Implementation and Evaluation of a Low-Literacy Diabetes Education Computer Multimedia Application BEN S. GERBER, MD 1 IRWIN G. BRODSKY, MD, MPH 2 KIMBERLY A. LAWLESS, PHD 3 LOUANNE I. SMOLIN, EDD 3 AHSAN M. AROZULLAH, MD, MPH 1,4 EVERETT V. SMITH, PHD 5 MICHAEL L. BERBAUM, PHD 6 PAUL S. HECKERLING, MD 1 ARNOLD R. EISER, MD 7 OBJECTIVE — To evaluate a clinic-based multimedia intervention for diabetes education targeting individuals with low health literacy levels in a diverse population. RESEARCH DESIGN AND METHODS — Five public clinics in Chicago, Illinois, par- ticipated in the study with computer kiosks installed in waiting room areas. Two hundred forty-four subjects with diabetes were randomized to receive either supplemental computer multimedia use (intervention) or standard of care only (control). The intervention includes audio/video sequences to communicate information, provide psychological support, and pro- mote diabetes self-management skills without extensive text or complex navigation. HbA 1c (A1C), BMI, blood pressure, diabetes knowledge, self-efficacy, self-reported medical care, and perceived susceptibility of complications were evaluated at baseline and 1 year. Computer usage patterns and implementation barriers were also examined. RESULTS — Complete 1-year data were available for 183 subjects (75%). Overall, there were no significant differences in change in A1C, weight, blood pressure, knowledge, self-efficacy, or self-reported medical care between intervention and control groups. However, there was an increase in perceived susceptibility to diabetes complications in the intervention group. This effect was greatest among subjects with lower health literacy. Within the intervention group, time spent on the computer was greater for subjects with higher health literacy. CONCLUSIONS — Access to multimedia lessons resulted in an increase in perceived sus- ceptibility to diabetes complications, particularly in subjects with lower health literacy. Despite measures to improve informational access for individuals with lower health literacy, there was relatively less use of the computer among these participants. Diabetes Care 28:1574 –1580, 2005 T here is a growing awareness of the impact of low health literacy on di- abetes (1,2). Low health literacy poses a major barrier to education and self-management (3). Health literacy di- rectly impacts health outcomes, such as hospitalization risk, particularly in those with chronic diseases (4,5). In one cross- sectional study (5) measuring the health literacy level of type 2 diabetic patients, patients with inadequate health literacy were less likely than those with adequate health literacy to achieve tight glycemic control. However, there is limited data from longitudinal studies regarding the impact of health literacy on changes in clinical outcomes over time (2). Despite increasing concern about the impact of low health literacy on diabetes care, there are few proven interventions available that address low health literacy (6). Recent evidence (6,7) suggests that diabetes education improves self- management and glycemic control in those with limited health literacy. Simul- taneously, clinicians are faced with less time and resources for disseminating in- formation. Regular attendance in diabetes education classes is disappointingly low, particularly for those with lower socio- economic status and those who have yet to develop diabetes complications (8). Additional barriers, including cultural factors and the inability to speak English, further complicate educational initiatives in diverse urban populations (9 –11). To overcome these challenges, a new computer-based multimedia application for individuals with diabetes was created (“Living Well with Diabetes”). The program utilizes extensive audio and video to sup- ply information, provide psychological support, and promote diabetes self- management skills without text or com- plex navigation. The application was available on touch-screen computers in clinical waiting areas for patients to utilize before appointments. The purpose of this study was to evaluate the impact of com- puter-based education in the clinical set- ting through a randomized controlled trial. A secondary objective was to evaluate the barriers and facilitators to implement- ing computer-based education. Prior re- search (12,13) designed to improve diabetes self-management often have not been generalizable beyond local environ- ments. Well-controlled trials frequently included selected motivated subjects and ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● From the 1 Department of Medicine, University of Illinois at Chicago, Chicago, Illinois; the 2 Maine Center for Diabetes, Maine Medical Center, Portland, Maine; the 3 Department of Curriculum, Instruction, and Evalu- ation, University of Illinois at Chicago, Chicago, Illinois; the 4 Jesse Brown VA Medical Center and VA Midwest Center for Health Services and Policy Research, Chicago, Illinois; the 5 Department of Educational Psychology, University of Illinois at Chicago, Chicago, Illinois; the 6 Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois; and the 7 Division of Clinical Education, Drexel University College of Medicine and Mercy Health System, Philadelphia, Pennsylvania. Address correspondence and reprint requests to Ben Gerber, MD, Department of Medicine (M/C 718), University of Illinois, 840 South Wood St., Chicago, IL 60612. E-mail: bgerber@uic.edu. Received for publication 3 January 2005 and accepted in revised form 6 April 2005. A table elsewhere in this issue shows conventional and Syste `me International (SI) units and conversion factors for many substances. © 2005 by the American Diabetes Association. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Clinical Care/Education/Nutrition O R I G I N A L A R T I C L E 1574 DIABETES CARE, VOLUME 28, NUMBER 7, JULY 2005