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Health literacy is defined as “the degree towhich individuals have the capacity toobtain, process, and understand basic health

information and services needed to make appropriatehealth decisions.”1 Unfortunately, “nearly half of allAmerican adults, 90 million people, have difficultyunderstanding and acting upon health information.”2

Limited literacy impacts health behaviors and healthdecisions, including the use of preventive services,thereby negatively impacting health outcomes.

Today’s health care environment is complex andrequires increased patient responsibility to navigate various

systems, make decisions about health, and follow therapeu-tic plans. Improved health literacy can lead to improvedhealth outcomes.3Yet most health materials are written athigher reading levels than most adults can understand.Health care providers frequently make broad assumptionsabout their patients’ ability to comprehend information.Graduating from high school, for example, does not guar-antee a patient can read at a 12th-grade level. A 5th- to6th-grade reading level is recommended for most patient-education materials.3,4 Cotungna, Vickery, and Carpenter-Haefele5 found that 50% of health education materialsreviewed are written above the 8th-grade level.

Implementing aVideo EducationProgram toImprove HealthLiteracy

ABSTRACTIn a world of increasingly complex health care choices, those with limited health literacyare at a disadvantage. Most health materials are written at higher levels than most adultscan understand. Limited literacy impacts health behaviors, decisions, and outcomes.Research suggests patient knowledge and comprehension can be increased by incorporat-ing visual images and words using video technology. A lack of videos that are sensitive tohealth literacy makes routine cost-effective implementation difficult. Development andimplementation of appropriate videos can be achieved cost effectively. This article discuss-es implementation of a cost-effective and literacy-sensitive video-education program.

Keywords: health literacy, health outcomes, provider communication, video/DVDeducation program © 2012 American College of Nurse Practitioners

Go to www.npjournal.org for a video introduction by the author.

Laurie Anne Ferguson, DNP, FNP

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Health care providers often use medical jargon, whichis a foreign language to people outside of health services.Limited health literacy is confounded by cultural and lan-guage differences in the United States. In addition, the fastpace of busy primary care practices does not allow foradequate time to assess and improve patients’ understand-ing, and the quality of health education may vary fromprovider to provider and from Monday morning to Fridayafternoon. Furthermore, many providers have not beeneducated in ways to enhance patients’ understanding. Fewincentives are available to support and reward patient edu-cation. A video/DVD with an accompanying pamphletthat highlights key points in simple language and picturescan be very effective in improving patient education.

BACKGROUNDVideo is an underutilized medium that can assist cliniciansin health education. Research suggests the use of videocan be particularly helpful in communicating healthinformation with people who have limited healthliteracy.6-9 According to Krouse, “three major uses forvideo include assisting with decision making, reducinganxiety about procedures, and teaching self-carepractices.10 The use of pictures closely linked to writtenor spoken text increased attention, comprehension, andrecall of health information in studies. A video may enablepatients to visualize and better understand specific healthtopics by concisely providing complex information in avisual format instead of only written educational materi-als.7 A culturally sensitive, socioeconomically neutral, andpractice-appropriate video-education program can have asignificant positive impact, particularly in situations whereindividuals need to make sensitive or difficult health caredecisions. Shared decision making, where the discussion isfacilitated between the provider and patient, can be facili-tated or augmented by the use of pictures.11

COGNITION, LEARNING, AND BEHAVIORResearch into how people learn, retain information, andmake subsequent behavior change is evolving and isimportant to consider in designing any patient-educationmaterial.12 Individuals can access and process only a finiteamount of information at a time. An individual’s abilityto focus and concentrate on information or workingmemory is impacted by his or her cognitive abilities andthe amount of stress being experienced.12,13 The conceptof “teachable moments” is understood to be influenced

by the individual’s ability to concentrate and willingnessto learn. Pain, a new diagnosis, or the stress of a new situ-ation can negatively affect an individual’s ability to com-prehend health information.

In addition to the limits of working memory, the diffi-culty of the task or concept or cognitive load may be over-whelming, such as learning to give insulin injections orcounting carbohydrates. The format in which information isdelivered can improve the amount understood and retainedby lessening a patient’s cognitive load. For printed material,the use of larger font, lots of white space, and word choice,linked closely with pictures, can improve cognition. The useof visual images in video format can improve comprehen-sion because it lessens the load of an individual’s workingmemory.12 Wilson and Wolf 13 and Mayer14 discuss applica-tion of research to the design of health materials, establishingevidence-based principles in designing educational material.Icons and illustrations used appropriately can additionallyincrease memory and comprehension.12

An effective tool in capturing both interest andacceptance of behavior change is the use of narrativecommunication.15 Visual storytelling, if done effectively,can powerfully convey information and empower viewersto make positive health decisions and lifestyle changes.Identification with the person providing informationabout personal struggles, with smoking cessation forinstance, can create a special bond between the viewerand the narrator. When individuals relate to the subject,they are “transported” into the narrative. According toHouston et al,15 “transportation can be a mediating fac-tor between exposure to the intervention and acceptanceof health beliefs in the story message.”

Narratives can provide powerful images to reducehealth disparities.16 Individuals will attempt to changebehavior if the behavior change has value or positivebenefits and if that behavior change is perceived asattainable.17 Visual media can convey via pictures manyconcepts that are difficult to achieve in mere words. Thecombination of visual media and printed materials canimprove the retention of health information.13 Effectivenarratives need to convey a clear link between negativebehaviors and positive alternatives to improve knowledgeand influence positive behavior.17

The use of gimmicks, however, can have negativeresults. Effective videos do not have to have lots of cre-ative embellishments that may actually distract from thecore message. Simple, straightforward information is more

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effective in enhancing comprehension.12 Myth busting ordeclaring a concept as untrue is a technique that is some-times used to change beliefs. Unfortunately, it can makeconcepts more confusing. According to Wilson andWolf,12 positive concepts are remembered more accu-rately than negative comments.

Simple does not have to be demeaning. Consider thepower of older black and white movies versus the highlytechnological, stunt-filled movies of today. Society mayenjoy the entertainment value of today’s cinematography,but stories were just as powerful 75 years ago.

Significant barriers may prevent the routine imple-mentation of video methodology. First, culturally sensi-tive videos of appropriate length are scarce. Manyavailable titles use cartoon animation, distracting graphics,or culturally and socioeconomically insensitive settingsand examples. Second, producing appropriate videos istime-consuming and expensive for practices to imple-ment. Third, introduction of routine video use in busyclinical practice involves a practice change, and staffacceptance and adoption can be challenging.

MEDIA CONSIDERATIONSA variety of media choices are available. PowerPoint pre-sentations can be very sophisticated and effective.However, these files require a computer to view.Computer greatly increase the cost of implementationand the risk of equipment damage. While PowerPointand computer programs can be interactive and engaging,the hardware or start-up costs can be prohibitive. Videoscan minimize implementation costs.

Doak, Doak, and Root18 discuss several things toconsider in choosing or producing videos for patienteducation. First is to consider the viewing time.Determining the length of the video is important.Krouse’s10 systematic review of video modeling forpatient education found the range was 7 to 30 minutes,with the mean length of 16.5 minutes. Doak, Doak, andRoot18 found that people with limited health literacylose the ability to concentrate after 8 minutes.

Second, videos should focus on the desired behaviorchange. When patients are overwhelmed with a lot ofinformation, education can actually have the oppositeeffect. Many individuals just give up when the task orbehavior change seems unobtainable. Large topics such asdiabetes care should be broken up into smaller segments.For instance, diet could be discussed in a series of videos

about portion control, carbohydrate counting, eating out,healthy cooking techniques, etc.

Doak et al18 also emphasize the importance of usinginteraction to engage the viewer and clarify information.Interaction can be incorporated in a variety of ways. Askingquestions or eliciting responses early is more positive andengaging than asking questions after a 20-minute DVD.

Consideration of cultural sensitivity is also veryimportant. Suggestions for healthy food choices shouldbe religiously and culturally appropriate. Video contentshould also be socioeconomically sensitive. For example,a Caucasian man working on his boat in the driveway ofhis expensive home, while discussing a health problem,may not resonate with all individuals. The lack of sensi-tivity can be viewed as insulting. In order to bridge thehealth literacy gap, the educational message needs to beclear, simple, and inclusive.

VIDEO/DVD PRODUCTION AND PRACTICEIMPLEMENTATIONThe lack of culturally competent, socioeconomically sen-sitive, and fiscally feasible products can pose challenges toroutine implementation of video education in the pri-mary care setting. However, careful planning and ingenu-ity can conquer this obstacle. Professional DVDs can bedeveloped at a reasonable cost (Table 1). Although secur-ing a professional sound studio and hiring professionalactors can be cost prohibitive, a professional alternativehas been found. The use of computer-based editing soft-ware with a green screen and an inexpensive digitalvideo camera allows clinicians to film and produce effec-tive educational videos. Nonprofessional home videocameras can be effective in capturing the essence of the

Table 1. Equipment

Digital Video Camera $300.00

High Definition video camera* ($1,100.00)

Digital Camera $800.00

Editing Software $200.00

Computer/Printer $1,200.00

Firewire Cable 6 pin – 12 pin $12.00

Tripod $50.00

(Pack of 25) DVDs $5.00

DVD player (each) $89.00 – 100.00

Brochure Paper (#150 sheets) $10.00

* Optional

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message in an effective way. Semiprofessional softwarepackages for video editing start as low as $200.

Script development and planning are the most time-consuming part of the project. Storytelling can be a verypowerful means to convey concepts and motivate behaviorchange.17,19 Concept mapping has been used by many dis-ciplines to diagram links between ideas and images as a wayto facilitate learning.20-22Visual maps allow the writer toplan and develop associations with prior knowledge orexperiences, and creating them is an important step inscript development. The time involved for the research ofthe chosen topic and careful choosing of simple language(1- to 2-syllable words) is indeed extensive.

One of the most difficult things to avoid duringscript writing and actual filming is the medical jargon soentrenched in health care provider vocabulary. Considerimportant topics and break them down into short, simplescripts. For instance, 1 of the most important concepts toconvey to a new asthmatic may be instructions oninhaler use instead of an extensive pathophysiology dis-cussion.7 Instruction on how to use an inhaler is alsotime-consuming in practice. A video with an accompa-nying pamphlet can reinforce learning and provide a ref-erence for the patient after he/she leaves the office.

Production and implementation of a video educationalprogram was developed for a busy rural family practice. Todate, 3 video topics and pamphlets are being used routinelyin practice, with 2 more under development. Each videolasts 5 minutes or less. Prior to implementation, the practicehad participated in a randomized control trial (RCT)assessing preferences for end-of-life care using video tech-nology.9 As a result of participating in the RCT, theproviders and staff saw the power and merit of such tech-nology in patient education and decision making.Unfortunately, few incentives are available for practices tomake a significant financial investment into patient educa-tion. Participation in the RCT using video technologyhelped reinforce the value of the methodology and thenecessity to accept a practice change.

Figure 1. Camera with green screen background Figure 2. Pamphlets to accompany DVDs

Figure 3. Iron deficiency anemia pamphlet

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In the series of videos developed, topics included howto use an inhaler, give medication to children, determinedietary portion control, and monitor iron deficiency ane-mia in children. Videos were filmed in a well-lit, quiet

room in front of a green screen (Figure 1), and a picture ofthe office exam room was edited and inserted as a back-drop to create a realistic scene. One of the practice’s healthcare providers was filmed providing information, following

Figure 4. Plan for developing educational DVDs

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a well-prepared script to ensure usage of easy-to-under-stand words and pictures. Each video topic was accompa-nied with a pamphlet with color pictures and bulletedinformation that succinctly summarized the informationprovided in the video (Figures 2 and 3).

Portable, cordless DVD players were purchased forless than $100 to play the video in examination rooms.More costly equipment is not practical given the damagerisk and capital outlay. The portability facilitates move-ment between rooms and maximum viewing opportuni-ties. A large TV with a DVD player available in thewaiting room may provide an additional viewing outlet.However, viewing videos in exam rooms allows topics tobe targeted. For instance, caregivers or parents may viewan educational video on preventing iron deficiency ane-mia while waiting for the provider during a well-childphysical. Suggestions for how to plan and develop healtheducational videos can be found in Figure 4.

Any practice change requires vigilant monitoring toensure implementation. While staff members were eagerto assist with project implementation, heavy patient loadsrequire frequent reminders to use the video methodol-ogy. Before implementation, there was concern thatequipment might get dropped or broken in an examina-tion room with busy children. However, to date, parentsand caregivers have monitored activity and protected theequipment. The novelty of the intervention has also con-tributed to a receptive excitement about the project.

CONCLUSIONVideo/DVD methodology can be a powerful tool inpatient education. Knowledge of the science of learning(especially by vulnerable patients with limited health lit-eracy) that incorporates cultural and socioeconomic sen-sitivity should guide purchase decisions or developmentof video methodology. Implementing appropriate videosin a rural primary care practice cost effectively is chal-lenging but achievable. Script development, filming, andediting the final product are a significant time investmentand therefore expensive. Workshops that teach strategiesfor filming, editing, and writing standardized scriptswould make research application more feasible. Changesin health policy to increase reimbursement for patienteducation would provide incentives for more extensiveadoption of the DVD methodology and thus improvehealth literacy and, ultimately, health outcomes.

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Laurie Anne Ferguson, DNP, APRN, FNP, is an associate pro-fessor in the Loyola University New Orleans School of Nursingin New Orleans, LA, and can be reached at larj-park@gmail.com. In compliance with national ethical guide-lines, the author reports no relationships with business orindustry that would pose a conflict of interest.

1555-4155/121/$ see front matter© 2012 American College of Nurse Practitionershttp://dx.doi.org/10.1016/j.nurpra.2012.07.025