useful in reaching some high-risk populations. Second, they not only allow for vicarious learning through the modeling of healthy behaviors, but they can actually allow users to select a particular "model" who they feel similar to or believe to be credible. Third, because the technology is interactive, it is more engaging than one-way communication, and it can still produce a tangible product for users to take with them, such as a printed letter, behavior change plan, or even a videotape.

Nonetheless, while a number of interactive multimedia programs have been developed for health promotion purposes, there remains a dearth of rigorously designed studies assessing their effectiveness. From a more practical standpoint, it is not at all clear that a majority of health-education practitioners presently have the means to develop such programs. Furthermore, although access to electronic media, such as the World Wide Web, is growing, it is hardly universal. Unlike some of these more advanced technologies, print communication programs are widely used, have demonstrated effectiveness, and are more feasible for practitioners to produce and disseminate.

While patient educational media are available for patients in most all physicians' offices, they are seldom used on a consistent basis and in a coordinated fashion together with physician advice. Yet in one study, patients who received a physician's advice to quit smoking, eat less fat, or get more exercise prior to receiving educational materials on the same topic were more likely to remember the materials, show them to others, and perceive the materials as applying to them specifically. They were also more likely to report trying to quit smoking, quitting for at least 24 hours, and making some changes in diet and physical activity. These findings support an integrated model of patient education in which physician advice is a catalyst for patient change, and patient educational media provide the depth of detail and substance necessary for sustained change.

MATTHEW W. KREUTER

DAWN C. BUCHOLTZ

(SEE ALSO: Assessment of Health Status; Audiotapes and Videotapes; Communications for Health; Health Promotion and Education; Health Risk Appraisal; Internet)

BIBLIOGRAPHY

Cacioppo, J. T.; Harkins, S. G.; and Petty, R. E. (1981). "The Nature of Attitudes and Cognitive Responses and Their Relationships to Behavior." In Cognitive Responses in Persuasion, eds. R. E. Petty, T. M. Ostrom, and T. C. Brock. Hillsdale, NJ: Erlbaum.

Cassell, M. M.; Jackson, C.; and Cheuvront, B. (1998). "Health Communication on the Internet: An Effective Channel for Health Behavior Change?" Journal of Health Communication 3:71–79.

DeFriese, G. H., and Fielding, J. E. (1990). "Health Risk Appraisal in the 1990s: Opportunities, Challenges, and Expectations." Annual Review of Public Health 11: 401–418.

Kreuter, M. W; Chheda, S. G.; and Bull, F. C. (2000). "How Does Physician Advice Influence Patient Behavior? Evidence for a Priming Effect." Archives of Family Medicine 9:426–433.

Kreuter, M. W.; Farrell, D.; Olevitch, L.; and Brennan, L. (2000). Tailoring Health Messages. Customizing Communication with Computer Technology. Mahwah, NJ: Lawrence Erlbaum Associates, Publishers.

Kreuter, M. W.; Lezin, N. A.; Kreuter, M. W.; and Green, L. W. (1998). Community Health Promotion Ideas That Work. Boston, MA: Jones and Bartlett Publishers.

Kreuter, M. W.; Strecher, V. J.; and Glassman, B. (1994). "One Size Does Not Fit All: The Case for Tailoring Print Materials." Annals of Behavioral Medicine 21(4):1–9.

McGuire, W. J. (1991). "Theoretical Foundations of Campaigns." In Public Communication Campaigns, 2nd edition. eds. R. E. Rice and C. K. Atkin. Newbury Park, CA: Sage Publications.

Mullen, P. D.; Evans, D.; Forster, J.; Gottlieb, N. H.; Kreuter, M. W.; Moon, R.; O'Rourke, T.; and Strecher, V. (1995). "Settings As an Important Dimension in Health Education/Promotion Policy, Programs, and Research." Health Education Quarterly 22(3):329–435.

Petty, R. E., and Cacioppo, J. T. (1981). Attitudes and Persuasion: Classical and Contemporary Approaches. Boulder, CO: Westview Press.

Petty R. T.; Cacioppo J. T.; Strathman A. J.; and Priester J. R. (1994). "To Think or Not to Think. Exploring Two Routes to Persuasion." In Persuasion: Psychological Insights and Perspectives, eds. S. Shavitt and T. C. Brock. Boston, MA: Allyn and Bacon.

Skinner, C. S.; Campbell, M. K.; Rimer, B. K.; Curry, J.; and Prochaska, J. O. (1999). "How Effective Is Tailored Print Communication?" Annals of Behavioral Medicine 21(4):290–298.