Patient Education and Counseling 89 (2012) 714

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Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Review

Comparative analysis of print and multimedia health materials: A review of the literature
Elizabeth A.H. Wilson a,*, Gregory Makoul b, Elizabeth A. Bojarski a, Stacy Cooper Bailey a, Katherine R. Waite a, David N. Rapp c, David W. Baker a, Michael S. Wolf a,c
a b c

Department of Medicine, Feinberg School of Medicine at Northwestern University, Chicago, USA Innovation and Learning Center, Saint Francis Care, Hartford, USA Department of Learning Sciences, School of Education and Social Policy, Northwestern University, Evanston, USA

A R T I C L E I N F O

A B S T R A C T

Article history: Received 9 February 2012 Received in revised form 15 May 2012 Accepted 6 June 2012 Keywords: Print Multimedia Health materials Literature review Health literacy

Objective: Evaluate the evidence regarding the relative effectiveness of multimedia and print as modes of dissemination for patient education materials; examine whether development of these materials addressed health literacy. Methods: A structured literature review utilizing Medline, PsycInfo, and the Cumulative Index to the Nursing and Allied Health Literature (CINAHL), supplemented by reference mining. Results: Of 738 studies screened, 30 effectively compared multimedia and print materials. Studies offered 56 opportunities for assessing the effect of medium on various outcomes (e.g., knowledge). In 30 instances (54%), no difference was noted between multimedia and print in terms of patient outcomes. Multimedia led to better outcomes vs. print in 21 (38%) comparisons vs. 5 (9%) instances for print. Regarding material development, 12 studies (40%) assessed readability and 5 (17%) involved patients in tool development. Conclusions: Multimedia appears to be a promising medium for patient education; however, the majority of studies found that print and multimedia performed equally well in practice. Few studies involved patients in material development, and less than half assessed the readability of materials. Practice implications: Future research should focus on comparing message-equivalent tools and assessing their effect on behavioral outcomes. Material development should include explicit attention to readability and patient input. 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction There is a tremendous volume of material for patient education and counseling, but very little guidance regarding the most effective modes of dissemination. The increasing exibility of multimedia technology enables effective and efcient communication about health and medicine. In fact, leveraging increasingly available health technologies (e.g., electronic health records and patient portals) to educate patients is a national priority highlighted in the HITECH act [1]. There may be great value in using dynamic systems such as streaming video on a health system website, as such avenues could enhance the consistency of information patients receive and foster just-in-time delivery of

* Corresponding author at: Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University, 750 N Lake Shore Drive, 10th Floor, Chicago, IL 60611, USA. Tel.: +1 312 503 5573; fax: +1 312 503 2777. E-mail address: eahwilson@northwestern.edu (Elizabeth A.H. Wilson). 0738-3991/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pec.2012.06.007

the materials (i.e., immediately before a clinical encounter). A multimedia approach, which may incorporate video, graphic design, and audio voice-over also has particular potential as a means for conveying information to patients with limited literacy skills [25]. Multimedia programs have proliferated as technology has made them easier to produce. However, theories from cognitive psychology and learning sciences suggest that whether multimedia-based materials help patients comprehend and retain presented information is a question worthy of investigation. Learning and correctly applying new health-related concepts is a complex process that requires patients to process, encode, retain, and accurately act on information at the appropriate time. For incoming information to be comprehended, working memory, which is dened as ones ability to manipulate and actively keep information available to be processed, must be effectively utilized [6,7]. Working memory is often described as a mental scratchpad that is limited in capacity. Ideally, according to cognitive load theory, well-designed educational materials should tax working memory as little as possible, freeing cognitive resources to process

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the information most necessary for successful comprehension and retention [8,9]. As described by Wilson and Wolf [10], there are numerous cognitive-load based advantages and disadvantages for learning new information via print as compared to other modalities such as multimedia. Specically, the benets of print materials are that they allow learners to control their own rate of learning and the order in which they choose to pay attention to information. Additionally, print materials also offer a very tangible source for personal engagement by being easy to physically carry and interact with as needed without the necessity of further equipment. Yet print materials are hindered by the fact that they rely on reading skills and cannot explicitly show certain types of information, such as motion or every step in a multi-step procedure. Conversely, although many multimedia programs have set pacing and order, viewers of such materials can more easily fall victim to potentially distracting visual information by the very nature of the amount of content that can be shown. Videos are less tangible than print but maintain the advantage of being able to explicitly depict motion and procedures while also allowing for audio tracks to convey material, making the modality less reliant on reading ability. Some multimedia tools also allow for re-review of material. With increasing advancements in mobile technologies, the convenience and accessibility advantages of print may become less salient, yet other issues may then become more relevant (e.g., size of viewing area for streaming video, internet connectivity, etc.). The advantages and disadvantages of different media for conveying intended messages have been shown in a general context [11] and may be even more apparent for patients with limited literacy, as they are more likely to experience difculties in comprehending, remembering, and adhering to medical instructions [1217].

Because patients with low literacy have been found to have poorer health outcomes including increased hospitalization and mortality [1825], understanding how best to convey requisite health knowledge and mitigate the adverse effects of inadequate health literacy would be particularly benecial. To date, little attention has been directed towards comparing the effectiveness of multimedia and print modalities for patient education purposes, especially while addressing health literacy concerns. We systematically reviewed the literature to investigate the outcomes associated with print and multimedia materials, and we specically sought to examine whether and how patients literacy skills were addressed. In this review we directed our focus towards articles that compared print and multimedia tools with equivalent message content in an effort to isolate the impact of modality on intervention effectiveness. Completion of a review of such studies can help dene the relative effectiveness of different media for delivering patient education and counseling messages.

2. Methods As illustrated in Fig. 1, we took a systematic approach to searching the medical and socio-behavioral literature for articles comparing print and multimedia versions of health materials. The primary search targeted articles published in English up to November 2010 and indexed in Medline, PsycInfo, or the Cumulative Index to the Nursing and Allied Health Literature (CINAHL). We used Ovid or Ebscohost to search the title, original title, abstract, and subject heading word elds of indexed articles within all three databases. The search used the following keywords:

PRIMARY SEARCH

SECONDARY SEARCH

Medline, PsychInfo, CINAHL: N=738 articles

Title Review 220 Excluded 477 Potentially Relevant Articles 41 Literature Reviews

Abstract Review 335 Excluded 129 Potentially Relevant Articles 13 Literature Reviews

Reference Review 148 Potentially Relevant Articles

Full Article Review 35 Excluded 94 Articles for Data Abstraction

Full Article Review 124 Excluded 24 Articles for Data Abstraction

From 118 Abstractions, Select Articles with Message Equivalence and Isolation of Print vs. Multimedia 30 Articles for In-Depth Analysis

Fig. 1. Article search and review process.

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1. patient education or informed consent or decision making or decision aid or patient participation; 2. (multimedia or video or audio or CD or DVD or interactive or computer-assisted instruction) AND (print or text or brochure or pamphlet or manual or booklet or leaet or reading material or written); 3. 1 and 2 limited to (humans) AND (English language). The primary search yielded 738 non-redundant articles from the electronic databases. Two members of the research team independently conducted a title review of all 738 articles, with the objective of eliminating studies that were clearly not empirical or not peer-reviewed. This step excluded 220 articles, all of which had been independently rejected by both reviewers (i.e., articles were retained if there was a disagreement). An additional 41 articles were literature reviews; these were set aside for the secondary search. Thus, 477 articles were retained for the next step. Two team members then independently conducted an abstract review of the 477 articles, with the objective of excluding studies that clearly did not involve a comparison of print and multimedia materials in the context of medicine, health, or healthcare. A total of 335 articles were excluded at this stage. Again, articles were retained if there was any disagreement about elimination. An additional 13 articles were identied as literature reviews from their abstracts. A total of 129 articles remained after this stage for further examination. The research team worked together to develop and rene a data abstraction form and trained research assistants to use it as a means of conducting a full article review. To evaluate each article, PRISMA criteria were used as a guide for completing data abstractions [26]. The data abstraction form included the following elds: author(s), article title, journal, publication date, research question, study design, sample, whether patient literacy level was tested, whether patients/consumers were involved in the development of the materials, description of multimedia and print tools, outcomes assessed and measures used, results, discussion, conclusions, and whether or not intervention arms across print and video were truly equivalent in content and isolated from each other. During the article review and abstraction process, it became evident that 35 articles did not actually compare print and multimedia materials. These were excluded, yielding 94 articles for further analysis. Our secondary search focused on relevant citations within articles obtained through the primary search process described above. We conducted a reference review of all articles captured in the previous stage to identify potentially relevant and nonredundant articles. Within this reference review, we also identied any relevant literature reviews to search for potentially relevant references within those articles. Combined, these searches yielded 148 additional articles, for all of which the research assistants completed full article reviews. During the full article review phase, 24 articles were found to meet the criteria for inclusion. Research assistants completed data abstraction forms for these articles as well as the 94 articles generated by the primary search, resulting in a total of 118 data abstraction forms. All data abstraction forms were reviewed to ensure accuracy, consistency, and quality control. Of the 118 articles we examined, only 30 reported that there was some attempt to ensure message equivalence across print and multimedia tools and to isolate print and multimedia as discrete interventions within the study design. Therefore, only this subset offered a fair comparison of print vs. multimedia. We examined these articles further to discern each studys context and setting, the study population size, whether or not it was a randomized trial, and what outcomes were assessed (preference, knowledge, anxiety, or behavior). We next summarized the main results of

each article to elucidate whether each study found an advantage for either presentation medium. Additionally, for each article analyzed, we examined whether or not literacy was tested, and if so, whether there was an effect of literacy. Finally, we assessed whether studies included measures of readability and/or patient feedback during the development of their educational materials. 3. Results 3.1. Overview The results of an in-depth analysis of these articles are reported below and summarized in Tables 15. Spanning 31 years (19792010), the 30 comparative studies [2756] are summarized in Table 1. Subjects were randomly assigned to an intervention group in 28 of the 30 studies. Settings were diverse, ranging from primary care to specialty practice and from home to community-based care. A variety of multimedia formats were represented, including video (such as tape or DVD), computer, lm, and slides accompanied by audiotape. A number of studies tested other modalities as well, such as oral communication with the provider, html, audiotape only, or multiple videos. Print materials included leaets and booklets of various length and content. 3.2. Evidence supporting use of print vs. multimedia materials Studies compared the effect of print and multimedia materials on various outcomes, including patient preference, knowledge, anxiety reduction, and behavior. Fourteen studies identied patient preference as an outcome of interest via different avenues including patient satisfaction, direct comparison of the different presentation options, or ratings of the different medias benecial natures. Of these, three provided evidence in favor of print, ve in favor of multimedia, and six found no signicant difference. Table 2 summarizes the results of these studies. Of the 24 studies with knowledge as an outcome variable, the evidence in one favored print, 12 favored multimedia (though caveats are included in some of the table entries), and 12 indicated that the effect of print and multimedia formats were essentially equal (the number of results does not equal 24 because one study had two opportunities for comparison and found differing outcomes depending on the type of material being covered). Table 3 displays the results of these studies. Anxiety was an outcome in ve studies, none of which found evidence for a difference in the effectiveness of print and multimedia in terms of anxiety reduction. Table 4 shows results from the studies that included anxiety as an outcome. Twelve studies assessed whether interventions inuenced behavior. The evidence favored print in one study, multimedia in four studies, and no found difference between print and multimedia in the remaining seven studies. Table 5 includes ndings from these studies. In sum, the 30 studies generated 56 opportunities for assessing whether print or multimedia had a more benecial effect on outcomes. In over half (54%) of these instances, no difference was obtained. When a difference was observed, the results tended to favor multimedia presentation. The perspective gained when looking across all outcomes suggests that, in most of the 30 studies, print and multimedia performed equally well. 3.3. Patients with limited literacy Four studies tested patient literacy levels to assess whether literacy was associated with the response to print and multimedia tools. Campbell et al. [27] found that enhanced print was

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Table 1 Characteristics of print vs. multimedia studies selected for in-depth analysis. Author (year) Research design R Agre (2003) Allen (1995) Astley (2008) Bader (2003)
a

Outcomec
b

Study groups (N)

Context Cancer trials Child behavior management for dentistry Coronary angiography Cancer communication

Setting Oncology clinics Consultation room Cardiac care unit at hospital Focus groups

PRF

KNW U U

ANX

BEH

U U U

Barkhordar (2000) Campbell (2004) Clayton (1995) Hill (2009) Hjelm-Karlsson (1989) Hopper (1994) Idriss (2009) Ilic (2008) Jenkinson (1988) Kim (2006) Marco (2006) Marshall (1984)

U U U U U U U U U U U U

Meade (1994) Mladenovski (2008) Murphy (2000) Olsen (1985) Osguthorpe (1983) Proctor (2006) Raynes-Greenow (2009) Renton-Harper (1999) Savage (2003) Stalonas (1979) Street (1998) Wilson (2010) Yazdani (2009) Yturri-Byrd (1992)
a b c

U U U U U U U U U

Control (105); print (116); video (116); computer (104) Print (30); oral (30); video (30); video with explanation (30) Verbal (32); written (34); audiovisual (33) Print (9); print in HTML (9); audio only (9); print + audio (9); video + audio (9) Print (26); multimedia (26) Print (62); enhanced print (57); video (58); computer (56) Print (264); video (82) Control (122); DVD (49); workbook (51) Print (22); oral (22); slide + audio (23); lm + audio (22) Print (80); computer (80) Print (39); video (39) Print (49); video (53); internet (54) Control (40); print (44); audio (41); print + audio (41) Print (22); web (28); control (23) Print (155); video (155); control (55) Print (20); slide + audio (20); slide + M D audio (20); oral (20); print + slide + MD audio (20) Control (356); print (370); video (374) Print (13); video (16) Print (96); video (96) Print (8); slide + audio (8) Control (50); print (50); print + video (50); video (50) Print (101); video (117); counseling (101) Print (202); audio-guided decision aid (193) Print (26); video (26) Print (48); multimedia (57) Print (8); oral (8); video (8) Print (54); multimedia (54) Print (107); video (220); control (108) Print (135); video (130); control (123) Print (38); video (34); one-on-one (31)

U U

U U

U U

Dental hospital Premature birth and heart transplant (hypothetical) Genetic screening Falls prevention Intravenous pyelography Intravenous contrast media Melanoma Prostate cancer screening Asthma Type 2 Diabetes Self-reported pain Contraceptive methods

Waiting room; Research room HeadStart facilities Clinics, hospitals, walk-a-thon Rehabilitation unit or orthopedic unit of two hospitals University hospital Radiology department Dermatology department Single medical center Home Outpatient diabetes clinic Emergency Department Primary care clinics

U U U U

U U

U U U U

U U U U U

U U U U

U U

Colon cancer Third molar surgery Sleep apnea Steroid use Psychiatric medication use Postpartum contraceptive counseling Labor analgesia Electric toothbrush Metered dose inhaler Alcohol Breast cancer screening Asthma (hypothetical) Oral cleanliness and gingival health AIDS

Primary care clinics University dental school Private sleep clinic University hospital VA psychiatric hospital Urban medical center Two obstetric hospitals Dental hospital Research room at general practices VA hospital Research room at family practice and free clinics Primary care centers Public schools Young adult clinic at a hospital U

U U U U U U U U U U U U U U U U U

U U

U U U U

R, randomized trial. N reects number of subjects analyzed when noted in individual articles. Outcome: PRF, preference; KNW, knowledge; ANX, anxiety; BEH, behavior.

associated with greater information recall for participants reading below the 8th grade level; there were no differences in the behavioral outcome of agreement to participate in hypothetical research. Meade et al. [28] reported that both print and multimedia increased patient knowledge across literacy levels. In a subset of patients with low literacy, Murphy et al. [29] showed that patients exposed to a video intervention had higher scores on 2 of 11 knowledge items than did patients in a print-only group. Wilson et al. [30] found that for procedure-based information, patients with low literacy performed better after seeing a video than print, but that for declarative content, the presentation medium did not impact performance for participants with adequate or low literacy. In addition, several studies collected information on years of school completed as a proxy for literacy level and investigated differences by modality, with mixed results [32,3436,39,42,54].

3.4. Development of health materials We carefully examined these 30 studies for information regarding the development of their various health materials to determine the extent of efforts to: (1) achieve a particular literacy/ readability level and (2) obtain patient/consumer input on form and/or content. In terms of literacy/readability, 12 of the studies mentioned efforts to monitor the reading level of text included in print and multimedia tools. Within these studies, the target literacy level varied widely and included 5th grade [35], 6th grade [32,34], 5th 6th grade [28], 7th grade [38], 8th grade [39,50,54], 9th grade [36], 8th10th grade [42], 11th12th grade [27], and 12th grade [29]. Measures utilized to assess literacy/readability level varied as well and when specied included a variety of formulas or programs

E.A.H. Wilson et al. / Patient Education and Counseling 89 (2012) 714 Table 2 Summary of print vs. multimedia outcomes: preference. Author (year) Evidence in support of medium Print Astley (2008) Bader (2003) Barkhordar (2000) Hjelm-Karlsson (1989) Hopper (1994) Idriss (2009) Jenkinson (1988) Marco (2006) Mladenovski (2008) Proctor (2006) Raynes-Greenow (2009) Savage (2003) Street (1998) Yazdani (2009) U U U U U U U U U U U U U Multimedia Tie U Summary of results

11

No signicant differences in satisfaction scores across participants in verbal, written, or audiovisual conditions The majority (81%) of patients interviewed chose the multimedia (Flash) version as their rst or second choice Results were mixed depending on type of preference question Print and multimedia materials were equally viewed as helpful Written consent signicantly more preferred than video, which took more time to complete Video group rated intervention as more useful than did print group. Across groups, participants reported a general preference for video Participants given both the book and audiotape preferred the book No signicant difference in helpfulness ratings between written and video groups Most patients preferred a combination of approaches, but multimedia was rated as more helpful than print 93.0% of print group was satised w/method vs. 91.3% of video group. Satisfaction rate was highest for counseling (99.0%) All participants recommended their respective aids, Should note that descriptively, slightly more negative comments were received in audio than print condition Multimedia was rated less boring than print Multimedia preferred overall, signicant interaction found with age and medium; younger women were more likely to prefer multimedia format More print participants rated their materials as good than did video participants

such as Flesch-Kincaid [27,36,54], SMOG (Simple Measure of Gobbledygook) [28,38], Grammatik [29,32], Fry [50], Gunning Fog Index [29], and others. Regarding patient involvement in the development process, ve studies included this step in their descriptions of material development. Clayton et al. [32] reported that written materials were repeatedly revised based on comments received from parents
Table 3 Summary of print vs. multimedia outcomes: knowledge. Author (year) Evidence in support of medium Print Agre (2003) Allen (1995) Astley (2008) Bader (2003) Barkhordar (2000) Campbell (2004) Clayton (1995) Hill (2009) Hjelm-Karlsson (1989) Hopper (1994) Idriss (2009) Ilic (2008) Jenkinson (1988) Marshall (1984) Meade (1994) Mladenovski (2008) Murphy (2000) Olsen (1985) Osguthorpe (1983) Raynes-Greenow (2009) Stalonas (1979) Street (1998) Wilson (2010) U U U U U U U U U U U U U U U U U Multimedia U U U U U U U Tie

of pediatric patients during pilot studies and from an advisory board. Murphy et al. [29] utilized feedback and suggestions from patients for both their video and print materials. Interestingly, for their brochures they incorporated suggestions from patients in areas surrounding literacy except for readability, which was held constant to maintain consistency between their video and print formats. Wilson et al. [30] and Street et al. [54] each reported

Summary of results

Yturri-Byrd (1992)

Slight improvements in knowledge with computer and video over written formats; less educated patients fared worse with computer and video formats Video formats demonstrated higher rates of self-reported well-informed subjects compared to print No signicant differences in recall scores across modality at any of the 3 recall time points Signicant improvements seen equally across both print and multimedia groups In multimedia group, signicant improvement in 9 of 11 knowledge items; only 6 of 11 for print Recall of protocol-specic information greater for enhanced print vs. video materials among those reading below 8th grade level Both written and video materials increased knowledge; greater interest in topic and educational level improved outcome DVD participants gave more desired responses to knowledge items than workbook participants No signicant difference across the groups overall. Should note though, only one sensory knowledge item on the questionnaire was signicantly better via multimedia channels Signicant improvement in knowledge for video compared to print, for female patients only Online video participants scores from pre- to post-test improved more than print participants scores No signicant difference in increase in knowledge across print, video, and internet groups. Both the tape and book + tape increased medication knowledge more than did the book alone Combination of methods and multimedia (slide and sound) all demonstrated signicantly higher knowledge increases compared to print Both print and multimedia improved knowledge across literacy groups compared to control No signicant difference change in knowledge scores pre-to post intervention between print and multimedia groups Increase in 3 of 11 knowledge items for video vs. print materials; patients reading below 7th grade improved knowledge with video for 2 of 11 items Audiovisual presentation (slide/tape) did signicantly better than written education materials; however those receiving slide/tape had lower pretest scores Videotape, written, and the combination of materials did not improve knowledge beyond control No signicant differences in improvements in knowledge between groups Videotape signicantly outperformed both written materials and live presentation Signicant increases in knowledge demonstrated equally by brochure and multimedia For declarative content, main effect of lit, but no sig. diff. b/w print and video. For procedural content, among literate participants, no sig. diff b/w groups, but for limited lit., video participants outperformed print receivers Knowledge improvements did not signicantly differ across types of education

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Table 4 Summary of print vs. multimedia outcomes: anxiety. Author (year) Evidence in support of medium Print Astley (2008) Hjelm-Karlsson (1989) Ilic (2008) Raynes-Greenow (2009) Street (1998) Multimedia Tie U U U U U No signicant difference in anxiety across the three modalities No signicant differences between modalities; trend suggests that multimedia reduced anxiety No signicant difference in anxiety scores across print, video, and internet groups Post-intervention anxiety did not signicantly differ between groups No differences between the brochure and multimedia groups in anxiety reduction Summary of results

Table 5 Summary of print vs. multimedia outcomes: behavior. Author (year) Evidence in support of medium Print Allen (1995) Campbell (2004) Hill (2009) Ilic (2008) Jenkinson (1988) Kim (2006) Marco (2006) Proctor (2006) Raynes-Greenow (2009) Renton-Harper (1999) Savage (2003) Yazdani (2009) U U U U U U Multimedia Tie U U U U U U No signicant differences in rate of consent; both videos and written format were outperformed by oral presentation No differences by format found in agreement to participate in hypothetical research studies DVD participants more motivated than workbook participants to engage in fall prevention strategies No signicant difference in decisional conict or screening interest across intervention types No differences in self-report of fewer doctor visits for asthma, but reduced compared to control There were no signicant differences across web-based and print participants for physical activity, fasting blood sugar, or HBA1C Video participants had signicantly (but not clinically) lower pain scores than print participants Neither education level nor type of intervention signicantly affected contraceptive choice No signicant difference in decisional conict between the audio-guided aid and the booklet Patients watching the video signicantly improved their plaque removal compared to written instructions; yet subject carry-over was identied Patients receiving multimedia education had signicantly better inhaler technique; ndings limited by poor response rate and inconsistent mailing of tool Both intervention groups improved cleanliness and gingival health relative to controls, with greater improvements for print participants compared to video participants Summary of results

patient feedback that occurred during development of their video materials. Raynes-Greenow et al. [36] alluded to pilot testing, but did not specify which medium was examined. 4. Discussion and conclusion 4.1. Discussion The results of the current review suggest that, although in some cases multimedia was found to be advantageous at promoting outcomes including preference, comprehension, and behavior, in other instances print was found to be more benecial. However, in the majority of cases print and multimedia performed equally well. There was no difference in patient anxiety between print and multimedia across any studies assessing this outcome, and no obvious patterns were found across studies examining the relationship between medium and other outcomes. Given the restricted quality and quantity of extant research, our review suggests that multimedia should be considered a promising but not proven medium for patient education and counseling. As found in our literature search, although a large number of studies were examined, relatively few actually isolated modality from other confounding variables such as content of message or amount of information. There is a great need for studies that compare message-equivalent tools (i.e., same content, different format) and include a variety of relevant and valid behavioral outcomes. Precisely because so few studies used message- and content-equivalent forms of interventions across modalities, we were unable to fully stratify intervention type within the overarching category of multimedia. This coarse grouping of intervention types including computer-based interventions, pas-

sively viewed videos, and audio recordings with visual slides may have impacted the ndings by potentially masking the benecial nature of especially high-quality multimedia applications. Therefore, given the limited quality and quantity of current studies, conclusions regarding modality should not be seen as denitive. In other words, the results of this literature review may be more useful in terms of informing future research directions than in dening a conclusive nal resolution to best practices regarding particular media for patient education experiences. Relatively few of the studies examined included literacy as a variable when assessing the benets of print vs. multimedia materials. Literacy is highly predictive of how well patients are able to interact with and understand health-related information [12,13,16,57,58], and therefore considerations of literacy may affect which modality might be optimal for presenting content to patient populations. Where literacy was assessed, some studies did nd differing results across participants with differing literacy skills. For example, Wilson et al. [30] found that in some cases, individuals with low literacy performed better after viewing video than reading print. A similar benet for video among individuals with low literacy was found by Murphy et al. [29]. In opposite ndings also with comprehension as the outcome, Campbell et al. [27] found an advantage for print vs. multimedia for patients with poorer literacy. While these results do not clearly indicate an optimal medium, they highlight the importance of considering low literacy populations when developing educational materials for patients and suggest a potential benet for standardizing both our understanding of literacy and our methods for assessing comprehension in such interventions. Despite the importance of including accessible, easy to read print materials when designing content for patients, our ndings

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also indicate that many studies fail to assess the reading level of text in print and multimedia tools. Additionally, material design rarely specied layperson feedback and input during the development of health education materials. However, it should be noted that, because not much detail regarding the development of the materials was provided in most of the studies assessed, it is possible that more effort was put into their development than was published in each paper. For example, although the study by Wilson et al. [30] did not specify reading level of the print materials used, unpublished work by members of our research team during the design of these materials found their readability to be at a 4th grade level as measured via Flesch-Kincaid scores and to have Lexile scores equal to or less than 740 for the passages of text included. 4.2. Conclusion Although multimedia materials provide a promising means of communication to patients, results of the current review suggest that multimedia and print interventions actually often perform equally well at promoting outcomes including preference, comprehension, lowered anxiety, and behavior. Patient involvement is an essential, though clearly overlooked, component in the development of patient education and counseling programs. Focus groups and surveys can provide information that claries both a sense of the audience and the potential scope of the material needed to be conveyed [59]. The development of educational tools, whether they are in print or multimedia formats, should address issues of literacy/readability from the outset. This goal can be accomplished by using readability assessments such as Lexile Analysis to initially gauge the potential understandability of text or audio messages. Additionally, feedback on the clarity of messages should be sought from members of the intended audience to either conrm their quality or guide any further renements [59]. Regardless of the medium designers choose to employ, it is also important to consider relevant theory and elements of instructional design. With these points in mind, rigorous research on different media for delivering message-equivalent patient education has the potential to move the eld of patient education forward and to facilitate communication, comprehension, and decision making for patients, family members, and providers. 4.3. Practice implications Designers of communicative materials aimed at patient populations should focus on the cognitive constraints of their audience, including universal limitations in working memory, when creating educational materials. Whether information is presented in a print vs. multimedia form of delivery is likely less important than the use of best practice principles designed to promote ease of understanding and retention. In order to accurately compare different media types, materials with equivalent content need to be stringently compared before conclusions can be drawn about different medias relative efcacies at promoting positive outcomes for patients. Acknowledgment This comparative analysis of print and multimedia health materials was funded, in part, by a grant from the Foundation for Informed Medical Decision Making (PI: Dr. Makoul). References
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