Chapter 15: Employing Multimedia and Mobile Technologies: Making Modern-day Tools Work for You and Your Patients

Before the advent of the Internet, individuals interested in learning 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 their smart phones.

An exclusive reliance on words- either printed or spoken - is often at the heart of health illiteracy. Multimedia provides clever avenues for presenting information, through the use of photographs, illustrations, animation, and video, allowing the creation of interactive learning environments that invite rather than discourage people with literacy issues to learn from them.

The success in communicating any message lies in 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 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 their smart phones. The Internet is also a valuable source of information on how skilled developers are using technology to improve health literacy.

Computer software

There are a growing number of programmes that help people deal with health issues. Some of these specially-designed programmes help:

• People on restricted diets to count calories or check the fat content of the food they eat.
• Patients understand specific exercise programmes recommended to them.
• Patients 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 some of these programmes (many of which are free) @ https://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 enable users to download free or inexpensive apps so that they can function as television remotes, bike speedometers and flashlights. Health apps also enable the smartphone to act as medical devices, helping patients monitor their heart rate or manage their diabetes. For example, the Plain Language Medical Dictionary (@ https://www.lib.umich.edu/plain-language-dictionary) is exactly what it sounds like - a simple widget that enables you to select a complicated medical term and see its definition in clear, concise, non-technical English. WebMD (@ https://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 users area. You can review a list of health-related phone apps @ https://www.informationweek.com/healthcare/patient/15-mobile-apps-for-betterhealth/227700177?itc=ref-true. 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 to their patients!

HealthPhone (@https://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 some of these are available in local Indian languages as well.

Smartphones are useful for doctors as well! drawMD (@https://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, its possible to craft text messages for individual patients. They can be tailored based on a patients 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 dont 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 enables 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 doesnt matter whether your patient is literate enough to read the instructions you give them for taking their medication if you dont 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 programme called ConverserT 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 programme is available not only for computers, but also for smart phones.

Medibabble (@https://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 five languages and contains thousands of translated questions and instructions, all reviewed by a panel of physicians from the University of California School of Medicine. Hearing-impaired patients can see a full-screen display of the selected phrases.

For uneducated 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 of patients is the use 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 patients temperature and then reports the result aloud in Spanish. Similar devices can be programmed for the Indian scenario.

New electronic health tools enable patients to engage with them easily. eHealth literacy is the ability to, find and understand health information from electronic sources and apply this to solving a health problem. Thoughtful developers can use the versatility of modern technology to be able to reach people who may not be able to read, but who can use touch screens to learn about their health problems. This 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 @https://www.youtube.com/watch?v=Bvo4GNUu RYY. 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

Its 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 simple 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 one, three and six 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 provide a safe avenue for patients to ask questions anonymously while accessing them on home computers, smart phones, or from the local library. This also spares people from the embarrassment of asking questions of their own doctors. A number of forums cater to specific audiences, such as the Diabetes Forum.com (@https://www.diabetesforum.com) and The Cancer Forums (@ https://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 sites 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 dont use jargon and are conversational, which means its much easier to read what they write. Since they are patients themselves, they are respectful of their readers, and dont talk down to them. They understand the readers 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 poor countries where health literacy is a major problem, poverty 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.

Placing web-enabled computers at 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 links. Where hospitals serve low literacy patients, touch-screen tablets or computers offer the best solution. On these flat-screen devices, specifically designed medical applications can present users with images, icons, photographs, and cartoon drawings. You just have to touch the screen to access information, both visual and spoken. This provides a much more intuitive form of computer interaction, which even uneducated patients can use with ease.

Taking 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 programmes, 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.

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 (@https://one.laptop.org/). The Indian government has also released a low cost tablet, Aakash, (@https://aakash.org.in/) prompting private companies to release competing products to meet health literacy needs of this under-served market.