Multimedia is a catch-all phrase for “alternatives to text.” As we discussed in previous chapters, the exclusive reliance on text – either printed or spoken – is often at the heart of health illiteracy. Multimedia provides other avenues for presenting information through the use of photographs, illustrations, animation, video, and interactive learning environments that invite rather than discourage people with literacy or language issues to learn.

The success of communicating any message is knowing your audience, and developing materials that address and respect their needs. Multimedia messages are much more effective than plain text, because patients remember:

•    10% of what they read
•    20% of what they hear
•    30% of what they see
•    70% of what they see AND hear

Before the advent of the Internet, individuals interested in learning more about their health would have had to refer to books or go to specialised medical libraries. Now they can access that information 24/7 from their home computers and from their smart phones. The Internet is also a valuable source of information on how clever developers are using technology to improve health literacy.

Computer software

There are a growing number of programs that help people deal with health issues. These include programs that:

•    Help people on restricted diets to count calories or check the fat content of foods they eat.
•    Help users with exercise programs their doctors have prescribed for them.
•    Help individuals keep track of the medications they take, remind them when to take them, and warn them of possible adverse drug interactions caused by combining them with other drugs or common foods.

You can download these programs (many of which are free) @ http://download.cnet.com


Mobile technology

In many developing countries, inexpensive mobile phones have become ubiquitous. Not only do they provide access to health information on the Internet, they also allow users to download free or inexpensive apps so that they can function as television remotes, bike speedometers and flashlights. Health apps also allow the smartphone to act as medical devices, helping patients monitor their heart rate or manage their diabetes. For example, the Plain Language Medical Dictionary (@ http://www.lib.umich.edu/plain-language-dictionary) is exactly what it sounds like – a simple widget that allows you to select a complicated medical term and see its definition in clear, concise, non-technical English. WebMD (@ http://www.webmd.com) is another free app, available for iOS and Android phones, that provides a useful symptom checker for common diseases, a first-aid guide, an extensive database of drug and pharmaceutical information (including warnings about possible adverse drug interactions), and listings for health centres in the user's area. You can review a list of health-related phone apps @ http://www.informationweek.com/healthcare/patient/15-mobile-apps-for-bet.... There are thousands of health-related apps available for download today on smartphones and tablets – all you need to do is go online and search for them. Soon, it may become routine for doctors to prescribe apps for their patients!


HealthPhone (@ www.healthphone.org) has created a library of health videos, which are preloaded free of cost on popular low cost mobile phones in India. They provide information on a wide range of topics, ranging from breastfeeding to hand washing; and are being made available in local Indian languages as well.
Smartphones are useful for doctors as well! drawMD (@ www.drawMD.com ) is an iPad app which provides a library of anatomical images which doctors can use to create detailed visuals to easily explain complex issues and procedures to patients in a simple, interactive, memorable visual way. It eliminates medical jargon, because patients can clearly see the process, and can take the image and notations home with them to refer to later. It bridges language and understanding barriers, inspires collaboration, and strengthens the physician/patient bond.
Basic mobile phones have also been used to improve health literacy through the clever use of text messaging (SMS). However, generic mass messages are not useful, and we need to tailor the content for the user. Using clinical analytics, it’s possible to craft text messages for individual patients. They can be tailored based on a patient’s age, sex, disease status, medication regimen, and past medical history. With the help of cloud-based computer systems that integrate pharmacy, medical, lab, and other health data, we now also have the potential to deliver messages at just the right times – for example, a message warning about the side effects of a drug at the time the patient is picking this up at the chemist. These messages become relevant and actionable, and therefore more effective. Tailoring resources and information for individuals can go a long way toward improving patient understanding and outcomes – we cannot use a one size fits all approach.

However, using even the most advanced technology cannot change patient behaviour on its own. After all, patients don’t just want access to data; they want answers to questions! When it comes to consumer messaging, we must first consider the following questions:

• What are we asking patients to do?
• Are we giving them the information and tools to take action?

Clinical data needs to be synthesised into concrete recommendations for patients, and this can be a challenging exercise. A blended model, which allows nurses or health coaches to send personalised messages to patients can be very helpful.

Translation tools

One of the major problems in the field of health literacy is translation. It really doesn't matter whether your patient is literate enough to read the instructions you give them for taking their medication if you don't speak their language.

Although you would probably not want to rely exclusively on Google Translate when trying to translate precise medical terms into another language, there are more specialised computer tools that are designed to do just that. For example, a company called Spoken Translation Inc. has developed a software program called Converser™ for Healthcare, which provides reliable two-way conversations between English-speaking physicians and Spanish-speaking patients and vice-versa. Both the doctor and the patient can type or speak in their own language, and the program will translate the words into the other language, creating a transcript of the conversation so as to verify its accuracy and providing alternative suggestions to words, terms, and phrases that are deemed inappropriate. This program is available not only for computers, but also for smart phones.

Medibabble (@ http://www.medibabble.com) is a free, high-quality medical translation application for mobile phones. It is a tool for history taking and is specifically designed for the care of non-English-speaking patients. Medibabble is available in 5 languages and contains thousands of translated questions and instructions, all reviewed by a panel of physicians from the University of California School of Medicine. Deaf and hearing-impaired patients can see a full-screen display of the selected phrases.

For illiterate patients, you can also use the free text to speech programs on your PC. These tools are included in most modern computers as an integral part of their accessibility options for the handicapped. You just need to select the text, and the computer reads it aloud to the patient.

Still another area in which technology can come to the rescue is in the area of "smart products," meaning medical tools that actually talk to you and in your own language. An example of just such a tool is the Accu-Chek thermometer, which takes a patient’s temperature and then reports the result aloud in Spanish.

New electronic health tools allow clever developers to make them easier for users to engage with. eHealth literacy is the ability to seek, find, and understand health information from electronic sources and apply the knowledge gained to solving a health problem. Thoughtful developers can use the versatility of technology to be able to reach many more people, who may not be able to read, but who can use touch screens to learn about their health problems. The good news is that technology is rapidly becoming less expensive and easier to use.


Patient education videos

Expert patients can create videos to help teach other patients. I am an IVF specialist, and one of the things most IVF patients understandably dread are the daily injections they need to take during their IVF treatment. I requested a patient to take a video of how she self administers her own Injections; and we then uploaded this to YouTube. You can see the video @ http://www.youtube.com/watch?v=Bvo4GNUuRYY. This has now been viewed thousands of times, and helps other IVF patients to overcome their fear of taking injections. Peer to peer learning is the most effective way of teaching, and they are convinced that if another patient can do it, so can they.


Caution! Sometimes low-tech is better than high-tech

It’s easy to get excited about new technologies and assume the newer and more high-tech, the better. However, As Henry David Thoreau reminded us in his book Walden, sometimes the best way to make life better is to "Simplify, simplify, simplify." Given the need in health literacy to make the complicated simpler and more understandable, high-tech can sometimes be unnecessary.

For example, one of the most effective health literacy visual aids was created by the worldwide leader in the field of diabetes testing equipment, Accu-Chek. The company treats diabetic patients worldwide, many of whom do not have the necessary literacy skills for reading and understanding food charts to determine what they can eat safely and what they should avoid. Accu-Chek solved the problem with a simple hand-out card, which shows colour photographs of foods labelled (for the Italian market) "Yes" and "No" – and for those who cannot read even those two words, green and red stop light symbols.

Another clever low-tech solution was created by the design agency Beattie McGuinness Bungay, with offices in New York, London, and Mumbai. Their socially conscious designers found that mothers of newborn babies were often confused as to how quickly their infants should be growing and were ignorant about basic information on how to take care of their babies.

The firm took the simplest and most common of baby accessories – the swaddling blanket – and printed essential health information for mothers directly on the blanket! Not only does the blanket keep the infants warm, it includes a visual growth chart showing the average size of children at the ages of 1, 3, and 6 months; a simple list of the warning signs of illness; basic information on breastfeeding; when to have the children vaccinated; and a reminder of how often they should take the children to a doctor.

Can social media contribute to health literacy?

Social media and social networking sites such as Facebook reach an estimated four out of five Internet users. Many of these social networking sites have forums or support groups on which people can ask questions and chat with others who may suffer from the same disease, thus increasing their knowledge about the disease and the effective treatments.

These forums and discussion groups can provide a safe avenue for patients to ask questions anonymously while accessing the forums through home computers, smart phones, or computers at the local library. This often spares people from the embarrassment of asking questions of their own doctors that might be seen as stupid or ignorant. This may also allow patients to more easily open up and thus gain valuable new information.

A number of forums cater to specific audiences, such as the Diabetes Forum.com (@ http://www.diabetesforum.com) and The Cancer Forums (@ http://www.cancerforums.net/).

However, it is important to be aware of the fact that the largely unmoderated nature of many of these forums puts patients at risk of being exposed to misinformation, in the form of partially or inaccurately reported science and “information” from people pushing quack cures. Therefore, before recommending any social media site to your own patients, be sure to spend some time evaluating the site’s content and moderation (i.e., how the content is managed by editors and reviewers). As part of your discussion with your patients, include some warning about receiving and/or applying any advice given on forums, especially that which contradicts your or other doctors’ advice.


Health 2.0 and expert patients

The Internet has grown and evolved, and it is not longer just a medium which patients use for accessing information. The user today no longer just passively consumes content – he actively generates it as well. (Anyone with a Facebook page is a web publisher, which just testifies to the fact that it has become very easy to post content online – and that millions of people are doing so every hour.) The web has become a platform where patients can share information with other and many expert patients publish their own blog. When patients write for other patients, this helps everyone. For one, they have a much better writing style. They don’t use jargon; and are conversational, which means it’s much easier to read what they write. Since they are patients themselves, they are respectful of their readers, and don’t talk down to them. They understand the reader’s viewpoint, as a result of which their writing is much more empathetic. They do not have an axe to grind, which means that the information they provide is usually not contaminated by commercial pressures. These “expert patients’ are a very interesting breed, because they serve as a valuable bridge between doctors and patients and social networking enhances access and communication.

Making technology accessible

These technological resources may be impressive and valuable, but they are of little use to people who lack access to these resources. In many countries where poor health literacy is a major problem, poverty itself makes it impossible for people to purchase home computers or even smart phones. In this section, we present a few of the ways in which health care organisations and professionals can help bridge the digital divide between the well-off and the poor and extend the benefits of improved health literacy to all. Taking down the barriers to Internet-based health care services and overcoming the digital divide require improved technology access as well as tailoring of design and services to reach those with limited health literacy.


Make computers available in doctors' clinics and hospitals

Doctors can help their patients access many of the multimedia resources available on the Internet by placing a number of web-connected computers in a public area dedicated for patients' use. A knowledgeable staff member can keep a bookmarked list and help patients access the most useful ones.

In areas with low literacy, touch-screen tablets or computers are a better solution.
Using these flat-screen devices, specifically designed medical applications can present users with images, icons, photographs, and cartoon drawings. Users can simply touch the screen to access more information, both visual and spoken. This provides a much more intuitive form of computer interaction, which even illiterate patients can use with ease.


Take advantage of schools and libraries

Many of these institutions are easily accessible and already have computers available for public use. A number of schools not only provide computers to children, but also provide them for adults in their continuing education programs, with many also offering free courses on how to use computers.

Virtually all public libraries these days also have computers that are available to everyone. Many of these libraries also have personnel who can get a computer novice "up and running" in no time.

The wave of the future – low cost smartphones and LCCDs

One of the technological trends that may help address the problems of health literacy is the movement to create Low Cost Computing Devices (LCCDs) and make them widely available. For example, Nicolas Negroponte, co-founder of the influential MIT Media Lab, has been working through his non-profit One Laptop per Child foundation to create a computer that can be produced and sold for under $100 (@ http://one.laptop.org/). The Indian government has also released the low cost tablet, Aakaash, (@ http://www.aakaash.org.in); and many innovative companies have released competing products, which bodes well for technology's ability to address the problems of health literacy.

HELP is organizing a conference on “ Putting Patients First Through Health Literacy  “. This will be on Sunday, 2nd December’12 at Nehru Center at 10.30a.m. to 1.p.m.  The website is www.patientpower.in/2012

The conference will be followed by a health literacy workshop in the afternoon. Helen Osborne, President, Health Literacy, a world renowned  Consultant from US , will be delivering the keynote and conducting the workshop.  Her website is at www.healthliteracy.com

At this time, we will be releasing the book, Deciphering Medical Gobbledygook: Promoting Health Literacy to Put Patients First , authored by Dr Aniruddha Malpani and Juliette Siegfried. This is Chapter 14 from that book